Public Health Commons^™

Interrogating Race And Place-Based Inequities In Hiv And Covid-19, Rohan Khazanchi

EMET Projects

Over the last four years, I have developed a research focus examining the intersections of race, place, and health. My M.D. Honors Thesis reflects a snapshot of these efforts. In this collection of brief research reports, I leverage area-based measures to investigate structural inequities in three contexts: the HIV epidemic in our hyperlocal community, the early stages of the COVID-19 pandemic, and clinical trials for novel COVID-19 therapeutics. I apply novel social epidemiologic tools to measure and explore disparate outcomes. And, in reflecting upon my findings, I discuss concrete implications for clinicians, researchers, and policymakers alike.

Chapter 1: Neighborhood-Level Deprivation …

The Correlation Between Vaccine Hesitancy And Privilege: Exploring The Degree To Which Education And Income Foster Resistance To Vaccination Efforts, Sophie Goldenberg

Independent Study Project (ISP) Collection

Vaccine hesitancy is a public health issue of growing concern. Extensive pre-existing literature offers several explanations and conflicting viewpoints regarding reluctance toward vaccinations. However, minimal research has been done exploring the upstream social determinants driving vaccine hesitancy. Utilizing academic and gray literature and interviews with experts in the field, this study addresses this gap in knowledge with the research question: To what extent does privilege impact vaccine hesitancy and resistance? Vaccine hesitancy appears globally and is particularly concerning given the re-emergence of vaccine-preventable diseases (VPDs). Additionally, due to inconsistent causes, vaccine hesitancy is difficult to combat. In referencing the history …

Epidemiology In Higher Education: Scarlet Fever At Gettysburg College, Addison E. Lomax

Student Publications

Throughout the early 20th century, the relationship between higher education and the spread of epidemic disease evolved in the United States. Two notable epidemics of scarlet fever in 1915 and 1920 serve as a lens through which the larger roles of disease and higher education can be analyzed. By assessing the roles both the administration and the students played at Gettysburg College, then Pennsylvania College, historians can understand the process of combating health crises in the future. Although the Pennsylvania College scarlet fever epidemics of 1915 and 1920 impacted campus to a smaller extent than the 2020 COVID-19 pandemic, the …

Associations Among Plant-Based Dietary Indexes, The Dietary Inflammatory Index, And Inflammatory Potential In Female College Students In Saudi Arabia: A Cross-Sectional Study, Ghadeer S. Aljuraiban, Rachel Gibson, Leenah Al-Freeh, Sara Al-Musharaf, Nitin Shivappa Mbbs, Mph, Ph.D., James R. Hébert, Linda M. Oude, Queenie Chan

Faculty Publications

Background Saudi Arabian diets are transitioning to more Western dietary patterns that have been associated with higher levels of inflammation. Emerging evidence suggests plant-based diets are related to lower levels of inflammation; however, the definition of plant-based diets varies. Objective The purpose of this study was to identify the extent to which an overall Plant-Based Diet Index (PDI), Healthy-PDI (hPDI), and Unhealthy-PDI (uPDI) vs Energy-Adjusted Dietary Inflammatory Index correlate with high-sensitivity C-reactive protein (hs-CRP) level. Design This was a cross-sectional study carried out at King Saud University. Data on dietary intake, anthropometrics, and hs-CRP were collected. Participants/setting Female students aged …

Longitudinal Analysis Of The Impact Of Oral Contraceptive Use On The Gut Microbiome, Xinwei Hua, Yueming Cao, David M Morgan, Kaia Miller, Samantha M Chin, Danielle Bellavance, Hamed Khalili

Department of Medicine Faculty Papers

Introduction. Evidence has linked exogenous and endogenous sex hormones with the human microbiome.Hypothesis/Gap statement. The longitudinal effects of oral contraceptives (OC) on the human gut microbiome have not previously been studied.Aim. We sought to examine the longitudinal impact of OC use on the taxonomic composition and metabolic functions of the gut microbiota and endogenous sex steroid hormones after initiation of OC use.Methodology. We recruited ten healthy women who provided blood and stool samples prior to OC use, 1 month and 6 months after starting OC. We measured serum levels of sex hormones, including estradiol, progesterone, sex hormone-binding …

