The Viral Respiratory Diseases of Sorok Island at Pandemic

Background: Dapsone is helpful in the molecular regulation of Nod-like receptor family pyrin domain-containing 3 (NLRP3). Objective: To study the targeting of NLRP3 itself or up-/downstream factors of the NLRP3 inammasome by Dapsone should be responsible for its observed preventive treatment effects, functioning as a competitor against Pandemic viral inammasome. Methods: We compared Hansen's disease (HD) patients with viral respiratory diseases (VRD) after prescribing Dapsone to standard treatment from 2005 to 2020. Results: The 3022 VRD participants who received the dapsone intervention (M = 201, SD = 34) compared to the 3961 VRD participants in the control group (M = 264, SD = 84) demonstrated signicantly better peak ow scores, t(28) = -2.7, p = .01. It demonstrated signicantly more prevalences of VRD in the DDS unprescribed group. Conclusion: This study is theoretical clinical data to warrant a pilot study with Dapsone for deteriorating leprosy patients at Pandemic.


Introduction
The Sorok island as a Japanese leper colony was established in May 1916 to quarantine leprosy patients. During the colonial period, the notorious expansion project for the Sorok Leprosarium was supposed from 1933 to 1941 because of its supposed competition with the Culion Leprosarium in the American -Occupied Philippines. The public health report led on June 4, 1946, succinctly stated that they would increase the capacity of Sorokdo Leper Colony to 8,000 -9,000 and make it the largest leprosarium in the world 1,2 . They self-administer a prescribed medication steadily. The missionaries went to Sorok Island to care for the leprosy patients. We analyzed the medical records of Sorokdo National Hospital from 2005 to 2020. Sister M. Stoeger and Sister M. Pissarek cared for the patients for forty years 3 . So we regarded those as a kind of standard-cared group initiated from 1962 to 2005.
The antibiotic Dapsone (4,4′-diaminodiphenyl sulfone, DDS) is predominantly associated with the treatment of leprosy 4 , and it is both an antibiotic and an anti-in ammatory agent. Dapsone has been used for leprosy, malaria, toxoplasmosis and Pneumocystis pneumonia in persons with human immunode ciency virus infection. Moreover, Dapsone is prescribed for dermatitis herpetiformis, linear IgA dermatosis, bullous pemphigoid, subcorneal pustular dermatosis, erythema elevatum diutinum, bullous systemic lupus erythematosus and other chronic in ammatory diseases characterized by the in ltration of neutrophils or eosinophils 5 . Dapsone may be helpful as an alternative therapy in some, especially colchicine resistant patients with Familial Mediterranean Fever (FMF) 6 . FMF is caused by homozygous or compounded heterozygous gain-of-function mutations in the Mediterranean fever gene, which encodes pyrin, an in ammasome protein 7 , which has a role in activating the proin ammatory cytokine interleukin (IL)-1β 8 . In the preliminary cross-sectional study, the Covid-19 acute respiratory distress syndrome (ARDS) standard treatment plus Dapsone resulted in clinical improvement within 24-48 hours at ARDS onset. The chi-square is 5.1836. The p-value is 0.022801. (signi cant at p < .05.) 9 .
