An Special Feature

Is Milwaukee ready for Ebola?

Lessons learned from past pandemic scares

1. Everybody was lined up at the bubbler, and then everybody was lined up to go to the bathroom

Photo © Center for Disease Control


Nathaniel Bauer had no idea how he was going to get through baseball practice.

Back in the spring of 1993, Bauer was a sophomore at Wisconsin Lutheran High School. Indoor baseball practice had recently begun inside the school’s gymnasium, but Bauer was struggling to make it through. His guts felt like they were fighting against him.

Bauer wasn’t the only one on the team suffering from some mysterious stomach ailment. Their early attempts at solutions certainly weren’t working.

"Nobody really knew what was happening," Bauer said. "They just said, ‘Hey, drink more. Drink more water out of the bubbler.' So everybody was lined up at the bubbler just drinking water, and then everybody was lined up to go to the bathroom."

It wasn’t just the baseball team. Half the school was doubled over, as was Bauer’s family. Soon, the city was ailing, emptying drug stores of toilet paper and Imodium

Eventually, orders came down from the health department and government: This is no ordinary flu; it’s the water.

"It was kind of one of those things that nobody expected or anticipated, and nobody kind of really knew how to react," Bauer said. "Wait a minute; it’s in the drinking water?

"It took a few days for everyone to be like, 'Yeah, this is really the case: Don’t drink the water.'"

A boil advisory was soon imposed.

The truth was becoming all too apparent: A pandemic breaking out in Milwaukee, one that would infect approximately 403,000 citizens and lead to at least 69 related deaths within a few weeks. Eventually, the microscopic culprit’s name was uncovered – cryptosporidium.

Now, as Ebola grips the national mindset, with perceived blunders in Texas and New York, the lessons learned during those weeks in 1993 will be just as important for another potential outbreak more than 20 years later.

The cryptosporidium outbreak is still fresh in the memory of Paul Biedrzycki. The current director of disease control and environmental health for the City of Milwaukee Health Department – at the time the city's environmental health manager – remembers the panic, the boil water order, the signs saying "No Imodium" in front of drug stores, the telltale signs that look so obvious now in perspective.

Two decades after, he still gets questions about crypto in Milwaukee, namely in the post-Sept. 11 bioterrorism age.

"If you look back at what happened with crypto, it was an emerging infectious disease that was not on our radar," Biedrzycki recalled. "It did not have a high case fatality rate, but it was unknown in terms of the epidemiology – like who was most at risk, how this would play out in terms of the trajectory of the illness, how many people would get sick and what it would do to health care capacity."

Biedrzycki still talks a lot today to health departments and researchers hoping to learn from Milwaukee’s handling of cryptosporidium – a naturally occurring event – in the hopes of preventing future outbreaks and especially thwarting bioterrorists using water as a conduit.

For the long-time public health worker, however, there are even more important lessons to be learned from the ’93 outbreak, ones that aim to make the Health Department more efficient at handling future pandemics and keep the city safe.

One of the biggest problems in cracking the crypto outbreak was a lack of communication between multiple parties – water utilities, public health and other stakeholders – about the growing number of red flags popping up in early spring of that year.

"I was there; the personal examples of dealing with water plant engineers who basically said, ‘Nothing's wrong with the water; it's operating according to standards,’" Biedrzycki said. "I know what they're saying, but what if it's a bug that falls beneath those standards? You're operating, your turbidity is fine, your chlorine residuals are fine, but what if it's resistant to chlorine and doesn't show up as turbid water? And they couldn't imagine that."

Later, when the Health Department looked through the Water Works' complaint logs, it discovered a significant spike in complaints around the start of the outbreak. For the Water Works, however, that spike was easily shrugged off: When the lake turns over in March, they argued, you get algae odor. The plant adjusted, and the complaints went no further.

All the while, the Health Department and Water Works were in the same building, separated by a mere three floors. Biedrzycki would even pass the Linnwood treatment plant manager in the cafeteria without any words spoken about troubling water trends or the sickness quietly escalating in the city, save for one conversation.

The plant manager phoned Biedrzycki to ask if Milwaukee was currently dealing with an uptick in flu cases. Biedrzycki didn’t know and recommended the manager ask their virologist. Months later, he put the pieces together.

