May 2007
Main Article:
TB in Corrections: Constant Companion and Future Scourge
Renee Ridzon, MD
Senior Program Officer
Bill and Melinda Gates Foundation
Anne S. De Groot, MD
Associate Professor of Medicine (Adjunct)
The Warren Alpert Medical School of Brown University
Disclosures:ADG: Virco, Consultant, Speaker's Bureau
RR: Nothing to disclose
Introduction
Tuberculosis (TB) has recently regained attention in the international infectious disease news with the emergence of disease caused by highly drug-resistant strains of Mycobacterium tuberculosis in South Africa and the former Soviet Union. This highly resistant form of disease is called extensively drug resistant TB or "XDR TB" and is caused by isolates that have developed not only resistance to isoniazid and rifampin, but also to a fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).1
The spread of TB and XDR TB is fueled by poor access to TB care, crowding, and the HIV epidemic.2 In the former Soviet Union, a weakened public health system has contributed to the emergence and spread of resistant TB - especially in prison settings. The epidemics of injection drugs and TB have converged in Soviet prisons, a problem that is compounded by frequent interruptions of TB medication supply and antiquated approaches to care.3
Box 1. Definitions of MDR and XDR TB
MDR TB, or multidrug-resistant TB, is a specific form of drug-resistant TB. It occurs when the TB bacteria are resistant to at least isoniazid and rifampicin, two first line TB drugs.
XDR TB, or extensively drug-resistant TB is caused by an organism that in addition to being resistant to isoniazid and rifampin (MDR) also has resistance to any fluoroquinolone and at least one of three injectable second-line drugs (capreomycin, kanamycin, and amikacin). |
While XDR TB is still not common (of 17,690 M. tuberculosis isolates obtained world-wide in 2003-2004, 20% were from patients with multidrug resistant (MDR) TB [i.e., resistant to isoniazid and rifampicin] and 2% were from patients with XDR TB) 1, the emergence of XDR TB in prison settings in the former Soviet Union, and the spread of XDR to the outside communities to which inmates and correctional officers belong, illustrates once again the important role that front-line professionals such as correctional health providers have to play in protecting the health of their charges and communities. This issue of IDCR will address a matter of perennial concern: TB treatment and prevention in correctional facilities.
XDR and MDR TB Prevalence
The emergence of resistance to anti-TB drugs is a phenomenon that occurs primarily due to poor TB control and inadequate management of TB disease. Problems include incorrect drug prescribing practices by providers, poor quality or erratic supply of drugs, and patient non-adherence.
XDR TB has been identified in all regions of the world but is most frequent in the countries of the former Soviet Union and in Asia. In the United States, 4% of MDR TB cases met the criteria for XDR TB. In Latvia, a country with one of the highest rates of MDR TB, 19% of MDR TB cases met the XDR TB criteria. Separate data on a recent outbreak of XDR TB in a population of HIV-infected patients in Kwazulu-Natal in South Africa was characterized by high mortality rates and deaths occurring within days to weeks after diagnosis. An investigation of this outbreak found that of the 544 TB patients studied, 221 had MDR TB; 47 out of the 544 patients and six health care workers were found to have XDR TB. Of the 53 subjects with XDR TB, 44 were found to have HIV infection, and 52 died, on average, within 25 days of XDR TB diagnosis, including those who were being treated with and responding to antiretroviral therapy.4
TB in the U.S.
In 2006, the prevalence of TB in the U.S. was 4.6 per 100,000 population. Although the TB case rates are much lower in the U.S. than rates elsewhere in the world, the rate of decline in TB prevalence has slowed in recent years, in part due to the persistence of TB among foreign-born populations and delayed diagnosis and treatment among members of racial and ethnic minority groups. Rates among American blacks, Asians and Hispanics were 8.4, 21.2, and 7.6 times higher than rates among whites, respectively. 5 The highest statewide TB case rate was 12.6 per 100,000, in Washington DC, (which is reported as a state in terms of U.S. TB surveillance). Seven
states (CA, FL, GA, IL, NJ, NY and TX) reported more than 500 cases each - these states account for 60% of all TB cases.5 (See Figure 1).
