4.0 PRACTICE PREPARATION AND TEAM TRAINING PERIOD

  • Between 23rd March 2020 and 2nd June 2020 all water lines in the practice were disinfected on a weekly basis. 

  • On Friday 5th June 2020, nurses and reception (with appropriate social distancing based on personal assessment of risk) were engaged in a training session as follows:

  • Patient journey from arrival to departure 

  • Role of infection control nurse who will be responsible for monitoring/supervising patients and clinical staff (on arrival and departure)

  • Infection prevention and control procedures

  • Setting up the surgery for AGP and Non-AGP procedures

  • Cleaning the practice/surgeries after each patient

  • New setting of the practice (lunch breaks, changing settings)

  • Hand hygiene

  • Visitors and delivery journey

4.1 RRR and SOP training and confirmation of understanding - role play and step by step staff training

  • It is important that all practice steps in this document are practiced before implementation. These steps will be rigorously tested by all staff prior to re-opening to ensure all processes run smoothly. This will give us important information: 

  • an idea of the practicalities of the recommendations 

  • a time and motion study of patient care and flow through the practice under the new recommendations 

  • required modifications to procedures to adapt to the recommendations 

  • ironing out issues in the protocols and finding solutions where issues present themselves. 

  • assessment of additional time and costs involved with additional procedures to build into the business plan of the practice to ensure viability 

  • refining and where possible simplifying the protocols as required

4.2 Confirmation of standard infection control procedures (HTM 01-05) and supplemental post-COVID 19 risk-reduction modifications

  • All standard pre-COVID-19 standard infection control processes as outlined under Health Technical Memorandum 01-05 (HTM 01-05): decontamination in primary care dental practices will remain in force as before lockdown. 

  • CODE is also aware of and has incorporated aspects of “COVID-19: infection prevention and control guidance” for additional aspects and current guidelines over and above HTM 01-05. 

  • Our regular decontamination, cleaning and sterilisation procedures already have a proven track record of being effective at prevention of cross infection of previous respiratory and blood-borne viruses. 

  • These procedures, already second nature to our team, will continue to be used until superseded by any modifications that may come into force following the pandemic.

4.3 Hand and Respiratory Hygiene

  • All persons entering and leaving CODE should thoroughly wash their hands in the designated changing setting as soon as they arrive at the practice. 

  • Handwashing should follow standard pre-operative techniques used routinely before surgery to include forearms. All sinks will have step-by-step images of the ideal handwashing process and videos are available at https://www.nhs.uk/live-well/healthy-body/best-way-to-wash-your-hands/

  • Hands should be washed at every reasonable opportunity with soap provided and especially at the following times: 

  • Immediately before attending to patient treatment and donning personal protective equipment (PPE) 

  • After any activity that may lead to hands becoming contaminated such as opening doors, receiving packages, typing on keyboards, before and after eating etc. 

  • After removal of PPE before leaving surgery 

  • After equipment decontamination in the sterilisation room before leaving the sterilisation room. 

  • After handling and disposal of waste 

  • At the start and end of every clinical procedure

  • Always after using the toilet facilities 

  • Alcohol based hand rub should be used adjunctively for 30 seconds after each handwashing session allowing access to all of the same surfaces of the hands and wrists as during handwashing 

  • Respiratory hygiene should follow the principle of “catch it, bin it, kill it”. Tissues are available in all areas of the practice and should be used to sneeze or cough into when required. The tissue should then be immediately discarded into the nearest bin and hands and face washed and decontaminated as above. 

  • If you need to sneeze or cough, please make every effort to distance yourself from anyone in close proximity by at least 2 meters and turn away to direct the cough or sneeze onto a tissue and away from any individual. If no tissue is immediately available, please catch in the crook of your elbow and ensure that your skin or clothing covering this area is washed as soon as possible. 

 

4.4 Staff Protocol and Clothing

  • Jewellery

  • All staff at CODE should refrain from wearing any jewellery in the form of rings, necklaces, earrings or piercings in the facial region. 

  • The only exception are small stud earrings to prevent closure of pierced ears. 

  • Plain wedding bands which should be removed at the start of each day and kept locked in the staff members locker after decontamination with alcohol hand gel disinfectant. 

  • Alarm Panel and light switches

  • The practice alarm panel should be covered in clear protective adhesive film by the last person to leave in the evenings and the alarm activated through the cling film. 

