Preparing For Another Flu Season

The 2009 flu season was dominated by the global H1N1 pandemic that infected millions worldwide and sparked widespread vaccine shortages. Thomas Frieden, director of the CDC, and NPR's Joe Neel explain what health experts learned from the H1N1 outbreak, how to stay healthy in the 2010 flu season and the latest update on so-called drug resistant "super bugs."

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NEAL CONAN, host:

This is TALK OF THE NATION. Im Neal Conan in Washington.

Last year's flu season, we focused on a global pandemic: H1N1, also known as the swine flu. For months, experts warned how dangerous it might be and debated how individuals and governments should respond. It never approached the worst-case scenarios, but the pandemic warning was only lifted last night, and conservative estimates conclude that millions were infected, and thousands died around the world.

Last week, summer again made way for autumn and flu season. So what lessons did we learn? How bad was it? And how will you prepare this time around? Our phone number: 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. Thats at npr.org. Click on TALK OF THE NATION.

Later in the program, Slate's Farhad Manjoo on the media mania for Apple and Google, but first the flu. In a few minutes, the director of the Centers for Disease Control and Prevention joins us, but first, Joe Neel is with us here in Studio 3A, NPR's health editor. Thanks very much for being with us.

JOE NEEL: Hi, Neal.

CONAN: And a lot of people believe that H1N1 was way overblown last year.

NEEL: Well, it was in retrospect, you can say not as many people died as might have. But it's impossible to predict what the flu will do from year to year.

The CDC released some numbers at the end of August, some revised estimates of how many people die from a seasonal flu each year, and it varies widely, from 3,000 to 40,000.

And so when you start out with a new strain, where people haven't been exposed to it before, it has certain characteristics. It's better to be safe than sorry. So, you know, getting things in gear, trying to get the vaccine out there early and making preparations was the prudent thing to do.

CONAN: But there's the Chicken Little effect. If you say the sky is falling, and it doesn't, people aren't going to be so willing to listen next time.

NEEL: You got that right. It's one of the central problems in public health. And in the end, only about one in five people actually got the swine flu or the H1N1 vaccine last year.

CONAN: The other thing we learned was about the rapidity with which the vaccine industry can respond and come up with something new.

NEEL: Yeah, it's still a pretty ancient technology. The flu virus has to be grown in chicken eggs. And so you have to have millions of chicken eggs to get the required number of doses of vaccine. I mean, we're talking tens - hundreds of millions of doses of vaccine here. And it's a tedious process.

And it turned out that this strain of H1N1, the pandemic strain, grew very slowly in eggs. So that complicated things, and the vaccine wasn't ready last year until the middle of October, even though we started seeing quite a few cases by early September.

I looked back at September 30 of last year, exactly a year ago today, and the CDC said that 60 people had died at that point of the pandemic flu strain and that about a million had been infected with the virus at that point. So it was taking off.

CONAN: It was taking off. And there are so few companies involved with this, and it's apparently not a big moneymaker.

NEEL: It's a marginal moneymaker when you look at how much they make off of regular drugs. And it's labor-intensive. I mean, you've got the whole chicken-farm operation.

So in a couple of years, two or three, I don't know how many years, there will be a different process that's more streamlined, and perhaps it will be more profitable for companies to be in this business.

CONAN: Let me also ask, just to anticipate some questions our callers may have, that is, well, we've just seen a big outbreak of salmonella in eggs. Is this going to be safe if you're using all those eggs to grow vaccines?

NEEL: Well, they test the eggs. They're grown in very controlled environments, high security. It's not anything like the agricultural things that we've seen out in Iowa. These are grown in very controlled circumstances.

CONAN: And again, people are going to ask questions about the effectiveness of preventive methods. Always a good one: wash your hands an awful lot. But the other one was masks. Are they effective, or are they a waste of time?

NEEL: Well, we don't know. I mean, we don't know if masks did anything last year or not. People, we didn't see people, in this country, at least, wearing masks to any great degree.

You know, masks are of limited effectiveness because they can't seal tightly enough against the face to prevent air from escaping around the side, and people sneeze in their masks and so...

I mean, they do provide some barrier, you know, in certain settings like hospitals and health care settings, it's probably advisable to think about using them.

