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Goal 4: Global Health Protection and Health Systems Strengthening

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Objective Strategy Progress
4A. Maximize NCHHSTP collaboration with and contributions to key global health initiatives and platforms (e.g., PEPFAR II, Global Health Initiative, Millennial Development Goals, WHO, Global Disease Detection, etc.).

I. Collaborate with key global health initiatives and platforms in providing technical leadership, direct assistance, and funding to Ministries of Health and other partners to enhance surveillance, prevention, and capacity building relevant to prevention and control of HIV, viral hepatitis, STD, and TB.

Indicator: Collaboration with key global health initiatives and platforms in at least 3 activity areas

FY 2011-2012 Accomplishments

  • Collaborated with Division of Global HIV/AIDS (DGHA) to assess HIV incidence in western Kenya; this should lead to improvements in linkage to HIV care.
  • Published study on parent-child communication about HIV/AIDS in Kenya.
  • Published study on baseline syphilis and HSV-2 prevalence in Bangkok MSM cohort.
  • Continued collaboration with WHO on the implementation of the Global YRBS in developing countries.
  • Collaborated with DGHA to promote HIV-VH coinfection integration in PEPFAR Platforms.
  • Worked with DGHA on projects in Vietnam, Uganda, and Tanzania to address HIV-VH coinfection.
  • Collaborated with GDD to work with Pakistan FETP in viral hepatitis surveillance.
  • Collaborated with WHO to assist in the development of a Global Hepatitis Program at HQ; support with staff to WHO.
  • Collaborated with WHO to complete guidelines on congenital syphilis surveillance, monitoring & evaluation (M&E).
  • NCHHSTP was a founding member of a new global partnership aimed at eliminating congenital syphilis: The Global Congenital Syphilis Partnership (GCSP).
  • Provided technical support to the WHO to develop and disseminate the 1) Global Action Plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae; 2) Methods for Surveillance and Monitoring of Congenital Syphilis Elimination within Existing Systems; and 3) Situational Analysis on the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in the Americas.
  • Provided technical leadership via active participation in at least 12 global and regional technical workgroups and conducted over 30 technical assistance missions to at least 22 countries.

FY 2013 Plans

  • Continue close collaboration with DGHA to assess HIV incidence in western Kenya and including a Nairobi slum (Kibera).
  • Study safety and immunogenicity of influenza vaccine in Bangkok MSM.
  • Study improved detection of acute HIV in heterosexually active adults in Kisumu using novel testing technologies.
  • Continue collaboration with WHO on the implementation of the Global YRBS in developing countries.
  • Work with WHO to support development of global guidelines in a) surveillance; b) hepatitis B birth dose implementation; c) treatment of HIV-VH coinfection guidelines.
  • Collaborate on WHO regional action plans/strategies developed in WPRO and EMRO.
  • Work with DGHA Vietnam to model collaboration with integration of viral hepatitis into CDC Platform including hiring a FSN and conducting VH research and MOH support of developing a VH program.
  • Work with GDD/Egypt to support comprehensive VH control strategy.
  • Collaborate with USAID in providing funding for VH control in Pakistan in collaboration with FETP.
  • Provide WHO with technical support for 2 regions to scale up surveillance, monitoring and evaluation for congenital syphilis elimination, including validation of disease elimination.
  • Meet with GCSP to map out donor support in countries of greatest need; continue ongoing efforts to enhance laboratory capacity in high burden countries.
  • In collaboration with WHO and global partners launch the Investment Case for Congenital Syphilis Elimination in October 2012.
  • Strengthen ongoing collaborations to leverage NCHHSTP’s opportunities for contributing toward the objective.
  • Continue to contribute to GHI efforts.
  • Promote integration of TB and HIV surveillance and program services in at least 5 countries.

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Goal is completed.

II. Assist the Division of Global HIV/AIDS in providing technical leadership, direct assistance, and funding to Ministries of Health and other PEPFAR partners to expand quality HIV/AIDS care and treatment services and implement effective HIV prevention programs.

