Cholera

Dr. Priyamadhaba Behera

References
WHO Document, 5th edition OTPH, 18th edition Harrison
principle of medicine, ...
Cholera-Introduction

MIASMA
THEORIES

versus
• Are gram-negative rods that are facultativel
word cholera is a derivative of the Greek word “choler” meaning bile
• Firs...
Epidemiology
• Cholera likely has its origins in the Indian
Subcontinent; it has been prevalent in the Ganges
delta since ...
Continued
• The first cholera pandemic occurred in the Bengal
region of India starting in 1817 through 1824.
• The disease...
Continued
• In Russia alone, between 1847 and 1851, more than
one million people perished of the disease
• Cholera hit the...
What Is the Current Situation?
Where are modern-day
An outbreak of cholera has been ongoing in epidemics of cholera?
Haiti...
Cholera : Causal Agent
•
•
•
•

Species: Vibrio Cholerae
Serogroup: O139 & O1
Biotypes :EL Tor Classic
Serotypes Hikojima,...
Reservoir
• Humans are the main reservoir of vibrio cholerae.
Other potential reservoirs are water

• Vibrios grow easily ...
Carriers and transmission
• The reservoir is mainly human, asymptomatic
(healthy) carriers and patients carry huge quantit...
Transmission
• Cholera is transmitted by the fecal –oral route through contaminated
water & food
• The infection dose of b...
Period of communicability
 Infected persons (symptomatic or not) can carry and
transmit vibrios during 1-4 weeks
 A smal...
RISK FACTORS
• Poor social and economic environment, precarious
living conditions Associated with insufficient water
suppl...
Case Definitions for Cholera
Suspected
 In an area where the disease is not known to be
present: severe dehydration or de...
Case definition for cholera
Confirmed
• A suspected case that is laboratory-confirmed.
(Isolation of Vibrio cholerae O1 or...
Symptoms and signs
The stool has a characteristic appearance: a nonbilious,
gray, slightly cloudy fluid with flecks of muc...
Role of laboratory test

 Bacteriological confirmation is compulsory on
the first suspected cases, in order to:
Confirm ...
Laboratory Test
• Confirmation on 10 to 20 stool samples is sufficient.

Samples can be taken using different methods : fi...
Selection of cases for bacteriologic sampling
• For confirmation of an outbreak, stool samples
should be collected from up...
Collection of specimens
• Stool should be collected either by:
 Collecting a swab from a freshly passed stool
specimen (f...
Antibiotics
 Should be given only in severe cases to reduce
the duration of symptoms and carriage of the
pathogen

 Sele...
Use of Ciprofloxacin : Offers short course for
cholera treatment
• Offers short course for cholera treatment
– Ease of adm...
Zinc Supplementation in Cholera : What is the
evidence ?

• Supplementation of zinc to the children with cholera
reduces b...
WHO and UNICEF’s Recommendation for
Zinc Supplementation
Age group

Dose

Duration

Infants under 6
months old

10 mg per ...
• Untreated cases: Average- 50%
Epidemics- 90%
• Treated cases: Less than 1%

What is the mortality rate of cholera?
WHO Global Task Force on Cholera
• Launched in 1992, 44th world health assembly
• Aim -reduce mortality and morbidity asso...
Current priority activities of WHO Global Task Force
on Cholera
• Encouraging improved surveillance , to identify high ris...
Prevention and control of cholera outbreaks: WHO
policy and recommendations
Main tools for cholera control
• Proper and ti...
Cholera vaccines
•WHO recommends that immunization with currently
available cholera vaccines be used in conjunction with t...
Cholera vaccines
• Parenteral cholera vaccine not recommended by WHO (low
protective efficacy and adverse reaction)
• Two ...
•
•
•

•

Dukoral
Vaccine with the b-subunit
Given in 150 ml of safe water
Short-term protection of 85–90% against V.
Chol...
International Health Regulations
• 194 countries across the globe, including all the
Member States of WHO
• Aim- the inter...
WHO recommendations to unaffected
neighbouring countries
• Improve preparedness to rapidly respond to an
outbreak, should ...
Measures should be avoided, (ineffective,
costly and counter-productive)
•

