From The Field |
Lessons from the Front Lines: The Prehospital Experience of the 2009 Novel H1N1 Outbreak in Victoria, Australia
Address correspondence and reprint requests to Erin Smith, Monash University, Department of Community Emergency Health and Paramedic Practice, Alfred Hospital, Lower Ground Floor, Medical School Building, Prahran, Victoria 3181, Australia (e-mail: Erin.Smith{at}med.monash.edu.au).
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The H1N1 (swine influenza) 2009 outbreak in Victoria, Australia, provided a unique opportunity to review the prehospital response to a public health emergency. As part of Ambulance Victoria’s response to the outbreak, relevant emergency response plans and pandemic plans were instigated, focused efforts were aimed at encouraging the use of personal protective equipment (PPE), and additional questions were included in the call-taking script for telephone triage of emergency calls to identify potential cases of H1N1 from the point of call. As a result, paramedics were alerted to all potential cases of H1N1 influenza or any patient who met the current case definition before their arrival on the scene and were advised to use appropriate PPE. During the period of May 1 to July 2, Ambulance Victoria telephone triaged 1598 calls relating to H1N1 (1228 in metropolitan areas and 243 in rural areas) and managed 127 calls via a referral service that provides specific telephone triage for potential H1N1 influenza cases based on the national call-taking script. The referral service determines whether a patient requires an emergency ambulance or can be diverted to other resources such as flu clinics. Key lessons learned during the H1N1 outbreak include a focused need for continued education and communication regarding infection control and the appropriate use of PPE. Current guidelines regarding PPE use are adequate for use during an outbreak of infectious disease. Compliance with PPE needs to be addressed through the use of intra-agency communications and regular information updates early in the progress of the outbreak.
Key Words: paramedic • emergency medical services • public health emergency • H1N1 • swine influenza • duty to respond • pandemics
In April 2009, a novel strain of influenza virus was identified in North America. The novel strain of influenza—H1N1 (swine) influenza—was identified as an acute, infectious respiratory disease. The first case of H1N1 influenza in Victoria, Australia, was diagnosed in the northern suburbs of Melbourne on May 20, 2009 ("D" day). Following this diagnosis, large numbers of patients with seasonal influenza, and an increasing proportion with swine influenza, began presenting to prehospital services, general practitioners, and hospitals in Melbourne.1,2
Ambulance Victoria received the first official alert from the Department of Human Services (DHS) on D+2. The DHS provided case-definition criteria when cases were first identified. The case-definition criteria included influenza-like illness [ILI] in a person; onset within 7 days of travel to Mexico, the United States, Canada, Japan, or Panama; or onset within 7 days of close contact with a person who has a confirmed case of H1N1 influenza. This case definition proved inadequate for measuring the true nature of community spread1 because more influenza was spreading locally than from confirmed contacts or travel.2 On D+14, the DHS updated the case definition for H1N1 influenza in the "protect" phase. During the protect phase, the clinical definition for an acute respiratory illness (ARI) is
- Fever (38°C or well-documented history) with cough and/or sore throat
- If the medical practitioner has assessed that there is H1N1 influenza 09 in the local community (community transmission), then anyone with ARI is considered to have H1N1 influenza 09
- In areas where there is no community transmission the medical practitioner should undertake a laboratory test to confirm H1N1 influenza 09 infection
Although the initial case definition was inadequate, the updated case definition was paradoxically too broad because it directed the provision of oseltamivir for all people with ILI who presented within 48 hours of symptom onset. Sentinel surveillance in Victoria during the first 2 weeks of June (D+12 to D+26) showed that 24% of patients presenting to general practice with ILI tested positive for influenza, of whom 18% had H1N1 influenza,3 suggesting that only about 5% of patients treated had the swine influenza strain. With 799 confirmed new cases of swine influenza in Victoria between D+12 and D+26, this suggested that on the order of 10,000 to 15,000 people may have been treated with oseltamivir for ILI that was not actually the novel H1N1 virus.2
At the beginning of July (D+41) there were more than 94,000 laboratory-confirmed cases of H1N1 influenza infection worldwide.4 Of the 5 countries with the highest number of laboratory-confirmed cases reported to the World Health Organization, Australia had the third-highest rate of infection.4 These figures must be interpreted with some caution because the countries with the highest numbers of laboratory-confirmed cases are likely to be those with the public health infrastructure in place to adequately identify cases and test a large number of samples, resulting in a bias toward developed nations (eg, the United States, Canada, Australia).6
