USAID Impact Photo Credit: USAID and Partners

Archives for Health

A Tale of Two Citizens

By: Clydette Powell, MD, MPH, FAAP

It was the best of times; it was the worst of times.  January 12’s earthquake, epicentered in Port-au-Prince, killed over 200,000 people, but also mobilized one of the largest humanitarian disaster responses in the Western Hemisphere in the last 60 years.  As Medical Officer at USAID/Washington, I was part of that response.

Dr. Clydette Powell on the USNS COMFORT in January 2010. Photo Credit: USAID/Global Health

They lay in adjacent incubators – two of Haiti’s newest citizens – one born in Port-au-Prince, the other born on a ship in the harbor. Both premature, weighing in at some three pounds.   Catherine was born one day before the earthquake. Barely 24 hours old on January 12, 2010, Catherine and her mom were suddenly homeless.  Her mom could not breastfeed, and Catherine became dehydrated and ill. After days of wandering the streets of Haiti’s capital city, Catherine’s mom was found by a medical triage team who sent them both to the US Navy hospital ship, the USNS COMFORT, which had just arrived in the harbor. On board, Isabella Rose, her incubator neighbor, had just been born by C-Section. Her mom had been severely injured during the earthquake, and went into premature labor. Again, another triage team sent Isabella Rose’s mom for emergency obstetrical care on the USNS COMFORT, and Isabella Rose took her first breaths on board a US Navy hospital ship.

On the evening of January 12, I had seen the broadcasts of the earthquake’s devastation and the misery it brought to people of a country where I had worked for USAID on numerous short term assignments since 2001. Without hesitation, I volunteered to be part of USAID’s response to this disaster.  Being the civilian-military liaison for our Health Office within the Bureau for Global Health, the medical officer in the Infectious Disease Division, and a member of the Haiti Health Team provided the foundation for quick deployment.  Invited by the Commanding Officer to serve on the USNS COMFORT, I sailed down with its crew and found myself in several roles, including as neurologist in the Pediatric Intensive Care Unit, when Catherine and Isabella Rose arrived.

Our USAID/Haiti Health team, themselves survivors of the earthquake, and our team on board the COMFORT quickly established communication links. We worked in tandem to triage, transport, and care for the most severely injured.  During the course of two months, the ship-based and the land-based teams collaborated in the care of over 1,000 patients. More than 2,000 helicopter flights transported patients and teams between ship and land. Public health priorities and support for the stewardship role of the Haitian Ministry of Health became daily (and nightly) discussions of both the ship and USAID land-based teams. As the relief effort grew, so did the complexities of patient management, the coordination of care, and the optimization of public health disaster relief responses.  Yet on a microcosm, there were still the Catherines, the Isabella Roses, and other children—the displaced, the orphans, some likely restaveks—and injured adults,  all of whom  sought emergency medical care on board the USNS COMFORT.

As I look back to one year ago, representing USAID in the Haiti earthquake response  generated in me a renewed sense of patriotism, increased admiration for our USAID/Haiti team,  greater esteem for the US Navy,  lasting gratitude for my medical and public health skills, and an even deeper respect  for  the Haitian people.  In the worst of times/best of times perspective, Catherine received her angel wings, to use the Navy parlance, but Isabella Rose bloomed. One of Haiti’s newest citizens, she became a symbol of her people’s resilience, and a tiny testimony to the effective collaboration of USAID, the US Navy, and the non-governmental organizations when all things can work together for the good.

Pharmaceutical Management – Assuring the Quality and Safety of Medicines

By Maria A. Miralles, PhD, USAID’s Senior Pharmaceutical Management Advisor

At the moment of using a medicine, do we trust that the product is of good quality and will not cause us any harm?   For those who live in countries with competent regulatory agencies and functioning systems, the answer is yes and this trust is generally well-placed.  This is pretty amazing when you consider the myriad of opportunities for problems to arise, from product development through to manufacture, distribution and use.  So, not many people were alarmed in April 2010 when the FDA informed the manufacturers of Children’s Tylenol® of violations in its Pennsylvania manufacturing plant affecting several dozens of products. The company immediately issued a voluntary recall, products were withdrawn from the market, potentially related morbidities and deaths were subsequently monitored.[i] Unfortunately, many developing countries lack the capacity to protect their citizens in this way, much less to protect them from unscrupulous drug manufacturers and vendors. What should be a matter of trust is more like a tragic game of chance with devastating odds.

