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					             History of Health Care
             Facility Evacuations


OSHA Training Institute – Region IX
University of California, San Diego (UCSD) - Extension


                     OSHA Training Institute             1
 “If you wish to
 control the
 future, study
 the past.”
-Confucius (551 B.C. to 479 B.C.)



                     OSHA Training Institute   2
Objectives
    Examine Hazard Risks for hospitals which
     could result in need for evacuation,and
     special considerations needed for them
    Recognize difference between Structural
     and Non-structural damage in a facility
    Review the history of selected prominent
     hospital evacuations in the U.S. & Canada
     and reasons for evacuations
    Review key lessons learned from these
     events
                    OSHA Training Institute      3
Risk Assessment for Hospitals-I
   Relatively high rates of occupancy 24 hours/day,
    increasing probability of serious injuries and
    casualties in building collapse or other events
   High incidence of special needs patients,
    immobile patients, and pts on life-support
    equipment
   Complex floor plans, confusing to patients if
    lights are off at night.
   Many chemical, biological and radiological
    products & explosive gases in hospitals


                      OSHA Training Institute      4
Risk Assessment for Hospitals-II
 Fires and explosions from damaged
  mechanical and electrical equipment are
  hazards to life and property
 Presence of infectious wastes and
  radioactive isotopes increase exposure
  risks over standard environments
 Heavy equipment is hazardous if
  overturned

                 OSHA Training Institute    5
Risk Assessment for Hospitals-III

 Desirable drugs, e.g. narcotics, may be
  sought after and stolen if normal security
  breaks down
 Are often sites for helicopter ops




                  OSHA Training Institute      6
Evacuations
   Move patients away from windows, to inner
    corridors
   Move patients from one end of a floor to another
    (horizontal evacuation)
   Move patients up or down one or more floors
    (vertical evacuation)
   Move patients outside, out of danger
   Direct inter-facility transports, or transports to
    patient evacuee shelters or Regional Evacuation
    Points

                      OSHA Training Institute        7
Main Building, Agnew
State Hospital , Santa
Clara County, CA.




                                 Built of unreinforced masonry,
                                 it collapsed in the San
                                 Francisco EQ, April 18, 1906.



                         OSHA Training Institute             8
  Agnew State Hospital
  “…pinned many of the patients under fallen walls and
  debris. The padded cells had to be to broken open and
  more dangerous patients were tied to trees out on the lawn
  in lieu of a safer place.” 170 out of 1,100 patients, 12
  attendants and the 2nd senior physician were killed.




Ref: http://www.sfgenealogy.com/santaclara/history /sc1906.htm
                          OSHA Training Institute              9
                                                   San Francisco
                                                   Earthquake
                                                   1906




Mechanic’s Pavilion: Makeshift hospital for EQ victims and
patients evacuated from St. Lukes & other hospitals
                         OSHA Training Institute             10
After the Earthquake came the fires….
                OSHA Training Institute   11
Mechanics Pavilion being evacuated as fire spreads
towards it.
                     OSHA Training Institute         12
U.S. Hospital Evacuations 1971-1999
     Study of 275 instances reported in the media
     Average of 21 per year in final decade
     Most in a year was 33 in 1994, due to
      Northridge EQ

Reference: Sternberg E, Lee GC, Huard D. Counting crises:
U.S. hospital evacuations, 1971-99. Prehospital & Disaster
Medicine 2004; 19:(2): 150-157.

    All were exceeded by the evacuations for
    Hurricanes Katrina and Rita, 2005
                        OSHA Training Institute              13
     Reasons for Hospital Evacuations,
                1971-1999
   Internal fire - 23%
   Internal Hazardous Materials (HAZMAT) events - 18%
   Hurricanes - 14%
   Human threat - 13%
   Earthquake - 9%
   External fire - 6%
   Flood - 6%
   Utility failure - 5%
   External HAZMAT events - 4%
Reference: Sternberg E, Lee GC, Huard D. Counting
crises: U.S. hospital evacuations, 1971-99. Prehospital
& Disaster Medicine 2004; 19:(2): 150-157.
                       OSHA Training Institute           14
Health care facility damage
   Structural
       Affects load-bearing structures in the facility
       Examples: Foundations, beams, staircase supports
   Non-structural
       Affects non-load bearing structures
       Examples: windows, ceilings, light fixtures, electrical circuits,
        medical gases, water and sewer pipes
       Includes contents of facility: shelving, cabinets, refrigerators,
        lab supplies, monitors, computers, furniture