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As of D+48, a total of 5298 cases of H1N1 influenza had been diagnosed in Australia.4 Ten deaths due to H1N1 influenza had been reported nationally.4 A total of 200 cases required hospitalization, with 18 requiring intensive care unit admission.5 Of those 5298 cases, 1691 cases (approximately 35% of all national H1N1 influenza cases in Australia at the beginning of July) were diagnosed in Victoria.6 Seven deaths were attributed to H1N1 in Victoria.6 As of D+43, 27 hospital admissions and 11 intensive care unit admissions resulted from the H1N1 influenza virus.4 On D+49, Victoria had the highest number of cases in the country, and the highest recorded per capita rate of swine influenza in the world.7
Peer-reviewed, published data on the epidemiology and clinical characteristics of the H1N1 virus in Australia have been largely limited to date to a small number of studies outlining the experience of general practitioners with the H1N1 outbreak.1,2,8 The most extraordinary statistic highlighted by these data is the disproportionate number of cases in Victoria, for which there is presently no explanation. As of D+26, 66% of all cases in Australia had been diagnosed in Victoria.1,9 By D+47, this number had dropped to 35%; however, the state still reported the highest rate of new cases in the country.7 This situation resulted in Singapore issuing a statement specifically advising against travel to Victoria. Furthermore, some Australian states and territories issued guidelines banning students from attending school for 7 days after returning from travel to Victoria.10 Authorities responded to the disparity in the number of national cases by placing Victoria in the "sustain" pandemic phase, whereas the other states and territories remained in the "contain" phase.11,12 The sustain categorization meant that, in part, Victoria had downgraded the response to H1N1 so as to consume fewer public health resources in light of the apparent low lethality of the virus (Table 1).
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TABLE 1 Pandemic Phases
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Before the present global outbreak of H1N1 influenza, assumptions regarding the lethality of a novel influenza virus proven to cross the species barrier and capable of sustained human-to-human transmission would have undoubtedly been a high case-fatality rate (as witnessed with H5N1 avian influenza). Although the mutation of the novel H1N1 influenza virus is not associated with a high case-fatality rate, the virus should not be dismissed as nonconcerning. Assuming a conservative attack rate of 20%, a hospitalization rate of 2% to 5% and a case-fatality rate of 0.2%, around 80,000 to 200,000 people in Australia may ultimately be hospitalized due to infection with the H1N1 virus, and ultimately, approximately 8000 deaths could be attributed to the virus.8 When compared to annual rates of seasonal influenza (18,000 hospitalizations and approximately 3000 direct and indirect deaths),13,14 the novel H1N1 virus remains an important public health threat and one that will continue to affect our public health infrastructure and system.
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Victoria, a southern state of Australia, covers approximately 227,590 km2 and has a population of approximately 5.4 million (median age of 37 years).15 Ambulance Victoria (AV) provides the prehospital response within the state, and is the only ambulance service within Australia that is a separate statutory body from the state government. Despite not being a governmental agency, AV still complies with directions given by and reports directly to the State Minister for Health. Victoria has a 2-tier ambulance dispatch system. The first tier of prehospital response is the advanced life support paramedic. The second tier of prehospital response is the mobile intensive care ambulance paramedic who has a broader range of advanced life support skills including intubation and has a greater range of drugs at his or her disposal. The ground crews are supplemented by an aeromedical retrieval system. Within the metropolitan region of the state, AV serves a population of approximately 3.6 million with 1300 paramedics across 84 ambulance stations. On average, 1320 cases of patient contact are made each day, with 750 emergency cases and 550 nonemergency cases transported each day by ground crews, with an additional 20 cases per day transported by aeromedical retrieval services.16
Within AV, the specialist emergency response department oversees the management of any health-related emergency or disaster in the state. The department developed the AV Emergency Response Plan to ensure that an appropriate response was provided during major incidents and to minimize the impact of these major incidents on normal business operations. The 3 key aims of the plan are to manage the impact on business, manage the impact on staff, and sustain business continuity during a major incident. The plan includes measures for both AV using a "whole of organization" approach, as well as the outline of key partnerships with external agencies. The plan allows for 4 levels of response: white (standard response), green (medium response), orange (major response), and red (severe response; Fig. 1).