A Streptococcus Pneumoniae Lineage Usually Associated With Pneumococcal Conjugate Vaccine (Pcv) Serotypes Is The Most Common Cause Of Serotype 35b Invasive Disease In South Africa, Following Routine Use Of Pcv, Kedibone M. Ndlangisa, Mignon Du Plessis, Stephani Lo, Linda De Gouveia, Chrispin Chaguza, Martin Antonio, Brenda Kwambana-Adams, Jennifer Cornick, Dean B. Everett, Sadia Shakoor

Department of Pathology and Laboratory Medicine

Pneumococcal serotype 35B is an important non-conjugate vaccine (non-PCV) serotype. Its continued emergence, post-PCV7 in the USA, was associated with expansion of a pre-existing 35B clone (clonal complex [CC] 558) along with post-PCV13 emergence of a non-35B clone previously associated with PCV serotypes (CC156). This study describes lineages circulating among 35B isolates in South Africa before and after PCV introduction. We also compared 35B isolates belonging to a predominant 35B lineage in South Africa (GPSC5), with isolates belonging to the same lineage in other parts of the world. Serotype 35B isolates that caused invasive pneumococcal disease in South Africa in …

Bright Light Treatment Of Combat-Related Ptsd: A Randomized Controlled Trial, Shawn D. Youngstedt, Christopher E. Kline, Alexandria Reynolds, Shannon K. Crowley, James B. Burch Ph.D., Nidha Khan, Seungyong Han

Faculty Publications

Introduction

Post-traumatic stress disorder (PTSD) is a prevalent consequence of combat with significant associated morbidity. Available treatments for PTSD have had limitations, suggesting a need to explore alternative or adjuvant treatments. Numerous rationales for bright light treatment of PTSD include its benefits for common PTSD comorbidities of depression, anxiety, and circadian misalignment and its relative ease of use with few side effects. The primary aims of this research were to examine the effects of bright light treatment for combat-related PTSD and associated morbidity. Materials and Methods

A randomized controlled trial was performed in N = 69 veterans with PTSD attributable …

“Pandemias Políticas: The Effects Of Political And Social Instability On Infectious Disease Epidemiology In Latin America"”, Sarah H. Noonan

Senior Theses

This paper seeks to analyze the relationship between political and social unrest and conflict and infectious disease epidemiology in Latin America. An analysis of published literature regarding epidemiological, biomedical, political, and historical content was conducted to highlight potential connections between infectious disease epidemics and sociopolitical conflict in the region. Specific analyses of Smallpox, Venezuelan Equine Encephalitis, Chagas disease, Cholera, Dengue, and COVID-19 were conducted, in an effort to uncover potential causations and context of epidemics of these conditions. Results of this analysis depict a necessity for further research into public health and disease control mechanisms during times of conflict and …

The Impact Of Cannabis And Alcohol Use On The Management Of Type 1 Diabetes Mellitus, Joshua Eric Sellner

Theses and Dissertations

This dissertation sought to contribute to the evidence-base of diabetes management and acute complications associated with alcohol and cannabis use among individuals with Type 1 Diabetes (T1DM). Three interconnected studies were initiated to complete this goal. First, existing literature surrounding the potential consequences of cannabis consumption among individuals with T1DM were summarized within a systematic review. Study results were combined to provide a single measure of association through a meta-analysis. Second, identified associations were further investigated through a cross-sectional study using the SEARCH for Diabetes in Youth data on alcohol and cannabis use on diabetes management and acute complications including …

Associations Of The Fto Gene And Risk Of Acute Myeloid Leukemia, Avery Ulrich

Theses and Dissertations

Background Acute Myeloid Leukemia (AML) is a blood cancer that affects ~70,000 people each year in the US. The Fat Mass and Obesity (FTO) gene on chromosome 16 has been reported to be associated with obesity, solid tumor cancers (lung, renal, breast, prostate, pancreatic, endometrial), and more recently with hematologic malignancies, like AML. In this thesis, we test the hypothesis that inherited variants within the FTO gene are associated with an increased risk of AML. Methods Using the DISCOVeRY-BMT (Determining the Influence of Susceptibility COnveying Variants Related to one-Year mortality after Blood and Marrow Transplantation), a well-powered genome-wide association study …

The Age Of E-Cigarette Initiation And Association With Frequency Of Use And Risk Of Combustible Tobacco Cigarette Smoking Initiation, Andy Hu

Senior Theses

Background - Studies have shown that electronic nicotine delivery systems (ENDS) are unsafe for consumption. However, the prevalence of e-cigarette use among adolescents and young adults continues to increase, which is being addressed by research. Little attention has been paid to the effects of earlier age of ENDS initiation.

