3.NISPID 2023 Pre-conference 2.pptx

NISPID 2023 Pre-
conference
Infectious Diseases
Surveillance:
Lessons Learned,
Lessons to Learn
16-17 January 2023
Prof Beckie Tagbo
• Director, Institute of Molecular
Medicine and Infectious Diseases,
College of Medicine, University of Nigeria
&
• Principal Investigator/ Site Coordinator,
WHO/FGN New Vaccines (Disease(
Surveillance

Why was it called 'surveillance'?
• Close observation of exposed persons to identify
onset of disease
• Definition changed in the 1950s
• What is the definition of public health
surveillance?
2

Surveillance
•Disease surveillance: The ongoing
systematic collection and analysis of data and
the provision of information which leads to
action being taken to prevent and control a
disease, usually one of an infectious nature.
3

What are the key elements of public health
surveillance?
• Ongoing
• Systematic
• Collection, analysis, interpretation, and
dissemination
• Data regarding a health-related event
• For use in public health action to reduce
morbidity and mortality and to improve health
4
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm
You do not begin surveillance
without the policy makers &
implementers of response to
outcomes

What types of surveillance strategies?
•National and Sentinel (hospital-
based)
•Active and Passive
•Indicator based and Event based
Examples:
•Polio
•Measles
•New vaccines
5

New Vaccines Surveillance:
When and why?
• Before vaccine introduction
• Demonstrate disease burden
• Justification to introduce vaccine
• Establish system to measure vaccine impact
• Identify circulating strains
• After vaccine introduction
• Monitor vaccination program impact
• Monitor any change in circulating strains: needs
strong laboratory support
• Platform to evaluate safety
6
(i.e., surveillance for
dxs targeted by new
vaccines)
E.g., Rotavirus & Paediatric Bacterial Meningitis surveillance

Sentinel vs. National
Surveillance
Sentinel:
1 Children's Hospital
National:
Every HCF, Every Case
•Easier, cheaper
•Likely good lab
•Better quality data (active
vs. passive)
•Monitor trends over time
•More severe cases, so not
representative of all disease
•More expensive, harder
•Transport samples to lab
•All disease in the country
(mild, severe)
•Monitor trends over time
•Identify outbreaks,
epidemics
Spain
Netherlands
7

Rotavirus Surveillance
Countries Participatingin the WHO Network and
Reporting Data for 2009
45
Data collected from WHO Regions and partners.
Slide date: 22 June 2010
The boundaries and names shown and the designations used on this map do not imply
the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps
represent approximate border lines for which there may not yet be full agreement.
©WHO 2010. All rights reserved
Yes (55 Member States or 28%)
Nigeria not reporting
any data on rotavirus
to WHO Geneva
indicated by plain
colour on the map

Rotavirus Surveillance
Countries Participating in the WHO Network
and Reporting Data for 2010
Data collected from WHO Regions.
Slide date: 2 August 2010
Yes (55 Member States or 28% of Member States)
46
Nigeria, represented
by ICH UNTH Enugu
Site, now reporting
data on rotavirus
surveillance to WHO
Geneva; indicated by
blue colour on the
map

There were challenges
• We took a big chance, but God gave us favour
• Govt & WHO came and saw our commitment and readiness
• We were adopted
• We trained/ established UITH, then Zaria & Bauchi >>> one
big family
• We did not just do data,…
• Consistently committed to strong evidence-based advocacy/
sensitization/ awareness towards vaccine introduction
• Vaccine should have been introduced much earlier…

There were challenges
• Government had her own challenges too
• Competing diseases and other aspects of health
• Apart from bureaucratic bottlenecks…
• Gavi application process… almost through…
• Vaccine brand had supply capacity issues – birth cohort - 7m
• Started Gavi process almost all over again
• Then COVID-19 struck
• Finally got Gavi approval and in Aug 2022, RV was launched
(Northern states), & Dec 2022 for Southern states
• Great story of eventual success
• RV in private market costs about N5,000-N30,000 per dose!
12

Some WHO Prequalified Rotavirus Vaccines
13
NPHCDA Training Manual 2022

ROTAVAC
14

Characteristics of Rotavac
15

Characteristics of Rotavac
16

Current Rotavirus Vaccine Introduction Status
21
As of January 2022, 114 countries have introduced
rotavirus vaccines