CONAN: When this final announcement was made, the director-general of the World Health Organization, Margaret Chan, said that an important part of why H1N1 was not more deadly was good luck.

NEEL: Oh, absolutely. It's just not like I said, you can never tell, at the beginning of a flu season, where it's going to go.

CONAN: And the other part, is this now incorporated as part of the annual flu vaccine that millions of people will get?

NEEL: Well, it will be this year. They expect it to be one of the dominant strains. Each year, the seasonal flu vaccine contains three strains. There's one for Influenza A, Influenza B and - two for Influenza A and one for Influenza B, I think. And this year, the H1N1 is in the seasonal vaccine.

CONAN: So, but that's a bit of a crapshoot, too. I mean, there could be other strains that come up.

NEEL: Could be, could be. It's never known. But generally, if you look over the long term, the seasonal flu vaccine is about 70 to 90 percent effective. It catches it in most years.

CONAN: The other thing we saw last year, as this epidemic occurred, was that there were interesting new ways to track it using computer devices, Google maps, basically. Are those being incorporated by places like the CDC?

NEEL: Oh, yeah, they have very intensive surveillance methods. And I was reading something about Google in Europe, that showed that it tracked the epidemic quite well.

CONAN: And so this is a good way to anticipate where it's going to blow up quicker than getting the reports from hospitals and that sort of thing?

NEEL: That's right. That's a slow process. It's still slow.

CONAN: We're talking with NPR health editor Joe Neel right now about the flu, and we're going to be joined in a few minutes by Dr. Thomas Frieden, who's the director of the Centers for Disease Control and Prevention. 800-989-8255. Email us, talk@npr.org. Laura's(ph) on the line, calling from Glen Burnie in Maryland.

LAURA (Caller): Hello, Neal, wonderful show, as always. I just want people to know, I just had my regular checkup with my doctor yesterday, and he said, you know, let me give you a flu shot while you're here.

And it's readily available, and it's one shot, combined, both the N1H1 and the seasonal flu. It's painless, and I haven't started to go oink, oink and run around in the garden.

CONAN: Well, give it time, Laura.

(Soundbite of laughter)

LAURA: Well, my point is that everybody should go out and get vaccinated. I think we were lucky last year and that we shouldn't mess around. And, you know, you can get it at the supermarkets, or at your doctor or whatever. It's one simple injection, and believe me, it doesn't hurt a bit, and there's no you know, I haven't had any side effects.

I just wanted people to know that. It's a wise thing to do.

NEEL: And I would point out, this year there's a new flu vaccine for people over 65. It's a higher-dose flu vaccine called Fluzone. I think I've got that right. Yeah, Fluzone, and it's three times the dose of the regular shot, and elderly people I'm just saying this for elderly people, trying to get this in here that they have weaker immune systems and need the higher dose.

CONAN: And there's a little gray in Joe's hair. So he will soon learn to say older people, not elderly people.

NEEL: Getting closer every day.

CONAN: Thank you very much for the call, appreciate it.

Joining us now from Atlanta is Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention, and thanks very much for taking the time to be with us today.

Dr. THOMAS FRIEDEN (Director, Centers for Disease Control and Prevention): Thanks very much for having me on the show.

CONAN: And we were just talking about the conclusion by the director of the World Health Organization. We were lucky last year? Do you agree with that?

Dr. FRIEDEN: I think it's important to put what happened last year into perspective. It was not a mild flu season. We had five times more deaths among children and young people than in an average flu year.

But it's certainly the case that it was nowhere near as bad as it could have been if we had had an organism that was as deadly as the 1918 flu pandemic.

CONAN: The other problem with that, of course, sure you have to be prepared for what might be just terrible flu season, but people were warned. Some people got a little disturbed, and then it turned out to be not as bad, at least in this country, as feared.

Dr. FRIEDEN: There was certainly relief that it wasn't as deadly as we initially heard out of the reports at the very beginning from Mexico. But in many parts of the country, it was quite disruptive. You had hundreds of cases in schools. You had many kids sick.

It was certainly a younger people's pandemic, not only in this country but throughout the world, and quite a bit of difference in different countries. So there were parts of the world where there was very little H1N1 last year for reasons that we really don't fully understand.