Purpose - This paper examined published research studies on the topic of the age of initiation of e-cigarette use in relation to 1) frequency of e-cigarette use and 2) risk of combustible tobacco cigarette smoking initiation. This research tested the hypothesis that an earlier age of e-cigarette initiation was associated with …

Changes In Physical Activity Associated With The Covid-19 Pandemic In Individuals With Overweight And Obesity: An Interrupted Time Series Analysis With Historical Controls, Michael C Robertson, Che Young Lee, Ivan Haw-Chong Wu, Yue Liao, Margaret Raber, Nathan Parker, Thuan Le, Leticia Gatus, Karen M Basen-Engquist

Faculty, Staff and Students Publications

The objective of this study was to investigate changes in physical activity patterns associated with the COVID-19 pandemic in individuals with overweight and obesity who were participating in a school district worksite weight loss program. We conducted comparative design interrupted time series analyses on physical activity device (Fitbit) data from the 2018-2019 and 2019-2020 school years (N = 211). We administered a questionnaire in 2020 to supplement device data. After the stay-at-home orders in 2020, participants tended to decrease their weekly step count (B = -1315.7, SE = 627.7, p = .045), decrease their weekly "Lightly active minutes" (B = …

Colonic Epithelial Angiotensin-Converting Enzyme 2 (Ace2) Expression In Blacks And Whites: Potential Implications For Pathogenesis Covid-19 Racial Disparities, Mart De La Cruz, David P Nunes, Vaishali Bhardwaj, Deepika Subramanyan, Caroline Zaworski, Priya Roy, Hemant K Roy

Faculty, Staff and Students Publications

BACKGROUND: Covid-19 toll is disproportionate in Blacks although the mechanisms remain incompletely understood. From a biological perspective, several host proteins have received most attention as logical susceptibility targets. Specifically, angiotensin-converting enzyme 2 (ACE2) serves as the epithelial cell receptor and acts in concert with transmembrane protease serine 2 (TMPRSS2). Intriguingly, ACE2 can also suppress the inflammatory response and therefore may impact the severity of Covid-19 infections (from the exuberant immune response a.k.a. "cytokine storm"). We, therefore, assessed expression of ACE2 and TMPRSS2 in Blacks versus Whites.

METHODS: Archived mucosal biopsies from colonoscopic biopsies of visually normal rectal mucosa without concurrent …

Longitudinal Relation Of Dietary Quality And Hemoglobin A1c In Youth And Young Adults With Diabetes, Hope Bercaw

Theses and Dissertations

Background Hemoglobin A1c (HbA1c) is a clinical measure of glycemic control among people with diabetes and is associated with health outcomes such as cardiovascular disease. It is possible to decrease HbA1c by improving diet, but it is largely unknown which dietary components are most important in targeting glycemic control.

Objective This study aims to examine whether changes in diet quality across diabetes duration, assessed with the 2015-Healthy Eating Index (HEI), are associated with HbA1c in youth and young adults (YYA) with type 1 (T1D) and type 2 diabetes (T2D). Additionally, we aim to assess whether these relationships differ when dietary …

Exploratory Analysis Of The Associations Between Neonicotinoids And Measures Of Adiposity Among Us Adults: Nhanes 2015–2016, Amruta M. Godbole, Sheniz Moonie, Courtney Coughenour, Cai Zhang, Aimin Chen, Ann M. Vuong

Environmental & Global Health Faculty Research

Background: Toxicology studies suggest that neonicotinoids may be associated with adiposity development via thyroid hormone disruption and increased oxidative stress. Prior epidemiological studies report mixed results for the association between neonicotinoids and adiposity measures.

Objective: To examine the association between detectable concentrations of parent neonicotinoids (imidacloprid, acetamiprid, clothianidin) and neonicotinoid metabolites (5-hydroxy-imidacloprid, N-desmethyl-acetamiprid) with adiposity measures among US adults, and whether sex modifies the associations for neonicotinoid metabolites with adiposity.