Indicator: Assist efforts of DGHA in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Published article assessing sexual behavior of adults receiving combination ART in Uganda.
  • With WHO/other CDC offices, initiated a demonstration project assessing feasibility and utility of integrated antenatal services (including maternal syphilis testing) in improving antenatal clinic service uptake and infant health outcomes.
  • With DGHA:
    • Collaborated with WHO to provide technical assistance to Zambia in support of integrated prevention of mother-to-child transmission of HIV and syphilis.
    • Conducted a systematic literature review of integrated antenatal interventions for preventing MTCT of HIV and syphilis.
    • Completed evaluation of cost-effectiveness of integrated routine offering of prenatal HIV and syphilis screening to prevent adverse pregnancy outcomes in China.
    • Completed PMTCT and CS Integration of Preventing Mother to Child Transmission of HIV and Syphilis Testing and Treatment in Antenatal Care Services in the Northern Cape and Gauteng Provinces, South Africa, 2005-2006 (in clearance).

FY 2013 Plans

  • With DGHA:
    • Continue support to Zambia in scaling up integrated prevention of MTCT of HIV and syphilis in additional districts, particularly in laboratory and M&E areas, and integrating as possible with WHO activities.
    • Malawi, complete evaluation of integrated antenatal services, including antenatal syphilis testing, in Machinga District in Malawi.

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Goal is in progress.
4B. Optimize NCHHSTP efforts to reduce impact of HIV, viral hepatitis, STD, and TB globally.

I. In HIV-infected populations, enhance efforts to reduce impact of viral hepatitis, STD, and TB as exemplified by expanding screening, vaccination, and treatment for chronic hepatitis B infection; improving screening for TB and implementation of isoniazid prophylactic therapy; enhancing screening for cervical cancer; expanding screening and treatment for genital ulcer disease; increasing prevention of mother-to-child transmission coverage; and implementing promising biomedical interventions, if proven efficacious.

Indicator: Enhanced efforts to reduce impact of co-infections in HIV-infected persons in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Provided support to U.S. Pacific Islands to enhance integrated surveillance of viral hepatitis, STD and TB among HIV infected persons.
  • Provided technical support to WHO HIV Unit on integrated STI surveillance.
  • Provided laboratory support for STI testing for Integrated Behavioral & Biologic Surveillance to support HIV Prevention in four African and Central American nations and regional laboratories.
  • Provided support to Barbados Health Ministry for enhanced STD program management.
  • CDC-led research identified a simple symptom screening approach that increased the diagnosis of TB in persons living with HIV and demonstrated that TB could be prevented in PWHA who screen negative for TB disease and receive treatment for latent TB infection. The strong evidence provided by these studies contributed to updates in the global Guidelines for intensified TB case-finding and isoniazid preventive therapy in PWHA in resource-constrained settings.

FY 2013 Plans

  • Continue integrated surveillance efforts in the U.S. Pacific Islands.
  • Enhance regional laboratory capacity to provide STI testing to support national IBBS programs for HIV prevention.
  • Conduct research assessing feasibility and costs of HPV vaccination among vulnerable women prior to initiating sex, including women living in nations with high HIV prevalence.
  • Collaborate with WHO and at least three low-resource countries to implement the recent WHO guidelines and evaluate impact.
  • Actively engage in the CDC Global TB Workgroup to support and enhance collaborations improve global TB control.

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Goal is in progress.

II. In support of integrated maternal and child health programs, to enhance efforts to reduce impact of HIV, viral hepatitis, STD, and TB.