Counterfeit ampicillin discovered through the PQM monitoring program in Southeast Asia. Photo Credit: Christopher Raymond (PQM/USP)

Many of us can remember the deaths of 138 Panamanians who consumed tainted cough syrup in 2006 and the 84 children in Nigeria in 2008 that were exposed to a teething medicine made with a counterfeit ingredient.  In both cases, investigations determined that these deaths could have been avoided had the responsible systems and authorities been vigilant and the systems sufficiently responsive.[ii] Deaths are not the only sign of potential product quality and patient safety problems.  Antimicrobial medicines with sub-therapeutic quantities of active ingredients have contributed to the rise in resistant strains of various infectious diseases rendering existing cheaper products useless and prolonging treatment periods. There is no question that there are likely to be many others cases we will never know about because they have occurred in places where there was no system in place to properly document them.

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Supporting Sustainable Livelihoods and Nutritious Meals

Food and nutrition are important elements across all cultures. In America there is a renewed sense of instilling good nutritional habits in children through the First Lady’s campaign against childhood obesity and the newly signed Healthy, Hunger-Free Kids Act. At USAID, we are concerned with not only feeding those in need around the world, but making sure they have access to healthy and nutritious meals on a regular basis, as well as a sustainable livelihood.

But for many people living with HIV/AIDS (PLWHA) like Thabit Obed, a farmer from Uganda, managing one’s health is no easy task. The infection causes or aggravates malnutrition through reduced food intake, increased energy needs, and poor nutrient absorption. Malnutrition weakens the immune system, which can hasten the progression of HIV, increase susceptibility to opportunistic infections, and reduce the effectiveness of treatment. Since food and nutrition support is such a critical component of successful HIV/AIDS care and treatment, USAID has an invested program to help those in need.

Mr. Thabit Obed, has mobilized fellow PLWHA to produce groundnuts for therapeutic food to treat malnourished PLWHA. Photo Credit: Mary Nabisere/NuLife

Thabit is a recipient of support from the USAID-funded program, NuLife—Food and Nutrition Interventions for Uganda, a program managed by University Research Co., LLC (URC) that works to improve the health and nutritional status of people infected and affected by HIV/AIDS through integration of nutritional assessment, counseling, and support (NACS) into HIV/AIDS services.

In addition to producing and prescribing food, such as RUTAFA a ready-to-use therapeutic food, the program also works to provide opportunities for farmers in Uganda to expand their businesses.

Through a partnership with RECO Industries, Ltd, a local manufacturer which produces RUTAFA, Thabit was able to expand his small coffee bean farm and begin growing groundnuts.

Thabit, an active community volunteer, became one of more than 4,000 farmers to grow groundnuts as input for RUTAFA. He was trained to support other PLWHA and raise awareness about HIV testing, counseling and treatment.

Through this program and similar partnerships, USAID NuLife has been able to help ensure HIV positive individuals who have recovered from malnutrition through treatment with ready-to-use therapeutic food are being offered an opportunity to earn a living, support their families’ and maintain a healthy nutritional status.

USAID/Uganda designed a program that not only reaches HIV positive clients with critical services and supports local industry and individual farmers, but connects those clients to sustainable livelihood opportunities producing inputs for the very product, RUTAFA, which can support their health and that of their fellow PLWHA.

“Helping Babies Breathe” Global Development Alliance Results in New Innovative Company

Sixty seconds – that is all it takes to breathe life into a newborn that is gasping for air.  This is the golden minute that can mean the difference between life and death for a newborn who is not breathing.  Jubaida, the community midwife, from Bangladesh was trained and equipped to act rapidly and appropriately when she heard no cry and felt no breathing when Baby Shifa was born.  Jubaida gently dried and rubbed the baby and, as the family looked on, she used a bag and mask and helped Baby Shifa breathe as the hands of the clock ticked by.