"He was trying to understand if the stomach flu was in a certain part of town because there were getting lots of complaints," Biedrzycki noted. "So that was probably an early call to me, but I didn't recognize it. He was asking about the flu. I had no idea, and it was late in the flu season. I sent him up to our virologist and never heard back. So, in retrospect, that could have been an early signal that I failed to recognize because we had no relation with the Water Works, and he gave me no other additional information."

As a result of flawed communication and partnerships, it took public health and the Water Works more time to discover and lock in on the water contamination. The event is said to have occurred in middle-to-late March; the eventual boil water advisory didn’t arrive until the first weekend of April.

"That was a big lesson," Biedrzycki said. "We didn't have those relationships. Not having those relationships made response extremely difficult. In fact, some people would say that if we had those relationships, we would've been able to detect the water contamination event weeks – literally weeks – earlier."

"If you don’t share information, you become silo-ed. Public health was a silo back then. We're not silo-ed anymore."

Now, the painful lessons learned in the crypto outbreak – "a pioneering event," Biedrzycki calls it – have led to improved communication and relationships between different parties. In the case of similar events, such as the isolated Ebola cases currently in the U.S., public health reaches out to non-profits, the private sector, utilities and other stakeholders for information. Improved partnerships have also been established with pharmacies, emergency departments, poison control centers and ambulance companies.

The Department of Public Health also makes greater use of a process called syndromal surveillance, a way of monitoring public behavior – an explosion in people purchasing a certain product, increased absenteeism at work, increased ambulance runs, social media – to help uncover an outbreak in progress.

In the case of cryptosporidium, Biedrzycki and public health were clueless about the frantic Imodium purchases from drug stores until several weeks into the outbreak.

"We had no idea that was occurring," Biedrzycki noted. "We looked then at nursing homes, places with captured institutional populations: a lot of diarrhea. We then contacted large businesses that said, ‘Yeah, we've seen 15 to 25 percent absenteeism the last couple of weeks.’ We have to take all of those signals and then look at them comprehensively to make a decision whether or not there might be illness. But that becomes a trigger then for investigation."

Syndromal surveillance signals can help provide a picture, but Biedrzycki noted that the resulting data is often "noisy," filled with false alarms, inaccurate or irrelevant information.

What got public health investigating crypto back in 1993 wasn’t syndromal surveillance; it was a call from a physician reporting a case of crypto in a non-immunally compromised patient.

"That's how I get turned onto these things, not through syndromic surveillance or lab specimens that are weeks old," Biedrzycki said. "We have better relationships and I'm confident that if they experience a surge, that they would call us or contact us. It's a big difference. Partnerships mean information sharing. Partnerships mean trust where you want to immediately share information. Without that, nothing good can happen."

2. Yet again, communication was a problem

Photo © Center for Disease Control


In 2005, the United States planned for a pandemic. The expectation was that it would be H5N1, the avian flu. Four years later, it finally arrived from the Mexico City area, but it wasn’t H5N1; it was swine flu, H1N1. Yet again, Biedrzycki remembers communication was a problem – this time not on a small scale city level, but between the Center for Disease Control and health departments.

"The initial clusters occurred in February and March of 2009, but we weren't alerted at the state or local level until April or end of April," Biedrzycki noted. "So I'm a little critical that an investigation of unusual respiratory illness in large numbers of young people who were otherwise healthy, that information wasn't shared with state and locals in the United States. I think it's because the CDC studies things for a lot longer time before announcing it. But there's got to be a fine line between when you have enough data to share versus secretive."

Photo © 2014

The CDC, however, changed and adapted since the H1N1 outbreak of 2009, moving closer to the sweet spot between sharing data and keeping it secret to avoid unnecessary mass panic. Now, when the CDC is investigating a potentially valid outbreak, the data is posted on a secure web-based network, called EPIX (short for epidemial intelligence exchange), to keep state and local officials in the loop when it comes to potential disease and health risks.

"The down side," Biedrzycki said, "is that we're getting a lot of data that has no real bearing on our life here. Most of it is not significant, but at least it gives us a heads up. It's at least their attempt at being more transparent and sharing data earlier than later, so that's changed."

As for the disease itself, for all of the panic and preparation, H1N1 ended up being a mild pandemic. Along with colleagues from the Harvard School of Public Health, Biedrzycki found H1N1 to be "about as severe as seasonal flu."