TB in U.S. Correctional Systems
While TB is on the decline in the U.S. and MDR TB rates are stable and low, both TB disease and latent TB infection (LTBI) are relatively prevalent inside U.S. prisons and jails. Reported TB case rates in federal and state prisons in 2003 were 29.4 and 24.2 cases per 100,000 inmates, respectively. These rates are considerably higher than the TB case rates reported for the non-inmate population in the U.S. reported for the same year (5.1 per 100,000 people).6 The incidence of new cases of TB is also higher among inmates than non-incarcerated populations. In 1994 in New Jersey, the incidence of TB was 91.2 cases per 100,000 inmates, compared to a rate of 11.0 cases per 100,000 persons among all New Jersey residents. In 1991, a TB case rate for inmates of a California prison was 184 cases per 100,000 persons, which was 10 times greater than the statewide rate. In 2005, 16.5% and 10.5% of all reported TB cases in AZ and TX, respectively were in persons who were residents of correctional facilities.7
An investigation of TB cases in Memphis County demonstrates the significant role that correctional facilities play in the transmission and potential control of TB. This study examined the history of incarceration in all TB cases in the county and found that 43% of the TB cases reported in 1995 through 1997 were in persons who had previous contact with the jail. This suggests that the jail may have played an important part in contributing to the transmission of M. tuberculosis in the community as well as provided a potential location for prevention efforts in those who eventually developed cases of TB.9
Latent TB in correctional settings
The prevalence of LTBI seen among U.S. inmates can be as high as 25%. 10 A correlation has also been demonstrated between length of incarceration and positive tuberculin skin test (TST) response, indicating that transmission of M. tuberculosis is not uncommon in correctional facilities.10 For this reason, jail and prison inmates, correctional officers and correctional health professionals are considered a "high risk group" that would benefit
from annual TST screening, the best means to determine if there has been recent transmission of M. tuberculosis within a correctional facility (See Diagnostic Tests for TB, below)
Outbreaks in correctional settings
At least three factors contribute to the high rate of TB in correctional and detention facilities. First, incarceration leads to the concentration of individuals at high risk for TB (e.g., users of injected drugs, persons of low socio- economic status, and persons with HIV infection) and who are unlikely to have received TB screening or treatment prior to incarceration. Second, crowded living conditions facilitate transmission. Third, the movement of inmates (without their medical records) from institution to institution, makes implementation of TB control measures difficult.
Reports of outbreaks of TB within U.S. prisons and jails are published on an almost annual basis.11-17 In most of these outbreaks, epidemiology and strain typing verified transmission of a single strain of M. tuberculosis. Some of these outbreaks involved MDR strains; in several of these outbreaks, transmission occurred not only among inmates, but also to health care staff within the correctional facilities, and to members of the communities to which inmates were released. Several outbreaks that have been recently reported are summarized below:
Florida, 2001-2004.This outbreak of TB described in the February 2005 issue of IDCR illustrates the need for periodic screening of correctional staff members.18 The outbreak investigation uncovered five cases of TB among correctional staff members that occurred over a period of two and a half years (May 2001-September 2004). The source case was an HIV-infected correctional staff member who was non-adherent with TB treatment. Restriction fragment length polymorphism, which is used to distinguish among strains of M. tuberculosis demonstrated that four of the five cases were caused by an identical strain, indicating a probable common source. Although mandatory screening and testing of all employees had been implemented three years prior to this outbreak, correctional staff members often did not comply. Additional prison-associated outbreaks have occurred in other regions of Florida; investigation of these outbreaks is ongoing.