22
Previous Rotavirus Vaccine Introduction Status

23
Always ask to see
the immunization
card during
clerking &
indicate in your
hx if card was
sighted. Tell
mother to
ALWAYS bring it
whenever
bringing child to
hospital for any
ill-health.
Nigerian national routine
immunization schedule (by age)
Revised
Routine
Immunization
Schedule

Current Rotavirus Vaccine Introduction
Status
• More than 70% of countries in sub-Saharan Africa
have introduced rotavirus vaccines.
• But because rotavirus disease burden is so high in
this region—more than half of all rotavirus deaths
occur in African countries—it is critical that the
remaining countries introduce vaccines to protect
their children from rotavirus.
24

25
Remember that vaccination is to be done in addition to all other existing measures

Nigeria Sentinel site surveillance
for Rotavirus
•Enugu (UNTH) - 2010
•Ilorin (UITH) - 2012
•Zaria (ABUTH) - 2017
•Bauchi (ATBUTH) – 2017
•Ilorin, Zaria and Bauchi sites were
established and mentored by Enugu
site
26
Lagos (LUTH) was scheduled for training in Dec 2022, but could
not hold due to logistics issues

Rotavirus surveillance shifts to vaccine impact
monitor and safety surveillance
• We have
therefore,
commenced
impact studies
and case-
controlled
series safety
study of a
projected
sample size of
800
• After vaccine introduction (Rotavac)
• Monitor any change in circulating strains:
needs strong laboratory support
When and why?

Our Data from 2010 to 2022
• Total Number of cases enrolled from inception =
5148
• Number positive =2262
• Percentage positivity = 44%
• Chronic cases =32
• Bloody Cases =64

Male, 2288
44.4%
Female, 2838
55.6%
# Enrolled based on gender 2010-OCT
2022 (n=5126)
Male, 1342
59.6%
Female, 917
40.6%
RV Positivity based on gender 2010-OCT 2022
(n=5126)

0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
0
100
200
300
400
500
600
700
2010201120122013201420152016201720182019202020212022
%
Positivity
No
of
Cases
Annual Positivity of Rotavirus 2010-Oct 2022
# Enrolled # Positive % Positivity

0
50
100
150
200
250
300
2010_10
2011_02
2011_06
2011_10
2012_02
2012_06
2012_10
2013_02
2013_06
2013_10
2014_02
2014_06
2014_10
2015_02
2015_06
2015_10
2016_02
2016_06
2016_10
2017_02
2017_06
2017_10
2018_02
2018_06
2018_10
2019_02
2019_06
2019_10
2020_02
2020_06
2020_10
2021_02
2021_06
2021_10
2022_02
Total vs Positive
# Enrolled # Positive

86.00
88.00
90.00
92.00
94.00
96.00
98.00
100.00
0
100
200
300
400
500
600
700
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Percentage
of
samples
collected
witin
48
hours
#
of
Cases Annual Distribution of samples collected within 48hours of presentaion
(Target=90%)
# Enrolled Collected within 48hrs % collected within 48hrs
Target 90%

1
2
3
5
7 7 7
9
5
8
10
1
3
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
0
2
4
6
8
10
12
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
%
Case
Fatality
#
of
Fatality Annual Case Fatality 2010-Oct 2022 (n=66, 1.3%)
No of deaths Case Fatality

Chronic /
Pesistent
Diarrhoea = 35,
36%
Bloody Diarrhoea
=62 64%
Proportion of Bloody and Chronic diarrhoea cases
collected from 2017 to Oct 2022
TaqMan Array Cards
are high-throughput,
accurate, sensitive,
and simple-to-use
tools for quantitative
analysis of mRNA or
miRNA transcripts
using a real-time
PCR protocol. They
utilize a microfluidic
card with 384 reaction
chambers and eight
sample loading ports.
Interesting findings
and the industry is
already working on
candidate
vaccines…
In one study, we
tested for 35
organisms at
once:
15 bacteria, 17
viruses, 1 fungus
and 2 protozoan

Nigeria Sentinel site surveillance for
Paediatric Bacterial Meningitis (PBM)
• Lagos (LUTH)
• Enugu (UNTH)
• Ilorin (UITH)
• Benin (UBTH)
• Bauchi (ATBUTH)
• Ilorin, Zaria and Bauchi
have been integrated into
the Enhanced Meningitis
Surveillance 37
• After vaccine introduction (Rotavac)
• Monitor any change in circulating strains:
needs strong laboratory support
When and why?