Methods: National Health and Nutrition Examination Survey (NHANES) 2015–2016 data was utilized to estimate covariate-adjusted associations between detectable neonicotinoids and fat mass index (FMI), lean mass index (LMI), waist …

Tick Surveillance And Pathogen Detection In Eastern South Dakota, Holly E. Black

Honors Thesis

Tick-borne diseases threaten the health of humans, animals, and ecosystems, but surveillance efforts are lacking in some regions. Throughout 2019, 2020, and 2021, we conducted tick surveys aimed at determining the status of the black-legged tick (Ixodes scapularis), the American dog tick (Dermacentor variabilis) and the lone star tick (Amblyoma americanum) in eastern South Dakota. Each year, ticks were collected using a flagging method and identified in the lab. A subset were tested for the presence of Borrelia burgdorferi, the causative agent of Lyme disease, by polymerase chain reaction (PCR). Dermacentor variabilis was the most commonly identified tick, …

A Quantitative Analysis Of The Efficacy Of Various Essential Oils Against The Sars Cov-2 Virus, Elizabeth Wagstaff, Chandrelyn Kraczek, Jack Brandon Lopez

Annual Research Symposium

A poster presentation and abstract for the Roseman Symposium. The project focuses on testing 3 essential oil blends and two disinfectants containing an essential oil blend against SARS CoV-2 in response to the COVID-19 pandemic. The project procedure involves plaque assays, disinfection, and neutralization techniques.

Depression And Factors Impacting Quality Of Life Among Adults With Asthma Presence In Nevada, Elizabeth D. Kahane, Lung-Chang Chien, Brian Labus, Dharini M. Bhammar, Jocy-Anna Chevalier, Sheniz Moonie

Epidemiology & Biostatistics Faculty Research

Background: Asthma, a chronic, non-communicable disease has been shown to negatively affect mental health and quality of life among adults. Annually approximately 8% of adult Nevadans report current asthma symptoms and 12.6% report having a lifetime diagnosis. The purpose of this study was to evaluate the association between asthma and depression and explore quality of life factors affecting adult Nevadans with asthma. Methods: Using behavioral risk factor surveillance system (BRFSS) data, this study evaluated the association between self-reported asthma and depression in Nevada using weighted multiple logistic regression. BRFSS asthma call-back survey (ACBS) data were used to determine the frequency …

On Efficacy And Effectiveness Of Vaccines: A Mathematical Approach Based On Conditional Probability With Applications To The Covid-19 Context, Flavius Guias

Spora: A Journal of Biomathematics

This paper presents a mathematically formalized approach which points out the relation between efficacy and effectiveness of vaccines. The first term denotes the relative degree of protection in clinical trials or under ideal conditions, while the latter is based on observed real-life data. We define the efficacy by a similar formula to the effectiveness, but the probabilities involved in the relative risk are conditional with respect to the exposure to the virus. If exposure and vaccination status are independent, the two quantities are equal. Otherwise, the observed value of the effectiveness is a biased one, as it could be seen …

Seroprevalence Of Severe Acute Respiratory Syndrome Coronavirus-2 (Sars-Cov-2) Among Healthcare Providers Prior To The Vaccine Era In An Integrated Midwestern Healthcare System, Elie A. Saade, Xiaochun Zhang, Jaime H. Noguez, Lisa M. Stempak, Daniel Tisch, Christine Schmotzer, Robert A. Salata

Faculty Scholarship

We performed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antinucleocapsid IgG testing on 5,557 healthcare providers and found a seroprevalence of 3.9%. African Americans were more likely to test positive than Whites, and HCWs with household exposure and those working on COVID-19 cohorting units were more likely to test positive than their peers.

Global Evolutionary Dynamics And Resistome Analysis Of Clostridioides Difficile Ribotype 017, Korakrit Imwattana, Papanin Putsathit, Deirdre A. Collins, Teera Leepattarakit, Pattarachai Kiratisin, Thomas V. Riley, Daniel R. Knight

Research outputs 2022 to 2026

Clostridioides difficile PCR ribotype (RT) 017 ranks among the most successful strains of C. difficile in the world. In the past three decades, it has caused outbreaks on four continents, more than other ‘epidemic’ strains, but our understanding of the genomic epidemiology underpinning the spread of C. difficile RT 017 is limited. Here, we performed high-resolution phylogenomic and Bayesian evolutionary analyses on an updated and more representative dataset of 282 non-clonal C. difficile RT 017 isolates collected worldwide between 1981 and 2019. These analyses place an estimated time of global dissemination between 1953 and 1983 and identified the acquisition of …

