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Interventions to improve water quality for preventing diarrhoea

  1. Thomas F Clasen1,*,
  2. Ian G Roberts2,
  3. Taber Rabie3,
  4. Wolf-Peter Schmidt1,
  5. Sandy Cairncross3

Editorial Group: Cochrane Infectious Diseases Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 21 JAN 2006

DOI: 10.1002/14651858.CD004794.pub2

Database Title

Additional Information

How to Cite

Clasen TF, Roberts IG, Rabie T, Schmidt WP, Cairncross S. Interventions to improve water quality for preventing diarrhoea. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004794. DOI: 10.1002/14651858.CD004794.pub2.

Author Information

  1. 1

    London School of Hygiene & Tropical Medicine, Department of Infectious and Tropical Diseases, London, UK

  2. 2

    London School of Hygiene & Tropical Medicine, Cochrane Injuries Group, London, UK

  3. 3

    London School of Hygiene & Tropical Medicine, Department of Infectious and Tropical Diseases, Disease Control and Vector Biology Unit, London, UK

*Thomas F Clasen, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. thomas.clasen@lshtm.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JAN 2009

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References

References to studies included in this review

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. Additional references
Alam 1989 {published data only}
  • Alam N, Wojtyniak B, Henry FJ, Rahaman MM. Mothers' personal and domestic hygiene and diarrhoea incidence in young children in rural Bangladesh. International Journal of Epidemiology 1989;18(1):242-7.
Austin 1993-i {unpublished data only}
  • Austin CJ. Investigation of in-house water chlorination and its effectiveness for rural areas of the Gambia [dissertation]. New Orleans: Tulane University School of Public Health and Tropical Medicine, 1993.
Austin 1993-ii {unpublished data only}
  • Austin CJ. Investigation of in-house water chlorination and its effectiveness for rural areas of the Gambia [dissertation]. New Orleans: Tulane University School of Public Health and Topical Medicine, 1993.
Aziz 1990 {published data only}
  • Aziz KM, Hoque BA, Hasan KZ, Patwary MY, Huttly SR, Rhaman MM, et al. Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications. Transactions of the Royal Society of Tropical Medicine and Hygiene 1990;84(3):433-8.
  • Hasan KZ, Briend A, Aziz KM, Hoque BA, Patwary MY, Huttly SR. Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh. European Journal of Clinical Nutrition 1989;43(12):837-43.
  • Henry FJ, Huttly SR, Patwary Y, Aziz KM. Environmental sanitation, food and water contamination and diarrhoea in rural Bangladesh. Epidemiology and Infection 1990;104(2):253-9.
Chiller 2004 {published and unpublished data}
  • Chiller TM, Mendoza CE, Lopez MB, Alvarez M, Hoekstra RM, Keswick BH, et al. Reducing diarrhea in Guatemalan children: a randomized controlled trial of a flocculant-disinfectant for drinking water. Data on file.
  • Chiller TM, Mendoza CE, Lopez MB, Alvarez M, Hoekstra RM, Keswick BH, et al. Reducing diarrhoea in Guatemalan children: randomized controlled trial of flocculant-disinfectant for drinking-water. Bulletin of the World Health Organization 2006;84(1):28-35.
Clasen 2004b {published and unpublished data}
  • Clasen T, Brown J, Collin S. Preventing diarrhoea with household ceramic water filters: an assessment of a pilot intervention in rural Bolivia. Data on file.
  • Clasen TF, Brown J, Collin SM. Preventing diarrhoea with household ceramic water filters: Assessment of a pilot project in Bolivia. International Journal of Environmental Health Research 2006;16(3):231-9.
Clasen 2004c {published data only}
  • Clasen TF, Brown J, Collin S, Suntura O, Cairncross S. Reducing diarrhea through the use of household-based ceramic water filters: a randomized, controlled trial in rural Bolivia. American Journal of Tropical Medicine and Hygiene 2004;70(6):651-7.
Colford 2002 {published data only}
