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Keywords:

  • needle stick injuries;
  • risk factors;
  • nursing staff;
  • developing countries;
  • training

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

Objectives  Despite a heavy burden of HIV/AIDS and other blood borne infections, few studies have investigated needle stick injuries in sub-Saharan Africa. We conducted a cross-sectional study at Mulago national referral hospital in Kampala, Uganda, to assess the occurrence and risk factors of needle stick injuries among nurses and midwives.

Methods  A total of 526 nurses and midwives involved in the direct day-to-day management of patients answered a questionnaire inquiring about occurrence of needle stick injuries and about potential predictors, including work experience, work load, working habits, training, and risk behaviour.

Results  A 57% of the nurses and midwives had experienced at least one needle stick injury in the last year. Only 18% had not experienced any such injury in their entire career. The rate of needle stick injuries was 4.2 per person-year. Multiple logistic regression analysis showed that the most important risk factor for needle stick injuries was lack of training on such injuries (OR 5.72, 95% CI 3.41–9.62). Other important risk factors included working for more than 40 h/week (OR 1.90, 95% CI 1.20–3.31), recapping needles most of the time (OR 1.78, 95% CI 1.11–2.86), and not using gloves when handling needles (OR 1.91, 95% CI 1.10–3.32).

Conclusions  The study showed a high rate of needle stick injuries among nurses and midwives working in Uganda. The strongest predictor for needle stick injuries was lack of training. Other important risk factors were related to long working hours, working habits, and experience.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

Sub-Saharan countries in Africa have a heavy burden of HIV/AIDS and other blood borne infectious diseases [Ugandan Ministry of Health, Resource Centre 2003; Ugandan Ministry of Health, STD/HIV/AIDS Control Programme 2003; World Health Organization (WHO), Joint United Nations programme on HIV/AIDS (UNAIDS) 2003] and high usage of injections (Jules 2003; WHO, Safe Injection Global Network 2003). Lack of safe devices in hospitals because of the low expenditure on health care and occupational safety and health services (Ugandan Ministry of Health, Resource Centre 2003) and a high ratio of patients to health care worker (WHO 1998, 2001; Ugandan Ministry of Health, Resource Centre 2003) contribute to a work environment predisposing the health care workers to a great risk of needle stick injuries, and consequently, to blood borne infections (Jagger et al. 1990; Willy et al. 1990; Yassi & McGill 1991; Khuri-Bulos et al. 1997; Lawrence et al. 1997; Grosch et al. 1999; Gershon et al. 2000). Only a few studies have been published on needle stick injuries from this area, or from developing countries in general (Adegboye et al. 1994; Gumodoka et al. 1997; Memish et al. 2002; Newsom & Kiwanuka 2002), although 90% of needle stick injuries occur in developing countries (WHO, Safe Injection Global Network 2003). Among the few studies conducted, none has specifically addressed the risk factors for needle stick injuries among the nursing staff. The objectives of this study were to assess the occurrence and risk factors of needle stick injuries among nurses at the Mulago national referral hospital in Kampala, the capital of Uganda, with the aim to recommend preventive measures applicable to work environments in developing countries.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

Study design and population

This was a cross-sectional study on needle stick injuries among nurses and midwives at Mulago national referral hospital in Kampala, Uganda. All nurses and midwives, who were present at work during the months of April and May 2004, and were involved in the direct management of patients, were invited to participate in the study. Nursing staff who were in general administrative positions or dealing with public health issues, as well as those who were on leave (maternity, annual, sick or study leave) during the study period were excluded. A total of 800 nursing staff were eligible for inclusion in the study. Sixty-six per cent returned the questionnaire, and after excluding six incomplete questionnaires, 526 nurses and midwives were included in the study. They answered a self-administered questionnaire inquiring about the occurrence and potential risk factors of needle stick injuries.

This study was approved by the ethical research committee of Mulago hospital and the procedures followed were in accordance with the Helsinki declaration. Signed informed consent was obtained from the participants.