Paediatric bacterial
meningitis
surveillance in
Nigeria, from 2010 to
2016
Tagbo BN, Bancroft R, Fajolu I, Abdulkadir MB, Bashir MF,
Okunola P, Isiaka A, Namadi L, Edelu BO, Onyejiaka N, Ihuoma
CJ, Ndu F, Ozumba UC, Udeinya F,Ogunsola F, Saka AO,
Fadeyi A , Aderibigbe SA, Abdulraheem J, Yusuf AG, Ogbogu P,
Kanu C, Emina V, Makinwa J, Gehre F, Yusuf K, Braka F,
Mwenda JM, Ticha JM, Nwodo D, Biey JN, Kwambana-Adams
BA, Antonio M, for the African Paediatric Bacterial Meningitis
Surveillance Network

Background
•Historically, Nigeria has experienced large
bacterial meningitis outbreaks causing high
morbidity and mortality in children <5 years
old.
•Streptococcus pneumoniae, Neisseria
meningitidis, and Haemophilus influenzae
are the predominant causes of this invasive
disease (using meningitis as proxy) which
are preventable by immunization.
•(Men:Pneumo >> 1:>9)

Background
• In collaboration with the World Health
Organisation, we conducted a longitudinal
surveillance study across five sentinel hospitals
within Nigeria to establish the burden of
bacterial meningitis,
• Aimed at providing data that supported the
decision to introduce the Pneumococcal
Conjugate Vaccine (PCV) to Nigeria’s
immunization program and monitor impact

Figure 1: A map of the 36 states within Nigeria, highlighting the 5 states in which the 5 sentinel hospitals are
situated

Methods
•From 2010 to 2016, Cerebrospinal Fluid (CSF)
was collected from children <5 years, admitted to
five sentinel Hospitals across Nigeria.
•Microbiological and latex agglutination techniques
were performed on samples to detect the presence
of S.pneumoniae, N.meningitidis and H.influenzae.
•Species-specific polymerase chain reaction (PCR),
and serotyping/serogrouping, was conducted to
determine specific causative agents.

Results
•In total, 5134 children with suspected meningitis
were enrolled at the five hospitals.
•A higher percentage of IBD was observed in children
with turbid CSF samples (10.5%) compared to those
with clear CSF (2.2%).
•The dominant pathogen was pneumococcus
(46.4%), followed by meningococcus (34.6%) and
H. influenzae (18.9%).
•The case fatality rate for confirmed bacterial
meningitis was 15%.

Results
•Overall, 53.6% of the pneumococcal
meningitis cases were caused by serotypes
covered by the PCV vaccines.
•The most prevalent meningococcal and H.
influenzae strains were serogroup W and
Hib respectively

Total Suspected Cases
5134
Culture
Negative
4664
Culture Positive
53
Culture Not
Done
126
Shipment to MRC Culture Positive
23
Received and PCR at MRC
1318
LUTH
NM =15
SP = 16
HI = 7
ATBUTH
NM =9
SP = 14
HI = 8
UITH
NM =0
SP = 1
HI = 2
UNTH
NM =1
SP = 4
HI = 0
UBTH
NM =3
SP = 2
HI = 0
LUTH
NM =0
SP = 4
HI = 2
ATBUTH
NM =10
SP = 12
HI = 7
UITH
NM =1
SP = 7
HI = 2
UNTH
NM =2
SP = 6
HI = 0
UBTH
NM =0
SP = 0
HI = 0
Culture
Negative
1179
Culture Not
Done
16
Culture at Sentinel
site
Others
291
Others
100
Many PCR
positive
cases
were
culture
negative