The problem revealed with the H1N1 outbreak, according to Biedrzycki, was once again a matter of proper communication – not between various health organizations, utilities and stakeholders this time, but between public health departments and the public itself.

The messages sent about H1N1 weren’t calibrated to the actual severity of the disease.

"We had high probability with H1N1 and low severity," Biedrzycki said. "A disease can be widespread, but if it's low severity, nobody cares. If it's low probability and high severity, everyone cares."

Ebola falls into the latter category.

3. The government still believes anthrax is the most likely bioterrorist scenario

Photo © Center for Disease Control


"I never thought in my lifetime I’d ever see Ebola in the United States."

Biedrzycki was working on his graduate degree around a decade after Ebola was first discovered and identified in 1976. Many years later, the virus caught Biedrzycki’s attention while he was working on post-Sept. 11 bioterrorism preparedness. Ebola was on a list of category A agents, along with smallpox, anthrax, tularemia, botulinum toxin and bubonic plague. At the time, most of the attention was focused on calibrating responses for anthrax due to the deadly mailings that occurred shortly after Sept. 11.

"Once that occurred, everyone's plan ultimately went toward anthrax, and the federal government – and I think they were well intentioned – still believes that anthrax is the most likely bioterrorist scenario," Biedrzycki said. "I would argue now that we've been through avian flu, SARS, MERS CoV and now Ebola, we should think more broadly."

Photo © 2014 Nahid Bhadelia, M.D.

Biedrzycki can see holes in the plans. Anthrax is a bacteria with medical countermeasures; Ebola is a virus without a cure. Ebola is also a much more gruesome, violent disease – causing intense vomiting, diarrhea and hemorrhaging – which would likely cause a greater panic and psycho-social impact during an outbreak than anthrax.

According to Biedrzycki, an outbreak of, say, 10 confirmed cases of Ebola in a city would take Milwaukee – and most cities, other than the country’s biggest metropolises – over surge capacity, meaning more stringent orders, including mandatory isolation and quarantine and the cancelling of non-essential public events, like concerts and other social gatherings. However, he feels good with the current state of the local Ebola-ready hospitals – as well as the virus' actually quite low contagious potential.

"I've met with their environmental disease staff, their physicians and nurses, and they're ready to go," he said. "Our EMS system here – the private ambulances and in particular the fire department – are very well prepared. The paramedics are very well prepared – trained, personal protective equipment, understand protocols for triage and handling. I feel good about the transport of somebody in the community to the hospital."

4. Volunteer compliance with cooperative individuals goes a much longer way than slapping the heavy duty stick

Photo © Center for Disease Control


The earliest precautions and procedures, instituted near the end of October, begin in the virus’ hot zone: West Africa. Exit screenings are conducted at airports abroad – a process Biedrzycki described as "not perfect, but it’s pretty good."

Flights out of at risk areas in Africa – namely Liberia, Guinea and Sierra Leone – land in five designated airports in the U.S. before they are able to take connecting flights to their home states. Passengers are taken through another screening process, including a questionnaire, another taking of temperature (with a contact-free thermometer), an interview and a check for visual signs of illness.

"If they're not symptomatic – they pass the screening, and they're not visibly sick – then we categorize them as either high risk, some risk, low risk and no risk," Biedrzycki continued. "Then that's reported to state health departments across the country."

If a person is considered no risk or low risk, he or she is free to go. However, considering Ebola can incubate inside a person for up to 21 days, the health department would, under public health directive, voluntarily monitor the person’s health for that three-week period.

"We’d ask you to take your temperature twice a day – eight hours apart – call us and let us know what you're temperature is, as well as monitor for symptoms of vomiting and diarrhea and headaches," Biedrzycki said. "Even if one day, you say you want to go visit your friends in California but it hasn't been 21 days, we'd probably let you go. In fact, we've let people do that. We just call the health department in San Diego or wherever you're going."

The health department asks that heavy social activity is kept to a minimum and that monitored individuals practice safe sex – especially because, in the case of semen in males, the Ebola virus can viable for 70 to 90 days.

Biedrzycki – along with law enforcement, the county jail and others – has mandatory quarantine orders ready to execute on those who don’t comply or who seem unreliable or noncompliant during the interview process ("an art more than a science," he noted). It’s something he’s had to do in the past in cases of tuberculosis, but for the most part, public health officials believe a person’s individual rights shouldn’t be trampled in the process.

