Enhanced surface accessibility of SARS-CoV-2 Omicron spike protein due to an altered glycosylation profile (preprint)

SARS-CoV-2 spike (S) proteins undergo extensive glycosylation, aiding proper folding, enhancing stability, and evading host immune surveillance. In this study, we used mass spectrometric analysis to elucidate the N-glycosylation characteristics and disulfide bonding of recombinant spike proteins derived from the SARS-CoV-2 Omicron variant (B.1.1.529) in comparison with the D614G spike variant. Furthermore, we conducted microsecond-long molecular dynamics simulations on spike proteins to resolve how the different N-glycans impact spike conformational sampling in the two variants. Our findings reveal that the Omicron spike protein maintains an overall resemblance to the D614G spike variant in terms of site-specific glycan processing and disulfide bond formation. Nonetheless, alterations in glycans were observed at certain N-glycosylation sites. These changes, in synergy with mutations within the Omicron spike protein, result in increased surface accessibility of the macromolecule, including ectodomain, receptor-binding domain, and N-terminal domain. These insights contribute to our understanding of the interplay between structure and function, thereby advancing effective vaccination and therapeutic strategies. TeaserThrough mass spectrometry and molecular dynamics simulations, SARS-CoV-2 Omicron spike is found to be less covered by glycans when compared to the D614G spike variant.

Single Nucleus RNA Sequencing of Remnant Kidney Biopsies and Urine Cell RNA Sequencing Reveal Cell Specific Markers of Covid-19 Acute Kidney Injury (preprint)

Acute kidney injury (AKI) in COVID-19 patients is associated with high mortality and morbidity. Critically ill COVID-19 patients are at twice the risk of in-hospital mortality compared to non-COVID AKI patients. We know little about the cell-specific mechanism in the kidney that contributes to worse clinical outcomes in these patients. New generation single cell technologies have the potential to provide insights into physiological states and molecular mechanisms in COVID-AKI. One of the key limitations is that these patients are severely ill posing significant risks in procuring additional biopsy tissue. We recently generated single nucleus RNA-sequencing data using COVID-AKI patient biopsy tissue as part of the human kidney atlas. Here we describe this approach in detail and report deeper comparative analysis of snRNAseq of 4 COVID-AKI, 4 reference, and 6 non-COVID-AKI biopsies. We also generated and analyzed urine transcriptomics data to find overlapping COVID-AKI-enriched genes and their corresponding cell types in the kidney from snRNA-seq data. We identified all major and minor cell types and states by using by using less than a few cubic millimeters of leftover tissue after pathological workup in our approach. Differential expression analysis of COVID-AKI biopsies showed pathways enriched in viral response, WNT signaling, kidney development, and cytokines in several nephron epithelial cells. COVID-AKI profiles showed a much higher proportion of altered TAL cells than non-COVID AKI and the reference samples. In addition to kidney injury and fibrosis markers indicating robust remodeling we found that, 17 genes overlap between urine cell COVID-AKI transcriptome and the snRNA-seq data from COVID-AKI biopsies. A key feature was that several of the distal nephron and collecting system cell types express these markers. Some of these markers have been previously observed in COVID-19 studies suggesting a common mechanism of injury and potentially the kidney as one of the sources of soluble factors with a potential role in disease progression. Translational StatementThe manuscript describes innovation, application and discovery that impact clinical care in kidney disease. First, the approach to maximize use of remnant frozen clinical biopsies to inform on clinically relevant molecular features can augment existing pathological workflow for any frozen tissue without much change in the protocol. Second, this approach is transformational in medical crises such as pandemics where mechanistic insights are needed to evaluate organ injury, targets for drug therapy and diagnostic and prognostic markers. Third, the cell type specific and soluble markers identified and validated can be used for diagnoses or prognoses in AKI due to different etiologies and in multiorgan injury.