  • The first person to arrive at and unlock the practice should turn off the alarm through the clear protective adhesive film and then remove the clear protective adhesive film. The clear protective adhesive film should be disposed off in clinical waste and proceed directly to the nearest handwashing sink as soon as the alarm has been turned off but before touching any light switches. Upon washing their hands and using alcohol handrub, they should return to the alarm panel, decontaminate the surface with suitable alcohol wipes and close the alarm panel cover. They should only then turn on all lights and equipment / electricals in the practice as normal. 

  • Staff Personal Hygiene

  • Staff should shower each morning and wear clean and ideally easily washable clothes to work each day. Male staff members are required to be clean shaven every day.  

  • Staff are required to bring two pillow cases to work, one for their clean clothes and one for their dirty scrubs and re-usable PPE

  • Please avoid the use of public transport where possible. Where this is necessary, use a face mask and disposable gloved during the course of your journey.

  • Staff should enter the practice and proceed to the changing area via the back entrance of the building to reduce street clothing exposure to the remainder of the practice. 

  • Staff temperatures will be logged daily and kept as a record as part of the risk assessment files.

  • Please proceed directly to the staff room where they should wash their hands and faces as above after having removed any wedding ring and prior to changing into work scrubs. 

  • Hands should be dried on disposable paper towels. Tea towels or other non-disposable fabric items must not be used. 

  • Street clothes should be regarded as contaminated from exposure and stored folded in your first pillow case, in the CBCT scan room/personal car if possible. 

  • Street clothes must not be worn anywhere in the practice other than the changing area. 

  • Shoes must be stored in a separate plastic bag and stored in the CBCT scan room/personal car and not left anywhere else. 

  • Lunch should be brought in sealed Tupperware containers and left in the fridge after hands have been washed. Staff should try to limit exiting the practice during the day as far as possible to reduce risks of carrying infection in either direction. The Microwave will be out of use until further notice. Please bring cold sandwiches which can be easily consumed without the need to heat it. 

  • Mobile phones should be switched off and left in your bag provided with all other personal property and should only be used during break and lunch periods after having thoroughly washed and disinfected hands. 

  • Scrub uniforms or practice clothing should be worn by all staff including administrative staff during working hours. Further clinical PPE measures are outlined below. Scrub uniforms must never be worn outside the practice other than in the practice quadrangle and must not come into contact with street clothing. 

  • Used Scrub uniforms should be placed directly into the second pillowcase, at the end of each day (or each session if soiled) and street clothes donned immediately prior to leaving the practice.

  • If scrubs need to be removed to exit the practice during the day, they can be stored over lunch hour in your washable bags/pillowcases, which should also be laundered at the end of the clinical day. 

  • Used work scrubs should be put on the most suitable wash cycle for the fabric at the end of each working day at home. This should be ideally 60 degrees, half the load and using sufficient amount of detergent. We recommend you do separate cycles for the clinical scrubs and pillow case and do not mix this with your clothing you wore to and from work. Hands should be washed, and the washing machine surfaces at home wiped down with surface disinfectant after this process. 

  • Work shoes / clogs / Crocs should be sprayed with surface disinfectant or machine washed with scrubs if appropriate. 

  • Street clothes should be removed and washed as soon as you return home and a similar protocol to the practice adopted for handwashing and antimicrobial alcohol hand rubs when arriving home after work. All staff should shower as soon as you return home. 

  • Avoid touching your face at all times when changing outside donning and removing mask, eye protection and visor PPE. 

  • All staff are required to adhere to strict protocol outside of work, to minimize the risk of exposing themselves to the virus and therefore risking the spread to our patients. The staff protocol outside of work needs to be strictly adhered to the government guidance.

Where we suspect that you have been not following the government guidance outside of work, we will have no choice but to advise you to self-isolate for a period of 2 weeks under SSP. 

4.5 Practice risk assessment and updated checklists

  • Updated practice risk assessments have been prepared by the Practice Manager. 

  • All staff should familiarise themselves with these documents during the staff training days. 

 

4.6 Changes to non-clinical patient and common areas

  • Non-clinical patient areas are defined as: 

  • The practice entrance waiting room

  • The main corridor

  • The common areas for staff only are defined as 

  • The bathroom

  • The staff room 

  • The outside quadrangle beyond the back entrance is regarded as open air and outside our premises. 

  • Cleaning and disinfection of all communal areas must be reinforced especially for often-touched areas such as door handles, using proprietary surface cleaners. This should ideally be handled by the greeting and runner nurse (Infection Control Nurse)

4.7 Changes to surgeries

  • All clinical and disinfection and sterilisation areas are normally subject to sessional, daily, weekly and monthly hygiene routines. These will be reinstated as normal prior to surgery opening and continue with our normal high standards as per HTM 01-05 procedures. 