Kansas, 2002.In Kansas, a single inmate with infectious TB had contact with more than 800 individuals as he was transferred from one jail (jail A) to two others (jails B and C) and eventually was remanded to a state prison. There was a lapse of 11 months between onset of symptoms and diagnosis. A contact investigation identified 318 of the possible 800 contacts; two were diagnosed with TB disease. Both were cellmates of the source case, one in jail A and the other in jail C. Isolates from all three patients had an identical-band RFLP. Of the 318 contacts, six with a prior documented negative skin test had a positive skin test and of 196 with no prior skin test information, 41 (21%) had a positive skin test.19
RFLP - restriction fragment-length polymorphism pattern- a molecular pattern that distinguishes one strain of TB from another. |
South Carolina, 1999-2000. Segregating HIV-infected prisoners in a South Carolina prison contributed to a TB outbreak in which 71% of prisoners residing in the same housing area as the source case either had new tuberculin skin test conversion or developed TB disease. Thirty-one prisoners and one medical student in the community's hospital subsequently developed TB disease.15
Control of TB in Correctional Facilities
Control of TB in correctional facilities hinges on several important measures. First and most important is the rapid detection and proper treatment of potentially infectious cases of TB among inmates and staff. This is best accomplished with a proper index of suspicion for signs and symptoms of TB disease as well as adequate treatment and isolation of those with potentially infectious disease so that transmission of infection to others is minimized. Second is the prompt initiation of a contact investigation with case finding for additional cases of disease and those with recently acquired infection so that treatment can be administered. Third is initial and periodic screening (where indicated) so that those with undetected LTBI can be identified and treatment of infection can be initiated and completed, averting future cases of TB.
All suspect TB cases and clusters of new infections should be reported to the local TB control program and treatment of infection and disease should be conducted by those with experience in the management of TB or in consultation of those experienced in the management of TB. Health care providers with experience in the treatment of TB should manage all cases of infection and disease caused by drug resistant strains of M. tuberculosis. Apart from outbreaks of MDR TB in the U.S. in the late 1980s and early 1990s drug resistant TB in correctional facilities has not been a significant problem.20,21This has not been the case for the correctional systems of the former Soviet Union where a significant number of cases of drug resistant TB, including MDR TB have been and continue to be seen. To date the outbreak of XDR TB in South Africa is not known to involve prisoners, but the possibility exists for introduction to correctional facilities where, as has been shown in many circumstances, transmission may be enhanced. Because TB remains a problem in correctional facilities, the Centers for Disease Control and Prevention (CDC) has recently issued updated guidelines for the control of TB in these settings.22 This latest set of guidelines focuses on case finding of persons (including inmates and staff) with potentially infectious pulmonary TB so that diagnosis and treatment (if indicated) can be promptly initiated to limit transmission of M. tuberculosis in the facility. The guideline outlines methods and timing that should be used to promptly screen inmates for TB disease in order to limit transmission within the facility. Recommendations for periodic screening are based both on the risk in individual inmates for TB and the risk of the facility as a whole. Below are some highlights from the CDC's 2006 Prevention and Control of Tuberculosis in Correctional and Detention Facilities guidelines (see reference for details on the recommendations outlined below).
Diagnostic Tests for TB
TST. The TST administered by injecting purified protein derivative (PPD) by the Mantoux method remains the most commonly used tool for the detection of infection with M.tuberculosis. In some persons with LTBI, reaction to tuberculin may wane over years.
When these persons are skin tested years after infection, they may have a negative reaction. However, the skin test may stimulate (or "boost") their ability to react to tuberculin, resulting in a positive reaction to a subsequent test. With serial testing, the boosted reaction may be misinterpreted as a newly acquired infection. Two-step testing is used to establish a reliable baseline TST status and reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection because the second step of testing uncovers boosting. According to the updated guidelines, two-step testing should be used for initial testing in any individual (including staff and inmates) who has not had a TST in the prior 12 months. It should not need to be used for periodic testing unless there is a lapse of greater than 12 months between periodic tests and should never be used in the context of a contact investigation. The two-step test is performed by placing an initial TST, and if that test result is negative, then a second step TST should be done one to three weeks later. A positive reaction to the second-step test of the two-step test probably represents a boosted reaction. Although a boosted reaction should not be considered a TST conversion, it does indicate that that an evaluation for TB disease should be undertaken and if TB is not present, treatment for LTBI should be recommended if indicated.
A more accurate test?