Questionnaire

We drafted a questionnaire on needle stick injuries and piloted it among 10 nurses at Mulago hospital. Their comments were used to design the final version of the questionnaire, which included four sections: (i) background information; (ii) occurrence of needle stick injuries, circumstances under which they had occurred, and information on working habits; (iii) reporting of needle stick injuries and the hospital policy on safety and health; and (iv) training received, perceptions and attitudes towards needle stick injuries, and suggestions how such injuries could be avoided.

Statistical methods

Outcome assessment.  The outcome of interest was needle stick injuries among nursing staff, defined as the parenteral introduction into the body of blood or other potentially infectious material by a hollow-bore needle or sharp instrument, including, but not limited to, needles, lancets, scalpels, and contaminated broken glass used during the performance of duties (Prüss-Üstün et al. 2003). Outcome assessment was based on answers to the questions on the number of needle stick injuries the participant had experienced in the last month and the last year. The participant was also asked whether he or she had ever sustained a needle stick injury.

Assessment of risk factors.  Potential risk factors for needle stick injuries were selected based on reviewing previous literature and developing our own hypotheses on factors that might increase the risk of sustaining a needle stick injury in sub-Saharan Africa. The assessment of the risk factors was based on self-reported answers to the questionnaire. Each factor was dichotomized and coded by giving 0 to the group hypothesized as having a lower risk and 1 to the group hypothesized as having a higher risk. The factors explored as potential predictors of needle stick injuries included age (≥35 years = 0; <35 years = 1), gender (female = 0; male = 1), duration of employment (≥10 years = 0; <10 years = 1), job category (senior and nursing officers = 0, enrolled nurses and midwives, nursing aides and others = 1), department (medicine and paediatrics = 0; surgery and obstetric and gynaecology = 1), working night shifts (not working nights = 0; working nights = 1), having received training at work on needle stick injuries (yes = 0; no = 1), hours worked per week (<40 hours = 0; ≥40 h = 1), number of patients attended to on average per day (<35 = 0; ≥35 = 1), recapping of the needles (never or sometimes = 0, most or all of the time = 1), use of gloves while handling sharp instruments (most or all of the time = 0; sometimes or never = 1), awareness of the hospital policy (yes = 0; no = 1), having concern about needle stick injuries (yes = 0; no = 1), perceived risk related to needle stick injuries (moderate or high = 0; low or none = 1), and considering needle stick injuries to be avoidable (yes = 0; no = 1).

Data analysis

SPSS computer software was used for data analysis. The event rate of needle stick injuries per person-year was calculated by summing the total number of reported needle stick injuries in the last year (12 months) (n = 2072) and by dividing it with the person-years contributed by the study population during the last year (496 person-years). The distributions of risk factors among those who had experienced one or more needle stick injuries during the entire career and those without any such injuries were calculated.

Multivariate logistic regression analysis was used to estimate the odds ratio (OR) and its 95% confidence interval (95% CI) for sustaining a needle stick injury related to the predictors. The outcome for this analysis was dichotomized into at least one needle stick injury during the entire career (coded 1) versus no such injuries (coded 0). The full model included all the potential risk factors of interest. To achieve a parsimonious final model, those risk factors with an OR close to one were excluded from the final model.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

Personal and work characteristics and occurrence of needle sticks injuries

Distributions of personal and work characteristics of the study population are presented in Table 1. Among the participants, 36% reported having experienced at least one needle stick injury in the last month, while 57% reported at least one needle stick injury in the last year. 82% reported having ever experienced such injury, while only 18% had not experienced any such injury in their entire career. Based on the last year (12 months), the rate of needle stick injuries was estimated as 4.18 per person-year.

Table 1.  Personal and work characteristics of the study population (total n = 526)
CharacteristicFrequency (n)PercentageMedianRange
MinimumMaximum
  1. * 16 (3.0%) no information on gender; † 42 (8.0%) no information on age; ‡ 3 (0.6%) no information on job title; § 3 (0.6%) no information on department; ¶ 44 (8.4%) no information on length of practice; ** 32 (6.1%) no information on number of patients; †† 21 (4.0%) no information on work hours/week; ‡‡ 2 (0.4%) no information on night shifts/month; N/A, non-applicable.