                               OSHA Training Institute                      15
Tasks to be Planned for Hospital Evacuations

   Warning of an impending threat…how is plan activated?
   Making the decision to evacuate
   Determining destinations for evacuated patients
   Safely moving out of damaged facility and to reception points
   Avoiding moving patients to other facilities that will also need to
    evacuate
   Tracking patients, attendees, and staff
   Provisioning staff to care for evacuees and themselves
   Transportation of patients and staff
   Management of medical records, pharmaceuticals
   Determining when it is safe to return, and managing it




                                OSHA Training Institute                   16
    Reported threats to hospital
    function: Power-related


   Generator failure
   Unanchored generator batteries, inadequately anchored generators
   Damage to gas lines carrying fuel to emergency generators
   Loss of water supply to cool emergency generators
   Location of generators and switching equipment in flood-prone
    basements
   Inadequate fuel supply for generators
   Inadequate surge protection; inadequate generator capacity
   Switching failure during kick-in of back-up power

                              OSHA Training Institute                  17
Hospital evacuations may become
necessary due to structural or non-
structural damage, or threat of
damage

Causes of actual damage: Earthquake, flood, fire, hurricane, tornado,
loss of power

 Examples of threatened damage: Hurricane warnings; Threat of
 dam or levee rupture; Encroaching wildfire; HAZMAT incident with
 evacuation area declared.


                           OSHA Training Institute                  18
Mississauga General Hospital
Evacuation - no damage to facility
    11/11/79: 24 of 106 railcars on Canadian Pacific Train 54 derailed in
     Mississauga, on western outskirts of Toronto. Rail cars carried 5
     different toxic and flammable chemicals, include propane, butane,
     styrene and a leaking chlorine tanker next to the burning train

    250,000 residents evacuated from the area

    Of 478 patients, 292 were discharged home, 186 transferred to 8
     other hospitals. Two receiving hospitals later told also to evacuate.


    Henry S. Mississauga Hospital: largest evacuation in
    Canada’s history. CMA Jour 122:582-586, 1980.
                               OSHA Training Institute                       19
When a wildfire threatens…




           OSHA Training Institute   20
When Wildfires threatened a hospital…




Children’s Hospital, San Diego, CA

    “ In case of evacuation, Children's Hospital of San
     Diego, in Kearny Mesa, south of the flames, made
     tentative arrangements to transfer patients to the
     Navy Hospital ship USNS Mercy, docked in San
     Diego Bay, and to Scripps Mercy Hospital.”
    http://www.signonsandiego.com/news/fires/weekoffire/2003
    1027-9999_7n27victims.html
                          OSHA Training Institute        21
                                                 Most
                                                 Significant
                                                 Hospital
                                                 Events,
                                                 U.S.

1971: Collapse of 4 buildings at
the Veterans Administration
Hospital, Sylmar,CA due to
6.6M San Fernando EQ. 49
deaths occurred. Unreinforced
masonry walls crumbled.
                       OSHA Training Institute                 22
VA Hospital, Sylmar, CA after 2/9/1971 EQ
               OSHA Training Institute      23
VA Hospital Evacuation, Sylmar
   300 patients evacuated to various VA Hospitals within 2.5 hrs using
    school buses and commandeered vehicles




   No first responder assistance for 90 minutes, hospital staff were “on
    their own.” Initial search & rescue done by 9 VA physicians & group
    of nurses and employees on scene. Unknown if PPE (hardhats,
    masks, gloves ) were available.
   Last survivor was extricated from the rubble 58 hours after the EQ;
    digging continued for 5 days




                            OSHA Training Institute                   24
VA Hospital Evacuation, Sylmar
   Key lessons learned:
     Set up Command Post.
     Availability of “bullhorns” was critical to on-scene
      communications
     Radios
     Establish ability to communicate with first responders


Ref. Heavey JF. “Firsthand account of earthquake
destruction of VA Hospital at San Fernando, Feb 9,
1971: “All hell broke loose- my first earthquake.”