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FIGURE 1 Ambulance Victoria emergency response matrix.
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AV became aware of the emergence of a novel strain of H1N1 influenza on April 26, 2009 (D+24) during a meeting of the Australia Health Protection Committee. Following this meeting, AV released its first internal communications regarding the novel virus on D+23 providing paramedics with an outline of the case definition and appropriate use of personal protective equipment (PPE), including the use of P2/N95 masks, for H1N1 influenza. At this time, additional questions were added to the call-taking script for ambulance 0-0-0 (equivalent to 9-1-1 in the United States) emergency call takers to identify potential cases of H1N1 influenza the point of contact. As a result, paramedics were alerted to all of the potential cases of H1N1 influenza and those patients meeting the current case definition before arrival, allowing them to use appropriate PPE. A well-established referral service within AV is used to identify the best management option for patients, whether that be emergency ambulance transport or direction to other resources, such as general practitioners. The referral service was supplemented as part of the pandemic response and was used to determine whether a patient required an emergency ambulance or could be diverted to a flu clinic as appropriate. In addition, the Victorian DHS diverted calls related to the H1N1 outbreak to the nurse on call service, which is a telephone service that provides immediate, around-the-clock expert health advice from a registered nurse.
The average number of 0-0-0 calls managed on a daily basis by AV is 1200 to 1500. During the period of D+19 to D+43, AV managed a total of 84,899 calls made to 0-0-0, 1598 of which were related to H1N1 (1228 in metropolitan areas and 243 in rural areas). AV also managed 127 calls via a referral service that provided specific telephone triage for potential H1N1 influenza cases based on the national call-taking script.
On D+22, AV escalated its pandemic influenza plan; however, it was identified so early in the outbreak that the progression of the H1N1 influenza pandemic did not match the severity of the predictions modeled for in the plan. In response, AV selected several core components of the plan to implement while overlooking other components that were deemed less relevant in the face of the mild nature of the virus. It was noted at this stage by the specialist emergency response department within AV that a focus on business continuity was needed. Business continuity planning was commenced around D+20, with a specific focus on identification of noncore activities within AV and activities that could be undertaken remotely to the workplace.
The Australian Health Management Plan for Pandemic Influenza 2008 and the Victorian Health Management Plan for Pandemic Influenza state that patients with influenza should be provided with a surgical mask, and that health care workers are required to wear a surgical mask only when they are within 3 ft of a patient. These plans indicate that P2/N95-level masks are required only when undertaking certain airway procedures on a patient that increase the risk of viral spread. AV, through the Ambulance Victoria Infection Control Manual, has standardized that paramedics wear P2/N95 masks when managing any patient with confirmed influenza, regardless of the procedure being performed. A state-wide audit of ambulance PPE was conducted by AV in May, resulting in an increased stockpile from approximately 90,000 P2/N95 masks to 135,000 P2/N95 masks. In addition, 10,000 P1 masks were added to the existing stockpile.