Epidemiology, Clinical Ramifications, And Cellular Pathogenesis Of Covid-19 Mrna-Vaccination-Induced Adverse Cardiovascular Outcomes: A State-Of-The-Heart Review, Talal Almas, Sarah Rehman, Eyad Mansour, Tarek Khedro, Ali Alansari, Jahanzeb Malik, Norah Alshareef, Vikneswaran Raj Nagarajan, Abdulla Hussain Al-Awaid, Reema Alsufyani

Medical College Documents

The coronavirus disease 2019 (COVID-19) has overwhelming healthcare systems globally. To date, a myriad of therapeutic regimens has been employed in an attempt to curb the ramifications of a severe COVID-19 infection. Amidst the ongoing pandemic, the advent and efficacious uptake of COVID-19 vaccination has significantly reduced disease-related hospitalizations and mortality. Nevertheless, many side-effects are being reported after COVID-19 vaccinations and myocarditis is the most commonly reported sequelae post vaccination. Majority of these diseases are associated with COVID-19 mRNA vaccines. Various studies have established a temporal relationship between these complications, yet the causality and the underlying pathogenesis remain hypothetical. In …

Television Viewing Time And All-Cause Mortality: Interactions With Bmi, Physical Activity, Smoking, And Dietary Factors, Christopher T. Swain, Julie K. Bassett, Allison M. Hodge, David W. Dunstan, Neville Owen, Yi Yang, Harindra Jayasekara, James R. Hébert Scd, Nitin Shivappa Mbbs, Mph, Ph.D., Robert J. Macinnis, Roger L. Milne, Dallas R. English, Brigid M. Lynch

Faculty Publications

Background Higher levels of time spent sitting (sedentary behavior) contribute to adverse health outcomes, including earlier death. This effect may be modified by other lifestyle factors. We examined the association of television viewing (TV), a common leisure-time sedentary behavior, with all-cause mortality, and whether this is modified by body mass index (BMI), physical activity, smoking, alcohol intake, soft drink consumption, or diet-associated inflammation. Methods Using data from participants in the Melbourne Collaborative Cohort Study, flexible parametric survival models assessed the time-dependent association of self-reported TV time (three categories: < 2 h/day, 2-3 h/day, > 3 h/day) with all-cause mortality. Interaction terms were fitted to test whether …

Skp2 Stabilizes Mcl-1 And Confers Radioresistance In Colorectal Cancer, Xinfang Yu, Li Zhou, Wenbin Liu, Lijun Liu, Feng Gao, Wei Li, Haidan Liu

Faculty, Staff and Students Publications

Overexpression of Skp2 plays a critical role in tumorigenesis and correlates with poor prognosis in human malignancies. Thus, Skp2 has been proposed as an attractive target for anti-tumor interventions. The expression of Skp2 in human colorectal cancer (CRC) and the role of Skp2 in tumorigenic properties and irradiation sensitivities of CRC cells were examined by anchorage-dependent and -independent growth assays, immunoblot, flow cytometry, immunohistochemical staining, ubiquitination analysis, co-immunoprecipitation assay, CRISPR-Cas9-based gene knockout, and xenograft experiments. Skp2 is highly expressed in CRC patient tissues. Blocking Skp2 expression reduces the tumorigenic properties of CRC cells in vitro and in vivo. Depletion of …

Monitoring Sars-Cov-2 In Wastewater During New York City's Second Wave Of Covid-19: Sewershed-Level Trends And Relationships To Publicly Available Clinical Testing Data, Catherine Hoar, Francoise Chauvin, Alexander Clare, Hope Mcgibbon, Esmeraldo Castro, Samantha Patinella, Dimitrios Katehis, John J. Dennehy, Monica Trujillo, Davida S. Smyth, Andrea I. Silverman

Publications and Research

New York City's wastewater monitoring program tracked trends in sewershed-level SARS-CoV-2 loads starting in the fall of 2020, just before the start of the city's second wave of the COVID-19 outbreak. During a five-month study period, from November 8, 2020 to April 11, 2021, viral loads in influent wastewater from each of New York City's 14 wastewater treatment plants were measured and compared to new laboratory-confirmed COVID-19 cases for the populations in each corresponding sewershed, estimated from publicly available clinical testing data. We found significant positive correlations between viral loads in wastewater and new COVID-19 cases. The strength of the …

