Acute pesticide poisoning among cut-flower farmers.
Much of the research done in the field of occupational health is focused on the service and manufacturing industries, giving very little data on agricultural hazards. The Philippine Department of Labor and Employment, a national agency, has reported that occupational injuries and illnesses were most prevalent in the agricultural sector, at more than 50 percent of the injuries and illnesses occurring in all other industries (Bureau of Working Conditions, 2002). The aim of the study reported here was to look at risk factors associated with increased pesticide exposure as well as pesticide-related health problems. The data will be used for the formulation of an integrated program on safety and health in the cut-flower industry.
The Philippines, which is a tropical country, are not conducive for growing certain vegetables and cut flowers, which require a cooler climate. The Philippine province of Benguet, however, is situated at a high altitude and thus is able to meet most of the vegetable and cut-flower needs of the country. The great demand for vegetables and fruits in modernizing and industrializing Manila, which is the capital city, has enabled the province to focus on meeting this demand. Benguet province produces 70 percent of the total vegetable needs of the country and has earned the name Salad Bowl of the Philippines. It is also called the Strawberry Country and, more recently, the cut-flower producer of the Philippines. According to Cheng (1994), "since 1986, the vegetable industry has maintained a yearly contribution of more or less 3.2 billion pesos to the Gross Domestic Product of the Cordillera Administrative Region (GDP-CAR). Forty percent, or 1.2 billion pesos, of this contribution comes from crucifers and leafy vegetables such as cabbage, broccoli, cauliflower, pechay, womboc, or Chinese cabbage" (p. 1969). Along with this agricultural success, however, pesticide use has increased.
The study reported here was conducted among cut-flower farmers in La Trinidad. This municipality grows cut flowers such as roses, chrysanthemums, angel's breath, and anthurium, accounting for a 50-billion-peso industry. The heavy use of pesticides has, however, posed a risk to the health of the farmers (Lu, 2005). The first and second phases of the study showed that 19 percent of respondents reported an illness associated with pesticides, and 32 percent were symptomatic. The illness of the farmers was associated with certain risk factors, such as farm use of pesticides for the past 12 months, exposure to pesticides during application, and inhalation of pesticide vapors and mists (p = .05). Other risk factors included re-entering recently sprayed farms, wiping sweat off the face with a contaminated piece of fabric, and spills on bodies during application of pesticides (p = .05). Symptoms included eye pain, dizziness, and respiratory problems.
The first phase of the study was conducted in four barangays (local communities) that were heavy pesticide users: Bahong, Alapang, Tawang, and Ambiong. The study looked into the work practices of farmers and their ambient-air exposure to pesticides. The second phase consisted of a survey questionnaire given to 52 households that comprised 114 respondents in Sadag, a barangay of Bahong. The survey looked into physical illnesses that might be associated with pesticide exposure as well as other significant risk factors. The third phase of the study focused on 102 farmers from the same set of 114 participants. In coordination with barangay officials, a predetermined set of respondents were assembled at a specified area and underwent comprehensive, one-on-one physical and laboratory examinations, including blood extraction for red-blood-cell cholinesterase levels, complete blood count, and kidney and liver function tests. Studies have shown that organophosphates cause a depression in cholinesterase activity that decreases neuromuscular function, manifesting in paralysis (Hernandez et al., 2004).
More than half (53.85 percent) of the farmers interviewed were in the 20-35 age group, with ages ranging from 15 to 83 years (mean: 32.58 [+ or -] 14.01). This result shows that farmers using pesticides in the cut-flower industry are mostly young and in their reproductive years. The majority of the respondents were male (66.8 percent) and a large proportion had finished high school (42.3 percent). Forty-four percent lived within 50 meters of the plantation, and a majority (71.1 percent) had lived in their residence for more than five years.
Hypertension was the most prevalent illness reported among the respondents and their families, with allergies and asthma placing a distant second. The rareness of cancer in the population (two cases, or 1 percent) supports earlier reports of an inconsistent association between malignancy and farming. In fact, in a meta-analysis done on cancers and agricultural associations, only cancer of the lip was found to be associated (Acquavella, Olsen, Colde, Ireland, Kaneene, Schuman, & Holden, 1998; Brownson, Reif, Chang, & Davis, 1989). For women, certain studies suggest an association of pesticides with the incidence of non-Hodgkin's lymphoma (Kato et al., 2004).