Investigating Whether Law Schools in the UK and Australia Are Workplaces that Support the Wellbeing of Law Teachers

There is now an extensive evidence-base across numerous countries demonstrating that approximately one-third of law students experience a decline in their wellbeing during their first year of legal education. As a result, law schools are seeking to enact strategies to prevent this decline and to positively support law student wellbeing-both through extra-curricula and curricula approaches. The success of these strategies depends largely on the capacity of law teachers and other faculty staff, and yet there is currently insufficient research on whether law teachers are well and able to support the wellbeing of their students. This chapter presents the results to-date of a longitudinal study conducted in the UK and Australia, both pre-COVID and post-COVID, considering the quality of the working life of law teachers in terms of the context of its impact on their capacity to promote law student wellbeing. We examine some of the prominent challenges that law teachers identify and recount some of their constructive suggestions which may assist law school managers and leaders in enacting structural and cultural change in support of the wellbeing of legal academics. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022.

Digital PCR Discriminates between SARS-CoV-2 Omicron Variants and Immune Escape Mutations.

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to evolve, mutations arise that will allow the virus to evade immune defenses and therapeutics. Assays that can identify these mutations can be used to guide personalized patient treatment plans. Digital PCR (dPCR) is a fast and reliable complement to whole-genome sequencing that can be used to discriminate single nucleotide polymorphisms (SNPs) in template molecules. Here, we developed a panel of SARS-CoV-2 dPCR assays and demonstrate its applications for typing variant lineages and therapeutic monoclonal antibody resistance. We first designed multiplexed dPCR assays for SNPs located at residue 3395 in the orf1ab gene that differentiate the Delta, Omicron BA.1, and Omicron BA.2 lineages. We demonstrate their effectiveness on 596 clinical saliva specimens that were sequence verified using Illumina whole-genome sequencing. Next, we developed dPCR assays for spike mutations R346T, K444T, N460K, F486V, and F486S, which are associated with host immune evasion and reduced therapeutic monoclonal antibody efficacy. We demonstrate that these assays can be run individually or multiplexed to detect the presence of up to 4 SNPs in a single assay. We perform these dPCR assays on 81 clinical saliva SARS-CoV-2-positive specimens and properly identify mutations in Omicron subvariants BA.2.75.2, BM.1.1, BN.1, BF.7, BQ.1, BQ.1.1, and XBB. Thus, dPCR could serve as a useful tool to determine if clinical specimens contain therapeutically relevant mutations and inform patient treatment. IMPORTANCE Spike mutations in the SARS-CoV-2 genome confer resistance to therapeutic monoclonal antibodies. Authorization for treatment options is typically guided by general trends of variant prevalence. For example, bebtelovimab is no longer authorized for emergency use in the United States due to the increased prevalence of antibody-resistant BQ.1, BQ.1.1, and XBB Omicron subvariants. However, this blanket approach limits access to life-saving treatment options to patients who are otherwise infected with susceptible variants. Digital PCR assays targeting specific mutations can complement whole-genome sequencing approaches to genotype the virus. In this study, we demonstrate the proof of concept that dPCR can be used to type lineage defining and monoclonal antibody resistance-associated mutations in saliva specimens. These findings show that digital PCR could be used as a personalized diagnostic tool to guide individual patient treatment.

From European Union Student Mobility to Lockdown: "Virtual Study Mobility” in the COVID-19 Era and a Case Study of Transnational Law in an International Classroom Delivered Online

This chapter comprises a case study of the adaptation of an undergraduate law module, European Union Criminal and Migration Law, necessitated by COVID-19. The short overseas study programme-field trip, incorporated in the module and shared by several European universities became, of necessity, an entirely online experience. Comprising a programme of lectures, workshops and presentations and placing considerable value on developing intercultural skills, the customary short study abroad programme could not take place in 2021 and was, therefore, replaced with a five-day online study week. The chapter surveys the literature, which consistently confirms key benefits of study abroad including and particularly for trips of short duration such as that delineated here. Ultimately, the authors of this chapter (the leaders of the module) seek to understand the extent to which, and the ways in which, an online experience can stand in for study abroad. The chapter aims to provide insights into how to design short term virtual study mobility, which as a result of COVID-19 is likely to become more widespread at least in the short term and possibly thereafter. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Pandemic Procedures: Adapting Problem-Solving Court (PSC) Operations and Treatment Protocols During COVID-19

With an ongoing pandemic claiming hundreds of lives a day, it is unclear how COVID-19 has affected court operations, particularly problem-solving courts (PSCs) which have goals rooted in rehabilitation for participants in their programs. Even with practical recommendations from national organizations directing courts on how to manage COVID-19, whether and how PSCs met the needs of PSC participants during this time is underexplored. This study, drawn from a larger national study using a survey of PSC coordinators, examines the COVID-19 responses of PSCs to remain safely operational for participants. A sub-sample of survey respondents (n = 82 PSC coordinators) detailed how the COVID-19 pandemic led to changes to their court and treatment operations amidst the constraints of the pandemic. The courts' shifts in policy and practice have important impacts for court participants' treatment retention and success in the PSC program, and these shifts need more in-depth research in the future.