What we do know is that you need this year's flu shot to protect you from this year's flu, and the flu vaccine that's available with plenty available now has not only the H1N1 but also the other strains that are most likely to be circulating.

CONAN: And is it just me, or am I seeing more of these signs, get your flu shot here, you know, at drug stores and even grocery stores that have pharmacy departments. I'm just seeing a lot more of those.

Dr. FRIEDEN: I think there's a steady increase in the number of places that people can get vaccinated. There's also lots more supply than there was in the past. And we're optimistic that more people will recognize that flu can be serious.

Every year, thousands of people die from the flu. So getting more people vaccinated is important, and for the first year, we're recommending that virtually everyone get a flu vaccine, everyone over the age of six months.

CONAN: Let's get a caller in. This is Jenny(ph), Jenny with us from Davidson in North Carolina.

JENNY (Caller): Hi there.

CONAN: Hi, Jenny.

JENNY: You just touched on the point I was calling about. We've just moved back to the States after living in Switzerland and then in England for the past seven years. And we've got four kids.

And in Switzerland, they did not want any of my kids or my husband and I to get the vaccine, even I had two that were premature children. And then in England, they were more open to it but nothing like it is here. And I'm just wondering if it's a cultural thing or if there's more of a need here. I'm just not sure if I should have my children get the flu vaccine here.

CONAN: Dr. Frieden?

Dr. FRIEDEN: Well, my kids are getting the flu vaccine this year and every year, and we certainly recommend it for parents and kids and everyone.

The flu isn't usually a mild illness. People think about the common cold. Flu can make you feel pretty miserable, knock you on your back for a few days, and particularly for young children and the elderly, can put you in the hospital and potentially can kill you. So...

CONAN: Is there a policy difference, though, in places like Switzerland?

Dr. FRIEDEN: There's a big difference in vaccine policy in different countries. In fact, in many countries in Europe, there aren't particularly high vaccination rates even for things like measles, which is quite deadly.

And as we think about the control of measles, and there's been no measles in this hemisphere for years, we look at Europe, and we wonder what more they might be doing soon to improve their control of conditions like that.

CONAN: Jenny, thanks very much for the call, good question. We appreciate it.

JENNY: Thank you.

CONAN: And let's say thanks to Joe Neel, NPR's health editor, who's been here manning the fort in Studio 3A. Thanks very much, Joe.

NEEL: Sure, thank you.

CONAN: When we come back, more questions with Dr. Thomas Frieden of the Centers for Disease Control and Prevention, also talking about their efforts overseas to pick up which diseases might be coming in to this country. Stay with us for that. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. Im Neal Conan in Washington.

We often hear from the CDC when an outbreak occurs in the United States, a virus or widespread food poisoning. Of course, they also offer recommendations on the flu and vaccines. They do a lot of other jobs, too.

What you may not know, the CDC also operates in more than 50 countries, working to stop the spread of disease before it ever reaches the U.S. coastline.

We're talking today with the head of the Centers for Disease Control and Prevention, Dr. Thomas Frieden. If you have questions for him about the CDC and its work, especially overseas, give us a call, 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. Go to npr.org. Click on TALK OF THE NATION.

And let's see if we can get another caller on the line. We'll go to Sara(ph), Sara with us from Grosse Pointe in Michigan.

SARA (Caller): Oh, hi, Neal. I had a question about who decides on the distribution of these vaccines? Living in Metro Detroit last year, I am the mother of a two-year-old, and just trying to get a vaccine, I had to go to 30 different pharmacies, and everyone was running out.

So I was just wondering if someone could answer, you know, who decides, who makes these decisions, and also, are we going to have enough - at least in Michigan?

CONAN: I'm guessing this was at about this time last year, you were looking for the H1N1 vaccine?

SARA: Yes, and I went to my pediatrician, and she was - she's like I'm out.

CONAN: Okay, that's...

SARA: And I would go to Rite Aid and all the other pharmacies, and they would say no, we just have the regular flu vaccine, not the H1N1, we're out.

CONAN: Okay, Dr. Frieden, can you help her out?

Dr. FRIEDEN: Sure. This year, there's plenty of vaccine. There are already 100 million doses out there. There's plenty. The question was who decides.