Routine treatment of a community with antibiot...
Key messages
• Cholera is an acute diarrhoeal disease that can kill within
hours if left untreated
• There are 100 000–120...
Key messages
• Surveillance is paramount to identify vulnerable populations
living in hotspots
• Cholera is a preventable ...
Cholera
Cholera
Cholera
Cholera
Cholera
Cholera
Cholera
Cholera
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  • {"38":"one with a recombinant B-sub unit, the other without\n","5":"It is useful to explain how cholera causes disease. Vibrio pass through the intestinal tract and produce a toxin that paralyzes the normal pumping mechanism of the epithelial cells. This ‘locks’ the cellular pump in the ‘on’ position and results in a major loss of water and electrolytes with little reabsorption. Dehydration ensues. But there is rapid turnover of the superficial epithelium of the intestine and both vibrio and dead, poisoned cells occurs. Regeneration of health epithelium stops the disease. Cholera is self-limiting. All that is required is rehydration. There is no invasion of the intestinal wall by the organism, and antibiotics are not required.\n","6":"Snow conducted his classic study in 1854 when an epidemic of cholera developed in the Golden Square of London. He began his investigation by determining where in this area persons with cholera lived and worked. He then used this information to map the distribution of cases on what epidemiologists call a spot map.\nBecause Snow believed that water was a source of infection for cholera, he marked the location of water pumps on his spot map, and then looked for a relationship between the distribution of cholera case households and the location of pumps. He noticed that more case households clustered around Pump A, the Broad Street pump, than around Pump B or C, and he concluded that the Broad Street pump was the most likely source of infection.\n","7":"1816-1826 - First cholera pandemic: Previously restricted, the pandemic began in Bengal, and then spread across India by 1820. 10,000 British troops and countless Indians died during this pandemic. The cholera outbreak extended as far as China, Indonesia (where more than 100,000 people succumbed on the island of Java alone) and the Caspian Sea before receding. Deaths in India between 1817 and 1860 are estimated to have exceeded 15 million persons. Another 23 million died between 1865 and 1917. Russian deaths during a similar time period exceeded 2 million.\n1829-1851 - Second cholera pandemic reached Russia (see Cholera Riots), Hungary (about 100,000 deaths) and Germany in 1831, London (more than 55,000 persons died in the United Kingdom) and Paris in 1832. In London, the disease claimed 6,536 victims; in Paris, 20,000 succumbed (out of a population of 650,000) with about 100,000 deaths in all of France. The epidemic reached Quebec, Ontario and New York in the same year and the Pacific coast of North America by 1834. A two-year outbreak began in England and Wales in 1848 and claimed 52,000 lives. \n","2":"British John Snow had so carefully described in his 1855 book, Italian Filippo Pacini had witnessed in his microscopic studies, and German Robert Koch had cultured in his field and laboratory studies\n","8":"1849 - Second major outbreak in Paris. In London, it was the worst outbreak in the city's history, claiming 14,137 lives, over twice as many as the 1832 outbreak. In 1849 cholera claimed 5,308 lives in the port city of Liverpool, England, and 1,834 in Hull, England. An outbreak in North America took the life of former U.S. President James K. Polk. Cholera spread throughout the Mississippi river system killing over 4,500 in St. Louis and over 3,000 in New Orleans as well as thousands in New York. In 1849 cholera was spread along the California and Oregon trail as hundreds died on their way to the California Gold Rush, Utah and Oregon. It is believed that over 150,000 Americans died during the two pandemics between 1832 and 1849. \n1852-1860 - Third cholera pandemic mainly affected Russia, with over a million deaths. In 1853-4, London's epidemic claimed 10,738 lives. \n1854 - Outbreak of cholera in Chicago took the lives of 5.5% of the population (about 3,500 people). The Soho outbreak in London ended after removal of the handle of the Broad Street pump by a committee instigated to action by John Snow. \n1863-1875 - Fourth cholera pandemic spread mostly in Europe and Africa. At least 30,000 of the 90,000 Mecca pilgrims fell victim to the disease. Cholera claimed 90,000 lives in Russia in 1866. The epidemic of cholera that spread with the Austro-Prussian War (1866) is estimated to have claimed 165,000 lives in the Austrian Empire. Hungary and Belgium both lost 30,000 people and in the Netherlands 20,000 perished. In 1867, Italy lost 113,000 lives. \n1866 - Outbreak in North America. It killed some 50,000 Americans. In London, a localized epidemic in the East End claimed 5,596 lives just as London was completing its major sewage and water treatment systems--the East End was