In May 2005, the U.S. Food and Drug Administration licensed QuantiFERONŽ-TB Gold. (QFT-G). This in vitro test measures the amount of cytokine (interferon-gamma) produced by cells in whole blood that have been stimulated by peptides present in M. tuberculosis but absent from all BCG strains and from the majority of commonly encountered non-TB mycobacteria. The guideline outlines how this new test can be used for screening in correctional settings and points out that the test can be used as a diagnostic tool for M. tuberculosis infection, including both TB disease and LTBI. The utility of this test and the TST in those with advanced HIV disease and others with severe immunosuppression may be limited because of false negative test results and the use of QFT-G in the context of HIV infection is an area where continued research is needed. A negative TST or QFT-G in persons with severe immunosuppression should not be used as evidence to exclude the diagnosis of TB if there is presence of a reasonable index of suspicion of TB or signs and symptoms consistent with disease.
Neither the QFT-G nor the TST can distinguish between LTBI and TB disease; both tests must be used in conjunction with risk assessment, clinical history and examination, radiography, and other diagnostic evaluations. Limitations of QFT-G include that a blood specimen must be collected and processed within 12 hours of collection, that only a limited number of laboratories process the test, and that there is a lack of clinical experience in interpreting test results. Advantages of the test include fewer false positive tests from reactions from prior BCG or infection with environmental mycobacteria and elimination of the second visit for reading the TST. The elimination of a second visit will likely render the QFT-G competitive for a screening tool.
These new guidelines call for a classification of correctional settings by risk of TB among inmates, and how TB screening should be conducted is dependent on the classification of the facility as a minimal risk or non-minimal risk facility. A facility is classified as minimal risk if it meets all the following criteria:
No cases of infectious TB have occurred in
the facility in the last year.
The facility does not house substantial nu-
mbers of inmates with risk factors for TB
(e.g., HIV infection and injection drug use).
The facility does not house substantial nu
mbers of new immigrants (i.e., persons
arriving in the U.S. within the previous five
(years) from areas of the world with high
rates of TB.
Employees of the facility are not otherwise
at risk for TB.
If these criteria are met, the facility should be classified as minimal risk. If not, it should be classified as non-minimal risk.
Regardless of type of facility, symptom screening for TB disease (including prolonged cough, weight loss, fever, night sweats) should be performed immediately on entry to a facility. Inmates who have symptoms suggestive of TB should be placed in an airborne infection isolation room and promptly evaluated for TB disease. If the facility does not have an airborne infection isolation room and there is a high suspicion of TB, the inmate should be transferred to a facility where he/she can be properly isolated so that a diagnostic evaluation can be conducted.23
For inmates in minimal risk facilities who have no symptoms of TB disease, only those with risk factors for LTBI or who are at increased risk of progressing from infection to disease should be screened within seven days of arrival with chest radiography or a TST or QFT-G. Risk factors that should trigger screening are shown in Box 2:
| Box 2: Risk factors that should trigger screening for TB disease
HIV infection (or suspicion of HIV
infection)
Recent immigration
History of TB
Recent close contact with a person
with TB disease.
Injection-drug use
Diabetes mellitus
Immunosuppressive therapy
Hematologic malignancy or lymphoma
Chronic renal failure.
Medical conditions associated with
substantial weight loss or malnutrition
History of gastrectomy or jejunoileal
bypass
|
Regardless of the TST or QFT-G result, inmates with known or suspected HIV infection or other severe immunosuppression should have a chest radiograph taken as part of the initial screening.
For those who are housed in non-minimal risk facilities, all inmates without symptoms should be screened
with a TST, QFT-G (where available), or a chest radiograph should be performed within 7 days of arrival.
HIV-infected inmates, those suspected of having HIV or those with immunocompromising conditions should have a chest radiograph regardless of TST or QFT-G result as part of the initial screening. The index of
suspicion for TB in those with HIV infection should be very high as the presentation and radiographic appearance of TB in persons with advanced immunosuppression can be atypical.
Persons who have a positive TST or QFT-G result should be further evaluated for TB disease with a chest radiograph and symptom screen. The number of individuals who can effectively be screened in jail setting
is limited because of the high rate of turnover and short lengths of stay.
In addition to screening for TB disease and for LTBI at entry, screening for LTBI should take place annually thereafter with either the TST or QFT-G in non-minimal risk settings and in those in minimal risk settings.