  • Colford JM Jr, Rees JR, Wade TJ, Khalakdina A, Hilton JF, Ergas IJ, et al. Participant blinding and gastrointestinal illness in a randomized, controlled trial of an in-home drinking water intervention. Emerging Infectous Diseases 2002;8(1):29-36.
Conroy 1996 {published data only}
Conroy 1999 {published data only}
Crump 2004-i {published and unpublished data}
  • Crump JA, Otieno PO, Slutsker L, Keswick BH, Rosen DH, Hoekstra RM, et al. A cluster randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhea prevention in the setting of highly turbid source water in rural western Kenya. Data on file.
  • Crump JA, Otieno PO, Slutsker L, Keswick BH, Rosen DH, Hoekstra RM, et al. Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial. BMJ 2005;331(7515):478-83.
Crump 2004-ii {unpublished data only}
  • Crump JA, Otieno PO, Slutsker L, Keswick BH, Rosen DH, Hoekstra RM, et al. A cluster randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhea prevention in the setting of highly turbid source water in rural western Kenya. Data on file.
Doocy 2004 {unpublished data only}
  • Doocy S. Point of use water treatment in the emergency context: a randomized intervention trial in Liberia. Data on file.
du Preez 2004 {unpublished data only}
  • du Preez M, Moyo S. AQUAPOL--South African filter trial. Data on file.
Garrett 2004 {unpublished data only}
  • Garrett V. Preventing diarrhoea in a high-risk rural Kenyan population with an inexpensive point-of-use water quality intervention. Data on file.
Gasana 2002 {published data only}
  • Gasana J, Morin J, Ndikuyeze A, Kamoso P. Impact of water supply and sanitation on diarrheal morbidity among young children in the socioeconomic and cultural context of Rwanda (Africa). Environmental Research 2002;90(2):76-88.
Handzel 1998 {published and unpublished data}
  • Handzel T. The effect of improved drinking water quality on the risk of diarrhoeal disease in an urban slum of Dhakar, Bangladesh: a home chlorination intervention trial [dissertation]. Chapel Hill (NC): University of North Carolina at Chapel Hill, 1998.
  • Sobsey MD, Handzel T, Venczel L. Chlorination and safe storage of household drinking water in developing countries to reduce waterborne disease. Water Science and Technology 2003;47(3):221-8.
Jensen 2003 {published data only}
  • Jensen PK, Ensink JH, Jayasinghe G, van der Hoek W, Cairncross S, Dalsgaard A. Effect of chlorination of drinking-water on water quality and childhood diarrhoea in a village in Pakistan. Journal of Health, Population, and Nutrition 2003;21(1):26-31.
Kirchhoff 1985 {published data only}
  • Kirchhoff LV, McClelland KE, Do Carmo Pinho M, Araujo JG, De Sousa MA, Guerrant RL. Feasibility and efficacy of in-home water chlorination in rural North-eastern Brazil. Journal of Hygiene 1985;94(2):173-80.
Luby 2004a-i {published data only}
  • Luby SP, Agboatwalla M, Hoekstra RM, Rahbar MH, Billhimer W, Keswick BH. Delayed effectiveness of home-based interventions in reducing childhood diarrhea, Karachi, Pakistan. American Journal of Tropical Medicine and Hygiene 2004;71(4):420-7.
Luby 2004a-ii {published data only}
  • Luby SP, Agboatwalla M, Hoekstra RM, Rahbar MH, Billhimer W, Keswick BH. Delayed effectiveness of home-based interventions in reducing childhood diarrhea, Karachi, Pakistan. American Journal of Tropical Medicine and Hygiene 2004;71(4):420-7.
Luby 2004b-i {published and unpublished data}
  • Luby SP, Agboatwalla M, Painter J, Billhimer W, Keswick B, Hoekstra RM. Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. Tropical Medicine & International Health 2006;11(4):479-89.
    Direct Link:
  • Luby SP, Agboatwalla M, Painter J, Keswick B, Billhimer W, Altaf A, et al. Effect of a novel water treatment and handwashing promotion on childhood diarrhea in Pakistan: a randomized controlled trial. Data on file.
Luby 2004b-ii {unpublished data only}
  • Luby SP, Agboatwalla M, Painter J, Keswick B, Billhimer W, Altaf A, et al. Effect of a novel water treatment and handwashing promotion on childhood diarrhea in Pakistan: a randomized controlled trial. Data on file.
Luby 2004b-iii {unpublished data only}