“This Isn’T Just Busy, This Is Scary”: Stress, Social Support, And Coping Experiences Of Frontline Nurses During The Covid-19 Pandemic, Erin S. Craw, Tess M. Buckley, Michelle Miller-Day

Communication Faculty Articles and Research

Despite having previous experience and extensive trauma training, the COVID-19 pandemic presented unprecedented challenges for nurses working in hospital settings. During the pandemic, nurses struggle to care for patients and protect themselves from infection, while navigating ongoing organizational changes. Guided by prior literature on social support and coping, this study explores nurses’ experiences of coping with stress while treating COVID-19 patients during the pandemic. In-depth semi-structured interviews were conducted with 14 active staff nurses working in hospitals and one licensed practical nurse (LPN) at a rehabilitation center who treated COVID-19 patients during the pandemic. An inductive thematic analysis was employed …

Knowledge Or Awareness Of Non-Communicable Diseases And Their Associated Risk Factors Among University Students In Fiji: A Cross-Sectional Study, Awadhesh Kumar Shirotriya, Kavita Batra

School of Medicine Faculty Research

Introduction: Chronic diseases (aka Non-communicable diseases, NCDs) contribute to the global burden of morbidity and mortality, with a significant share of premature deaths among low-and middle-income countries (LMICs), including Fiji. The early exposure to the risk factors of NCDs affects the entire life course; knowledge or awareness of adolescents towards NCDs and associated risk factors is critical for health promotion. This study aims to investigate the knowledge or awareness level of chronic conditions and their risk factors among Fijian students. Methods: In this cross-sectional study, a sample of 338 university students was recruited using the paper as well as web-based …

Genetic Variants Associated Mrna Stability In Lung, Jian-Rong Li, Mabel Tang, Yafang Li, Christopher I Amos, Chao Cheng

Faculty, Staff and Students Publications

BACKGROUND: Expression quantitative trait loci (eQTLs) analyses have been widely used to identify genetic variants associated with gene expression levels to understand what molecular mechanisms underlie genetic traits. The resultant eQTLs might affect the expression of associated genes through transcriptional or post-transcriptional regulation. In this study, we attempt to distinguish these two types of regulation by identifying genetic variants associated with mRNA stability of genes (stQTLs).

RESULTS: Here, we presented a computational framework that takes advantage of recently developed methods to infer the mRNA stability of genes based on RNA-seq data and performed association analysis to identify stQTLs. Using the …

Determinants Of Covid-19 Vaccinations Among A State-Wide Year-Long Surveillance Initiative In A Conservative Southern State, Lídia Gual-Gonzalez, Maggie S.J. Mccarter, Kyndall Dye-Braumuller, Stella Self, Connor H. Ross, Chloe Rodriguez-Ramos, Virginie G. Daguise, Melissa Nolan Ph.D., Mph

Faculty Publications

By the end of 2021, the COVID-19 pandemic resulted in over 54 million cases and more than 800,000 deaths in the United States, and over 350 million cases and more than 5 million deaths worldwide. The uniqueness and gravity of this pandemic have been reflected in the public health guidelines poorly received by a growing subset of the United States population. These poorly received guidelines, including vaccine receipt, are a highly complex psychosocial issue, and have impacted the successful prevention of disease spread. Given the intricate nature of this important barrier, any single statistical analysis methodologically fails to address all …

Structural And Computational Studies Of The Sars-Cov-2 Spike Protein Binding Mechanisms With Nanobodies: From Structure And Dynamics To Avidity-Driven Nanobody Engineering, Gennady M. Verkhivker

Mathematics, Physics, and Computer Science Faculty Articles and Research

Nanobodies provide important advantages over traditional antibodies, including their smaller size and robust biochemical properties such as high thermal stability, high solubility, and the ability to be bioengineered into novel multivalent, multi-specific, and high-affinity molecules, making them a class of emerging powerful therapies against SARS-CoV-2. Recent research efforts on the design, protein engineering, and structure-functional characterization of nanobodies and their binding with SARS-CoV-2 S proteins reflected a growing realization that nanobody combinations can exploit distinct binding epitopes and leverage the intrinsic plasticity of the conformational landscape for the SARS-CoV-2 S protein to produce efficient neutralizing and mutation resistant characteristics. Structural …