                        OSHA Training Institute            25
Most Significant Hospital Events, U.S.
                                       LA County-Olive View
                                        Medical Center
                                         New 6 story complex,
                                          dedicated on 1/9/71
                                         Life span of one month
                                         “Totaled” on 2/9/71
                                         3 deaths occurred
                                                2 on ventilators
                                                1 struck by falling debris
                                                 when running outside
                                           The Community Mental
                                            Heath Bldg at the Center
                                            totally pancaked down one
                                            story
                                                No one in basement
                                                 when 6.6 EQ occurred at
                                                 06:00



              OSHA Training Institute                                     26
Olive View Medical Center, 1971
  Ambulance crushed by overhang




Collapsed outdoor stair tower
Olive View Medical Center
                                                     1st floor entrance to
                                                     medical clinics area
                           OSHA Training Institute                           27
    Lessons Learned from San
    Fernando Earthquake - 1971

 Building codes were inadequate for
  hospitals to withstand Earthquakes.
 Resulted in Uniform Building Code and
  1972 Hospital Act and 1973 VA D
 Design standard for hospitals; increased
  standards by 50% in 1976


                 OSHA Training Institute     28
    Impact of Hurricane Hugo on Surgical
    Services in a University Hospital, 1989

   Winds led to loss of
    emergency power and water
   System failures occurred in
    air conditioning, vacuum
    suction, steam and ethylene
    oxide sterilization, plumbing,
    central paging, lighting and
    refrigeration

                                              Hurricane Hugo making
                                                 landfall in Carolinas
                         OSHA Training Institute                    29
    Impact of Hurricane Hugo on Surgical
    Services in a University Hospital, 1989

   Surgical support services lost:
      Blood   bank: No platelet packs for 2
       days
      Radiology: CT/MRI Scanners
       damaged; flooding ruined patient files
      ICU: No monitors; hand ventilation of
       ventilator patients
      OR: Loss of temperature and humidity
       control (steam, H2O, suction); elective
       surgery halted for 11 days.

                          OSHA Training Institute   30
    Impact of Hurricane Hugo on Surgical
    Services in a University Hospital, 1989


   Recommendations for planning
    for hurricanes

        Augmented ancillary services staffing
        Evacuation of as many critical
         patients as possible before the storm.




                  Norcross ED, et al. Am Surg 59(1):28-33, 1993

                               OSHA Training Institute            31
Hospital Disaster Operations during
the 1989 Loma Prieta Earthquake
   Magnitude 7.1 EQ struck northern CA on 10/17/89 at
    1704 hrs
   Epicenter 75 miles south of SF near Loma Prieta Peak in
    the Santa Cruz Mts.
   42 people killed in collapse of the Cypress Structure (
    elevated freeway in Oakland.)
   Major impact on health care services




                        OSHA Training Institute          32
Hospital Disaster Operations
during the 1989 Loma Prieta EQ
   43% of hospitals had inadequate back-up power
    configurations
   5 hospitals sustained total back-up generator
    failure
   20 hospitals performed partial evacuations; none
    required complete evacuations




                      OSHA Training Institute     33
Hospital Evacuations during
the 1989 Loma Prieta EQ
   Evacuees were:
     Ambulatory     psychiatric or alcohol-rehab patients in 3
      hospitals
     From clinic and medical office buildings at 4 hospitals
     Horizontal patient evacuations (moved to another
      area on same floor) at 3 hospitals due to broken
      windows
     Vertical evacuations of non-ambulatory, Med-Surg,
      OB, Nursery and Pediatric patients at 3 hospitals
          Non-ambulatory patients were hand-carried downstairs on
           sheets or in wheelchairs.

                            OSHA Training Institute                  34
EQ-related equipment dysfunction
during the 1989 Loma Prieta EQ in 51
hospitals
   Elevators:
     Lack
         of power in 20 (39%)
     Damage by shaking in 6 (11.8%)
   Roof fans knocked off bolts in 6 (11.8%)
   Water pipes damaged by shaking in 5 (9.8%)
   Cabinet contents spilled by shaking in 5 (9.8%)
   Potential HAZMAT spill in 4 (7.8%)
   Equipment falling (monitors, O2, TV sets) in 3
    (5.9%)
                      OSHA Training Institute         35
Loma Prieta EQ: Staff anxiety and fear
   Hospital and health care institution staff in an EQ are also
    victims of the EQ
   Fear for family and homes pose significant problems
   One hospital excused one person per floor to check the
    families of the staff for that floor
   Firefighters brought the children of hospital employees
    into the hospital
   Child care on site for day(s) after the EQ is key (due to
    school closures) in relieving staff anxiety