Of 380 reported pregnancies, 20 (5.26 percent) were preterm and 6.3 percent were abortions. Two cases of congenital anomalies were also found. Preterm delivery has previously been associated with the use of yard herbicides (Savitz, Arbuckle, Kaczor, & Curtis, 1997) and increased organophosphate levels during the latter part of pregnancy (Eskenazi et al., 2004), while increased rates of miscarriages have been found with the use of thiocarbamates, carbaryl, and certain unclassified pesticides. In addition, infertility has been found to be more common in women involved in agriculture and those who live on farms (Fuortes, Clark, Kirchner, & Smith, 1997).
Clearly, these studies show the developmental and reproductive effects of long-term pesticide exposure. Other effects include cryptorchidism (Weedner, Moller, Jensen, & Skekkebek, 1996), oral-facial clefts (Nurminen, 1995), and limb deformities in association with other organ system anomalies (Lin, Marshall, & Davidson, 1994). Further inquiry is warranted to ascertain the spectrum of possible implications for women and children and to identify certain etiologic relationships.
Alcohol drinking was common among the respondents (50.5 percent). The same is true for cigarette smoking (25.5 percent). The majority used gas stoves and microwave ovens for cooking, while deep wells were the predominant water source (26 percent) closely followed by water from the water district (21.6 percent) and springs (21.2 percent). The farmers' diet consisted mainly of vegetables (55.8 percent), which is not surprising since vegetables are one of Benguet's major exports. Seafood (except fish) and seaweed were the next most commonly reported dietary components.
Since the majority of farmers worked as pesticide applicators/mixers/loaders, they worked directly and frequently with pesticides, which placed them at increased risk of experiencing toxicity and adverse side effects. Indeed, 82 percent of the respondents reported using pesticides, the most frequently used kind of pesticide being fungicides (39.9 percent) and insecticides (37.5 percent). Herbicides and nematocides were rarely used. Farmers used an average of five pesticides at a time. The top five products, containing similar active components, were Dithane (47 percent), Selecron (31 percent), Agrimek (22.6 percent), Tamaron (23 percent), Matador (20 percent), Atonik (16 percent), and Basudin (8 percent). The respondents had been in contact with considerable amounts of these chemicals (the mean amount of Dithane used was 1,185.6 mL) for prolonged periods of time. The longest period of use was for Tamaron (an average of 17 years). Hence, chronic pesticide poisoning is a distinct probability for these farmers and should be assessed.
The majority of pesticides used by farmers were in categories Ib and II, the categories of moderately or highly hazardous chemicals. This finding was also confirmed by the monitoring of pesticides in the ambient air. All pesticides monitored were detected in air samples with a colorimetric method. It must be noted, however, that several pesticides were mixed together as farmers believed that mixing made the formulation more potent in killing the pests.
Dithane, which was commonly used by the farm workers, can cause tearing of the eyes, blurred vision, and irritation of throat and nose.
The average spraying time was three hours per day for about one to four days a week. Dilution time in the preparation of pesticide was 15 minutes per application load, with an average of three loads per day. The average total mixing and loading time per load was 46 minutes.
Work and Safety Practices Related to Pesticide Use
Written material was the source of information on pesticide most commonly used by the participants (28 percent), followed by informal talks (25 percent) and classroom lectures (14.9 percent).
The activities performed by the farmers while working with pesticides were loading, applying, and mixing (76.4 percent, 77.4 percent, and 76.4 percent, respectively). Through these activities, they were exposed more than 12 times per year, which is considerable. The study also found that the majority of respondents practiced behaviors associated with an increased risk of pesticide exposure, such as re-entering a recently sprayed area, wiping sweat off the face, spraying against the wind, and incurring spills on their backs during spraying, loading, and mixing. Pesticide application and working with pesticides on more than one farm have also been found to be positively associated with pesticide poisoning (Faria, Facchini, Fassa, & Tomasi, 2004). Spills were most likely to occur during spraying (51.9 percent), and the average spraying time was 3.16 hours per day or 1.59 days per week.