Indicator: Enhance efforts to integrate maternal and child health programs in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Published study on combination ART for breast-feeding mothers and its impact on drug resistance.
  • Chaired and coordinated CDC Global Perinatal Integration Working Group (GPIWG).
  • Completed evaluation of introduction of antenatal syphilis screening as part of larger evaluation of integrated MCH programs in two districts in Nyanza Province, Kenya (in collaboration with other CDC programs).
  • Initiated demonstration project assessing feasibility of integrated MCH programs to improve maternal and health outcomes in Machinga District, Malawi, in collaboration with others.
  • With WHO, developed proposal for “Saving Lives at Birth” Grand Challenge: Accelerating introduction of dual syphilis/HIV rapid tests (i.e., on a single platform). This proposal was chosen as one of 65 “finalists” invited to present at the Gates Foundation in June 2012.
  • Participated in a coordinating committee to develop the first CDC-wide global MCH Strategy.

FY 2013 Plans

  • Continue collaboration with Health Ministries of Kenya and Malawi on district-wide projects to scale up syphilis screening as part of integrated antenatal services, including publication and dissemination of evaluation results.
  • Web dissemination of newly developed structured training on rapid syphilis testing aimed at clinicians (nurses) working in low level health facilities.
  • Continue work in evaluating dual syphilis/HIV rapid tests (on a single platform) in laboratory and field settings, including publication of a report on these evaluations.

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Goal is completed.

III. In other targeted settings or general populations, enhance efforts to reduce impact of HIV, viral hepatitis, STD, and TB.

FY 2011-2012 Accomplishments

  • Conducted qualitative research on HPV vaccine in collaboration with KEMRI/CDC.
  • Evaluation studies of integrated antenatal interventions, including maternal syphilis screening.
  • Provided laboratory support for STI testing in sex workers, men who have sex with men, and migrant populations in four African and Central American nations.

FY 2013 Plans

  • Implement phase 2 study of new microbicide gel for the prevention of HIV infection.
  • Site visits to provide technical support in laboratory services, surveillance and STI programs to U.S. Pacific Islands – including initiation of an improved means of providing gonorrhea and chlamydia testing in 2 islands (Yap, Saipan).

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Goal is in progress.
4C. Apply CDC strengths to Health Systems Strengthening efforts.

I. Expand global surveillance, monitoring, and evaluation, information systems and epidemiologic science to monitor trends and inform policy development.

Indicator: Enhanced efforts to strengthen health systems in ≥ 3 areas of data collection and analysis

FY 2011-2012 Accomplishments

  • Worked to help Thailand MOH adopt recommendation to conduct venue-based HIV surveillance.
  • Provided technical and fiscal support for the implementation of the Global YRBS in 36 countries.
  • Assigned STD epidemiologist at WHO to support global STD surveillance, M&E of congenital syphilis and other STD areas.
  • Supported global efforts on TB impact measurement including: 1) participation in the WHO Global Task Force on TB Impact Measurement; 2) the implementation of TB disease prevalence surveys in three countries; and 3) piloted in seven countries the development of a tool to validate surveillance data.
  • Provided technical assistance to WHO to revised the TB case and treatment outcome definitions given the introduction and use of WHO approved rapid diagnostics (Xpert MTB/RIF).

FY 2013 Plans

  • Provide technical and fiscal support for the implementation of the Global YRBS in 10 to 15 developing countries.
  • Provide technical and fiscal support for national field tests of the Global School Health Policies and Practices study in 3 African countries.
  • Provide support to WHO and Regions to scale up global antimicrobial resistance surveillance for highly resistant gonorrhea.
  • Provide technical support WHO/PAHO to validate elimination of congenital syphilis in pilot country (Chile).
  • Support up to 10 high burden countries in initiating surveillance, M&E for congenital syphilis elimination.
  • Continue to collaborate with WHO and partners to complete TB drug resistance surveys in at least three countries and implement the tool to validate surveillance data.
  • Collaborate with WHO to pilot and measure the impact of the revised TB case and treatment outcome definitions in at least three countries.

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Goal is completed.

II. Promote transfer of appropriate laboratory technology and enhancement of laboratory quality to enhance screening, care and treatment, and surveillance programs.