                            OSHA Training Institute            36
Northridge, CA Earthquake -
1994
        6.7 M EQ at 04:31 hrs on Jan. 17, 1994
        Sepulveda VA Hospital, all power and
         emergency generators failed; broken pipes
         flooded many buildings, staff scrambled to
         manually ventilate pts on respirators, often
         crawling thru debris. Supply doors jammed
         shut; Suction machines were under rubble.
        Decision was made to evacuate facility,
         ambulatory pts first, then wheelchair pts, using
         flashlights to see. 331 pts. evacuated by
         06:00 hrs.

                   OSHA Training Institute            37
Northridge, CA EQ - 1994
        Six hospitals evacuated patients
         immediately
        4 evacuated all inpatients
        5 evacuated sickest patients first.
        6th evacuated healthiest first, fearing
         imminent collapse, “…the greatest good for
         greatest number.” 334 pts evacuated to
         open areas outdoors in 2 hours.
        All used improvised transport devices
         (backboards, blankets, mattresses)


                   OSHA Training Institute            38
                                         Damage, 3rd
                                         floor, water
                                         break from roof
                                         tank




Northridge EQ 6.7 M
Granada Hills Community
Hospital

Pts. On top 2 floors evacuated
to 1st floor, ED stays open
                      OSHA Training Institute              39
          Medical office building,
          of recent construction,
          reinforced concrete,
          fails during Northridge
          EQ, Jan 17, 1994.




OSHA Training Institute          40
                          Sept. 2, 1993
                          “ a faulty
                          respirator
                          exploded in the
                          ICU, leading to 3
                          deaths and the
                          evacuation of
                          120 others….”




OSHA Training Institute                   41
Tropical Storm Allison, Houston, TX
             June 2001

                             Texas Medical
                              Center:
                                     40 institutions
                                     54,000 employees in
                                      downtown Houston
                             12-15 inches of rain in
                              < 9 hours.




            OSHA Training Institute                         42
        Tropical Storm Allison, Houston, TX
                       June 2001




   Shortly after midnight on 6/9/01,10 million gal. of water
    poured into basement and the ground floor of the UTX
    Medical School and Memorial Hermann Hospital
   Had to reassure, treat and transfer 540 patients to other
    hospitals, up to 200 miles away.
                         OSHA Training Institute            43
        Tropical Storm Allison, Houston, TX
                     June 2001

   Issues at Memorial Hermann Hospital
     Staff worked for 48 or more hours straight,
      without sleep
     ICU pts on ventilators required ventilation by
      hand with Ambu- bags for hours to days
     Evacuations of 540 pts was on backboards down
      unlit, hot, humid stairwells by flashlight
     Creation of a “temporary Emergency room” for
      patients and staff who might get ill during their
      transfer



                       OSHA Training Institute            44
Tropical Storm Allison, Houston, TX – June 2001

    Issues at Memorial Hermann Hospital
      Paper  trail for each patient had to be created, to
       track where they went.
      No 911 or EMS system for back up, due to
       flooding, power issues
      New helicopter LZ had to be created for Medevac
       by USCG, National Guard and Life Flight
       rotorcraft, with attendant safety issues for people
       not used to working around helicopters



                        OSHA Training Institute          45
    How are such events “Planned for?”
   Use of HICS, the “Hospital Incident Command System”
   Creation of an “Internal Emergency Action Plan,” a
    Disaster Plan for Internal Events
   Exercise of the plan regularly, to avoid the “Paper Plan
    Syndrome”
   Involvement of all levels of facility administration and
    operations people in exercise planning and response
   Improve the plan through Exercise Critiques, “Hot
    Washes,” After Action Reports, Lessons Learned




                         OSHA Training Institute               46
Super Typhoon Pongsona, Guam – December 2002

                                  Located 3,700 miles SW
                                   of Hawaii (other side of
                                   Int’l Dateline)
                                  Struck Guam and Rota
                                   on Dec 8-9, 02
                                  180 mph winds, 15-25
                                   foot wave heights
                                  Fuel tank farm fire
                                   decreased availability of
                                   fuel for generators