Predicting employee telecommuting preferences and job outcomes amid COVID-19 pandemic: a latent profile analysis.

In this two-study research using latent profile analysis (LPA), we investigated intra-individual combinations of conscientiousness, autonomy, self-regulation, and extraversion. Based on these combinations, we designed profiles and explored telecommuting preferences and job outcomes of employees during the COVID-19 pandemic. In Study 1, we recruited 199 participants (77 females, ages ranging from 18 to 65). Results of this study revealed three profiles. One profile scored high on all of the variables and displayed preferences for working on-site more than the other profiles. Additionally, this profile showed higher work engagement, job satisfaction, and perceived productivity than the other two profiles. To validate these findings, we conducted a second study with a sample of 492 participants (169 females; age ranged from 18 to 65). The results yielded five profiles, one scoring high on all of the variables. Similar to Study 1, this profile exhibited higher work engagement, job satisfaction, and perceived productivity than the other four profiles. Individuals in this profile preferred to work on-site compared to individuals in other profiles. Our findings add to the research demonstrating the importance of personality characteristics for telecommuting preferences and work-related outcomes. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12144-021-02496-8.

Large clones of pre-existing T cells drive early immunity against SARS-COV-2 and LCMV infection.

T cell responses precede antibody and may provide early control of infection. We analyzed the clonal basis of this rapid response following SARS-COV-2 infection. We applied T cell receptor (TCR) sequencing to define the trajectories of individual T cell clones immediately. In SARS-COV-2 PCR+ individuals, a wave of TCRs strongly but transiently expand, frequently peaking the same week as the first positive PCR test. These expanding TCR CDR3s were enriched for sequences functionally annotated as SARS-COV-2 specific. Epitopes recognized by the expanding TCRs were highly conserved between SARS-COV-2 strains but not with circulating human coronaviruses. Many expanding CDR3s were present at high frequency in pre-pandemic repertoires. Early response TCRs specific for lymphocytic choriomeningitis virus epitopes were also found at high frequency in the preinfection naive repertoire. High-frequency naive precursors may allow the T cell response to respond rapidly during the crucial early phases of acute viral infection.

COVID-19: A review of therapeutics under investigation.

The COVID-19 outbreak has disrupted global health care networks and caused thousands of deaths and an international economic downturn. Multiple drugs are being used on patients with COVID-19 based on theoretical and in vitro therapeutic targets. Several of these therapies have been studied, but many have limited evidence behind their use, and clinical trials to evaluate their efficacy are either ongoing or have not yet begun. This review summarizes the existing evidence for medications currently under investigation for treatment of COVID-19, including remdesivir, chloroquine/hydroxychlorquine, convalescent plasma, lopinavir/ritonavir, IL-6 inhibitors, corticosteroids, and angiotensin-converting enzyme inhibitors.

Evolution of antibody immunity following Omicron BA.1 breakthrough infection.

Understanding the longitudinal dynamics of antibody immunity following heterologous SAR-CoV-2 breakthrough infection will inform the development of next-generation vaccines. Here, we track SARS-CoV-2 receptor binding domain (RBD)-specific antibody responses up to six months following Omicron BA.1 breakthrough infection in six mRNA-vaccinated individuals. Cross-reactive serum neutralizing antibody and memory B cell (MBC) responses decline by two- to four-fold through the study period. Breakthrough infection elicits minimal de novo Omicron BA.1-specific B cell responses but drives affinity maturation of pre-existing cross-reactive MBCs toward BA.1, which translates into enhanced breadth of activity across other variants. Public clones dominate the neutralizing antibody response at both early and late time points following breakthough infection, and their escape mutation profiles predict newly emergent Omicron sublineages, suggesting that convergent antibody responses continue to shape SARS-CoV-2 evolution. While the study is limited by our relatively small cohort size, these results suggest that heterologous SARS-CoV-2 variant exposure drives the evolution of B cell memory, supporting the continued development of next-generation variant-based vaccines.