BINAX
Pastorex
Culture
PCR
BINAX
Pastorex
Culture
PCR
Pastorex
Culture
PCR
Pastorex
Culture
PCR
0
25
50
75
100
Distribution
(%)
Detected Not Detected
All Pathogens S.pneumoniae N.meningitidis H.influenzae
3 15
110 580 4825 1322 580 4825
110 1322 580 4825 1322 580 4825 1322
29 37 13 28
13 5 11 17
3 33
53
82
Sensitivity of Diagnostic Tests Used
Most
organisms
were
identified by
Pastorex &
PCR

Distribution of Bacterial Meningitis per month
January
February
M
arch
April
M
ay
June
July
August
Septem
ber
October
Novem
ber
Decem
ber
0
5
10
15
20
25
Number
of
Meningitis
Cases
per
Month
(n)
S.pneumonaie N.meningitidis H.influenzae
N.
meningitidi
s was more
in the first
half of the
year

2
0
1
0
2
0
1
1
2
0
1
2
2
0
1
3
2
0
1
4
2
0
1
5
2
0
1
6
0
2
4
6
8
10
0
2
4
6
8
10
Number
of
Meningitis
Cases
1
4
5
6A/6B/6C/6D
14
18A/18B/18C/18F
19A
19F
23A
23F
Non-Typeable
PCV10
PCV13
7a.
2
0
1
3
2
0
1
4
2
0
1
5
2
0
1
6
0
2
4
6
8
10
Number
of
Meningitis
Cases
B
C
W
Non-Groupable
7b.
2
0
1
2
2
0
1
3
2
0
1
4
2
0
1
5
2
0
1
6
0
2
4
6
8
10
Number
of
H.influenzae
Cases
Hia
Hib
Hic
7c.
Prevalence of each Bacterium and their Serotypes/Serogroups
Spn
Nm Hi
Spn: Apart from
the Non-typable
strains, majority
were vaccine
strains
Nm:
Serogroups
vary by year

Recommendation
•Due to Nigeria’s large population vaccine
programs for preventing meningitis were
introduced in phases.
•Continued surveillance is required to estimate
vaccine impact as coverage improves and to
determine the distribution of
serotypes/serogroups of the predominant
meningitis-causing pathogens across Nigeria in
the post-vaccine era.

My
description
of disease
surveillance
•Disease Surveillance is simply:
•How do I pick up disease occurrence/
outbreaks earliest?
•How do I report / document earliest?
•How do I make meaning out of the data?
•How do I respond earliest?
•How do I monitor to see it has been
adequately addressed?
•How do I maintain vigilance thereafter to pick
subsequent occurrences/ outbreaks or even
new diseases?
•How do I carry out all these in a coordinated
manner on a large scale/ country wide / region
wide scale?
How do I ensure
that I continue to
improve and
adapt the entire
system/process
to emerging
trends?

Arriving
disease
will not
pre-
announce
itself!
So, the way to pick it up is to put
in place continuous, consistent,
sensitive and untiring
mechanisms and strategies
Disease will not announce, “I am
coming, station yourselves to pick
me”

Keywords – Sensitive and Responsive
Surveillance System (Quality)
The 2 keywords are sensitivity and responsiveness
on a background of inclusiveness or
comprehensiveness
Questions?
How do we make surveillance more sensitive?
How do we make it more responsive?
How do we build capacity?
Entire System
• Processes
• Human resources
• Material resources/
infrastructure
• Governance

DS system in Africa is relatively young
Dx surveillance system in Africa is
Relatively Young
Still developing
Has sub-optimal coverage >>>
True disease burdens unknown?

Disease
Surveillance
system in
Africa is
young
Outbreaks missed or detected
late
Responses not prompt / not
properly coordinated
Resource allocation low >>
Political / public perception of
need low?