Indicator: Efforts to promote laboratory technology and quality in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Provided support to WHO to complete Guidelines on Strategies and Laboratory Methods for Strengthening Surveillance of STIs.
  • Continued collaboration with WHO as a Collaborating Centre for Syphilis Serology.
  • Laboratory evaluation of dual HIV and syphilis rapid tests (single platform) prior to field testing (in progress with HIV Laboratory).
  • Provided support to two regional laboratories in enhancing STI testing for HIV prevention.
  • Developed a phased process for TB laboratories to follow to achieve accreditation. Harmonized this process with the CDC/WHO Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) and Strengthening Laboratory Management Towards Accreditation (SLMTA).
  • Participated with WHO to define best practices for incidence testing and to define the optimal parameters for HIV incidence tests.
  • Collaborated with NCEZID to provide Model Performance Evaluation Program (MPEP) to assess participating laboratory’s drug susceptibility testing process for Mycobacterium tuberculosis complex.
  • Developed a stepwise electronic implementation guide to assist public health laboratories to become accredited.

FY 2013 Plans

  • Continue support of DHAP Laboratory in Kisumu.
  • Renew collaboration with WHO Collaborating Center with expanded activities to include regional laboratory capacity building for STI testing and support for gonorrhea AMR surveillance.
  • Field test dual HIV and syphilis rapid tests on single platform in at least one high prevalence setting.
  • Provide direct technical support in Zambia for national laboratory quality control required for scaling up preventing MTCT of HIV and syphilis in antenatal services.
  • Pilot test the electronic implementation guide in laboratories conducting testing for TB and for HIV.
  • In collaboration with the African Society of Laboratory Medicine (ASLM), incorporate the checklists for TB laboratory accreditation into the SLIPTA assessors program.
  • Pilot test the electronic implementation guide in laboratories conducting testing for TB and for HIV.
  • In collaboration with the ASLM, incorporate the checklists for TB laboratory accreditation into the SLIPTA assessors program.

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Goal is in progress.

III. Promote transfer of relevant management and service delivery of NCHHSTP-related activities to host governments and local indigenous implementing partners; maintain strong ties to foster leadership and governance for health based on the best available science.

FY 2011-2012 Accomplishments

  • Provided technical support to Ministry of Health Barbados on enhancing STD Management and Surveillance evaluation activities, using model developed by CDC-World Bank project.
  • Provided technical support to WHO/HQ on development of sexual health indicators.
  • Provided technical support and training to health districts in Kenya and Malawi on antenatal syphilis screening as part of antenatal services, including use of rapid test.

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Goal is completed.
4D. Apply CDC strengths to train health professionals to increase their expertise in epidemiology, laboratory science, and public health administration.

I. Expand global surveillance and public health capacity in epidemiology, laboratory science, and public health administration (e.g., field epidemiology and laboratory training program and Sustainable Management and Development Program training programs).

Indicator: Efforts to expand capacity in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Training and collaboration with KEMRI/Kisumu, Thai Ministry of Public Health, and Uganda’s TASO NGO health professionals.
  • Conducted 13 Global YRBS Survey Implementation Workshops for ministry of health and education representatives from 27 developing countries.
  • Developed training materials, templates, and roadmaps to help countries develop with TB laboratory strategic planning.
  • Developed consensus training materials for conventional and molecular diagnostic tests for TB suitable for use in high-burden, resource-limited settings.
  • Supported courses to train TB laboratory managers from 11 countries on the use of the Tuberculosis Control Assistance Program (TB CAP) Laboratory Toolbox.
  • Trained over 100 national, regional and local staff on TB infection control in Cambodia, Thailand, India, and Vietnam.
  • Provided education and training in mycobacteriology for public health laboratories (national and international).
  • Partnered with APHL for the National Laboratory Training Network.

FY 2013 Plans

  • Conduct at least 1 Global YRBS Survey Implementation Workshop and 1 Global YRBS Data Analysis and Reporting Workshop for MOH and education officials in developing countries.
  • Conduct training courses on implementation of molecular diagnostic tests for TB.