On D+14, in response to the national move from the delay to the contain phase of the pandemic, AV escalated the Emergency Response Plan to its highest rating. Although the Ambulance Emergency Operations Centre remains active, the Emergency Response Plan was deescalated 2 days later following the state’s move to the modified phase of the pandemic: sustain (Table 1). At present Victoria is at the protect phase of the pandemic. The protect phase signals a move toward identifying people in whom the disease is likely to be moderate or severe and providing appropriate medical care. In the protect phase antiviral medication will be provided to people with moderate or severe acute respiratory illness or who are rapidly deteriorating from H1N1 influenza and those with influenza-like-illness identified as vulnerable. Because most people are presenting with a mild form of H1N1 influenza in Victoria, antivirals will not be routinely provided for treatment during the protect phase (unless the person is vulnerable or has moderate or severe disease) or for the prevention of disease in contacts with an infected person.17
During the first few months of the prehospital response to the H1N1 influenza outbreak, 1 paramedic employed by AV was diagnosed as having H1N1. This infection was likely due to social transmission rather than transmission due to occupational exposure. Caution must be taken in determining how many paramedics have been infected with H1N1 occupationally because the presentation of illness is so mild in most cases that many people with swine influenza may have gone undiagnosed and therefore their cases unreported. Paramedic infection with H1N1 elsewhere in Australia includes 3 paramedics in Tasmania diagnosed as having H1N1, with a further 13 paramedics in isolation.18 Furthermore, an ambulance patient became infected with H1N1 following exposure to a paramedic in Tasmania who has since been diagnosed as having the virus. The Director of Public Health in Tasmania reported that the patient was infected by the paramedic before it became obvious that the paramedic was ill.19 Although the number of paramedics infected and in quarantine due to H1N1 has placed a burden on the staffing at the local ambulance stations within the North-West area of Tasmania, AV reports that absenteeism resulting from exposure, illness, or unwillingness to work during the outbreak in Victoria has not been an issue to date.
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One of the key lessons learned from the prehospital experience with the H1N1 influenza outbreak of 2009 has been the need to continually reinforce education and communication concerning infection control and the use of PPE. AV reported that it was "business as usual" during the response to the outbreak, with no change to present infectious disease management practices; however, early use of AV internal communications regarding the H1N1 outbreak was an important methodology used to promote increased compliance with PPE in the field. Paramedic compliance with PPE is a universal concern, and early interventions such as the communication initiatives undertaken by AV at the beginning of the H1N1 outbreak are in line with the findings of a postsevere acute respiratory syndrome (SARS) study that suggested that individual beliefs and attitudes toward the use of PPE and infection control methods are best addressed through changes in workforce culture and through visible workplace initiatives.20 From the experience with the H1N1 outbreak, AV recognized that existing infection control guidelines are appropriate to protect paramedics against infection, if followed. Education during an outbreak of a new infectious disease, such as H1N1, is needed to reinforce awareness and correct use of appropriate protective measures during epidemics and pandemics.
It has been the Victorian prehospital experience that existing pandemic preparedness plans, although comprehensive and useful, did not adequately guide the response to a pandemic that was not as severe as anticipated. Some activities outlined within the Victorian pandemic influenza plan were not appropriate given the mild form of illness resulting from H1N1 infection, highlighting the need for contingency plans, where existing plans can be ramped up or down depending on the situation. This resulted in AV essentially choosing which parts of the plan were relevant to the situation based on the severity of illness and the risk to paramedics. It is important, therefore, to have preparedness plans for pandemics that are flexible enough to allow for the turning on and off of parts of plans that are not relevant to the actual presentation of disease and illness in the community.
Prophylactic antiviral medication was not made routinely available to paramedics within AV during the H1N1 outbreak, and presently, no vaccination for the novel H1N1 virus is available. AV was not solitary in the nonuse of prophylactic antiviral treatment. Prophylaxis with antiviral medication such as Tamiflu has not been practiced by any group of health care providers in Victoria to date. Although it is believed that paramedics would be among the first to receive this vaccination once it became available in Australia, a recent study of Victorian paramedics indicated that even if the vaccination were to be made available to them, they were unlikely to want to be "guinea pigs" and be among the first to take a largely untested vaccination.21
The continuing threat of both naturally emerging and manmade public health emergencies has brought the issue of emergency health care workers’ responsibilities and duty to respond into question. These questions are complicated by the potential risk that emergency health care workers face during the frontline response to such health disasters. As a core component of the frontline response, paramedics are at high risk for a variety of health risks. These risks were highlighted by the exposure, infection, illness, and death of paramedics and emergency health care staff during the SARS outbreak in 2003.22 SARS exposed the vulnerabilities of our health care systems, in which health care workers bore the brunt of the outbreak and were the most at-risk population for SARS, accounting for 21% of all cases worldwide.23
Public health emergencies, such as outbreaks of infectious disease, place unprecedented demands on the health care system in regards to surge capacity and test health care workers’ personal commitment to the health care profession. Despite this challenge, professional codes of ethics and health services management guidelines are largely silent on the issue of duty to respond during public health emergencies, thus providing no guidance on what is expected of health care workers, or how they ought to approach their duty to care and respond in the face of risk.24 In the context of the current swine flu pandemic it is imperative that health care agencies, including ambulance services, consider the responsibilities and duty to respond of their employees and give a clear indication of what standard of care is expected in the event of a public health emergency.