Multimorbidity prevalence and chronic disease patterns among tuberculosis survivors in a high-income setting.

OBJECTIVES: Multimorbidity is the presence of two or more chronic health conditions. Tuberculosis (TB) survivors are known to have higher prevalence of multimorbidity, although prevalence estimates from high-income low-TB incidence jurisdictions are not available and potential differences in the patterns of chronic disease among TB survivors with multimorbidity are poorly understood. In this study, we aimed to (1) compare the prevalence of multimorbidity among TB survivors with matched non-TB controls in a high-income setting; (2) assess the robustness of aim 1 analyses to different modelling strategies, unmeasured confounding, and misclassification bias; and (3) among people with multimorbidity, elucidate chronic disease patterns specific to TB survivors. METHODS: A population-based cohort study of people immigrating to British Columbia, Canada, 1985-2015, using health administrative data. Participants were divided into two groups: people diagnosed with TB (TB survivors) and people not diagnosed with TB (non-TB controls) in British Columbia. Coarsened exact matching (CEM) balanced demographic, immigration, and socioeconomic covariates between TB survivors and matched non-TB controls. Our primary outcome was multimorbidity, defined as ≥2 chronic diseases from the Elixhauser comorbidity index. RESULTS: In the CEM-matched sample (n=1962 TB survivors; n=1962 non-TB controls), we estimated that 21.2% of TB survivors (n=416), compared with 12% of non-TB controls (n=236), had multimorbidity. In our primary analysis, we found a double-adjusted prevalence ratio of 1.74 (95% CI: 1.49-2.05) between TB survivors and matched non-TB controls for multimorbidity. Among people with multimorbidity, differences were observed in chronic disease frequencies between TB survivors and matched controls. CONCLUSION: TB survivors had a 74% higher prevalence of multimorbidity compared with CEM-matched non-TB controls. TB-specific multimorbidity patterns were observed through differences in chronic disease frequencies between the matched samples. These findings suggest a need for TB-specific multimorbidity interventions in high-income settings such as Canada. We suggest TB survivorship as a framework for developing person-centred interventions for multimorbidity among TB survivors.

RéSUMé: OBJECTIFS: La multimorbidité est la présence de deux affections chroniques ou plus. On sait que la prévalence de la multimorbidité est plus élevée chez les survivants de la tuberculose, mais il n'y a pas d'estimations de prévalence disponibles dans les entités administratives à revenu élevé et à faible incidence de tuberculose, et les différences potentielles dans les structures de la morbidité chronique chez les survivants de la tuberculose atteints de multimorbidité sont mal comprises. Dans cette étude, nous avons voulu 1) comparer la prévalence de la multimorbidité chez des survivants de la tuberculose appariés à des témoins sans tuberculose dans un milieu à revenu élevé; 2) évaluer la robustesse des analyses du 1er objectif par rapport à différentes stratégies de modélisation, à la confusion non mesurée et au biais d'erreur de classification; et 3) élucider, chez les personnes atteintes de multimorbidité, les structures de la morbidité chronique propres aux survivants de la tuberculose. MéTHODE: Nous avons mené à l'aide de données administratives sur la santé une étude de cohorte populationnelle des personnes ayant immigré en Colombie-Britannique (Canada) entre 1985 et 2015. Les participants ont été divisés en deux groupes : les personnes ayant un diagnostic de tuberculose (« survivants de la tuberculose ¼) et les personnes n'ayant pas de diagnostic de tuberculose (« témoins sans tuberculose ¼) en Colombie-Britannique. Un appariement exact avec groupement (coarsened exact matching [CEM]) a permis d'équilibrer les covariables démographiques, socioéconomiques et d'immigration entre les survivants de la tuberculose et les témoins sans tuberculose appariés. Notre principal résultat a été la multimorbidité, définie comme étant la présence de ≥ 2 affections chroniques selon l'indice de comorbidité d'Elixhauser. RéSULTATS: Dans l'échantillon CEM (n = 1 962 survivants de la tuberculose; n = 1 962 témoins sans tuberculose), nous avons estimé que 21,2 % des survivants de la tuberculose (n = 416), contre 12 % des témoins sans tuberculose (n = 236), étaient atteints de multimorbidité. Dans notre analyse primaire, nous avons obtenu un ratio de prévalence doublement ajusté de 1,74 (IC de 95 % : 1,49-2,05) entre les survivants de la tuberculose et les témoins sans tuberculose appariés pour ce qui est de la multimorbidité. Chez les personnes atteintes de multimorbidité, des différences ont été observées dans la fréquence des maladies chroniques entre les survivants de la tuberculose et les témoins appariés. CONCLUSION: Les survivants de la tuberculose avaient une prévalence de multimorbidité supérieure de 74 % à celle des témoins sans tuberculose appariés selon la méthode CEM. Les structures de multimorbidité propres à la tuberculose ont été observées selon les différences dans la fréquence des maladies chroniques entre les échantillons appariés. Ces constatations indiquent qu'il faudrait mener des interventions sur la multimorbidité propres à la tuberculose dans des milieux à revenu élevé comme le Canada. Nous suggérons d'utiliser la survie à la tuberculose comme cadre d'élaboration d'interventions centrées sur la personne pour lutter contre la multimorbidité chez les survivants de la tuberculose.