A key lesson
We can make it
happen

The Nigerian partnership model
NCDC Ebola response -
received international
commendation
Improved upon for Covid19
response in Nigeria
Risk perception is key
Partnership with private sector
was good
But only a small percentage
who met certain requirements
(orientation, std of care,
resources and FG support/
collaboration) which should be
upscaled (no of private facilities
involved) and expanded
(diseases covered)
Spoke and wheel

Other
lessons
• Local data is very important and better
than extrapolation or assumptions
• Local strains are also important and
could differ significantly from globally
common strains
• Policy making should not only be
evidence based but include local
evidence
• Helps monitor progress – burden, impact
of control measures, strain replacement,
dx agent replacement, platform for
vaccine safety surveillance

How do you set up a public health
surveillance system?
Steps in planning a surveillance system
1.Establish surveillance objectives
2.Develop case definitions for target diseases
3.Determine data sources data-collection
mechanism (type of system)
4.Determine data-collection instruments / tools
5.Field-test methods
6.Develop and test analytic approach
7.Develop dissemination mechanism
8.Assure use of analysis and interpretation

Lessons to learn
Private sector is largely untapped in DS
• Constitutes 33-60% of health facilities, >70% iof healthcare spending
in Nigeria and cannot be ignored (60% of the population in Anambra)
• How to fully integrate the private sector in DS
Quality & Relevance
• How to make surveillance more sensitive, responsive, comprehensive
(every case), inclusive (no of disease covered)
• More focus on disease elimination
New / Emerging diseases
• Heighten index of suspicion for outbreak of new diseases
• Event surveillance,
• One-health principle / orientation

Case studies-1
Background
Population > 5million
>60% of health services are
provided by private health
facilities
weak collaboration between the
private and public health sector
The engagement of private
sector health practitioners
significantly improved
Integrated Disease Surveillance
and Response (IDSR).
Methods
To achieve this, a multipronged
approach was used, including:
Involvement of the private
health sector groups in key
sector stakeholder’s meetings,
capacity building events and
provision of working tools
State training of 862 health care
workers on IDSR with 30% from
private sector
Engagement of private sector stakeholders in
strengthening disease surveillance and response
yields results (Anambra state Southeast Nigeria

Case studies-1
Inclusion of private sector in
grassroot Integrated Data
validation meetings across the
21 LGAs/Districts
Procurement / distribution of
documentation tools to all
functional health facilities
including the privately owned
ones
Orientation of the Association
of General and Private Medical
Practitioners of Nigeria
(AGPMPN) among others
Done with funding support from
the EU to WHO for implementing
the project: “Strengthening the
Nigerian Health System towards
Achieving Universal Health
Coverage”
Results
Since the beginning of the EU
funded health systems
strengthening intervention in the
State, the capacity for disease
detection, diagnosis, case
management, stock
management and documentation
have improved
Engagement of private sector stakeholders in strengthening disease surveillance
and response yields results (Anambra state Southeast Nigeria July 2019

Case studies-1
Response rate in implementation of
policies & standards increased.
Knowledge on disease notification and
response as well as data management
capacity equally improved
Number of private health facilities
generating and reporting IDSR data
moved from 48 in May 2018 to 165 in
December 2018
Significant increase in the coverage of
TB services from 180 facilities in 2017
to 323 by 2018 ending, representing a
45% increase compared to previous
year
Overall, 23%
increase in TB cases
detection by
December 2018
(2,300) compared to
1,800 detected in the
previous year
 This achievement is
an all-time high for
Anambra and
occurred within a few
weeks of the IDSR
capacity scale up and
orientation of the
AGPMPN
Engagement of private sector stakeholders in strengthening disease surveillance
and response yields results (Anambra state Southeast Nigeria July 2019

Case studies-2
Background
To explore evidence regarding the
involvement of private practitioners
in routine disease notification
Method
Systematic review, Search of
databases, 40 papers reviewed
Results
Low private sector participation
Main barriers - inadequate
knowledge, unsatisfactory attitudes
and misperceptions that influence
practices
Complex reporting system with
unclear guidelines
Unsatisfactory attitudes of public
sector program staff
Infrastructural barriers e.g.,
unavailability of computers
Inadequate skilled human
resources
Conclusion
Periodic training, supportive
supervision and regular feedback
to both public and private sectors in
order to improve case notification.
Governments – provide leadership,
foster public-private collaborative
partnerships, regulatory role
From habits of attrition to modes of inclusion: enhancing the role of
private practitioners in routine disease surveillance. Phalkey RK et al