  • Luby SP, Agboatwalla M, Painter J, Keswick B, Billhimer W, Altaf A, et al. Effect of a novel water treatment and handwashing promotion on childhood diarrhea in Pakistan: a randomized controlled trial. Data on file.
Lule 2005 {published data only}
  • Lule JR, Mermin J, Ekwaru JP, Malamba S, Downing R, Ransom R, et al. Effect of home-based water chlorination and safe storage on diarrhea among persons with human immunodeficiency virus in Uganda. American Journal of Tropical Medicine and Hygiene 2005;73(5):926-33.
Mahfouz 1995 {published data only}
  • Mahfouz AA, Abdel-Moneim M, al-Erian RA, al-Amari OM. Impact of chlorination of water in domestic storage tanks on childhood diarrhoea: a commuity trial in the rural areas of Saudi Arabia. American Journal of Tropical Medicine and Hygiene 1995;98(2):126-30.
Messou 1997 {published data only}
  • Messou E, Sangare SV, Josseran R, Le Corre C, Guelain J. Effect of hygiene measures, water, sanitation and oral rehydration therapy on diarrhea in children less than five years old in the south of Ivory Coast [Effet de l'observance des mesures d'hygiene, d'approisionnement en eau et de la therapie par voie orale sur les diarrhees chez les enfants de moins de 5 ans dans le sud de la Cote D'Ivoire]. Bulletin de la Société de Pathologie Exotique (1990) 1997;90(1):44-7.
Quick 1999 {published and unpublished data}
  • Quick RE, Venczel LV, Mintz ED, Soleto L, Aparicio J, Gironaz M, et al. Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiology and Infection 1999;122(1):83-90.
  • Venczel L. Evaluation and application of a mixed oxidant disinfection system for waterborne disease prevention [dissertation]. Chapel Hill (NC): University of North Carolina at Chapel Hill, 1997.
Quick 2002 {published data only}
  • Quick RE, Kimura A, Thevos A, Tembo M, Shamputa I, Hutwagner L, et al. Diarrhea prevention through household-level water disinfection and safe storage in Zambia. American Journal of Tropical Medicine and Hygiene 2002;66(5):584-9.
Reller 2003-i {published data only}
  • Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411-9.
Reller 2003-ii {published data only}
  • Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411-9.
Reller 2003-iii {published data only}
  • Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411-9.
Reller 2003-iv {published data only}
  • Reller ME, Mendoza CE, Lopez MB, Alvarez M, Hoekstra AR, Olson CA, et al. A randomized controlled trial of household-based flocculant-disinfectant drinking water treatment for diarrhoea prevention in rural Guatemala. American Journal of Tropical Medicine and Hygiene 2003;69(4):411-9.
Roberts 2001 {published data only}
  • Roberts L, Chartier Y, Chartier O, Malenga G, Toole M, Rodka H. Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial. Bulletin of the World Health Organization 2001;79(4):280-7.
Semenza 1998 {published data only}
  • Semenza JC, Roberts L, Henderson A, Bogan J, Rubin CH. Water distribution system and diarrheal disease transmission: a case study in Uzbekistan. American Journal of Tropical Medicine and Hygiene 1998;59(6):941-6.
Torun 1982 {published data only}
  • Torun B. Environmental and educational interventions against diarrhea in Guatemala. In: Chen LC, Scrimshaw NS editor(s). Diarrhea and malnutrition: interactions, mechanisms and interventions. New York: Plenum Press, 1982:235-66.
URL 1995-i {published data only}
  • Universidad Rafael Landivar. Preventing infant morbidity: artisanal filters and education [Contra la morbilidad infantil: filtros artesanales y education]. Revista de Estudios Sociales 1995;IV(53):1-66.
URL 1995-ii {published data only}
  • Universidad Rafael Landivar. Preventing infant morbidity: artisanal filters and education [Contra la morbilidad infantil: filtros artesanales y education]. Revista de Estudios Sociales 1995;IV(53):1-66.
Xiao 1997 {published data only}
  • Xiao S, Lin C, Chen K. Evaluation of effectiveness of comprehensive control for diarrhea diseases in rural areas of east Fujian and analysis of its cost-benefit. Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine] 1997;31(1):40-1.