not quite complete. William Farr, using the work of John Snow et al. as to contaminated drinking water being the likely source of the disease, was able to relatively quickly identify the East London Water Company as the source of the contaminated water. Quick action prevented further deaths. Also a minor outbreak at Ystalyfera in South Wales. Caused by the local water works using contaminated canal water, it was mainly its workers and their families who suffered, 119 died. In the same year more than 21,000 people died in Amsterdam, The Netherlands. \n1881-1896 - Fifth cholera pandemic; According to Dr A. J. Wall, the 1883-1887 epidemic cost 250,000 lives in Europe and at least 50,000 in Americas. Cholera claimed 267,890 lives in Russia (1892); 120,000 in Spain; 90,000 in Japan and 60,000 in Persia. In Egypt cholera claimed more that 58,000 lives. The 1892 outbreak in Hamburg, Germany killed 8,600 people. Although generally held responsible for the virulence of the epidemic, the city government went largely unchanged. This was the last serious European cholera outbreak. \n1899-1923 - Sixth cholera pandemic had little effect in Europe because of advances in public health, but major Russian cities (more than 500,000 people dying of cholera during the first quarter of the 20th century) and the Ottoman Empire were particularly hard hit by cholera deaths. The 1902-1904 cholera epidemic claimed 200,222 lives in the Philippines. The sixth pandemic killed more than 800,000 in India. The last outbreak in the United States was in 1910-1911 when the SMS Moltke brought infected people to New York City. Vigilant health authorities isolated the infected on Swinburne Island. Eleven people died, including a health care worker on Swinburne Island. \n1961-1970s - Seventh cholera pandemic began in Indonesia, called El Tor after the strain, and reached Bangladesh in 1963, India in 1964, and the USSR in 1966. From North Africa it spread into Italy by 1973. In the late 1970s, there were small outbreaks in Japan and in the South Pacific. There were also many reports of a cholera outbreak near Baku in 1972, but information about it was suppressed in the USSR. \nJanuary 1991 to September 1994 - Outbreak in South America, apparently initiated when a ship discharged ballast water. Beginning in Peru there were 1.04 million identified cases and almost 10,000 deaths. The causative agent was an O1, El Tor strain, with small differences from the seventh pandemic strain. In 1992 a new strain appeared in Asia, a non-O1, (NAG) named O139 Bengal. It was first identified in Tamil Nadu, India and for a while displaced El Tor in southern Asia before decreasing in prevalence from 1995 to around 10% of all cases. It is considered to be an intermediate between El Tor and the classic strain and occurs in a new serogroup. There is evidence of the emergence of wide-spectrum resistance to drugs such as trimethoprim, sulfamethoxazole and streptomycin. \n","36":"The full kit provides treatment for:\n100 severe cases of cholera in a cholera treatment centre (CTC) taking into account that patients with severe dehydration need IV fluids and antibiotics at the beginning of the treatment and oral rehydration salts (ORS) during the recovery phase. The drugs consist of: IV fluids for 100 severe adult cases, and antibiotics for 65 adults and 60 children.\n400 mild or moderate cases of cholera in an oral rehydration unit (ORU).\n100 adults and 100 children affected by Shigella dysentery.\nNote:\nThis kit does NOT include sprayers for disinfection and chlorine.\nThis kit does NOT contain the material to physically set up a CTC and equip the staff.\nBreakdown per module\nBasic module:\nDrugs\nORS, as well as Ringer Lactate for ten severe cases only (with an average of eight litres per patient)\nCholera: Doxycycline (65 adults), Erythromycin (60 children); zinc tablets (250 children)\nShigella: Ciprofloxacin (100 adults and 100 children); zinc tablets (100 children)\nDisinfectant.\nRenewable supplies, including culture swabs\nEquipment\nDocuments on diarrhoeal disease management in emergencies.\nORS module:\nORS for 400 cholera patients with no - or with moderate - dehydration. This material covers the needs for two ORUs.\nInfusion module:\nRinger Lactate with IV giving sets for 90 severe cholera cases (with an average of eight litres per patient)\nIn case of local purchase infusion AND giving set have to be ordered.\nSupport module:\nNon-medical items necessary for running a cholera treatment centre (CTC).\nSoap can usually be purchased on the local market: one bar of soap (100 g) per patient should be foreseen.\nThe full inventory list can be found in annex.\n","3":" the International Committee on Zoological Nomenclature, by naming the cholera causing bacteria as Vibrio Cholerae Pacini 1854. This happened 82 years after Pacini’s death.\n","42":"; set up a cordon sanitaire at borders, a measure that diverts resources, hampers good cooperation spirit between institutions and countries instead of uniting efforts.\n"}
  • Cholera