Evolving spike-protein N-glycosylation in SARS-CoV-2 variants (preprint)

It has been three years since SARS-CoV-2 emerged and the world plunged into a \"once in a century\" pandemic. Since then, multiple waves of infection have swept through the human population, led by variants that were able to evade any acquired immunity. The co-evolution of SARS-CoV-2 variants with human immunity provides an excellent opportunity to study the interaction between viral pathogens and their human hosts. The heavily N-glycosylated spike-protein of SARS-CoV-2 plays a pivotal role in initiating infection and is the target for host immune response, both of which are impacted by host-installed N-glycans. We compared the N-glycan landscape of recombinantly expressed, stabilized, soluble spike-protein trimers representing seven of the most prominent SARS-CoV-2 variants and found that N-glycan processing is conserved at most sites. However, in multiple variants, processing of N-glycans from high mannose- to complex-type is reduced at sites N165, N343 and N616, implicated in spike-protein function.

Improving the timeliness of health expenditure tracking in OECD and low-and middle-income countries

The COVID-19 pandemic has highlighted that access to timely health spending data is crucial for informed policy-making. This Health Working Paper summarises and compares the methodologies applied in around half of OECD countries to estimate public and private health spending for the most recent year (i.e. t-1) as well as the approaches taken by the OECD Secretariat to fill existing data gaps for the remaining OECD countries. For the first time, the paper also explores the feasibility of nowcasting health spending for the current year (i.e. t) and examines data sources that could be potentially useful in such an exercise. While this review should help OECD countries that do not yet have experience in estimating health spending for year t-1 to improve the timeliness in their data reporting, a special focus in this paper lies on testing the applicability of the methods in low- and middle-income countries (LMIC), using the WHO Western Pacific Region (WPRO) as an example. Generally, different data sources exist in many countries that would allow for a more timely estimation for health spending aggregates.

Variation in postoperative outcomes of patients with intracranial tumors: insights from a prospective international cohort study during the COVID-19 pandemic.

BACKGROUND: This study assessed the international variation in surgical neuro-oncology practice and 30-day outcomes of patients who had surgery for an intracranial tumor during the COVID-19 pandemic. METHODS: We prospectively included adults aged ≥18 years who underwent surgery for a malignant or benign intracranial tumor across 55 international hospitals from 26 countries. Each participating hospital recorded cases for 3 consecutive months from the start of the pandemic. We categorized patients' location by World Bank income groups (high [HIC], upper-middle [UMIC], and low- and lower-middle [LLMIC]). Main outcomes were a change from routine management, SARS-CoV-2 infection, and 30-day mortality. We used a Bayesian multilevel logistic regression stratified by hospitals and adjusted for key confounders to estimate the association between income groups and mortality. RESULTS: Among 1016 patients, the number of patients in each income group was 765 (75.3%) in HIC, 142 (14.0%) in UMIC, and 109 (10.7%) in LLMIC. The management of 200 (19.8%) patients changed from usual care, most commonly delayed surgery. Within 30 days after surgery, 14 (1.4%) patients had a COVID-19 diagnosis and 39 (3.8%) patients died. In the multivariable model, LLMIC was associated with increased mortality (odds ratio 2.83, 95% credible interval 1.37-5.74) compared to HIC. CONCLUSIONS: The first wave of the pandemic had a significant impact on surgical decision-making. While the incidence of SARS-CoV-2 infection within 30 days after surgery was low, there was a disparity in mortality between countries and this warrants further examination to identify any modifiable factors.