Despite the high risk and frequency of exposure, farmers did not observe proper personal protection while working with pesticides. Boots were the only protective equipment worn by the majority of the farmers, and practically no one used aprons or gauntlet gloves. Cloth face masks, which do not offer adequate coverage for some chemicals, were used by a number of respondents (41 percent). Improvised forms of personnel protective equipment (PPE) were also used, including handkerchiefs, long sleeves, and plastic pants.
The respondents are not alone in this practice. In a study in the municipality of Paty do Alferes in Brazil, it was found that as many as 92 percent of workers who directly handled pesticides used no protective clothing or gear of any form (Delgado & Paumgartten, 2004).
The stated risk behaviors and inadequate PPE practices pose considerable threat to the farm worker, and incidents of poisoning and even death have been documented as a result of these behaviors. In 2002, a poisoning outbreak was reported in Poland after applicators re-entered a contaminated area before the required safety period had elapsed, and 22 cases were seen as a result of spraying without adequate protective gear (Przybylska, 2004).
The field was the most common storage site for agricultural pesticides, whereas home pesticides were kept at home. Most (47.6 percent) farmers sold the empty containers to dealers. Some, however, still practiced unsafe disposal methods such as throwing containers in the garbage, stocking, and burying. It was a common practice for the respondents to clean their sprayers in the field and their PPEs at home. Further investigation is warranted since these practices have great implications for the environment.
Pesticides and Health
Seventy-one workers, or 34.1 percent of participants, reported that they had been ill because of work in the past 12 months, with episodes occurring at an average of twice a year. Illness most commonly occurred at a frequency of one to five times a year (79 percent) and the antecedent exposure was occupational in 42.2 percent of respondents. Exposure usually occurred during pesticide application (42.2 percent) and field re-entry (33.8 percent), with the majority of incidents occurring in the field and at storage sites. The route of entry was respiratory in 76.0 percent and ocular in 71.8 percent of farmers. Skin and eye contact and lung absorption through inhalation have previously been identified as mechanisms of pesticide overexposure (Boiko et al., 2005).
After exposure, onset of symptoms was usually immediate (64.8 percent) and usually lasted for one to three hours (77.5 percent). Most of the respondents recovered spontaneously from their illness and did not seek medical consultation.
The most common medical complaints among the farmers were dizziness (10.6 percent) followed by symptoms of the head, eyes, ears, nose, and throat, most of which were associated with irritation and allergy (eye tearing, itchiness, and redness). Neurologic manifestations were also prominent and included confusion, weakness, and headache. Other documented acute neurologic effects of organophosphate poisoning are memory loss, decreased concentration, irritability, and personality changes of varying degrees (Dahlgren et al., 2004). Permanent neurological damage has also been reported, including neuropsychiatric defects, peripheral neuropathy, impaired performance on neuropsychiatric testing, and multiple chemical sensitivity (Meggs & Langley, 1997). For people who are chronically exposed, like the respondents in the study reported here, documented side effects include peripheral neuropathic dysfunction and subtle neuropsychiatric changes. Parkinson's disease has also been suggested as a possible complication of chronic organophosphate poisoning (Kamel & Hoppin, 2004).
Upon physical examination, 90 (88.2 percent) of those examined were found to have abnormal peak expiratory flow rate (PEFR); the next most prevalent symptoms were abnormal temperature (81.3 percent) and abnormal general findings (75.5 percent). Forty-one percent were also found to have elevated blood pressure (Table 1).
Health Problems Found in Laboratory Examinations: Kidney and Liver Function Test
Upon follow-up, 53 males and 49 females (N = 102) with a mean age of 36.4 [+ or -] 13.09 years (range 15-68), underwent comprehensive medical and laboratory examinations. It was found that general symptoms (weakness, fever, lethargy) were the predominant abnormal manifestations among those examined (63.8 percent). This result contrasts with the results of a study done by O'Malley (1997), in which adverse skin reactions were the symptom most commonly identified.
Head, ear, eyes, nose, and throat symptoms (blurring of vision, deafness, headache) were also predominant among the farmers. Such symptoms have also been documented in a report by Dahlgren and co-authors (2004) on acute exposure to diazinon, which is the active component of Basudrin, the pesticide seventh most frequently used by respondents in our study.
Our study also noted involvement of the skin, with 21 percent of farmers having integumentary abnormalities. Dermatological involvement has been previously reported in association with exposure to organophosphates, pyrethroids, and carbamate pesticides (Amer, Metwalli, & Abu el-Magd, 2002).