                 OSHA Training Institute                       47
Super Typhoon Pongsona, Guam – December 2002

                              Guam Memorial Hospital, the only
                               civilian hospital on the island, is a
                               former navy hospital.
                              GMH emergency dept flooded,
                               windows broke in the ICU caused
                               significant wind damage in halls,
                               ceilings
                              No injuries, due to evacuating staff
                               and patients to “inside rooms.”
                               Critical patients were evacuated to
                               the ICU at Naval Medical Center in
                               Guam



                 OSHA Training Institute                         48
Super Typhoon Pongsona, Guam – December 2002


                              US Air Force Field Hospital,
                               flown in from Japan, was set
                               up outside hospital
                              DMATs deployed to provide
                               care, substituting for MD
                               officers, pharmacies, “unload
                               ERs.”




                 OSHA Training Institute                 49
         Hurricane Katrina-Aug. 2005
• Three Landfalls: 8/25/05 near Miami, FL
(Cat 1) & 8/29/05 Near New Orleans delta
area (Category 4) at 06:10 hrs; and near
11:00 hrs-Noon near Gulfport/Biloxi, MS

• >80% of the City of New Orleans flooded
from levee breaks

• Official death toll as of 3/7/06 = 1,422.
(includes >1,000 in LA)

• Displaced >1,000,000 people

• Area covered by disaster declaration
= 90,000 sq.mi., almost equals area
of UK.                       OSHA Training Institute   50
Hurricane Katrina – Aug. 28, 2005
   97 Hospitals were impacted by Hurricane Katrina
    (Southern LA, AL & MS)
       70 Medical Surgical Hospitals
       11 Psychiatric Hospitals
       1 Children's Psychiatric Hospital
       4 Rehabilitation Hospitals
       2 Other Specialty Treatment Hospitals
       1 Children's Medical Surgical Hospital
       1 Obstetric and Gynecology
       2 Acute Long Term Care Hospital
       1 Children's Acute Long Term Care Hospital

                        http://planning2.com/NewOrleansHospitalsKatrina.htm
                             OSHA Training Institute                    51
Hurricane Katrina – Aug. 28, 2005

   30 hospitals evacuated, accounting for 22,200
    hospital workers and 5,048 beds
   Accounted for >145,000 inpatient admissions in
    2004




    http://planning2.com/NewOrleansHospitalsKatrina.htm
                       OSHA Training Institute            52
    Partial list of evacuated hospitals following Katrina 9/5/05
VA Gulf Coast Veterans         GULFPORT           MS            39531     Closed, Not Accepting Patients
Chalmette Medical Center       CHALMETTE          LA            70043     Evacuated
Children's Hospital            NEW ORLEANS        LA            70118     Evacuated
Crosby Memorial Hospital       PICAYUNEMS         39466         Evacuated
Healthsouth Specialty Hosp     NEW ORLEANS        LA            70127     Evacuated
Healthwest Rehab Hospital      GRETNA             LA            70056     Evacuated
Kenner Regional Medical Center KENNER             LA            70065     Evacuated
Kindred Hospital - New Orleans NEW ORLEANS        LA            70115     Evacuated
LifeCare Hospital, Chalmette   CHALMETTE          LA            70043     Evacuated
LifeCare Hospital, Baptist     NEW ORLEANS        LA            70115     Evacuated
LifeCare Hospital, Kenner      KENNER             LA            70065     Evacuated
Lindy Boggs Medical Center     NEW ORLEANS        LA            70119     Evacuated
Meadowcrest Hospital           GRETNA             LA            70056     Evacuated
Memorial Medical Center        NEW ORLEANS        LA            70115     Evacuated
Methodist Hospital             NEW ORLEANS        LA            70127     Evacuated
New Orleans Adolescent         NEW ORLEANS        LA            70118     Evacuated
River Oaks Hospital            NEW ORLEANS        LA            70123     Evacuated
St Charles General Hospital    NEW ORLEANS        LA            70115     Evacuated
Touro Infirmary                NEW ORLEANS        LA            70115     Evacuated
Tulane University Hospital     NEW ORLEANS        LA            70112     Evacuated
VA Medical Center              NEW ORLEANS        LA            70112     Evacuated
Med Center of LA at N.O.       NEW ORLEANS        LA            70112     Evacuated
River Oaks Child & Adolescent NEW ORLEANS         LA            70123     Evacuated
Lakeside Hospital              NEW ORLEANS        LA            70117     Evacuated