There is no consensus as to how explicit requirements for duty to respond should be.25 Enforcing duty to respond would echo previously discarded policies from codes of ethics that clearly stipulated that physicians have a duty to care even in the face of risk to their own life. Is this reasonable? Furthermore, is this ethical? This type of policy would likely be viewed as unacceptable in current thinking because it infringes on personal liberties. It has been suggested that forcing professional obligations such as duty to respond on health care workers is akin to requiring them to behave like "supreme Samaritans."26 The ever-present threat of emerging public health disasters demands a transparent discourse regarding the acceptable standard of professional engagement, whether that be at the level of "supreme, good, or merely decent."24,26
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It is only due to the low virulence of the first wave of novel H1N1 influenza virus that this pandemic has merely stressed local emergency service delivery and not paralyzed ambulance services statewide. However, the emergence of the new strain of influenza virus has opened Pandora’s box by revealing potential gaps that will alter conventional ways in which the populace seeks and obtains care. One of the key outcomes of this first wave of H1N1 cases in Australia has been a heightened awareness and concern regarding the potential for, and implications of, a more virulent and more lethal second wave of the disease in the coming months. Key lessons learned include the need for continued education and communication with a specific focus on infection control and use of PPE, and the need for prehospital services to be able to ramp up or down existing management regimes and utilize the components of pandemic preparedness plans that are relevant to the manifestation of each individual infectious disease threat. Existing national and state pandemic plans provide a good overview as to how to respond to a new outbreak of infectious disease, but are largely inflexible. Finally, given the risk posed to paramedics during the response to a public health emergency, a critical examination of the role and responsibilities of paramedics during public health emergencies is needed to provide guidelines detailing professional obligations and responsibilities, as well as rights of the paramedic to decline to respond.
The authors acknowledge the support of Ambulance Victoria through the provision of data for inclusion in this manuscript.
Ms Smith is Senior Lecturer, Monash University, Department of Community Emergency Health and Paramedic Practice; Dr Burkle is Senior Fellow, Harvard Humanitarian Initiative; Mr Holman is Operations Manager, Specialist Emergency Response Department, Ambulance Victoria; Mr Dunlop is Manager of Emergency Management, Specialist Emergency Response Department, Ambulance Victoria; Dr Archer is Head of Department, Monash University, Department of Community Emergency Health and Paramedic Practice.
Received for publication July 21, 2009; accepted August 27, 2009.
Authors’ Disclosures
The authors report no conflicts of interest.