The dapsone hypersensitivity syndrome is a severe idiosyncratic drug reaction characterized by the clinical triad of fever, rash, and systemic involvement. HLA-B * 13:01 was described with a 99.8% negative predictive value and a 7.8% positive predictive value as a risk factor among Chinese patients for dapsone hypersensitivity in 2013 10 . HLA-B * 13:01 is comparatively absent among Europeans and Africans 11 . The a nity of dapsone binding to HLA-B*13:01 is greater than that of HLA-B*13:02 and binds to the HLA-B*13:01 greater 12,13 . CD8+ clones displayed an HLA-B*13:01-restricted pattern of activation. Dapsone activates speci c T cells from hypersensitive patients expressing the risk allele HLA-B* 13: 01. HLA-B*13:01-CD8+ T-cells (also called cytotoxic T lymphocytes) induce a dapsone-responsive immune response 14 . Covid-19 induces an immune response in CD8+ T-cells 15,16 , and it may be in a pathway similar to that of Dapsone. CD8+ T-cell feedback activates the NLRP3 in ammasome in antigenpresenting cells in an antigen-dependent manner to promote IL-1β maturation 17 . They might be originated from T-cell activation caused by HLA polymorphism 18,19 .
Targeting Nod-like receptor family pyrin domain-containing 3 (NLRP3) in ammasome may be essential for Covid-19 treatment, and its activation is implicated in Alzheimer's disease, prion diseases, type 2 diabetes, and numerous infectious diseases. SARS-CoV-2 activates in ammasomes, which are large multiprotein assemblies that are broadly responsive to pathogen-associated and stress-associated cellular insults. In ammasomes lead to the secretion of the IL-1β and IL-18 pleiotropic IL-1 family cytokines 20 . The activation of cytokines or pathogen-associated molecular patterns leads to the transcriptional upregulation of canonical and noncanonical in ammasome components. Therefore, we investigated the Hansen' disease (HD) patients that have been prescribed with an in ammasome competitor, Dapsone, following the Dementia Management Act (DMA) in Sorokdo National Hospital. Dapsone has been the treatment and prevention drug for mild cognitive impairment, Alzheimer's disease, and Covid-19 ARDS as an in ammasome competitor 9,21-23 . Therefore, it is necessary to compare  Table S11-S14, Fig. S4) Safety Dapsone's adverse reactions are well documented. Consequently, all HD patients and medical staff in Sorok Island already avoided the known side effects of Dapsone very carefully. The adverse reactions associated with this drug include the clinical triad of fever, rash, and systemic involvement, which can cause severe organ dysfunction (most commonly of the liver and the hematologic system). Dapsone hypersensitivity can also lead to leukocytosis and eosinophilia, resembling a mononucleosis infection. The drug is also associated with haematological effects, such as hemolytic anaemia and methemoglobinemia: hepatitis/liver toxicity, cholangitis, colitis, thyroiditis, pancreatitis and pleural effusion: acute renal failure: myocarditis, dapsone-induced hypersensitivity syndrome-associated complete atrioventricular block, myocardial injury: pneumonitis, pneumonia or multiple organ failure.