Case studies-3
Background
Assessed knowledge and practice
of the private health-care facilities
in DSN and explored models for
private sector engagement in DSN
in Southwestern Nigeria
Methods
Descriptive cross-sectional, using
a semi-structured self-administered
questionnaire
Medical directors of 60 private
health-care facilities in Osun State
Results
53.3% ever notified LGA authorities
38.3% of facilities notified in the
last 3 months
90.0% were willing to participate
with Govt
15.0% regularly shared data with
government monthly
Predictors of good notification
practice include:
Having good knowledge of DSN
Having received feedback from
government or notified centers
Having a designated DSN officer
Conclusions
High awareness and knowledge
but poor practices of DSN were
recorded
Knowledge and practice of disease notification among private medical
practitioners in Osun State, Southwestern Nigeria . Adebimpe W & Oluremi A

Case studies-4
Background:
In Nigeria, private health
facilities make up 33% of health
facilities, >70% of healthcare
spending, and >60% of
healthcare contacts
However, level of participation in
DS system has been questioned
Methods:
Cross-sectional survey
507 private health facilities in
South-West Nigeria (6 states)
Investigate the level of
compliance with disease
surveillance reporting
Factors that affect their
participation
Results:
40% of the private health
facilities complied with routine
DS reporting (17% to 60%
across the 6 states in the zone)
34% had data collection tools,
Compliance with disease surveillance and notification by
private health providers in South-West Nigeria Makinde et al.

Case studies-4
49% had designated professionals
assigned to health records
management
Only 7% of the clinicians could
properly identify the data tools
Predictive factors to compliance
with disease surveillance
participation included:
Awareness of a law on disease
surveillance (OR=1.55 95%
CI=1.08-2.24),
Availability of reporting tools
(OR=13.69, 95% CI=8.85-21.62),
Availability of a designated health
records officer (OR=3.9, 95%
CI=2.68-5.73),
Health records officers (OR=10.51,
95%CI=2.86-67.70) and clinicians
(OR=2.49, 95% CI=1.22-5.25) with
knowledge of DS
Conclusion
Private health facilities were poorly
compliant with disease surveillance
resulting in missed opportunities for
prompt identification and response
to threats of disease outbreaks
Makinde et al. Compliance with disease surveillance and notification by private health providers in South-
West Nigeria. Pan African Medical Journal. 2020;35:114. [doi: 10.11604/pamj.2020.35.114.21188]

Starting
steps…
Develop a roadmap with incremental
targets of private sector coverage/
disease coverage
Private sector involvement must be
wholesome starting from planning
stages…case definitions, etc.
Sustainable funding strategis too!

DS & R is developing in Africa
Gross under-reporting especially from private sector
Government stewardship / leadership is key
Sensitive & responsive, quality inclusive/comprehensive DS
Generate and apply evidence based boosting strategies
Sustainable funding strategies
Develop a comprehensive roadmap / framework
Summary / Way forward

References
NCDC. Strategies to improve surveillance for COVID-19, guidance for states
NCDC. Integration of private sector laboratories in national COVID-19 response
Ahmadi et al. Disease Surveillance and Private Sector in the Metropolitans: A Troublesome Collaboration. Int J Prev Med
2013;4:1036-44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793485/pdf/IJPVM-4-1036.pdf
Kumar A, Furtado KM. Disease Surveillance: Engaging the Private Sector - The National Institution for Transforming India
(NITI Aayog) https://www.niti.gov.in/sites/default/files/2019-01/Disease_surveillance_pvtsector.pdf
Engagement of private sector stakeholders in strengthening disease surveillance and response yields results (Anambra state
South East Nigeria July 2019 https://www.niti.gov.in/sites/default/files/2019-01/Disease_surveillance_pvtsector.pdf
Anambra State Strategic Health Development Plan II, 2018 – 2022
From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance Revati
K. Phalkey et al
Adebimpe W & Oluremi A. Knowledge and practice of disease notification among private medical practitioners in Osun State,
Southwestern Nigeria Nig J Clin Pract. 2019;17
Makinde et al. Compliance with disease surveillance and notification by private health providers in South-West Nigeria. Pan
African Medical Journal. 2020;35:114. [doi: 10.11604/pamj.2020.35.114.21188] Available online at: https://www.panafrican-
med-journal.com/content/article/35/114/full

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