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-
1
- Grayson ML, Johnson PDR. Australia’s influenza containment plan and the swine flu epidemic in Victoria. Med J Aust. 2009;191:150.[Medline] 2
- Eizenberg P. The general practice experience of the swine flu epidemic in Victoria—lessons from the front line. Med J Aust. 2009;191:151–153.[Medline] 3
- Department of Human Services, Victoria. Victorian H1N1 Influenza 09 Update. July 1, 2009. http://humanswineflu.health.vic.gov.au/downloads/media/media-release010709_2.pdf. Accessed July 2, 2009. 4
- World Health Organisation. Pandemic (H1N1) 2009—Update 58. http://www.who.int/csr/don/2009_07_06/en/index.html. Accessed July 7, 2009. 5
- Department of Health and Ageing, National Case Update, June 27, 2009. http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/news-270609. Accessed July 2, 2009. 6
- Department of Human Services (DHS) Victoria, H1N1 Influenza 09 (Human Swine Flu) Current Situation, July 7, 2009. http://humanswineflu.health.vic.gov.au. Accessed July 7, 2009. 7
- Ryan S, Creedy S. Victoria records world’s worst swine flu rate. The Australian, June 8, 2009. http://www.theaustralian.news.com.au/story/0,25197,25602993-26103,00.html. Accessed July 2, 2009. 8
- Senanayake SN. Swine flu update: bringing home the bacon. Med J Aust. 2009;191:138–140.[Medline] 9
- Australian Government Department of Health and Ageing. Health Emergency. H1N1 09 Outbreak. National case update. June 15, 2009. http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/health-swine_influenza-index.htm#june155am. Accessed July 6, 2009. 10
- Miletic D, Gregory P. Victoria on swine flu alarm list. The Age (Melbourne). June 6, 2009. http://www.theage.com.au/national/victoria-on-swine-flu-alarm-list-20090605-bylc.html. Accessed July 6, 2009. 11
- Australian Government Department of Health and Ageing. Health Emergency. H1N1 09 Outbreak. Increased public health response in Victoria. June 3, 2009. http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/health-swine_influenza-index.htm#3junehv. Accessed June 6, 2009. 12
- Cheng AC, Dwyer DE, Kotsimbos ATC, et al. Summary of the Australasian Society for Infectious Diseases and the Thoracic Society of Australia and New Zealand guidelines: treatment and prevention of H1N1 influenza 09 (human swine influenza) with antiviral agents. Med J Aust. 2009;191:142–145.[Medline] 13
- Newall AT, Scuffham PA. Influenza-related disease: the cost to the Australian healthcare system. Vaccine. 2008;26:6818–6823.[CrossRef][Medline] 14
- Owen R, Barr IG, Pengilley A et al. Annual report of the National Influenza Surveillance Scheme, 2007. Commun Dis Intell. 2008;32:208–226.[Medline] 15
- Australian Bureau of Statisitics. Population Clock. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3101.0. Accessed July 7, 2009. 16
- Holman P. AV Emergency Response Plan: A Whole of Organisation Response to an Incident. Melbourne, Australia: Ambulance Victoria; 2009. 17
- Australian Capital Territory Department of Health, Chief Health Officer Message, July 1, 2009. http://www.health.act.gov.au/c/health?a=da&did=11044035&pid=1246578419. Accessed July 7, 2009. 18
- Brown D. Third ambo flu case. The Mercury: Voice of Tasmania. http://www.themercury.com.au/article/2009/06/07/78045_most-popular-stories.html. Accessed July 7, 2009. 19
- Pickin C. Human Swine Flu Update. http://www.media.tas.gov.au/release.php?id=26946. Accessed July 7, 2009. 20
- Moore D, Gilbert M, Saunders S, et al. Occupational health and infection control practices related to severe acute respiratory syndrome. AAOHN J. 2005;53:257–266.[Medline] 21
- Smith E. Paramedic Perception of Risk and Willingness to Work During Disasters: A Quantitative and Qualitative Analysis. Unpublished PhD thesis. July 2009. 22
- Maunder R. The Experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned. Phil Trans R Soc London. 2004;359:1117–1125.
[Abstract/Free Full Text] 23 - World Health Organization. WHO Consensus Document on the Epidemiology of Severe Acute Respiratory Syndrome (SARS). Geneva: World Health Organization; October 17, 2003. 24
- Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and the duty to care: whose duty? Who cares? BMC Med Ethics. 2006;7:E5.[CrossRef][Medline] 25
- Singer PA, Benatar SR, Bernstein M, et al. Ethics and SARS: lessons from Toronto. BMJ. 2003;327: 1342–1344.
[Free Full Text] 26 - Clark CC. In harm’s way: AMA physicians and the duty to treat. J Med Philos. 2005;30:65–87.
[Abstract/Free Full Text]
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