Limitations
The limitation is that this study was conducted in an island area and to the HD patients. So, more studies are required to compare the COVID 19 survival rates later. Furthermore, since Dapsone's maximal allowance price in South Korea was very low in 2016, pharmaceutics, which produced it in Korea, stopped the production of Dapsone except for the supply for HD patients 26 . So we could not examine the full pharmacological e cacy of Dapsone. Nonetheless, we trusted the Korean FDA.

Discussion
The application of Dapsone and the introduction of multi-drug therapy containing rifampin and Clofazimine were decisive for eradicating leprosy 27 . Clofazimine inhibits cell fusion mediated by the viral spike glycoprotein, as well as the activity of the viral helicase 28 . However, all leprosy patients were cured, and only 0-4 people per year in South Korea were using multi-drug therapy 29 . Some people took Dapsone for more than 50 years from our survey 30 . When we studied the longevity index, leprosy-affected males showed higher longevity values than their male counterparts in the comparison groups 31 .
Dapsone as a supplement can be used for the optimum second-line treatment of immune thrombocytopenia 32 . Dapsone reduced the local expression of mRNA transcripts encoding in ammationrelated molecules, including endothelin-1, macrophage in ammatory protein-1-alpha, and transforming growth factor-beta. Dapsone decreased the paraquat-induced generation of superoxide anions in mouse lung broblasts 33 . The administration of Dapsone reversed the alterations induced by doxorubicin in serum levels of creatine kinase-MB fraction (CK-MB), electrocardiographic parameters, papillary muscle contractility, and excitation: the measurement of malondialdehyde, superoxide dismutase, and TNF-α levels in tissue indicated that Dapsone signi cantly reduced oxidative stress, consistent with histopathological analysis 23 . Dapsone prevents ischemic injury, inhibits apoptosis and shows functional improvement post-ischemia. It repressed pro-apoptotic proteins c-Jun N-Terminal Kinases (JNK), Phosphatase and Tensin Homologue (PTEN), Calpain, Caspase-3 of cerebral ischemia along with activation of pro-survival protein Brain-derived Neurotrophic Factor (BDNF) 34 . Dapsone protects microvascular integrity from high-fat diet-induced low-density lipoprotein (LDL) oxidation 35 . Dapsone on acetic acid-induced colitis in rats reduced acetic acid-induced in ammatory response in rat colon tissue through inhibition of NF-kB signalling pathway 36 .
Dapsone binds to myeloperoxidase and regulates the production of hypochlorite. It reduces the in ammatory response of cells. DDS has a structure that can competitively reduce the positively charged sulfur radical production rate because it is similar to methionine sulfoxide 23 . The reversibility of ubiquitination by deubiquitinating enzymes (DUBs) serves as a signi cant regulatory layer within the ubiquitin system. The human genome encodes approximately 100 DUBs, and DUBs have implicated pathologies, including neurodegeneration and cancer 37 . The conjugation of ubiquitin can be reversed by DUBs, which re ect additional regulation of ubiquitin 38 . The nucleophilic properties of Dapsone compete with Ub, similar to DUBs. Before loading Ub onto the substrate, the Ub-activating (E1)/Ub-conjugating (E2)/E3 ligase acts at each stage of the ubiquitination process. The identical mechanism can potentially ubiquitinate cysteine thiols and hydroxyls on serines, threonines, leucines, and tyrosines 37 39 . Dapsone noncovalently binds/interacts with the minor groove of DNA. Docking analysis revealed that Dapsone preferentially binds to the AT-rich region of DNA. The nucleophilic properties of DDS also compete with NLRP3. ORF8b activates NLRP3 through the interaction of the AT-rich repeat domain of NLRP3. The redox properties of DDS dependent on amine and sulfone moieties explain the oxidation mechanism of DDS by electron transfer 23 . (Figure 4) BNT162b2 is a lipid nanoparticle-formulated and nucleoside-modi ed RNA vaccine expressing the fulllength prefusion spike glycoprotein (S) of SARS-CoV-2 40 . BNT162b2 and mRNA-1273 produce crossneutralizing antibodies against B.1.351 and P.1, as well as against other variants, suggesting that they can protect against them. However, cross-neutralization e cacies have been signi cantly lower compared with the ancestral variant 41,42 . Thus, we need to develop broadly protective T-cell-based vaccines because the emergence of SARS-CoV-2 variants escapes convalescent and vaccine-induced antibody responses 43 . Adverse events of special interest (AESI) include vaccine-associated enhanced disease 44,45 . In addition, mRNA vaccine is associated with an elevated risk of myocarditis, lymphadenopathy, appendicitis, herpes zoster infection [46][47][48] . Therefore, we studied a supplement that might reduce the future risk of AESI or others induced by the various in ammasome after vaccination. Early indications of supplement care with vaccination may potentially alleviate the course of Covid-19 prevention.

Conclusion
This study is theoretical clinical data to warrant a pilot study with Dapsone for deteriorating leprosy patients at Pandemic.

Declarations
Acknowledgments: After graduating from the University of Innsbruck Nursing School in Tyrol, Western Austria, Sister Marianne Stoeger, who worked at a hospital in Innsbruck, joined Sorok Island in February 1962. Sister Margaritha Pissarek entered Sorok Island in October 1967. They left Sorok island on November 21, 2005. Their dedication to medical service made this study possible.