And the way it works generally is that the market decides, and that works pretty well in an average flu year. It didn't work very well last year, when there just wasn't enough soon enough because the vaccine ended up growing slowly in eggs, and the methods we have to make it are slow, and in fact, that ties in to the issue that was just raised about global health.

This virus, H1N1, probably emerged in Mexico a couple of months before it was recognized, and it was actually first detected here in the United States. If we had known about it a couple of months earlier, it would have made a big difference because we would have had much more vaccine available earlier in this country, and that's one of the things that reminds us that we're all connected by the air we breathe and by the food that we eat.

CONAN: And all connected globally. It's not just those of us who travel around this country, too. Sara, I think you should not expect any difficulties at this time this year.

SARA: Oh, good. Well, thank you so much.

CONAN: Thanks very much for the call, appreciate it. My doctor, writes Adele(ph) by email, my doctor has told me in the past I should not get my flu shot too earlier in the year because the flu season often extends into the spring, and immunity can wear off.

Dr. FRIEDEN: It's a great question, and for most people, really any time in the year is fine. What we worry about most is that people will go to their doctor and say, well, I want to put it off for a month, and then maybe they don't come back in a month, or a month later, they don't get the flu shot because it slips through the cracks.

So really, any time to get a flu shot is a good time. It is true the peak of flu season usually doesn't come until around January or February, and we see cases in April and May.

The only population that we worry about a little bit more in terms of that immunity waning, are frail elderly, where the vaccine immunity may wane within a couple of months. And that's why this year for the first time there is the higher-dose product available for seniors.

Now, we don't know for sure that it will protect you better against the flu, but we do know that the laboratory tests suggest that you get a higher boost to your immunity from it.

CONAN: Back in April, the Washington Post reported that half of the nation's 229-million-dose stockpile of vaccines went unused. Tens of millions of doses were destroyed. First, what happened? And how much of the immunization program expenditures, at one point $6 billion, does that represent?

Dr. FRIEDEN: Well, first remember that when we began vaccine production, it was assumed that everyone would require two doses of vaccine. Since it was a new virus that people were not exposed to, all of our experience with similar situations in the past suggested that to protect people, it would be necessary to get two doses.

Second, it turned out, good news, that most people, everyone over the age of nine, only needed a single dose. So that greatly reduced the amount of vaccine that was needed in the end. And of course, the vaccine wasn't available as soon as we would have wished.

If there were a way, if technology had cooperated, if the virus and the vaccine strains had cooperated, we would have had vaccine much sooner, and a much greater proportion of it would have been used.

CONAN: Let's see if we can get another caller on the line. Let's go next to this is Michael(ph), Michael with us from Carson City in Nevada.

MICHAEL (Caller): Hi, I have a question. There are nurse call lines throughout the world now, and they generate a continuous, real-time stream of data on symptoms from the people that are calling in. Has that been tapped into as part of the CDC surveillance program?

Dr. FRIEDEN: That's a great question. There are a lot of very important ways to look at early warning systems for flu and other infectious diseases.

As you mentioned earlier, Google has one. We've worked closely with emergency departments so that when we get an increase in the proportion of people coming to emergency departments with fever and cough, we can detect that as a signal.

All of those signals are important. They're important to assess which are most accurate. We found, for example, that school attendance is not very accurate. There are lots of reasons kids don't come to school, and sometimes, illness is not the primary one.

But what's important for any of those signals is that there's then a way to investigate, to figure out, through both tracking individuals and doing laboratory testing, what's really going on. And we have a network in this country and around the world to follow up on signals like that.

Influenza is really an interesting example because there are influenza laboratories around the world, and we collaborate globally to determine what strains are circulating, and then we decide globally what strains to put into the vaccine each year to match the most likely strains that will circulate each year.

MICHAEL: Is anyone tapping into that database for the call lines?

Dr. FRIEDEN: Yes, we've looked at call lines, emergency department visits, pharmacy sales of cough medications, a number of other...

CONAN: Do you look at the Google maps?

MICHAEL: Well...

CONAN: Hold on, Michael. Let him answer my question. Just a second. I get some, too. Go ahead.