Protection of Staff
A medical history relating to TB should be obtained and recorded for all new employees upon hire, and a physical examination should be required. In addition, TST or QFT-G screening should be mandatory for employment. An annual TST or QFT-G should be performed for all employees with negative TST or QFT-G test.
Box 3. Diagnosis and treatment of LTBI
CDC Recommendations:
Regardless of age, correctional facility staff and inmates in the following high-risk groups should be given treatment for LTBI if their reaction to the TST is >5 mm or is the QFT-G is positive:
- HIV-infected persons
- Recent contacts of a TB patient
- Persons with fibrotic changes on chest
radiograph consistent with previous TB
disease
- Patients with organ transplants and
other immuno-compromising cond-
tions who receive the equivalent of >15 mg/day of prednisone for >1 month
Other inmates and staff
All other correctional facility staff and inmates should be considered for treatment of LTBI if their TST result is >10 mm induration or if the QFT-G is positive |
Treatment
LTBI. The preferred treatment for LTBI is nine months of daily isoniazid or biweekly dosing administered by directly observed therapy (DOT). Individuals who have received BCG vaccine are still considered to have LTBI if their TST is positive (> 10mm). (See Table 1)
TB disease. In Spring 2003, the American Thoracic Society Infectious Diseases Society of America (IDSA),
and the CDC issued updated guidelines for the treatment of TB.1 These guidelines are substantially longer and significantly more comprehensive than the prior guidelines and should be referred to when treating a patient with TB disease or LTBI. The guidelines provide a complete discussion of the drugs currently available to treat TB, including dosing, dose adjustments needed for renal or hepatic dysfunction, toxicities, management of common adverse effects and information about interactions betweenantituberculosis drugs and otherdrugs. Because rifamycins have the potential for drug-drug interactions, including some antiretroviral medications, there is special attention given to the treatment of the patient with co-infection with HIV and M. tuberculosis (See TB 101). There is discussion of treatment issues in special groups such as children and pregnant and breast-feeding women. Treatment completion is now determined by the number of doses delivered as well as the duration of therapy. Also included is an algorithm on how to manage treatment interruption, a problem that is not uncommon in correctional settings.
TB disease and LTBI should be treated by a provider experienced in the management of TB, or in consultation with an experienced clinician. All cases of suspected or confirmed TB disease should be promptly reported to the local TB control program and a contact investigation should be promptly initiated, if indicated. Cure of TB disease and successful treatment of infection depends on completion of the recommended course of therapy. Since the primary determinant of treatment outcome is adherence to
the regimen, DOT is the preferred treatment strategy. DOT should be used throughout the entire course of
therapy. In the case of intermittent treatment regimens for LTBI, nonadherence to dosing results in a larger proportion of total doses missed than daily dosing; therefore, all patients on intermittent treatment should also receive DOT. DOT should also be used with daily dosing of LTBI treatment whenever feasible. Practitioners providing treatment to inmates should coordinate DOT with the local health department on an inmate's release.
DOT implementation in corrections can require a rigorous approach. The first order of business is the crafting of reliable inmate/patient logs, which may be paper or electronic. These should generate daily listings of all DOT inmate/patients to receive medication that day. In concert with security, recall systems are required in order to track down and bring to the clinic all "No-Shows" for receipt of DOT. This may entail tracking down not only voluntary "No-Shows", but also the few cases that be unavailable to receive medicine, such as detainees/inmates who may have been in court that day, or were temporarily absent for a variety of reasons. Finally, with inmates waiting for DOT security cooperation in the form of a Deputy or correctional officer will be needed. Once medication is administered, there should be assurance that it has been swallowed. This can be done by shining a flashlight into the inmate/patient's
throat after medication is given. On the inside of prison walls, as is also often true on the outside, patients are likely to be more adherent if they are well educated about their disease.
Conclusions
Correctional facilities are not closed institutions and are a part of the surrounding community. Good public health practices inside will lead to improved public health outside. Movement between the facility and the community occurs through the arrival and departure of inmates, staff and visitors. Because of this movement, poor TB control within correctional facilities will eventually result in problems with TB control outside of these facilities. Conversely, good TB control practices within correctional facilities will translate to better TB control within correctional facilities as well as the surrounding communities. Correctional facilities house and congregate members of vulnerable populations who are at high risk for TB. While this creates a situation where undetected TB can spread easily, it also presents an opportunity to provide interventions for detecting and treating TB disease and LTBI among a high risk population, resulting in an overall benefit to the inmates and society and a means to strive toward the goal of TB elimination in the U.S.