Specifically, headache was the most frequently reported symptom (48 percent), closely followed by easy fatigability (46.1 percent) and cough (40.2 percent). Blurring of vision and palpitations were also common (36.3 percent and 33.3 percent respectively). These symptoms, along with others reported by the respondents, have also been documented in agricultural workers working with pesticides in other areas (Delgado & Paumgartten, 2004).
Upon physical examination, 90 respondents, or 88.2 percent of those examined, were found to have abnormal peak expiratory flow rate (PEFR). Abnormal temperature was found in 81.3 percent, and the next most frequent finding was abnormal general-survey results, at 75.5 percent. Forty-one percent were also found to have elevated blood pressures. This is consistent with the reported prevalence of hypertension among the farmers and their families that was mentioned earlier. Cranial-nerve dysfunction and impaired mental status were also seen in 43.1 percent and 17.6 percent of farmers, respectively (Table 2). This is consistent with the findings of Kamel and Hoppin (2004). Specifically, dental caries (48 percent) and cranial-nerve II anomalies (34.3 percent) were the most common abnormal findings.
The symptoms of pesticide poisoning are a result of the binding and inhibition of cholinesterase enzymes at the synapse (Hernandez et al., 2004), resulting in the accumulation of the neurotransmitter acetylcholine and subsequent over-stimulation of cholinergic systems such as muscles, glands and nerves. As a general rule, symptoms of poisoning do not manifest until cholinesterase levels reach 50 percent below an individual's baseline. Patients may, however, complain of mild symptoms without obvious cholinesterase depression (Boiko et al., 2005). The clinical manifestations of the respondents (headache, weakness, dizziness, eye redness, and tearing) indicate that only mild poisoning has occurred. In more severe instances, tremors, abdominal cramps, excess urination, bradycardia, staggering gait, pinpoint pupils, and hypotension may be observed (Boiko et al.).
Cholinesterase actually corresponds to two enzymes: acetylcholinesterase and butyrylcholinesterase (also called plasma cholinesterase) (Boiko et al., 2005). The activity of cholinesterase enzymes in the blood can be utilized as a biomarker for the effect of organophosphates. An exposed person will show abnormally low levels of cholinesterase enzyme activity as measured in the serum or in red blood cells (as RBC cholinesterase). The latter is more closely correlated with cholinesterase activity in the nervous system (National Pesticide Information Center, 2004).
It should be noted, however, that RBC cholinesterase is more difficult to measure and is depressed more slowly than is plasma cholinesterase. Certain pesticides also exhibit preferential inhibition of one or the other enzyme. Hence, levels of both enzymes should be assessed for accurate determination of pesticide exposure (Boiko et al., 2005).
Cholinesterase measurements also have limitations, since the rate of enzyme inhibition and subsequent recovery may differ with exposure to varying organophosphates. Cholinesterase levels are also affected by inter- and intra-individual variability (National Pesticide Information Center, 2004). Therefore, pre-exposure baseline levels should be established for each individual so that meaningful changes in cholinesterase levels may be detected (Boiko et al., 2005).
In addition, certain conditions other than pesticide exposure can lower plasma and RBC cholinesterase levels, confounding interpretation of test results. Plasma cholinesterase levels can be decreased by liver disease, malnutrition, alcoholism, nephrotic syndrome, early pregnancy, contraceptive pills, and metaclopramide. RBC cholinesterase levels are lowered by hemolytic and pernicious anemia, recovery from hemorrhage, and reticulocytosis. Other factors that may result in false cholinesterase levels are collection, shipping and laboratory errors, and poor record keeping and organization (Boiko et al., 2005).
In Sitio Sadag, 51 percent of respondents had cholinesterase levels below the mean value of 0.7 [DELTA] pH per hour, and 25.5 percent exhibited a more than 10 percent depression in the level of RBC cholinesterase. Certain hematological parameters were also abnormal, namely hemoglobin, hematocrit, and eosinophil count. These laboratory findings are similar to those found by Svoboda (2001). It is noted that kidney and liver function tests were within normal range (Table 3).