Dr. FRIEDEN: Yes, we've looked at the Google maps. We found that the emergency department systems are a little quicker, and Google trends is very interesting. All of the information sources are helpful.

CONAN: Michael, go ahead now, I'm sorry.

MICHAEL: Well, I just it's real-time data, and it's coming from the home, which gives you the phone number and the zip code. You can and it allows you to hit those things much more quickly than when people wander into an emergency room.

I'm familiar with the ER data-reporting system. It is, you know, you get a lifetime of...

CONAN: Michael, excuse me, he said they use it.

MICHAEL: Pardon?

CONAN: He said it's good data, and they use it.

MICHAEL: Oh, I'm sorry. I didn't catch that part.

CONAN: Okay, yes he did. So he's alive to your concerns.

MICHAEL: Great, thank you very much.

CONAN: Okay, thanks very much for the phone call. Let's see if we can go next to this is Robert(ph), Robert with us from Cape Coral in Florida.

ROBERT (Caller): Hello there. Given that according to the CDC statistics last year, the H1N1 was approximately .056 percent fatal. And one would need to cross the road several thousand times to have it as fatal as the H1N1.

Now, I'm not underestimating how serious influenza could be because some people did die from it, but given that the Lancet published a study comparing vaccinated and unvaccinated influenza patients, patients who had, you know, either were vaccinated or unvaccinated in assisted-living facilities in the United Kingdom, 2007, I think it was February in the Lancet, they said in the conclusion that the influenza vaccine was, verbatim, practically useless in preventing influenza-like disease.

And that's what I've experienced in my own practice is that those who get the influenza shot are no less likely to get sick, other than from getting neurological issues.

CONAN: And you say your practice, you're a doctor, Robert?

ROBERT: That's correct.

CONAN: Okay, let's get a response from Dr. Frieden.

Dr. FRIEDEN: Well, I think the literature is actually quite clear that influenza vaccine is protective. It will vary from year to year, depending on how much influenza is out there and how well the vaccine matches the strains that are circulating.

The one group where there's been debate is in the elderly, where particularly in the frail elderly, the flu vaccine may induce very limited immunity, and again, that's why this year for the first time, and we don't know that it will be more effective, but it may be, there's a high-dose vaccine for seniors, which in the laboratory at least induces more antibodies.

Whether those antibodies correlate with being protected if you're exposed to flu remains to be seen, but I think there's...

CONAN: I'm sorry, Robert?

ROBERT: I would contradict you on that, that the production of antibodies is how vaccines are measured in their effectiveness. They're not measured by whether they're protective or not.

Dr. FRIEDEN: Actually, that's...

ROBERT: If we look at antibodies and consider that they perhaps provide immunity, we can look at people with HIV, shingles, hepatitis...

CONAN: Robert...

ROBERT: ...you name it. And those people would then be healed because of the antibodies, but they're not.

CONAN: Dr. Frieden?

Dr. FRIEDEN: Well, I agree with you partly, but I disagree with you partly. I agree with you that the antibodies don't always protect against the infection in the cases you mentioned, absolutely. In influenza, I don't know whether the high-dose vaccine is going to be more effective in people or not. That's what science is about. We'll know that with more studies over time.

But I do know that we do very systematic analysis of what's called vaccine efficacy - how well vaccines work. And there is very strong evidence that the flu vaccines are very effective at reducing both the likelihood of getting flu and how sick you'll be if you do get flu. They reduce hospitalizations and illness.

CONAN: And, Robert, I hear you wantign to come in and debate this point, and that's interesting. And I'm glad you called, but we have to give some other people a chance.

ROBERT: Independent research says otherwise, more or less.

CONAN: All right. We hear your last point.

ROBERT: Thank you.

CONAN: Thanks very much for the phone call. Appreciate it. One last email on this. Tina(ph) in Hillsboro, Kansas: What's the best option for a child with an egg allergy? Also, will the FDA approve another flu vaccine that's safe for people allergic to egg in the near future?

Dr. FRIEDEN: I would have to double-check, but I believe the nasal vaccine is not - I'm actually not sure. I don't want to give misinformation, so I would say consult your doctor. It's a rare occurrence that there's a true egg allergy, but it does occur, and that is pretty much the one contraindication to flu vaccination.