    1. 1. Cholera Dr. Priyamadhaba Behera References WHO Document, 5th edition OTPH, 18th edition Harrison principle of medicine, Articles however applicable 1
    2. 2. Cholera-Introduction MIASMA THEORIES versus
    3. 3. • Are gram-negative rods that are facultativel word cholera is a derivative of the Greek word “choler” meaning bile • First discovered by Filippo Pacini in Italy in 1854, Pacini’s results were published under the title, “Microscopic observation and pathological deductions on cholera • Robert Koch independently discovered a bacillus, the same that Pacini discovered 30 years back
    4. 4. Epidemiology • Cholera likely has its origins in the Indian Subcontinent; it has been prevalent in the Ganges delta since ancient times • The disease first spread by trade routes (land and sea) to Russia in 1817, then to the rest of Europe, and from Europe to North America • Seven cholera pandemics have occurred in the past 200 years, with the seventh originating in Indonesia in 1961 6
    5. 5. Continued • The first cholera pandemic occurred in the Bengal region of India starting in 1817 through 1824. • The disease dispersed from India to Southeast Asia, China, Japan, the Middle East, and southern Russia. • The second pandemic lasted from 1827 to 1835 and affected the United States and Europe. • It killed 150,000 Americans during the second pandemic. • The third pandemic erupted in 1839, persisted until 1856, extended to North Africa, and reached South America, for the first time specifically infringing upon Brazil. 7
    6. 6. Continued • In Russia alone, between 1847 and 1851, more than one million people perished of the disease • Cholera hit the sub-saharan african region during the fourth pandemic from 1863 to 1875 • The fifth pandemic raged from 1881–1896 • Sixth pandemics raged from 1899-1923 • Between 1900 and 1920, perhaps 8 million people died of cholera in india • These epidemics were less fatal due to a greater understanding of the cholera bacteria 8
    7. 7. What Is the Current Situation? Where are modern-day An outbreak of cholera has been ongoing in epidemics of cholera? Haiti since October 2010. According to the Ministere de la Sante Publique et de la Population (MSPP), as of August 4, 2013, 669,396 cases and 8,217 deaths have been reported since the cholera epidemic began in Haiti. Among the cases reported, 371,099 (55.4%) were hospitalized1 • HAITI
    8. 8. Cholera : Causal Agent • • • • Species: Vibrio Cholerae Serogroup: O139 & O1 Biotypes :EL Tor Classic Serotypes Hikojima, Ogawa& Inaba
    9. 9. Reservoir • Humans are the main reservoir of vibrio cholerae. Other potential reservoirs are water • Vibrios grow easily in saline water and alkaline media. They survive at low temperatures but do not survive in acid media
    10. 10. Carriers and transmission • The reservoir is mainly human, asymptomatic (healthy) carriers and patients carry huge quantities of vibrio in faeces and in vomit; up to 108 bacteria can be found in 1 ml of cholera liquid • The infective dose depends upon individual susceptibility, but in general a 108 doses is needed • Cholera is transmitted by a faecal-oral route
    11. 11. Transmission • Cholera is transmitted by the fecal –oral route through contaminated water & food • The infection dose of bacteria required to cause clinical disease varies with the source • If ingested with water the infective dose should be higher • When ingested with food fewer organism are required to cause the disease
    12. 12. Period of communicability  Infected persons (symptomatic or not) can carry and transmit vibrios during 1-4 weeks  A small number of individuals can remain healthy carriers for several months.  Incubation period-6hr to 5 days
    13. 13. RISK FACTORS • Poor social and economic environment, precarious living conditions Associated with insufficient water supply (quantity and quality) • Poor sanitation and hygiene practices • High population density: internally displaced or refugee Camps and slum populations • Inhabitants of rural areas, particularly along rivers and lake shores • Diaster had took place
    14. 14. Case Definitions for Cholera Suspected  In an area where the disease is not known to be present: severe dehydration or death from acute watery diarrhoea in a patient aged 5 years or more;  In an area where there is cholera endemic: acute watery diarrhoea, with or without vomiting in a patient aged 5 years or more  Epidemic ongoing: acute watery diarrhoea with or without vomitting