"I believe in the least restrictive means of voluntary compliance because as long as you don't have symptoms, you're not contagious," Biedrzycki explained.

"How does public health engage the community authentically and being a part of the solution instead of the public thinking I'm going to go around slapping orders on everyone? I could do that early on in an outbreak in order to control the disease; it might be effective. But when it's all over the place, what good does it do? Then you have to think broadly, like how do you control disease by having voluntary education, making sure that they're monitoring their illness and when they're sick, taking certain precautions. That’s education. It’s not going to come from me slapping orders on people."

Photo © Sergey Uryadnikov/Shutterstock

Since the beginning of the Ebola scare, about 12 to 15 people in Milwaukee have been monitored for potential illness. All were asymptomatic; all were considered low risk. Most have timed out of the incubation period. Only a handful remain under watch.

In the case of a symptomatic citizen, the first goal would be confirming the diagnosis of Ebola, rather than some other illness. Immediately after deeming the symptoms credible, steps would be taken to triage, transport and isolate the patient to one of the two Milwaukee hospitals currently prepared for Ebola patients and isolation: Froedtert and Children’s Hospital.

"During the discussion with the state, we were willing to fulfill our responsibility to the community and the people of Wisconsin," said Dr. Sid Singh, associate chief medical officer at Froedtert & the Medical College of Wisconsin. "It is our responsibility to step up in moments like these and help out the best we can. As a result of that discussion, we became one of the designated hospitals."

According to Singh, that discussion took place over several weeks in late October and early November. Since that time, Froedtert has been preparing for Ebola, thoroughly training its personnel, setting up areas for taking care of patients carefully and obtaining proper personal protective equipment. The hospital already had the personnel and most of the necessary equipment – with only a few items needed to be stocked up to a sufficient quantity – but the space for an Ebola patient needed to be altered.

"There were little modifications that needed to be made, but the most important thing is that you need to have sufficient room where you put on and take off your personal protective equipment," Singh noted. "So we found rooms where this space was available and designated that space for wearing and removing that equipment."

Photo © 2014

As for the training, according to Singh, the treatment for the Ebola virus required no additional training of hospital staff. Once again, the crucial part of preparing the doctors and nurses for a potential Ebola patient was the wearing and removal of the protective equipment.

Each designated Ebola hospital in the state is prepared and ready to handle one Ebola patient at a time, though Singh notes that the hospital can adapt to changing situations.

"Whenever such a situation arises, it’s not an issue that only Milwaukee has to respond to by itself as a city," Singh said. "It is an issue that the broader community has to respond to. If there ever is a hypothetical scenario like having five patients in any city, I think the country would get together, federal and state resources would be deployed and that’s how we would address such a situation."

There are still a few small gaps Biedrzycki and the health department are working on closing. They’d like to get public health nurses and others who may encounter the virus up to the standard as the hospitals and EMS systems training and preparation. He’s also still in need of the staff and equipment for local health departments to safely and effectively go to the houses of high risk or symptomatic patients. However, the city is prepared, and due to the mistakes made with the Ebola case in Dallas, more gaps in the procedure have been found and corrected.

"The health care provider didn't even recognize that they met the case definition of symptoms in travel," Biedrzycki noted. "This person said, ‘I'm from Liberia; I have a fever,’ and he was turned away, told to go home and take two aspirin. So that will never happen here. Infection control has also been tightened so there's no breach in protocol potential. You can never say never, right, because these are human beings. But I think we understand the kind of protective equipment, the training and the level of contact that needs to occur to ensure that exposure is minimized, to the public or others."

Safe decontamination procedures – of linens, fabrics and Ebola-contaminated waste – as well as hospital infrastructure have also been tightened due to the lessons learned from Dallas. In fact, Biedrzycki noted that – all things considered – the local and national response to Ebola can be considered a success.

"In all the outbreaks I've managed, this is the fastest change in policy, procedures and protocol around a communicable disease outbreak that I've seen – including H1N1," he said. "Now, the question becomes could we do it faster? Absolutely. And I think this is going to be the new benchmark for communicable disease response. It's not going to be like going back to the old days anymore."