References to studies excluded from this review

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. Additional references
Asaolu 2002 {published data only}
  • Asaolu SO, Ofoezie IE, Odumuyiwa PA, Sowemimo OA, Ogunniyi TA. Effect of water supply and sanitation on the prevalence and intensity of Ascarias lumbricoides among pre-school-age children in Ajebandele and Ifewara, Osun State, Nigeria. Transactions of the Royal Society of Tropical Medicine and Hygiene 2002;96(6):600-4.
Azurin 1974 {published data only}
Bahl 1976 {published data only}
Bersh 1985 {published data only}
Chongsuvivatwong 94 {published data only}
  • Chongsuvivatwong V, Mo-suwan L, Chompikul J, Vitsupakorn K, McNeil D. Effects of piped water supply on the incidence of diarrhoeal diseases in children in southern Thailand. Southeast Asian Journal of Tropical Medicine and Public Health 1994;25(4):628-32.
Colwell 2003 {published data only}
  • Colwell RR, Huq A, Islam MS, Aziz K, Yunus M, Khan NH, et al. Reduction of cholera in Bangladeshi villages by simple filtration. Proceedings of the National Academy of Sciences of the United States of America 2003;100(3):1051-5.
Conroy 2001 {published data only}
  • Conroy RM, Meegan ME, Joyce T, McGuigan K, Barnes J. Solar disinfection of drinking water protects against cholera in children under 6 years of age. Archives of Disease in Childhood 2001;85(4):293-5.
Deb 1986 {published data only}
  • Deb BC, Sircar BK, Sengupta PG, De SP, Mondal SK, Gupta DN, et al. Studies on interventions to prevent eltor cholera transmission in urban slums. Bulletin of the World Health Organization 1986;64(1):127-31.
Esrey 1991b {published data only}
  • Esrey SA, Habicht JJP, Latham MC, Sisler DG, Casella G. Drinking water source, diarrhoeal morbidity, and child growth in villages with both traditional and improved water supplies in rural Lesotho, southern Africa. American Journal of Public Health 1988;78(11):1451-5.
Fewtrell 1994 {published data only}
Fewtrell 1997 {published data only}
  • Fewtrell L, Kay D, Wyer M, O'Neill G. An investigation into the possible links between shigellosis and hepatitis A and public water supply disconnections. Public Health 1997;111(3):179-81.
Ghannoum 1981 {published data only}
  • Ghannoum MA, Moore KE, Al-Dulaimi M, Nasr M. The incidence of water-related diseases in the Brak area, Libya from 1977 to 1979, before and after the installation of water treatment plants. Zentralblatt für Bakteriologie, Mikrobiologie und Hygiene. 1. Abt. Originale B, Hygiene 1981;173(6):501-8.
Hellard 2001 {published data only}
  • Hellard ME, Sinclair MI, Forbes AB, Fairley CK. A randomized, blinded, controlled trial investigating the gastrointestinal health effects of drinking water quality. Environmental Health Perspectives 2001;109(8):773-8.
Hoque 1996 {published data only}
  • Hoque BA, Juncker T, Sack RB, Ali M, Aziz KM. Sustainability of a water, sanitation and hygiene education project in rural Bangladesh: a 5-year follow-up. Bulletin of the World Health Organization 1996;74(4):431-7.
Iijima 2001 {published data only}
  • Iijima Y, Karama M, Oundo JO, Honda T. Prevention of bacterial diarrhea by pasteurization of drinking water in Kenya. Microbiology and Immunology 2001;45(6):413-6.
Jensen 2002 {published data only}
  • Jensen PK, Ensink JH, Jayasinghe G, van der Hoek W, Cairncross S, Dalsgaard A. Domestic transmission routes of pathogens: the problem of in-house contamination of drinking water during storage in developing countries. Tropical Medicine & International Health 2002;7(7):604-9.
    Direct Link:
Khan 1984 {published data only}
Macy 1998 {published data only}
  • Macy JT, Quick RE. Evaluation of a novel drinking water treatment and storage intervention in Nicaragua. Revista Panamericana de Salud Pública [Pan American Journal of Public Health] 1998;3(2):135-6.
Maeusezahl 2003 {unpublished data only}
  • Maeusezahl D, Tanner M, Hobbins M. The SODIS health impact study. Data on file.
McCabe 1957 {published data only}
Mertens 1990 {published data only}
  • Mertens TE, Cousens SN, Fernando MA, Kirkwood BR, Merkle F, Korte R, et al. Health impact evaluation of improved water supplies and hygiene practices in Sri Lanka: background and methodology. Tropical Medicine and Parasitology 1990;41(1):79-88.
Nanan 2003 {published data only}
  • Nanan D, White F, Azam I, Afsar H, Hozhari S. Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan. Bulletin of the World Health Organization 2003;81(3):160-5.
Payment 1991a {published data only}
  • Payment P, Franco E, Richardson L, Siemiatycki J. Gastrointestinal health effects associated with the consumption of drinking water produced by point-of-use domestic reverse-osmosis filtration units. Applied and Environmental Microbiology 1991;57(4):945-8.
Payment 1991b {published data only}
  • Payment P, Richardson L, Siemiatycki J, Dewar R, Edwardes M, Franco E. A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards. American Journal of Public Health 1991;81(6):703-8.
Pinfold 1990 {published data only}
  • Pinfold JV. Faecal contamination of water and fingertip-rinses as a method for evaluating the effect of low-cost water supply and sanitation activities on faeco-oral disease transmission. II. A hygiene intervention study in rural north-east Thailand. Epidemiology and Infection 1990;105(2):377-89.
Rubenstein 1969 {published data only}
Sathe 1996 {published data only}
Shiffman 1978 {published data only}
  • Shiffman MA, Schneider R, Faigenblum JM, Helms R, Turner A. Field studies on water, sanitation and health education in relation to health status in Central America. Progress in Water Technology 1978;11:143-50.
Shum 1971 {published data only}
  • Shum H, Sum CY, Chan-Teo CH. Water-borne dysentery due to Shigella sonnei in Hong Kong. Southeast Asian Journal of Tropical Medicine and Public Health 1971;2(2):180-5.
Sorvillo 1994 {published data only}
  • Sorvillo FJ, Lieb LE, Nahlen B, Miller J, Mascola L, Ash LR. Municipal drinking water and cryptosporidiosis among persons with AIDS in Los Angeles County. Epidemiology and Infection 1994;113(2):313-20.
Tonglet 1992 {published data only}
Trivedi 1971 {published data only}
  • Trivedi BK, Gandhi HS, Shukla NK. Bacteriological water quality and incidence of water borne diseases in a rural population. Indian Journal of Medical Sciences 1971;25(11):795-801.
VanDerslice 1995 {published data only}
  • VanDerslice J, Briscoe J. Environmental interventions in developing countries: interactions and their implications. American Journal of Epidemiology 1995;141(2):135-44.
Varghese 2002 {unpublished data only}
  • Varghese A. Point-of-use water treatment systems in rural Haiti: human health and water quality impact assessment [dissertation]. Cambridge (MA): Massachusetts Institute of Technology, 2002.