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Goal is completed.

II. Foster training and provide leadership opportunities for CDC’s in-country locally employed staff to strengthen local programs.

Indicator: Efforts to foster training and leadership opportunities in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Trained and oversaw locally employed HIV staff in Uganda, Kenya, Botswana and Thailand.
  • Trained:
    • 36 local staff in rapid syphilis testing in Kenya including four staff working directly with CDC.
    • 23 local staff in rapid syphilis testing in Malawi, including four staff working directly with CDC.
    • 3 laboratory including CDC/KEMRI staff in dried tube specimen evaluations for evaluation of syphilis rapid tests in Kenya.
    • National program including local CDC/DGHA staff in syphilis serologic testing and specimen collection in Mozambique.
  • Developed, organized, and facilitated operational research (OR) training project and mentorship in India involving 42 participants (including local staff) who completed 14 OR projects leading to 12 manuscripts that are under peer review and changes program policy and practices at national and subnational levels in India.
  • Provided training of lab staff in Kenya to perform assays which determine recent HIV infection.
  • Supported courses to train TB laboratory managers from 11 countries on the use of the Tuberculosis Control Assistance Program Laboratory Toolbox.

FY 2013 Plans

  • Provide laboratory training opportunities for local staff in Atlanta and in country.
  • Replicate the OR training and mentoring model in Uganda and Vietnam.
  • Develop a protocol to support training of GS 7-11 laboratory scientists to continue development of the next generation of laboratory staff subject matter experts.
  • Pilot test the materials for developing TB laboratory strategic planning and harmonize with materials for public health laboratory strategic planning.
  • Conduct training courses on implementation of molecular diagnostic tests for TB.

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Goal is in progress.

III. Continue to promote opportunities for NCHHSTP staff to gain global experience through the International Experience and Technical Assistance program.

FY 2011-2012 Accomplishments

  • Supported for travel by staff in support of various studies in Uganda, Kenya, Botswana and Thailand.
  • Four EIS officers involved in international evaluations (Malawi, Kenya, Vietnam and Peru), with two completing international site visits.

FY 2013 Plans

  • Two EIS officers will initiate international activities, with one planned to conduct an international site visit support validation of congenital syphilis elimination.

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Goal is in progress.
4E. Conduct operational research and program evaluation in global health settings to enhance health outcomes in HIV, viral hepatitis, STD, and TB at home and abroad through improved diagnosis, treatment, and prevention efforts.

I. Foster innovative, locally relevant research and program evaluation.

Indicator: Completion of locally relevant research and program evaluation efforts in in ≥ 2 activity areas

FY 2011-2012 Accomplishments

  • Completed structured training course to support clinicians in providing rapid syphilis testing in remote settings (available on web).
  • Collaborated with DGMQ to provide on-site technical assistance to Haiti and Dominican Republic to evaluate and strengthen laboratory capacity for screening of U.S. bound immigrants and refugees.
  • Evaluated the use of TST as an entry point to screen for latent and active TB in Thai people living with HIV.

FY 2013 Plans

  • Determine the potential benefit of a point-of-care CD4 measuring device to improve linkage to care through a randomized trial in Kisumu.
  • Evaluate rapid syphilis testing course and disseminate findings.
  • Translate syphilis course into French as well as English and make it available online.
  • Collaborate with Division of Global Migration and Quarantine (DGMQ) to evaluate implementation of the updated Technical Instructions for Tuberculosis Screening and Treatment in at least two countries.
  • Replicate the OR training and mentoring model in India and Uganda in FY 2013.

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Goal is completed.