Helping baby Shifa breathe in Bangladesh. Photo Credit: Tore Laerdal

Every year, 10 million babies require help to breathe immediately after birth. Simple means to stimulate breathing, including drying and rubbing, and ventilation with bag and mask, could save the majority of these babies. Such lifesaving care is currently only available for less than one out of four newborns.  Scaling up newborn resuscitation is challenging because it requires provider skills, appropriate equipment, and systems strengthening.  In order to meet the Millennium Development Goal 4, birth attendants in large numbers must acquire the basic skills and equipment to help newborns breathe.

Challenged by this, USAID searched for a feasible and effective approach to scale up newborn resuscitation and found the answer in the Global Development Alliance model.  On June 16, 2010, USAID launched a Global Development Alliance (GDA).  The objective of the GDA is to reduce newborn mortality by expanding access to high-quality, affordable newborn resuscitation training materials and devices, improving the competence of birth attendants to resuscitate newborns, strengthening health systems and promoting global commitment and resources for life-saving newborn care.  A seemingly impossible task of scaling up newborn resuscitation became programmatically possible by bringing together diverse partners in an alliance.

This partnership is ground-breaking in many ways. The GDA model is a new way of doing business in the field of newborn health and has now become a key USAID strategy to roll out newborn resuscitation globally.  The approach is not without risks since, except for the long-standing partnership between USAID and Save the Children, it has forged a partnership between other organizations who had not previously worked together.  The GDA has also brought two USG Agencies – NICHD and USAID – together in a concrete and actionable way that took advantage of each Agency’s comparative advantage, i.e., NICHD’s research capacity and USAID’s program implementation capacity.  The individual partners of the GDA are themselves creators of innovative solutions: Laerdal developed a very low cost, life-like manikin (NeoNatalie) and a transparent suction bulb in response to the global need for a low-cost, resuscitation training simulator and an easy-to-clean and boilable device to clear the newborn’s airway; these life-saving technologies are available on a not-for profit basis to all 68 Millennium Development Goal countries.   AAP developed the “Helping Babies Breathe” curriculum that simplified the resuscitation action algorithm so that it can be implemented even in peripheral health facilities and communities.

Within six months of launching the GDA, 17 countries are planning to integrate “Helping Babies Breathe” within their newborn programs, AAP has pledged to train one million health providers by 2015, and Laerdal decided to spin off a new company called Laerdal Global Health to focus on developing new technologies at the base of the pyramid to address maternal and child health.

From Lab to Communities: Pioneering Low-Cost Approaches to Prevent Death and Treat Severe Illness

The third installment of the 2010 Health Research Report to Congress is newborn health. Today, we look at USAID’s seminal role in working to focus global attention on the issue of newborn survival as well as its investments in establishing the research foundation for action in this area.

USAID works to accelerate innovations through the complete development cycle — out of the labs and through a massive scale-up, into the communities to directly benefit the world’s poor. Our goal is to develop ways to save more lives and reduce the burden of diseases as effectively and efficiently as possible.

Of the estimated 8.8 million children under 5 that die each year – 3.7 million are newborn infants who die within the first four weeks after birth. Up to two-thirds of these deaths can be prevented through existing effective interventions delivered during pregnancy, childbirth and in the first hours, days and week after birth. USAID develops and tests simple, low-cost approaches with the greatest potential to prevent death and treat severe illness in low-resource settings with limited access to quality facility-based care.

An Afghan nurse checks a crying newborn boy who was born that morning in the maternity ward of a hospital in Kabul on March 15, 2010. Afghanistan has one of the highest maternal mortality rates in the world with an estimated 1,800 maternal deaths per 100,000 live births.  Photo Credit: AFP PHOTO/BEHROUZ MEHRI

A growing body of knowledge has shown that home visits by appropriately trained workers to provide newborn care can significantly reduce neonatal mortality even where health systems are weak. Building on an evidence review, WHO/UNICEF released recommendations in 2009 providing new guidance on the importance of home visits in a baby’s first week of life. USAID is promoting and supporting partner country adoption of these recommendations into national programs, encouraging further investment in this area and assisting with capacity building efforts for health care providers and community cadres providing home-based care.

In countries with high mortality rates and weak health systems, high impact community-based approaches such as diagnosis and treatment of child pneumonia and newborn sepsis must be as accessible when it is needed to the people who stand to benefit the most. Approximately one-third of newborn deaths can be attributed to infections caused by birth in unhygienic conditions. A multi-country trial supported by USAID, in partnership with the Bill & Melinda Gates Foundation’s Save the Children/Saving Newborn Lives program; and WHO, is researching different combinations of oral and intramuscular antibiotic regimens for simplified treatment of newborn sepsis in the community.