References to studies awaiting assessment

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. Additional references
Clasen 2005 {published data only}
  • Clasen T, Garcia Parra G, Boisson S, Collin S. Household-based ceramic water filters for the prevention of diarrhea: a randomized, controlled trial of a pilot program in Colombia. American Journal of Tropical Medicine and Hygiene 2005;73(4):790-5.
Colford 2005a {published data only}
  • Colford JM, Wade TJ, Sandhu SK, Wright CC, Lee S, Shaw S, et al. A randomized, controlled trial of in-home drinking water interventions to reduce gastrointestinal illness. American Journal of Epidemiology 2005;161(5):472-82.
Colford 2005b {published data only}
  • Colford JM, Saha SR, Wade TJ, Wright CC, Vu M, Charles S, et al. A pilot randomized, controlled trial of an in-home drinking water intervention among HIV + persons. Journal of Water and Health 2005;3(2):173-84.
Rose 2006 {published data only}

Additional references

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. Additional references
Baqui 1993
  • Baqui AH, Black RE, Sack RB, Chowdhury HR, Yunus M, Siddique AK. Malnutrition, cell-mediated immune deficiency, and diarrhea: a community-based longitudinal study in rural Bangladeshi children. American Journal of Epidemiology 1993;137(3):355-65.
Bartram 2003
  • Bartram J. New water forum will repeat old message. Bulletin of the World Health Organization 2003;83(3):158.
Black 1993
Blaser 1995
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Blum 1983
Briscoe 1984
Briscoe 1986
  • Briscoe J, Feachem RG, Rahaman MM. Evaluating health impact: Water supply, sanitation, and hygiene education. Ottawa: International Development Research Centre, 1986.
Byers 2001
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Cairncross 1989
Clasen 2004a
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Curtis 2003
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Esrey 1985
  • Esrey SA, Feachem RG, Hughes JM. Interventions for control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities. Bulletin of the World Health Organization 1985;63(4):757-72.
Esrey 1986
Esrey 1991a
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Feachem 1983
Fewtrell 2005
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Wright 2004
  • Wright J, Gundry S, Conroy R. Household drinking water in developing countries: a systematic review of microbiological contamination between source and point-of-use. Tropical Medicine and International Health 2004;9(1):106-17.
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Zhang 1998
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