5. They have to think about their role in protecting the community

Photo © yodiyim/Shutterstock

Public health’s most important tool in fighting a pandemic – more so than a hazmat suit or other medical equipment – is accurate public knowledge. This can be a struggle considering the panic surrounding a notoriously vicious virus with no countermeasures.

Though the exacerbated public worry has likely helped drive the fast procedural changes and newly established preventative measures, the fears are mostly irrational. The symptoms of Ebola may be highly severe, but the actual probability of contracting the disease is very low.

Ebola can only be transmitted when a host patient becomes symptomatic, and even then, the virus can only be transmitted through direct contact with infected blood, vomit or feces.

"Unless you're a healthcare worker, your chances of being exposed to Ebola are very slim," said Dr. Laurieann Klockow, virologist and assistant professor of biomedical sciences at the College of Health Sciences at Marquette. "Even if you look at the case of Thomas Duncan in the United States, the people he was living with for days – even after he was symptomatic – didn't get Ebola. It was the two nurses who were treating him when he was in the end stages of the disease who were coming, who actually transmitted it."

"You have to come in direct contact, and it has to be with an open wound," Biedrzycki said. "It's not airborne. There could be vomit and diarrhea in a person’s bed, and unless you were rolling around there with abrasions, you would not contract this disease. But I think people don't understand that."

If airborne, the virus could be catastrophic. Unless it is weaponized, however, the rumor of the virus adapting and evolving to go airborne is exactly that: a rumor. Viruses mutate constantly, but according to Klockow, no virus has even changed into an airborne disease.

"You can compare it to HIV, which is also transmitted through bodily fluids," Klockow noted. "HIV has infected millions and millions of people since it was first discovered back in the 1980s, and we also know that HIV mutates at a faster rate than Ebola. Yet HIV continues to be transmitted through bodily fluids. So I just don't think that Ebola would be the very first human virus ever to mutate to suddenly become airborne."

Viruses are, however, notoriously difficult to develop cures and countermeasures against, due to their composition. Structurally, viruses are simple pathogens, made up solely of nucleic acid and protein with few other molecules and cellular processes to target. However, there are a number of drugs currently in testing that have shown in animal tests and cells to be effective. There is another reason, however, why Klockow believes an Ebola cure has taken so long to develop.

"I think the biggest reason why we don't have any drugs yet is just because there isn't a lot of research on Ebola," she said. "It's such a rare disease, and it's something that happens in such remote villages of Africa and then kind of burns out, so there's not a lot of motivation – financial motivation – for pharmaceutical companies to do really do research on this. There's nothing really inherent about the virus itself that makes it super difficult to treat. It's just that nobody has really studied that much on it relative to coming up for drugs to other diseases."

Though there is no cure, when spotted early, Ebola can be treated. The virus’ 60 percent fatality rate would seem to say otherwise, but that number comes from West Africa, countries without quick and easy access to good health care – as well as customs and traditions that increase the risk of infection.

In a country with good health care, that could quickly begin a symptomatic patient with rehydration therapy, the odds of survival would be significantly higher. Just look at the current epidemic: Out of the nine reported cases of Ebola in the U.S., only one has died – closer to 10 percent than 60 percent.

In fact, with low risk citizens carefully monitored, procedures in place and the disease’s actual contagiousness potential, the center of public health’s focus lies mostly thousands of miles away on a whole other continent.

"As long as there's an outbreak in West Africa, there's a threat to the rest of the world," Biedrzycki cautioned. "You can layer protective measure after protective measure, but until you control West Africa, you're going to have leakage – short of putting a fence around every border and not letting anyone move in or out, which we don't want to do; it would cause government collapse, economic collapse and we wouldn't be able to get health care workers in there to help. Short of that, we're always going to have leakage."

Image © Nathan Bauer

For Bauer – and most of Milwaukee – cryptosporidium is now just a memory, one of intense discomfort and boiling water. As it turns out, his baseball practices – a painful struggle with the illness – were what helped him and his teammates get through the ailment faster than most of his classmates.

"One of the things that we did as baseball players back then was drink a ton of Gatorade," Bauer recalled. "So, by the time we actually muscled through a couple practices and were chugging down some Gatorade, we ended up feeling better. So not having any idea what was making anybody sick, we thought let's just keep chugging Gatorade. There was a good bunch of us on the baseball team that that ended up making it through practice just fine, while most folks had to go home and take a few days off."