    15. 15. Case definition for cholera Confirmed • A suspected case that is laboratory-confirmed. (Isolation of Vibrio cholerae O1 or O139 from stools in any patient with diarrhoea is the laboratory criteria for diagnosis)
    16. 16. Symptoms and signs The stool has a characteristic appearance: a nonbilious, gray, slightly cloudy fluid with flecks of mucus, no blood, and a somewhat fishy, inoffensive odor. -"rice-water“ Clinical symptoms parallel volume contraction At losses of <5% of normal body weight, thirst develops 5–10%, postural hypotension, weakness, tachycardia, and decreased skin turgor are documented >10%, oliguria, weak or absent pulses, sunken eyes (and, in infants, sunken fontanelles), wrinkled ("washerwoman") skin, somnolence, and coma are characteristic Complications -include renal failure due to acute tubular necrosis. Muscle cramps are common d/o electrolyte imbalance Fever is usually absent
    17. 17. Role of laboratory test  Bacteriological confirmation is compulsory on the first suspected cases, in order to: Confirm cholera  Identify the strain, biotype and serotype  Assess antibiotic sensitivity
    18. 18. Laboratory Test • Confirmation on 10 to 20 stool samples is sufficient. Samples can be taken using different methods : filter paper, Cary Blair medium or rapid tests • Rapid tests can give a quick confirmation of a cholera diagnosis, however, rapid tests • Do not provide information on antibiotic sensitivity nor can they be used for biotyping,and therefore must always be followed by sampling
    19. 19. Selection of cases for bacteriologic sampling • For confirmation of an outbreak, stool samples should be collected from up to 10-20 previously “untreated” cases who meet all of the following criteria: – onset of illness less than four days before sampling – currently having watery diarrhoea – have not received antibiotic treatment for this illness Selection of transport media Most reliable, currently available transport medium is carry-blair
    20. 20. Collection of specimens • Stool should be collected either by:  Collecting a swab from a freshly passed stool specimen (fresh stool should be less than 1 hour old) or from  A swab of the rectal contents (rectal swab)
    21. 21. Antibiotics  Should be given only in severe cases to reduce the duration of symptoms and carriage of the pathogen  Selective chemoprophylaxis may be useful for members of a household who share food and shelter with cholera patient
    22. 22. Use of Ciprofloxacin : Offers short course for cholera treatment • Offers short course for cholera treatment – Ease of administration: Single dose – Assurance of patients compliance – Reduction of cost of treatment • Evidence: Single dose Ciprofloxacin (500 mg) is shown to be effective in both adults and children (Cure rate was 94% in adults and 60% in children: Resolution of diarrhoea within 48 hours of the start of treatment and no recurrence during 5 day stay in the hospital1 (Ref: Lancet 1996; 348: 296-300 and Lancet 2005; 366: 1085-93)
    23. 23. Zinc Supplementation in Cholera : What is the evidence ? • Supplementation of zinc to the children with cholera reduces both stool volume and duration of diarrhoea, an effect that was more pronounced in malnourished children 1 1.S.K. Roy, K E Islam, et al. Impact of Zinc on Children with Cholera. Presented during 10 th Annual Scientific Conferences (ASCON) of ICDDR,B, Dhaka)
    24. 24. WHO and UNICEF’s Recommendation for Zinc Supplementation Age group Dose Duration Infants under 6 months old 10 mg per day 10-14 days Children above 6 months old 20 mg per day 10-14 days Ref: WHO/UNICEF Joint Statement on Clinical Management of Acute Diarrhoea, May 2004
    25. 25. • Untreated cases: Average- 50% Epidemics- 90% • Treated cases: Less than 1% What is the mortality rate of cholera?
    26. 26. WHO Global Task Force on Cholera • Launched in 1992, 44th world health assembly • Aim -reduce mortality and morbidity associated with the disease and to address the social and economic consequences of cholera • Partnership brings together governmental and nongovernmental organizations, UN agencies, and scientific institutions • Develop technical guidelines and training materials for cholera control
    27. 27. Current priority activities of WHO Global Task Force on Cholera • Encouraging improved surveillance , to identify high risk areas and guide intervention • Providing evidence based support to countries for preparedness and response • Gaining evidence on the use of oral cholera vaccines as an additional public health tool to diminish incidence of cholera in high risk areas and vulnerable groups • Linking health and management of the environment in order to improve access to safe water for vulnerable populations and diminish incidence of waterborne diseases