References:
1. CDC. Notice to Readers: Revised Definition of Extensively Drug-Resistant Tuberculosis. Morbidity and Mortality Weekly Report Vol 55, No MM43;1176.
2. CDC. Emergence of Mycobacterium tuberculosis with extensive resistance to second-line drugs-worldwide, 2000-2004. MMWR 2006;55:301-05.
3. Drobniewski FA et al. (2005). Tuberculosis, HIV seroprevalence and intravenous drug abuse in prisoners. Eur Respir J, 26(2): 298-304.
4. Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, Zeller K, Andrews J, Friedland G Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. The Lancet. 2006;368:1575-80.
5. CDC. Trends in Tuberculosis Incidence --- United States, 2006 MMWR 2007;56(11);245-50.
6. CDC. Reported Tuberculosis in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, CDC, September 2006.
7. CDC. Prevention and control of tuberculosis in correctional facilities: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1996;45(No. RR-8):1-27.
8. CDC. Probable transmission of multidrug-resistant tuberculosis in a correctional facility-California. MMWR 1993;42:48-51.
9. Jones TF, Craig AS, Valway SE, Woodley CL, Schaffner W. Transmission of tuberculosis in a jail. Ann Intern Med 1999;131:557-63.
10. Lobato MN, Leary LS, Simone PM. Treatment for latent TB in correctional facilities: a challenge for TB elimination. Am J Prev Med 2003;24:249-53.
11. CDC. Tuberculosis transmission in a state correctional institution-California, 1990-1991. MMWR 1992;41:927-29.
12. CDC. Probable transmission of multidrug-resistant tuberculosis in a correctional facility-California. MMWR 1993;42:48-51.
13.Valway SE, Greifinger RB, Papania M, et al. Multidrug resistant tuberculosis in the New York State prison system, 1990-1991. J Infect Dis 1994;170:151-56
14. CDC. Transmission of multidrug-resistant tuberculosis among immunocompromised persons in a correctional system-New York, 1991. MMWR 1992;41:507-09.
15. CDC. Drug-Susceptible Tuberculosis Outbreak in a State Correctional Facility Housing HIV-Infected Inmates-South Carolina, 1999-2000. MMWR.49(46):1041-44.
16. Mohle-Boetani JC, Miguelino V, Dewsnup DH, et al. Tuberculosis outbreak in a housing unit for human immunodeficiency virus-infected patients in a correctional facility: Transmission risk factors and effective outbreak control. Clin Infect Dis 2002;34:668-76.
17. Kimerling ME. The Russian equation: an evolving paradigm on tuberculosis control. Int J Tuberc Lung Dis 2000;4:S160-67.
18. Ashkin D., Malecki, J., Tuberculosis outbreak among staff in correctional facilities, Florida, 1002-2004: Lessons Re-Learned. IDCR Feb 2005;8(2).
19. Tuberculosis Transmission in Multiple Correctional Facilities --- Kansas, 2002-2003. MMWR August 20, 2004 / 53(32);734-38
20. Valway SE, Greifinger RB, Papania M, Kilburn JO, Woodley C, DiFerdinando GT, Dooley SW. Multidrug-resistant tuberculosis in the New York State prison system, 1990-1991.J Infect Dis. 1994 Jul;170(1):151-56.
21. Valway SE, Richards SB, Kovacovich J, Greifinger RB, Crawford JT, Dooley SW. Outbreak of multi-drug-resistant tuberculosis in a New York State prison, 1991.Am J Epidemiol. 1994 Jul 15;140(2):113-22.
22. CDC. Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC. MMWR 2006;55(No.RR-9).
23.MacNeil JR, Lobato MN, Moore M. An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003. Am J Public Health. 2005 Oct;95(10):1800-05.
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Infectious Diseases in
Corrections Report
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Infectious Disease in
Corrections Report
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