Bauer, now 37, still lives and works in Milwaukee as a digital strategist. While his high school experience with crypto is in the past, it keeps him cautious about the future.

"I would be hard pressed to find somebody who didn't live through that who isn't far more acutely sensitive to things that come out," Bauer said. "Anytime there is a murmur or bubbling over of some possible thing – be it water supply or virus or something else – having lived through that and understanding that it can come from anywhere – even something as mundane or ubiquitous as a water supply – definitely makes you a little bit more aware of where you get your stuff from."

Even so, he’s skeptical about Ebola’s chances of spreading to a dangerous level in the United States. Or he’s comfortable at least with the steps taken and the knowledge he’s received. He’s looked up data and Ebola facts, and feels that, once identified, the spread of Ebola can be easily contained.

Bauer is technically correct, and the fact that Bauer feels educated – about the realities of Ebola, not the hype – is music to Biedrzycki's ears.

"This low probability and high severity is really about psycho-social impact: how people will react to risk messaging, what behaviors build resiliency and which of those compromise resiliency," Biedrzycki noted. "We want that fine line between people either being overly panicked about the specter of Ebola or being complacent. We're not in that sweet spot. They're either over-reactive or don't care at all; I want them to be right in the middle.

"It's still a threat; it's still has severe consequences. We still don't have medical countermeasures. I don't want them to freak out, but I don't want them to ignore it. I don't want health care workers not to be looking for Ebola."

In fact, in many cases, the biggest dangers gaps and problems in pandemic preparedness isn’t the virus or bacteria itself; it’s people. The department of health is constantly trying to make decisions that straddle the line between satisfying the needs of public health and a private individual’s rights, a challenge Biedrzycki sees growing as time goes on.

"I'd argue – this is just an old guy – that I've seen in my career that I've seen people get more selfish," he said. "They really are all about the individuals. And I respect that. You talk unity, but when it comes to public health, I've seen a lot of people say they don't care about public health. We look at these diseases like, ‘That's not me; that's older people and younger people getting it. That's people across seas.’ They have to think about how it's spread and their role in protecting the community."

It’s not just Ebola either; it’s all sorts of diseases, many might consider mundane, common or of no concern because they don’t have the violently horrifying symptoms of this current virus. Measles, mumps, influenza and many other common diseases are 10 times more contagious than Ebola. Yet vaccination rates for those common diseases are lower, even below what public health calls the Threshold of Suppressing Outbreaks.

The number is set at 95 percent; Milwaukee is at 87.

Biedrzycki still also wants to improve public health departments’ informational outreach: how best to protect, impact and inform people about disease without reliance on government or it in part having to bring down a big stick.

For Biedrzycki, people need to care because what concerns him isn’t what happens before or during an outbreak situation, but what happens after: People forget. The lessons go unlearned. The accurate knowledge and calculated concern fades away.

"I think the Ebola thing will unfortunately die because nobody cares about Africa," Biedrzycki said. "If we don't see cases here, people forget. One of the reasons why I'm interested in keeping the conversation going is because there are vulnerabilities that I've identified. While Doctors Without Borders and these missionaries you hear about going over there are saints as far as I'm concerned, just remember we have tons of health care professionals that would tell you they did not sign on to handle Ebola. That's a problem. It's not because I'm critical of them; it's because I'm relying on them. So let's have that conversation now. Let's find out why Ebola is a problem and what they feel like."

Because if there’s one universal lesson learned through time – from crypto to anthrax to H6N1 to H1N1 to SARS to Ebola – it’s that there’s always another bug.

Biedrzycki noted that they already have their eyes on three infectious diseases – avian influenza, H7N9 and H6N1 – circulating and "figuring things out" in Southeast Asia.

There’s MERS CoV, the Middle Eastern respiratory virus that’s circulating with a high case fatality rate, especially in middle-aged males. And then there’s Ebola, which is certainly still a risk in West Africa.

"Ebola is one of many infectious diseases that we will most likely face in our lifetime; It's not the only one," Biedrzycki said. "That's what I think the public needs to do: They need to weigh in on that dialogue. What are we doing now, and what are we doing that will inform future response instead of just reactionary to Ebola? Ebola's kind of a call to action to do that. Even though it's a low probability, why would you think you'll never see anything like this again?"

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