Statement of Ethics
This study was based on FDA guidelines in accordance with the World Medical Association Declaration of Helsinki. Informed consent was obtained from all subjects and/or their legal guardians. We administered medicines in compliance with medical and pharmacy laws with the informed consent of the patient. The National Agency approved this study for Management of Life-sustaining Treatment, which certi ed that the life-sustaining treatments were managed properly (Korea National Institute for Bioethics Policy (KoNIBP) approval number P01-202007-22-006). The KoNIBP approved the observational study of patients ethically based on FDA guidelines following the World Medical Association Declaration of Helsinki. Therefore, we carried out all methods following relevant ethical guidelines, regulations and reported the study results. Sorokdo National Hospital provided the necessary information in accordance with Article 13 of Act on Information Disclosure of Public Institutions . Sorokdo National Hospital obtained informed consent from all participants or if participants are under 18, from a parent and/or legal guardian.

Con icts of Interest
The author has no con icts of interest to declare.

Funding: No Funding
Author contributions: JL did conceptualization, methodology, investigation, and writing the original draft. CJL, CS, JP, SO, SJL, SC, MDC examined, reviewed, updated and discussed the study and result of the manuscript.
Competing interests: "Authors declare that they have no competing interests." Data and materials availability: "All data are available in the main text or the supplementary materials." Additional data that support the ndings of this study are available from the corresponding author upon reasonable request. In addition, the complete detailed survey is provided as a separate le. https://osf.io/3js4u/. The stable DOI for the repository is DOI 10.17605/OSF.IO/3JS4U.
The p value is < 0.00001. I t is significant at p < .05.
*Four groups were classified: T1 group is DDS-prescribed (+) with VRD-diagnosed (+) subjects, and T2 group is DDS-unprescribed (-) with VRD-diagnosed (+) subjects, and T3 group is DDS-prescribed (+) with VRD-undiagnosed (-) subjects, and T4 group is DDS-   The retrospective cohort study at Sorok Island from 2005 to 2019. T1 group is DDS-prescribed with VRDdiagnosed subjects, and T2 group is DDS-unprescribed with VRD-diagnosed subjects, and T3 group is   SARS-CoV-2 uses the endogenous cellular machinery to replicate itself inside the cell49. I. Though COVID-19 patients exhibit neurological signs and symptoms, the histopathological examination of brain specimens shows hypoxic changes. Pathogen-associated molecular patterns (PAMP) or dangerassociated molecular patterns (DAMP) induced by SARS-CoV-2 may affect neurological symptoms.
Dapsone binds to myeloperoxidase and regulates the production of hypochlorite, thereby reducing the cellular circumstance. DDS blocks bicarbonate to promote two-electron oxidation, as mediated by hydrogen peroxide after the generation of peroxymonocarbonate (HCO4−). II. The bicarbonate/carbon dioxide pair stimulates one-electron oxidation mediated by the carbonate radical anion (CO3•−), which e ciently oxidizes the thioether sulfur of the methionine residue to sulfoxide, so bicarbonate cannot promote two-electron oxidations mediated by hydrogen peroxide after the generation of peroxymonocarbonate (HCO4−). The topological properties of Dapsone, such as electron density and its Laplacian delocalization index, the negative potential of the vicinity of O and O atoms is susceptible to severe electrophilic attack. The nucleophilic/electrophilic region of Dapsone interacts with amino acids by molecular bonding. Dapsone has a structure that can reduce the sulfur radical production rate by electron charge transfer. III. Nucleophilic properties of Dapsone compete with NLRP3 in the mode of DDS-DNA complex can be understood through the nucleophilic properties of DDS for ubiquitination. IV.
Proteins contain many nucleophilic sites capable of attacking a ubiquitin (Ub)-conjugating enzyme (E2)-Ub thioester linkage and undergoing ubiquitination. The best-described sites are the amine-containing internal lysine residues and the free amine of the polypeptide backbone's N-terminus. Ub is activated by a Ub-activating (E1) enzyme, using energy from ATP hydrolysis, and passes to a Ub-conjugating (E2) enzyme. Ub can then be passed to a substrate protein, speci ed by the distinct E3 ligase that binds both the substrate and the E2. Thus, Dapsone can compete with the ubiquitination cascade23.

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