Pearson's r (Table 4) showed the following findings. Factors strongly associated with illness due to pesticides include using a contaminated piece of fabric to wipe sweat off (p. = .01) and reusing pesticide containers to store water (p = .01). Recycling of containers poses great health hazards and risks of contamination, and the current recommendation is that used containers should be buried, destroyed, rendered unusable by puncturing holes in the container, or sent out for proper disposal (NPMCC, 2004). There is a moderate relationship between illness and average number of years of pesticide use (p = .05), and between illness and re-entering a recently sprayed area (p = .05). The latter has previously been identified as having a significant association with pesticide poisoning (Faria et al., 2004).
Table 5 shows results from various statistical tests in order to highlight differences in certain variables. Respondents 30 years of age and younger were less likely to become ill from pesticides than were those over 30 years of age. Among farmers exposed to pesticides, abnormal symptoms of the eyes and extremities were more likely to occur. The reason is that those areas of the body are the ones most commonly exposed to pesticides (Boiko et al., 2005). People with motor scale scores of [less than or equal to]15--normal values--were less likely to be sick. The greatest adverse effect among people who were exposed was an abnormal cholinesterase level, which confirms earlier studies on the effect of pesticides on the body. Organophosphate pesticides inhibit acetylcholinesterase at its various sites of action--the central nervous system, the sympathetic and parasympathetic divisions of the autonomic nervous system, and the neuromuscular junction--resulting in the continuous action of acetylcholine at post-synaptic areas (National Pesticide Information Center, 2004). People who are exposed to pesticides are two times more likely to have abnormal cholinesterase level. The greatest aggravating factor is not consulting a doctor after becoming ill. Early detection and treatment mitigate adverse health effects and prevent progression of illness. It is therefore necessary to consult a physician when symptoms of pesticide poisoning occur.
Table 5 shows the adverse health effects from exposure for more than five years. Age was a strong risk factor. Among respondents exposed for more than five years, the older farmers (>30 years of age) were more likely to become ill than were the younger (30 years of age and younger) (p = .01). The statistics given in Table 5 also show that among respondents who had been exposed to pesticides for more than five years, the most prevalent effects were effects in the eyes (p = .05) and lowered mean corpuscular volume. The latter effect may be due to disruption of hematopoiesis and a decrease in nonspecific immunity (Undeger & Basaran, 2005).
The three phases of the study showed a strong indication that pesticide exposure is associated with adverse health effects among cut-flower farmers in La Trinidad, Philippines, as evidenced by the considerable number of respondents (34.1 percent) who became ill in the 12 months before the study. These illnesses included allergic reactions involving the eyes, ears, nose, skin, and extremities. These adverse health effects commonly occur immediately after exposure, and have been confirmed by laboratory tests showing abnormalities in cholinesterase level and mean corpuscular volume. The study also showed that risk factors such as re-entering a recently sprayed area (p = .05), wiping sweat with a contaminated piece of fabric (p = .01), and reusing pesticide containers for storage of water (p = .01) are associated with illness. It has also been shown that spills most commonly occur during pesticide application; therefore, recommendations for safety practices should focus on this activity. The most significant factor associated with illness was not seeking medical help. In addition, it was found that younger farmers were less likely to become ill than were older farmers (>30 years of age), a result that suggests age is a significant factor in the occurrence of illness among people exposed to pesticides.
The author recommends that a massive dissemination of information be conducted among cut-flower farmers in La Trinidad in coordination with local government units, the Department of Agriculture, the Department of Labor and Employment, and cooperatives. All stakeholders should realize that the health of the farmers is essential to the farmers' quality of life, as well as to their productivity.
Acknowledgements: Special acknowledgements go to St. Louis University in Baguio, the National Poison Management and Control Center (previously known as the National Pesticide Information Center), and Benguet State University, which were collaborating partners.
Corresponding Author: Jinky Leilanie Lu, Research Associate Professor, University of the Philippines, National institutes of Health, Unit 1514 President Tower, 81 Timog Avenue, Quezon City, Philippines. E-mail: firstname.lastname@example.org.
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Although most of the information presented in the Journal refers to situations within the United States, environmental health and protection know no boundaries. The Journal periodically runs International Perspectives to ensure that issues relevant to our international constituency, representing over 60 countries worldwide, and addressed. Our goal is to raise diverse issues of interest to all our readers, irrespective of origin.