CONAN: And Rob(ph) in Saint Louis: H1N1 came in from Mexico. Public health officials rightly focus on the risks of novel influenza developing in other parts of the world, particularly Southeast Asia. In fact, we depend on each country to share information internationally about novel influenza. One concern is that developing countries claim they might not share with the world community information about novel influenza strains they discover within their own borders, unless the U.S. and other developed countries guarantee that developing countries will receive vaccine during a pandemic. Meanwhile, wealthy countries appear reluctant to share scarce pandemic vaccine. What sort of progress is being made to resolve this disagreement?

Dr. FRIEDEN: Another great question. One of the things that CDC does is to help countries build their own capacity to monitor health problems, both by developing laboratories to test for conditions, to implement vaccine programs. We have staff around the world who work with health ministries and other organizations. We have influenza assignees who help countries develop their own laboratories, so that they can determine what's happening there. And we are all connected by the air we breathe, so once any country, whether it's the U.S. - because it was actually the U.S. that diagnosed H1N1 first - or any other country finds it, it's in everyone's interest to get that information out there.

The CDC provided diagnostics for H1N1 to virtually every country in the world. We also provided the seed strains for the vaccine to anyone who wanted it, any manufacturer who wanted it. And the issue that you raise of the equity of vaccines nationally and globally is a very important one.

In this country, we had tremendous progress with something called the Vaccines for Children's(ph) Program, which ensures that whether you're insured or not, whether you're rich or poor, you have equal opportunity to get vaccinated. And that's really important, not just from a justice standpoint, but from a disease-control standpoint. Everyone is better off if people get vaccinated.

Globally, there's Global Alliance for Vaccines and Immunisation, or GAVI, and it's very important in promoting vaccination. There are lots of vaccines that would save many lives and aren't yet being widely used, so the urgent need really is to continue to increase the availability of funds and the implementation of programs in global immunization and also to drive those costs down whenever possible.

CONAN: Dr. Thomas Frieden of the Centers for Disease Control. You're listening to TALK OF THE NATION from NPR News.

And I know we're focusing on flu because it's the start of flu season, and I guess it's the one disease that everybody has - well, we have to worry about it every year, but there are some other things that the CDC watches out for. And we've heard lately of something called the super-bug, which comes to us from India. Can you tell us a little bit about it, and how worried we might be?

Dr. FRIEDEN: We know that, basically, from the first time there have been antibiotics, there have been organisms that have developed resistance to those antibiotics, and that resistance has gotten worse and worse over the years. Basically, we have a race between how careful we are in using antibiotics, so it doesn't - we don't promote the development of resistance and how flexible the bacterial and viral genomes are in developing resistance.

And we need to be very careful with the antibiotics we have, so that we can reduce the risk and reduce the risk that we'll be at some point - we talked today about a pre-antibiotic and an antibiotic era, and we have to be careful where at some point for some germs, we're going to be in a post-antibiotic era. That means controlling the use of antibiotics, only using them when absolutely necessary, and then when using them, making sure that they're used correctly. Diagnosing these resistant organisms when they are present and then controlling them within hospitals and other settings.

CONAN: The super-bug is a bug resistant to antibiotics and because of its genetic adaptation, and what kinds antibiotics?

Dr. FRIEDEN: It's widely resistant. And we've seen in - even barring that strain, we've seen in this country organisms that are resistant to virtually all antibiotics, where we're relegated to using either very toxic or not very effective drugs. And that's why it's very important that we continue to control infections. CDC has a major effort along with other federal agencies to reduce infections in hospitals, where there are many preventable infections each year. We've seen some progress in some areas, but much more progress is possible.

CONAN: Dr. Frieden, thank you very much for your time today.

Dr. FRIEDEN: Thank you.

CONAN: And good - and we wish all of us the best of luck this flu season.

Dr. FRIEDEN: Thank you. It's great to be here, and do get a flu vaccine. It's a very effective vaccination.

CONAN: Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, and he talked to us from Atlanta, Georgia, where the CDC is based.

Coming up, for all those people who are sick about hearing about Apple and Google in the news, Farhad Manjoo says, too bad. We'll find out why he will not stop writing about Apple and Google, next. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION, from NPR News.

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