Each year, 10 million babies suffer from birth asphyxia; 10 percent of these newborns do not survive. USAID has supported the development and validation of newborn resuscitation training materials and devices used to develop the American Academy of Pediatrics’ Helping Babies Breathe (HBB) training curriculum. The Helping Babies Breathe Global Development Alliance (GDA), a public-private partnership launched by USAID along with several partners, is introducing HBB in multiple countries and offers evidence-based training and technical support on newborn resuscitation and high quality, affordable resuscitation devices to birth attendants in low-resource settings.

USAID is also supporting studies looking at the prevention and treatment of neonatal infections through the application of antiseptic to the newborn cord in parallel with research efforts to determine optimal product packaging; the effectiveness of low-cost resuscitation devices in treating birth asphyxia; and strategies to manage care for low-birth weight children including kangaroo mother care or skin-to-skin care.

A recent article in the Lancet noted USAID’s seminal role in working to focus global attention on the issue of newborn survival as well as its investments in establishing the research foundation for action in this area. Under the President’s Global Health Initiative, USAID will expand investments in game-changing innovation through promotion of research and development. Expanding these programs will mean providing easier access at a single location for a broader set of medical and health interventions. It means focusing more clearly and getting the full package of basic health services out to those people who are most vulnerable because they lack access to any protective care at all.

 

Photo Essay: Riding for Health in Lesotho

The USAID-supported Horse Riding for Health program engages pony riders and motorcycle riders to transport blood tests, drugs, and supplies to Lesotho‘s remote mountain health clinics.

The system allows people to receive HIV test results sooner, access life-saving drugs, and ensure an uninterrupted supply of medication.

In this photo essay, follow the riders to homes and clinics throughout tiny Lesotho to meet:

Maamohelang Hlaha: An HIV-positive mother of four whose village is inaccessible by vehicles and a three-hour hike from the nearest health clinic

Potso Seoto and Thuso Khanare: Dedicated riders who transport life-saving medicines while supporting their families through a stable job

Dr. Leopold Buhendwa: The Elizabeth Glaser Foundation’s Lesotho country director who works to prevent mother-to-child transmission of HIV

 

2010: A Year in Review

With 2011 on the horizon, USAID looks at back at its accomplishments in 2010. Among them:

  • Supported the game-changing CAPRISA study, which in July provided the first ever proof of concept that a vaginal microbicide could safely and effectively reduce the risk of heterosexual transmission of HIV from men to vulnerable women. Science Magazine recently named the CAPRISA study one of the top ten breakthroughs of 2010.
  • Piloted a groundbreaking mobile banking technology to increase Haitians’ access to much-needed financial resources following January’s devastating earthquake.
  • Provided shelter, food and medical supplies for the more than 20 million people affected by the floods in Pakistan this summer.
  • Assumed leadership of Feed the Future, the U.S. government’s signature food security initiative, in December. USAID quickly established the Bureau for Food Security committed to addressing chronic hunger.
  • Announced the first recipients of Development Innovation Ventures (DIV) funds that will, among other outcomes, improve rural solar access and produce affordable, fuel-cell powered bicycles. The DIV promotes innovative and scalable solutions to core development challenges.
  • Launched a country-based strategic planning approach, with 20 Country Development Cooperation Strategies (CDCS) already underway. The CDCS will help the agency make evidenced-based decisions, prioritize investments, and hold itself accountable for results.

For more about USAID, please visit www.usaid.gov.

Integrating Family Planning, HIV, and MNCH Services in Ethiopia and Kenya

Alice arrives at a health center in Western Province, Kenya, with her nine-month-old baby girl, who has a recurrent fever. Alice suspects malaria, which is endemic in the area. Two hours later, she leaves with malaria medication and a free insecticide-treated bed net. To the casual observer, Alice got what she came for and had her health needs met. She even received a bed net she wasn’t expecting.