              Courtesy of Planning 2.0 LLC, Franklin, TN
                                      OSHA Training Institute                                  53
Kiholo Bay EQ

 Kona Community Hospital: 94 bed acute and long-term
 community hospital in Kealakekua, HI
    Beds: 49 acute, 11 psychiatric, 34 long-term beds
 Sunday, 10/14/06: Two EQs (6.6 & 5.8 magnitude) caused
 moderate non-structural damage to facility, loosened ceiling
 tiles, equipment knocked to the floor; 10 acute-care pts
 evacuated to Hilo. ED remained open.
 30 nursing-care-level pts evacuated temporarily to nearby
 Sheraton Conference Center, HI-1 DMAT activated, deployed
 to manage evacuees
                          OSHA Training Institute           54
Kiholo Bay EQ

                                          Ceiling
                                          tiles
                                          downed
                                          after EQ




                OSHA Training Institute              55
    Kiholo Bay EQ 2006
   Other evacuations and
    Hospital impacts:
     KohalaCommunity Hospital,
      Kapaau (North Kohala), HI
          28 bed facility
          evacuated long-term care
           residents to the cafeteria to
           allow clean-up of non-
           structural damage




                                 OSHA Training Institute   56
    Kiholo Bay EQ 2006

   Other evacuations and Hospital impacts:
     Hale   Ho’ola Hamakua Hospital, Honukaa, HI
        Worst damage from broken water pipes
        49 patients evacuated to temp. shelter in parking lot,
         then 47 relocated to Hanokaa Hospital. ER stayed
         open.




                            OSHA Training Institute               57
SUMMARY
   Risk Hazards for hospitals reviewed
   Differences between Structural and Non-
    structural damage at medical care facilities
   Reviewed several historical hospital evacuation
    scenarios and lessons learned from them
   Examined some risks specific to the hospital
    evacuation scenario, which merit planning,
    training, and exercise at your health care
    facilities

                      OSHA Training Institute         58
References
   Santa Clara County Geneaology: Effects of the 1906 earthquake in San
    Jose. http://www.sfgenealogy.com/santaclara/history/sc1906.htm
   Chavez CW, Binder B. A hospital as victim and responder: the
    Sepulveda VA Medical Center and the Northridge EQ. J Emerg Med
    14(4):445-54, 1996
   Henry S. Mississauga Hospital: largest evacuation in Canada’s history.
    CMA Jour 122:582-586, 1980.
   Koegler RR & Hicks SM. The destruction of a medical center by
    earthquake: Initial effects on patients and staff. Calif Med 116:63-67,
    1972
   Martchenke J , Pointer JE. Hospital disaster operations during the
    1989 Loma Prieta EQ. Prehosp & Disast Med 9(3):146-153, 1994
   Nates SL. Combined external and internal hospital disaster: impact &
    response in a Houston trauma center ICU. Crit Care Med 32:686-90,
    2004
   Norcross ED, et al. Impact of a major hurricane on surgical services in
    a university hospital. Am Surg 59(1):28-33, 1993


                              OSHA Training Institute                         59
References (cont’d)
   Olive View Medical Center photos:
    http://earthquake.usgs.gov/regional/states/events/1971_02_09_photos.php
   Sternberg E, Lee GC, Huard D. Counting crises: U.S. hospital evacuations,
    1971-99. Prehospital & Disaster Medicine 2004; 19:(2): 150-157.
   Wolff, C. “Three patients die in hospital explosion,” New York Times, Sept. 2,
    1993
   Gima C. Tremors rattle isles: two earthquakes in succession hit the Big
    Island the hardest http://starbulletin.com/2006/10/16/news/story04.html
   Adamski M. Kona facility has limited operations, but structure is deemed to
    be stable http://starbulletin.com/2006/10/18/news/story05.html
   “East Hawaii medical centers respond to Sunday morning
    earthquake.”http://www.hawaiireporter.com/story.aspx?c0b55e68-bc2e-
    4790-b8f6-d5a2b758314b




                                 OSHA Training Institute                       60

				
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