Gender*
 Male478.9N/AN/AN/A
 Female46388.0
Age† (years)
 20–2910720.335.22160
 30–3923544.7
 40–4910019.0
 ≥50428.0
Job title‡
 Senior/nursing officer203.8N/AN/AN/A
 Nursing officer32261.2
 Enrolled midwife5610.6
 Enrolled nurse7013.3
 Nursing aide356.7
 Others203.8
Department§
 Obstetrics and gynaecology19837.6N/AN/AN/A
 Surgery12423.6
 Medicine9718.4
 Paediatric10419.8
Years in nursing practice¶
 ≤511722.2100.4239.0
 6–1012323.4
 11–158716.5
 16–206512.4
 21–25356.7
 26–30336.3
 >30224.2
Number of patients attended to per day**
 ≤2013625.9301100
 21–4015830.0
 41–6010520.0
 61–80438.2
 >80529.9
Hours worked per week††
 ≤205310.140684
 21–4024346.2
 41–6018334.8
 61–80234.4
 >8030.6
Night shifts worked per month‡‡
 None18835.75022
 1–513225.1
 6–1015729.8
 11–15356.7
 16–20122.3
 >2020.3

Procedures related to needle stick injuries

As shown in Figure 1, almost 40% of the needle stick injuries reported in the last year were related to administering of injections (19% injecting an patient and 17% putting up an intravenous line). These procedures were followed by the process of disposing used needles, which caused about 16% of the injuries. Recapping of used needles, suturing, especially during episiotomies, and cleaning after patient care were related to about 13% of the injuries each. Despite encouragement of the nursing staff not to recap the needles, it was still a common practice, as almost 50% of the participants were recapping most or all the time. Needle stick injuries were less commonly related to an unattended needle left after the procedure (5.6%) or to an accidental injury from a colleague (4%).

image

Figure 1. Frequency of procedures during which needle stick injuries (−NSI) occurred (as % of total NSI in the last year).

Download figure to PowerPoint

Risk factors for needle stick injuries

The distribution of potential risk factors for needle stick injuries among the nursing staff stratified by whether they had experienced such injuries are shown in the Table 2. Multivariate logistic regression analysis of the OR for sustaining needle stick injuries in relation to these potential risk factors are presented in Table 3. Gender, age, working night shifts, the perceived level of risk related to needle stick injuries, and considering needle stick injuries to be avoidable were not related significantly to the risk of sustaining needle stick injuries (OR close to 1), and were excluded from the final model.

Table 2.  Distributions of potential risk factors for needle stick injuries stratified by the occurrence of such injuries during the entire career
Risk factorAt least one needle stick injury
Yes (n = 419), n (%)No (n = 90), n (%)
  1. * NSI, needle stick injuries.

Gender
 Male39 (83.0)8 (17.0)
 Female380 (82.3)82 (17.7)
Age (years)
 Young (<35)198 (82.2)43 (17.8)
 Older (≥35)205 (84.7)37 (15.3)
Job title
 Enrolled nurses and midwives, nursing aides and others137 (75.7)44 (24.3)
 Senior/nursing officers292 (85.6)49 (14.4)
Medical disciplines
 Surgical275 (85.7)46 (14.3)
 Medical155 (77.1)46 (22.9)
Years in practice
 <10243 (85.6)41 (14.4)
 ≥10172 (78.2)48 (21.8)
Number of patients attended to daily
 <35220 (88.4)29 (11.6)
 ≥35191 (78.3)53 (21.7)
Hours worked per week
 <4062 (73.8)22 (26.2)
 ≥40354 (84.3)66 (15.7)
Working night shifts
 No153 (81.4)35 (18.6)
 Yes279 (82.8)58 (17.2)
Recapping needles
 Never/sometimes209 (78.6)57 (21.4)
 Most/all of the time209 (86.7)32 (13.3)
Aware of the hospital policy on NSI*
 No330 (84.2)62 (15.8)
 Yes86 (76.1)27 (23.9)
Received training on NSI*
 No378 (87.9)52 (12.1)
 Yes47 (56.0)37 (44.0)
Having concerns about NSI*
 No52 (85.2)9 (14.8)
 Yes370 (83.0)76 (17.0)
Perceived risk related to NSI*
 No/low risk54 (83.2)11 (16.8)
 High/moderate risk370 (82.6)78 (17.4)
Considering NSI* to be avoidable
 No122 (79.2)32 (20.8)
 Yes286 (83.5)56 (16.5)
Table 3.  Multivariate logistic regression analysis of odds ratio (OR) for needle stick injuries in relation to potential risk factors (OR = 1 in the reference category)
Risk factorFull modelFinal model
OR (95% CI)P-valueOR (95% CI)P-value
  1. OR, odds ratio; 95% CI, 95% confidence interval.