A nurse in Meshualekia Health Center, in Addis Ababa, explains how to use the injectable contraceptive, Depo-Provera. The client will also be offered an HIV test as part of the Ministry of Health’s efforts to integrate HIV and family planning services. Photo Credit:Ed Scholl, AIDSTAR-One

But consider what Alice didn’t receive. Had her daughter been weighed, the nurse would have noticed that her growth was faltering because Alice is not yet supplementing her diet with nutritious weaning foods. Her daughter also missed the measles immunization she was due for. Alice was not offered an HIV test, which would have revealed that she is HIV-positive. Finally, no one asked Alice, who has six children and does not want to get pregnant again, if she is using a family planning method or would like information about contraceptives available at the health center. In short, Alice’s immediate need was met, but multiple underlying health needs went undetected by the health center staff.

Alice’s story is unremarkable. Similar scenes play out every day in health care settings around the world. In sub-Saharan Africa, where the burden of HIV, unintended pregnancies, and infant mortality is highest, missed opportunities to meet health care needs, such as those of Alice and her baby, can be deadly.

Fortunately, programs in Kenya and Ethiopia are leading the way in integrating family planning, HIV, and maternal/neonatal and child health (FP/HIV/MNCH) services. In Kenya, the government has made integration of FP and HIV a national policy. USAID/Kenya’s AIDS, Population and Health Integrated Assistance II (APHIA II) project promotes integrated service delivery throughout the country in public, private, and faith-based facilities. Visiting the APHIA II project in Western Province (implemented by PATH), I noted that the Ministry of Health trains nurses and health officers to deliver both FP and HIV services. The project has supported FP/HIV/MNCH integration at 276 health centers and hospitals in Western Province. USAID/Kenya’s new APHIA Plus Project will expand integrated services in 2011.

Ethiopia’s Ministry of Health also supports integration and strives to offer an HIV test to all clients coming to public sector facilities. Clients are also assessed for family planning needs and offered counseling and FP methods. The government’s Health Extension Program, supported by USAID/Ethiopia, provides FP counseling and contraceptives in the home, HIV and child health counseling, and referral for services. These public sector efforts are complemented by such programs as FHI’s Home and Community-Based Care (HCBC) program (PDF), which strengthens integrated FP and HIV services offered in the community. The HCBC program is working with local iddirs—traditional neighborhood-based burial societies—that now provide mutual aid services to households affected by poverty and illness, including HIV. The iddirs recruit and manage community health volunteers, who provide home-based care and support to those living with HIV and counsel clients about FP and child health.

I observed many different models of FP/HIV/MNCH integration in Kenya and Ethiopia, including intra- and inter-facility referrals and strong linkages between home and community-based programs and health facilities. The type of integration model used is not as important as the fact that health workers in both countries now view clients more holistically and address more than a single health problem in a consultation or home visit.

The integrated programs I visited in Kenya and Ethiopia all report challenges, such as training health care workers in multiple disciplines and struggling to meet the complex needs of clients in crowded facilities, where it is difficult to focus on more than one health issue at a time. But providers are addressing these challenges through training and task shifting, the use of job aids and reporting systems that capture integrated services, and ensuring that contraceptives, HIV test kits, and other necessary commodities are available. The next time Alice visits a facility supported by these programs, odds are she will have more than just one child’s fever addressed.

Ed Scholl serves as AIDSTAR-One Project Director. AIDSTAR-One is funded by USAID’s Office of HIV/AIDS, and provides rapid technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs and promotes new leadership in the global campaign against HIV.

Pic of the Week: “A Historical Look Back”

USAID 50th Anniversary Logo

Peace CorpsThe work of USAID has been far-reaching and long-standing as evidenced by this photo of a Peace Corps volunteer working in the ORT center funded by USAID. In the mid 1970′s Joan Wadelton, a Peace Corps Volunteer from Princeton, New Jersey, holds one of the children she helps at a maternal and child health center in Niger. The center is operated by ORT, a voluntary agency, and the Nigerienne Ministry of Health, is financed by USAID. Photo is from USAID.

Maternal Death Preventable and Treatable with Low-Cost Interventions

In September, the World Health Organization (WHO) reported that fewer women die each year from complications during pregnancy and childbirth than previously estimated, but efforts to sharply cut maternal mortality by 2015 are still off track. A new report found that 358,000 women died during pregnancy or childbirth in 2008, mostly in poor countries of sub-Saharan Africa and South Asia. While the number of deaths is disturbing enough, it is estimated that an additional 15-20 million women suffer debilitating consequences of pregnancy.