Jinky Leilanie Lu, Ph.D.
TABLE 1 Abnormal Physical Examination Findings (N = 102) Parameter Number Percentage PEFR (Peak expiratory flow rate) 90 88.2 Abnormal temperature 83 81.3 General 77 75.5 Throat 59 57.8 Extremities 50 49.0 Cranial nerves 44 43.1 Blood pressure 42 41.2 Eyes 37 36.3 Head 27 26.5 MSE 18 17.6 Ears 17 16.7 Neck 17 16.7 Heart rate 16 15.7 Cerebellars 5 4.9 Lungs 4 3.9 Respiratory rate 4 3.9 Sensory 4 3.9 Heart 2 2.0 Abdomen 2 2.0 Motor nerves 1 1.0 Nose 1 1.0 Reflexes 0 0 TABLE 2 Mean and Abnormal Laboratory Examination Abnormal Results Laboratory Examination Mean Results Number Percentage Hemoglobin 134 [+ or -] 17.21 16 15.7 White blood cell count 7.06 [+ or -] 1.57 35 34.3 Hematocrit 0.35 [+ or -] 0.04 22 21.6 Platelet count 289.50 [+ or -] 65.38 4 3.9 AST 26.0 [+ or -] 8.16 13 12.7 ALT 25.06 [+ or -] 14.08 25 24.5 Creatinine 110.59 [+ or -] 30.30 21 20.6 RBC Cholinesterase 0.694 [+ or -] 0.097 52 51.0 Percent depression 11.24 [+ or -] 8.20 26 25.5 TABLE 3 Pearson's r of Risk Factors Associated with Illnesses Due to Pesticide Exposure Illness Due to Pesticides Risk Factors Pearson's r Average hours of exposure to pesticides in a week .260 (.040) Reuse of pesticide container for storage of other things .437 (.000) Throwing container away -.191 (.130) Re-entering a recently sprayed area .236 (.060) Use of contaminated piece of cloth .392 (.001) TABLE 4 Statistics on Illnesses and Other Factors Associated with Pesticide Exposure Likelihood Factor Ratio, [X.sup.2] Odds Ratio Sex (0 is female; 1 is male) 0.692 Age (0 is >30; 1 is 3.394 (0.065) 0.373 [less than or equal to]30) Years of pesticide use (0 is >5; 1 is 4.830 (0.028)* 0.205 [less than or equal to]5) Eyes (0 is abnormal; 1 is normal) 0.963 Lungs (0 is abnormal; 1 is normal) 1.211 Extremities (0 is abnormal; 1 is normal) 4.989 (0.026)* 0.306 MSE score (0 is 0.590 [less than or equal to] 15; 1 is >15 RBC cholinesterase (0 is abnormal; 1 is 2.121 normal [0.75-1]) Mean corpuscular volume (0 is 13.992 (0.000)# 0.116 [less than or equal to]80; 1 is > 80) Does not consult a doctor when sick after n/a 23.786 using pesticide Has information on PPE 0.515 Mixes pesticides 0.263 Relative Relative Risk--No Risk--Yes, Factor Illness Illness Sex (0 is female; 1 is male) 0.871 1.258 Age (0 is >30; 1 is 0.704 1.889 [less than or equal to]30) Years of pesticide use (0 is >5; 1 is 0.643 3.143 [less than or equal to]5) Eyes (0 is abnormal; 1 is normal) 0.986 1.024 Lungs (0 is abnormal; 1 is normal) 1.070 0.884 Extremities (0 is abnormal; 1 is normal) 0.626 2.046 MSE score (0 is 0.795 1.348 [less than or equal to] 15; 1 is >15 RBC cholinesterase (0 is abnormal; 1 is 1.316 0.621 normal [0.75-1]) Mean corpuscular volume (0 is 0.448 3.854 [less than or equal to]80; 1 is > 80) Does not consult a doctor when sick after 7.255 0.305 using pesticide Has information on PPE 0.758 1.471 Mixes pesticides 0.509 1.933 Note: Italics = significant. Bold = very significant. Note: The figures indicate significant are indicated with *. The figures indicate very significant are indicated with #.
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|Title Annotation:||INTERNATIONAL PERSPECTIVES|
|Publication:||Journal of Environmental Health|
|Date:||Sep 1, 2007|
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