II. Identify effective intervention and prevention programs with relevance to improving domestic programs.

Indicator: Completion of research and program evaluation efforts with domestic implications in > 2 activity areas

FY 2011-2012 Accomplishments

  • Published results of the HPTN052 study in which early initiation of combination ART in HIV-infected persons was found to reduce HIV transmission by 96%.
  • Published results of TDF2 study that showed 62% reduction in incidence of HIV in heterosexually active Botswana adults taking daily PrEP (Truvada).
  • Published results of Partners PrEP study (we contributed site in Uganda) that showed 67-75% reduction in incidence of HIV in HIV serodiscordant couples in Uganda adults taking daily PrEP (Truvada or tenofovir).
  • A study conducted by CDC’s TB Trials Consortium (Study 26), including participants for the U.S., Canada, Brazil and Spain, demonstrated that a 12-dose 3-month Rifapentine-Isoniazid regimen for treatment of latent TB infection offers a safe and effective alternative to the current standard 9 months INH regimen. Based on the study results, CDC recommended use of this regimen in the U.S.

FY 2013 Plans

  • Analyze and disseminate primary results of the Bangkok Tenofovir Study (PrEP) for the prevention of HIV infection among injection drug users.
  • Open label extension of PrEP (for HIV prevention) among heterosexually active adults in Botswana.
  • Continue open label trial of alternative dosing for PrEP (for HIV prevention) among MSM in Thailand.
  • In collaboration with State and local TB programs, conduct a post-implementation assessment of 12-dose 3-months Rifapentine-Isoniazid regimen.
  • Conduct a follow-up study to determine if directly observed treatment is required to achieve LTBI treatment rates equivalent to what was observed in the base study (Study 26).

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Goal is completed.

III. Describe, quantify, and address burden of disease associated with migration or movement to the United States from high-prevalence countries.

Indicator: Completion of efforts to address burden of disease associated with migration or movement to the United States in > 2 activity areas

FY 2011-2012 Accomplishments

  • Published article on HIV epidemiology of persons born outside the United States and US-born persons diagnosed in the United States.
  • Collaborated with the Center for Liver Disease of Virginia Mason Medical Center to conduct a meta-analysis to determine country-specific pooled chronic hepatitis B prevalence rates. And to estimate the number of foreign-born persons with chronic hepatitis B by country of birth.
  • Collaborated with the Hepatitis B Foundation (HBF), Hepatitis B Coalition (HBC) and the Hepatitis Education Project (HEP) to conduct hepatitis B screening, vaccination and referral for care for foreign-born persons from hepatitis B endemic countries.
  • Collaborated with DGMQ to evaluate hepatitis B screening and vaccination programs in refugee health clinics in four states.
  • Released an FOA (Viral Hepatitis, Early Education, and Linkage to Care for Persons with Chronic HBV and HCV Infections) to conduct hepatitis B screening among foreign-born persons from hepatitis B endemic countries. Funding is restricted to the top 50 cities with the highest Asian and African foreign-born populations.
  • Collaborated with DGMQ to estimate the Impact of Newly Arrived Foreign-Born Persons on Tuberculosis incidence in the United States.
  • Conducted an analysis to determine whether the prevalence of drug resistance among foreign-born TB cases in the U.S. is better predicted by data from previous years of the WHO Global Project on Anti-tuberculosis Drug Resistance Surveillance (Global DRS) or from previous years of the U.S. National TB Surveillance System.

FY 2013 Plans

  • Continue collaboration with the HBF, HBC, and HEP to provide screening, vaccination and referral to care for foreign-born persons from endemic countries.
  • Continue collaboration with DGMQ to evaluate refugee health clinics’ hepatitis B screening and vaccination programs.
  • Award funds for the Viral Hepatitis, Early Education, and Linkage to Care for Persons with Chronic HBV and HCV Infections project in up to ten sites.
  • Continue collaboration with DGMQ to better document the burden of TB and latent TB infection (LTBI) in non-immigrant visitors (e.g., students, visitors, etc.) and develop strategies for diagnosing and treating TB and LTBI in non-immigrant visitors.

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Goal is in progress.


FY 2010-2011 Goal 4: Global Health Protection and Health Systems Strengthening
 
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