    28. 28. Prevention and control of cholera outbreaks: WHO policy and recommendations Main tools for cholera control • Proper and timely case management in cholera treatment centres • Specific training for proper case management, including avoidance of nosocomial infections • Sufficient pre-positioned medical supplies for case management (e.g. Diarrhoeal disease kits) • Improved access to water, effective sanitation, proper waste management and vector control • Enhanced hygiene and food safety practices • Improved communication and public information
    29. 29. Cholera vaccines •WHO recommends that immunization with currently available cholera vaccines be used in conjunction with the usually recommended control measures in -Areas where cholera is endemic -Areas at risk of outbreaks • Vaccines provide a short term effect while longer term activities like improving water and sanitation are put in place
    30. 30. Cholera vaccines • Parenteral cholera vaccine not recommended by WHO (low protective efficacy and adverse reaction) • Two types of safe and effective oral cholera vaccines currently available  Both are whole-cell killed vaccines  Both have sustained protection of over 50% lasting for two years in endemic settings.  Both vaccines are WHO-prequalified and licensed over 60 countries.  Both vaccines are administered in two doses given between seven days and six weeks apart  Recently, however, researchers have suggested that oral cholera vaccines induce “herd immunity”1 1.Ali M, Emch M, von Seidlein L, Yunus M, Sack DA, Rao M, Holmgren J, Clemens JD.Herd immunity conferred by killed oral cholera vaccines in Bangladesh: areanalysis.Lancet. 2005 Jul 2-8;366(9479):44-9
    31. 31. • • • • Dukoral Vaccine with the b-subunit Given in 150 ml of safe water Short-term protection of 85–90% against V. Cholerae O1 among all age groups at 4–6 months following immunization Shanchol Provides longer-term protection against V. Cholerae O1 and O139 in children under five years of age
    32. 32. International Health Regulations • 194 countries across the globe, including all the Member States of WHO • Aim- the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide • Surveillance for prevention, preparedness and early warning • Imposing travel and trade restrictions have proven inefficient and risk to divert useful resources. • WHO has no information -imported food from affected countries has ever been implicated in outbreaks of cholera in importing countries
    33. 33. WHO recommendations to unaffected neighbouring countries • Improve preparedness to rapidly respond to an outbreak, should cholera spread accross borders, and limit its consequences • Improve surveillance to obtain better data for risk assessment and early detection of outbreaks, including establishing an active surveillance system
    34. 34. Measures should be avoided, (ineffective, costly and counter-productive) • Routine treatment of a community with antibiotics, or mass chemoprophylaxis (no effect on the spread of cholera, can increase antimicrobial resistance and provides a false sense of security) • Restrictions in travel and trade between countries or between different regions of a country (hampers good cooperation spirit between institutions and countries instead of uniting efforts)
    35. 35. Key messages • Cholera is an acute diarrhoeal disease that can kill within hours if left untreated • There are 100 000–120 000 deaths due to cholera every year of which only a small proportion are reported to WHO • Up to 80% of cases can be successfully treated with oral rehydration salts (ORS) • About 75% of people infected with Vibrio cholerae O1 or O139 do not develop any symptoms • Typical at-risk areas of cholera include peri-urban slums with limited access to safe drinking water and lack of proper sanitation
    36. 36. Key messages • Surveillance is paramount to identify vulnerable populations living in hotspots • Cholera is a preventable disease provided that safe water and proper sanitation are made available • Cholera is a preventable disease provided that safe water and proper sanitation are made available • Safe and effective oral cholera vaccines are now part of the cholera control package • Today, no country requires proof of cholera vaccination as a condition for entry

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