  2. * NSI, needle stick injuries.

Gender
 Female1   
 Male1.04 (0.46–2.35)0.940  
Age (years)
 Older (≥35)1   
 Young (<35)0.92 (0.46–1.31)0.541  
Job category
 Enrolled/nursing aides and others1 1 
 Senior/nursing officers1.86 (1.17–3.00)0.0061.91 (1.21–3.02)0.005
Medical discipline
 Medicals1 1 
 Surgicals1.68 (1.12–2.78)0.0141.76 (1.13–2.79)0.013
Work experience (years)
 ≥101 1 
 <101.62 (1.04–2.6)0.0411.67 (1.04–2.62)0.032
Number of patients attended to daily
 ≥351 1 
 <352.08 (1.27–3.48)0.0042.21 (1.32–3.58)0.002
Hours worked per week
 <401 1 
 ≥401.76 (1.07–3.26)0.0281.90 (1.10–3.31)0.023
Working night shifts
 No1   
 Yes1.07 (0.59–1.65)0.712  
Recapping needles
 Never/sometimes1 1 
 All/most of the time1.47 (1.12–2.77)0.0191.78 (1.11–2.86)0.017
Use of gloves
 All/most of the time1 1 
 Never/sometimes1.85 (1.09–3.32)0.0341.91 (1.10–3.33)0.022
Knowing hospital policy on NSI*
 Yes1 1 
 No1.65 (0.94–2.48)0.0951.55 (0.94–2.59)0.088
Having attended training on NSI*
 Yes1 1 
 No5.67 (3.41–9.56)0.0005.72 (3.41–9.62)0.000
Having concerns about NSI*
 Yes1 1 
 No1.12 (0.66–2.69)0.2611.19 (0.56–2.51)0.201
Perceived risk related to NSI*
 High/moderate1   
 No/low1.02 (0.72–2.07)0.953  
Considering NSI* to be avoidable
 Yes1   
 No0.88 (0.68–1.14)0.336  

The results showed that the strongest risk factor for needle stick injuries was not having attended any training session on such injuries in the workplace compared with having received some training (OR 5.72, 95% CI 3.41, 9.62). Other factors significantly related with an increased OR for needle stick injuries were being senior or nursing officer (OR 1.91, 95% CI 1.21, 3.02), working on the surgical disciplines (OR 1.77, 95% CI 1.13, 2.80), having work experience for less than 10 years (OR 1.65, 95% CI 1.04, 2.62), working long hours (OR 1.90, 95% CI 1.10, 3.31), recapping needles all or most of the time (OR 1.78, 95% CI 1.11, 2.86), and not using gloves (OR 1.91, 95% CI 1.10, 3.33). Somewhat surprisingly, those who were attending to less than 35 patients per day had a higher risk of sustaining needle stick injuries (OR 2.08, 95% CI 1.27, 3.48) compared with those attending to more patients.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

Among the nursing staff working at a national referral hospital in Uganda, a high rate of needle stick injuries (4.18 per person-year) was observed. A total of 57% of the study population had experienced at least one needle stick injury in the last year. Only 18% had not experienced any such injury in their entire career. The importance of this high rate of needle stick injuries is highlighted by the statistics of HIV infections among the patients at Mulago hospital. For example, 20–45% of the patients attending the sexually transmitted diseases clinic and 5–8% of those attending antenatal care are HIV positive.