Private equity in ophthalmology and optometry: a time series analysis from 2012 to 2021.

Purpose: To identify temporal and geographic trends in private equity (PE)-backed acquisitions of ophthalmology and optometry practices in the United States from 2012 to 2021. Methods: In this cross-sectional time series, acquisition data from 10/21/2019 to 9/1/2021 and previously published data from 1/1/2012 to 10/20/2019 were analyzed. Acquisition data were compiled from 6 financial databases, 5 industry news outlets, and publicly available press releases. Linear regression models were used to compare rates of acquisition. Outcomes included number of total acquisitions, practice type, locations, provider details, and geographic footprint. Results: A total of 245 practices associated with 614 clinical locations and 948 ophthalmologists or optometrists were acquired by 30 PE-backed platform companies between 10/21/2019 and 9/1/2021. Of 30 platform companies, 18 were new vis-à-vis our prior study. Of these acquisitions, 127 were comprehensive practices, 29 were retina practices, and 89 were optometry practices. From 2012 to 2021, monthly acquisitions increased by 0.947 acquisitions per year (P < 0.001*). Texas, Florida, Michigan, and New Jersey were the states with the greatest number of PE acquisitions, with 55, 48, 29, and 28 clinic acquisitions, respectively. Average monthly PE acquisitions were 5.71 per month from 1/1/2019 to 2/29/2020 (pre-COVID), 5.30 per month from 3/1/2020 to 12/31/2020 (COVID pre-vaccine [P = 0.81]), and 8.78 per month from 1/1/2021 to 9/1/2021 (COVID post-vaccine [P = 0.20]). Conclusions: PE acquisitions increased during the period 2012-2021 as companies continue to utilize regionally focused strategies for acquisitions.

Use of live streaming systems in field‐based learning

Field‐based learning is a key element in wildlife management curriculum as it is a valuable teaching tool for natural resource topics. There are multiple constraints that restrict use of field‐based learning techniques in wildlife programs that have been complicated by the COVID‐19 pandemic. Many academic programs were forced to rapidly transition to online instruction, but despite these difficulties, there was a need to provide interactive, in the field learning opportunities for students. This necessity resulted in the development of a live streaming system to provide an interactive learning experience (Leopold Live!). In this case study, we describe the technology used in Leopold Live! to augment an online, wildlife habitat management course at Texas A&M University, and the associated challenges and adjustments needed to improve delivery in the future. We conclude that Leopold Live! serves as a potential method to meet the challenge of providing interactive, field‐based learning in a distance education setting. [ABSTRACT FROM AUTHOR] Copyright of Wildlife Society Bulletin is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The Ultra fit community mask—Toward maximal respiratory protection via personalized face fit

Effective masking policies to prevent the spread of airborne infections depend on public access to masks with high filtration efficacy. However, poor face-fit is almost universally present in pleated multilayer disposable face masks, severely limiting both individual and community respiratory protection. We developed a set of simple mask modifications to mass-manufactured disposable masks, the most common type of mask used by the public, that dramatically improves both their personalized fit and performance in a low-cost and scalable manner. These modifications comprise a user-moldable full mask periphery wire, integrated earloop tension adjusters, and an inner flange to trap respiratory droplets. We demonstrate that these simple design changes improve quantitative fit factor by 320%, triples the level of protection against aerosolized droplets, and approaches the model efficacy of N95 respirators in preventing the community spread of COVID-19, for an estimated additional cost of less than 5 cents per mask with automated production.