Despite the challenges faced in reducing maternal mortality, USAID has helped to demonstrate that real progress can be made.  Our work proved that many of the major causes of maternal death are substantially preventable and treatable with low-cost interventions.  USAID has sharpened its focus on a set of effective interventions targeting high-mortality complications of pregnancy and birth – hemorrhage, hypertension, infections, anemia, and prolonged labor.  Together, these complications account for two-thirds of maternal mortality.  Hemorrhage alone accounts for almost one-third, and USAID has been in the forefront of promoting “active management of the third stage of labor (AMTSL),” a highly-effective technique for preventing postpartum hemorrhage.

The active management of the third stage of labor is a combination of actions to speed the delivery of the placenta and prevent up to 60% of postpartum hemorrhage cases. Through these simple actions, trained providers can prevent postpartum hemorrhage and play a vital role in saving women’s lives.

Spreading best practices like AMSTL are critical to saving lives of women and improving health around the world.  The U.S. Global Health Initiative has set ambitious targets like a 30% decrease in maternal mortality in assisted countries, with a priority on supporting innovation and sharing best practices, as well as building up the health systems that deliver these interventions.

A nationally representative facility-based delivery survey funded by USAID and conducted in 10 countries found limited use of AMTSL in only 0.5 to 32 percent of observed deliveries, and revealed multiple deficiencies in practice. These surveys helped to identify barriers and served as important catalysts to action. With the evidence and this data, USAID has worked with professional societies, researchers, UN agencies, NGOs and the private sector to safely and effectively introduce and expand AMTSL use in at least 40 high-mortality countries.

USAID supported efforts have led to policy changes in 16 countries in Asia, sub-Saharan Africa and South America. The Agency and its partners also contributed to the development and dissemination of the 2007 WHO recommendations for the Prevention of Postpartum Hemorrhage providing a clear global policy on the correct application of AMSTL and the 2009 WHO guidelines for the management of PPH and retained placenta. The strength of multiple implementation strategies—policy change, systems strengthening, social mobilization, technology development, and research— has yielded many valuable lessons about opportunities, challenges, and strategies for scaling up AMTSL.  A key lesson we have learned is that, when there is political commitment, AMTSL is rapidly scalable.

But USAID asks hard questions and supports the renewed attention to the programmatic implementation of this approach.  With that in mind, USAID is supporting a WHO-led study on the impact of eliminating the most complicated element- of AMSTL, controlled cord traction. If this study has positive results, a simplified AMTSL regimen would significantly reduce the complexity of training and AMTSL practice in health facilities and in the community.

Community-based strategies for preventing PPH are also important since between 40-50% of births occur at home.  USAID has piloted community-based distribution of misoprostol and  use of the Uniject® device prefilled with oxytocin, to address these needs.   Misoprostol is an effective uterotonic to prevent postpartum bleeding; unlike oxytocin, it can be administered orally and does not require refrigeration. USAID-supported studies in Nepal, Afghanistan, and Senegal have shown the feasibility of community-based distribution of misoprostol, indicating that the drug should be considered when oxytocin is not available at the community level. In Nepal, where 82 percent of women do not give birth in health facilities, a USAID-supported study showed that it is feasible to achieve high-population coverage of misoprostol through trained community health volunteers under the Government primary health care system and still have increased use of facility births due to the education provided to women/ families through the program.  USAID’s partnerships in Nepal contributed to a change in national policy and the pilot study has now become the Nepal government’s national program.  With support from multiple partners, the program is now being scaled up throughout the country.  Pilot projects or studies on oxytocin in Uniject in Mali proved that a 6-month trained birth attendant (matron) could provide oxytocin as safely as the midwives or physicians.  Mali has also changed its policy to allow matrons to use oxytocin and practice AMTSL.

Maternal mortality is still unacceptably high.  Together, we need to seize the momentum and enhance family planning and maternal health programs to quickly reduce the still unacceptably high toll of preventable maternal deaths. Secretary Clinton challenged USAID to build on existing global health programs and create lasting change. We have made great strides with previous investments, but as she noted, in many places a woman might be treated for HIV but die in childbirth.  This is not acceptable.

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