The rate of needle stick injuries observed in this study was slightly higher than estimates in earlier African studies (Adegboye et al. 1994; Gumodoka et al. 1997; Newsom & Kiwanuka 2002). This difference could be explained by the fact that our study population included only nurses, while the other studies have included all health care workers. Some of the other studies indicated that the rates be higher for nurses than for other health care worker groups.

We were not able to identify any earlier study addressing the predictors of needle stick injuries focusing on nurses in developing countries. Some studies investigated the risk factors for needle stick injuries among health care workers in general, but almost all of them have been carried out in developed countries.

Combining the senior and nursing officers, these employees were at a significantly increased risk of sustaining needle stick injuries (OR 1.91, 95% CI 1.21–3.02) compared with the combined other nursing staff. This could be explained by the fact that in Uganda, as in most developing countries, a high patient-to-doctor ratio results in the senior and nursing officers having to take on some of the doctors’ responsibilities, e.g. carrying out minor surgical procedures. They may not be adequately trained for these and consequently are exposed to a high risk of needle stick injuries.

Training was found to be the crucial factor in predicting the occurrence of needle stick injuries among the nursing staff in our study. Those nurses who had not attended any training on prevention and management of needle stick injuries in their workplace were at a significantly greater risk of sustaining such injury compared with those who had attended some kind of training (OR of 5.72, 95% CI, 3.41–9.62). This finding has great importance for planning preventive measures in developing country environments, where arranging proper training is a more feasible target than buying expensive equipment.

Mulago hospital had a policy concerning precautions to prevent transmission of infections and guidelines that included hand washing after patient contact, use of personal protective equipment, such as gloves, and minimization of manual manipulation of sharp instruments and devices and safe disposal of used sharp items. However, a high proportion of nurses (75%) in our study were not aware of the existence of a hospital policy on needle stick injuries, a fact that also suggests insufficient training at the workplace. Lack of awareness of the policy had borderline significance with respect to the risk of needle stick injuries, with an OR of 1.55 (95% CI 0.94–2.59). Some earlier studies have shown that additional training at work increases compliance with some precautionary measures (Fahey et al. 1991; McCormick et al. 1991; Haiduven et al. 1992). One study from USA showed a reduction in needle stick injuries in association with training combined with an intervention concerning the location of containers for needles (Haiduven et al. 1992). However, that study was not able to estimate the influence of training alone.

Our study showed a significantly increased risk of needle stick injuries among those who were recapping needles most or all of the time compared with those who were not recapping. This finding is consistent with earlier studies (Goldwater et al. 1989; Jagger et al. 1990; McGreer et al. 1990; Morgan 1991; Whitby et al. 1991; Yassi & McGill 1991; Aiken et al. 1997). Almost 50% of the participants in our study were recapping needles most or all of the time, while only 21% did not recap needles at all. Location of the sharps containers may explain a part of this high rate of recapping needles. Among those who had sustained at least one needle stick injury, 11% reported there was no safe container available when their last injury occurred and 4% reported that the nearest sharps container was on the next ward at the time of their last injury. Use of gloves while handling sharp instruments is a precautionary measure recommended and compliance with this seemed to be an indicator for risk behaviour. Those nurses who used gloves only sometimes or not at all were at a significantly greater risk of sustaining needle stick injuries than those who were using them regularly. Some earlier studies (Morgan 1991; Gershon et al. 1995) have linked glove use to compliance with precautions in general. Recapping of needles, placing sharps containers and not using protective gloves are factors that could be improved by training, but lack of protective equipment and safe needles are common in many developing countries and can partly explain such risk behaviour among nurses (Morgan 1991; Gershon et al. 1995; Gumodoka et al. 1997; Newsom & Kiwanuka 2002). In our study, lack or poor supply of gloves was given as one of the reasons for not using the gloves regularly.

Only 16% of the nurses had attended workplace training on needle stick injuries, so most depended on their skills improving with experience, in addition to the knowledge they had acquired from school. Consistent with this, nurses who had been in service for less than 10 years were at a higher risk of sustaining needle stick injuries compared with those with more than 10 years of work experience.

Working long hours was also a significant predictor of the risk of needle stick injuries, and has been previously associated with recapping and poor compliance with precautions (Adegboye et al. 1994; Dejoy et al. 1995; Aiken et al. 1997; Grosch et al. 1999; Gershon et al. 2000), but it has not been linked directly to the occurrence of needle stick injuries. Working excessive hours can result in stress and emotional and physical exhaustion, which are likely to increase the chance of human error and contribute to a tendency towards risky behaviours, such as recapping needles and poor compliance with the precautions in general (Dejoy et al. 1995; Gershon et al. 1995; Aiken et al. 1997; Grosch et al. 1999; Gershon et al. 2000). Long working hours is also an indicator of understaffing, a common phenomenon in developing countries (Porta et al. 1999; WHO 2001; Ugandan Ministry of Health, Resource Centre 2003).

Somewhat surprisingly, we found a higher injury rate among those attending to less than 35 patients per day compared with those attending to more patients. It is possible that those who were doing invasive procedures accompanied by a higher risk for needle stick injuries were attending to fewer patients.

The perceptions and attitudes towards needle stick injuries did not seem to influence the occurrence of such injuries much. However, those who did not have any concerns about the health consequences of needle stick injuries had a slightly higher risk of getting a needle stick injury compared with those who had concerns, although this estimate did not reach statistical significance.

Validity of the results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

The response rate in this study was good (66%) and we think that our results are likely to reflect quite well what was happening among the nursing staff. The participating hospital is a national referral hospital in the capital city. It has a high patient turn out, but the working conditions are likely to be somewhat better compared with rural hospitals. Thus, our estimate of the rate of needle stick injuries is probably underestimating the rate in Uganda as a whole. On the other hand, the important risk factors identified in this study are likely to reflect the situation in the whole country, and indeed in sub-Saharan Africa.

The questionnaire was answered anonymously, so that the participants could answer with no fear of being linked to their response, and this might have promoted the accuracy of the answers. Because of the voluntary participation into the study some degree of selection bias could not be ruled out, as those who had got needle stick injuries might have been more eager to participate. This could lead to some overestimation of the injury rate, but would not affect the relations observed with the risk factors, unless selection had happened simultaneously according to these predictors. If any selection according to risk factors would have taken place, it is likely that the participation had been more active among those interested in training and precautionary measures, and thus, the observed relations might slightly underestimate the true risk ratios. We were able to collect information on several potential risk factors and assess their relative contribution to the risk while adjusting for the other factors.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

This study demonstrates a high rate of needle stick injuries among nurses and midwives working in Uganda. Lack of training at the workplace was identified as the strongest risk factor for needle stick injuries. Other risk factors included long working hours, factors related to working habits (i.e. recapping of used needles, not using protective gloves), short experience in nursing profession, and other work-related factors (working on surgical disciplines, being a senior/ nursing officer). This study suggests that needle stick injuries could be considerably reduced in developing country environments by organizing adequate training on needle stick injuries. Future research should investigate what type of training is most effective. In addition, attention should be paid to reducing heavy workloads and to adequate training for specific work tasks among the nursing workforce.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References

We thank Dr Kikampiaho, the Director of Mulago hospital, for granting us the permission to carry out the study in the hospital and for supporting it, and Dr Kamya for his valuable assistance with the data collection. Fredrich M. Nsubuga and this study were supported by a grant from the Kulika Charitable Trust.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Validity of the results
  8. Conclusions
  9. Acknowledgements
  10. References
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