  • All surgeries have been cleaned by removal of all objects from inside cupboards and drawers, surface disinfection of the insides of the cupboards and drawers and surfaces of all items.

  • All chair water lines have been fully run through and disinfected with hydrogen peroxide or hypochlorous acid (HOCl) solution as appropriate for the manufacturer. This will be repeated immediately prior to reopening and as per our normal HTM 01-05 procedures at the end of each patient treatment session. We have ordered further equipment to increase production for use in disinfection of the whole practice. 

  • All non-essential items from worktops have been removed and placed into cupboards or drawers 

 

4.8 Changes to decontamination and sterilisation room

  • Similarly, to the surgeries, the contents and interiors of all cupboards and drawers have been sorted, cleaned and disinfected in the same way. 

  • The autoclave, purified water  production machinery will be thoroughly cleaned, put  through at least three cycles and serviced where required to ensure that they are cleaned, disinfected and fit for purpose immediately before opening. 

 

4.9 PPE requirements  

 

4.9.1 PPE Definitions

  • PPE is the acronym for Personal Protective Equipment and is defined as any item that is worn by a healthcare worker or indeed any person for the purposes of protecting the user against health and safety risks.  

  • In this context it includes additional precautions that may reduce the risk of cross infection of coronavirus, the causative agent of SARS COVID-19 to those normally used in primary dental care such as face masks or respirators, eye protection, visors and surgical gowns and hoods. 

  • The question of personal protective equipment is highly topical and also presents the greatest challenge for dental practices that plan to reopen due to a global level of demand which far outstrips supply especially for higher level protection. We regard personal protective equipment as the following: 

  • Work scrubs made of high temperature washable polycotton as basic uniform within the practice for both clinical and, from 1st June, also non -clinical staff. 

  • Suitable respirator (Respiratory Protective Equipment or RPE) matched to the risk level of the patient and the procedure and certified fit tested by qualified fit tester where appropriate.  

  • Respirators contain multiple layers of fine filters that not only physically trap tiny droplets and particles but are also electrostatically charged to attract particles to be caught within the mesh of the filters rather than allowing them to pass through unimpeded. 

  • Respirators are classified as “filtering face piece” respiratory protective equipment (RPE) - FFP1, FFP2 or FFP3 and can be valved or un-valved.  

  •  FFP1 - standard surgical face mask loop or tied. Protection against large solid particles or droplets with a minimum filter efficiency of 78%.

  • FFP2 - protection against solid and liquid aerosols with minimum filter efficiency of 92% to 95% 

  • FFP3 - protection against solid and liquid potentially toxic aerosols with a minimum filter efficiency of 98% to 99% when fit-tested

  • Valved versus non-valved

  • Valved masks protect the wearer from aerosol generated from the patient but allows exhalation of unfiltered air to escape through the valve. i.e. it is protective in one direction only by protecting the wearer i.e. the healthcare worker from the patient. It makes wearing the mask more comfortable but does not prevent cross infection from the wearer to other people.  

  • Un-valved masks protect both the wearer and anyone close to them from aerosol by filtering inhaled and exhaled breath equally in both directions, i.e. both the healthcare worker and the patient are protected from each other. However, they are considerably more uncomfortable to wear especially for prolonged periods and in hotter environments. 

  • It should be noted that valved respirators are not fully fluid resistant unless they are also “shrouded” where the valve is covered by additional fabric to protect it from splatter or aerosol or is protected by a second standard surgical mask for the same purpose. 

  • Eye protection against direct splatter and aerosol compatible with magnifying loupes and coaxial lights vital for the practice of fine dentistry. 

  • Face visors to complement eye and facial protection from direct splatter and reduce aerosol and direct splatter contamination of eye protection and loupes. 

  • Hair nets or surgical hoods to reduce aerosol and direct splatter contamination of hair and exposed forehead skin. 

  • Disposable or washable water-resistant gowns to reduce aerosol and direct splatter contamination of working scrub suits and exposed forearm skin. 

  • Plastic aprons and heavy-duty gloves during the decontamination and sterilisation processes outside the surgery.

  • Shoe Covers there is no enough evidence that wearing shoe covers is adding extra protection, however the practice staff will use the shoe covers existing in stock until further guidelines will be issued.

4.9.2 Fit testing and respirators

Governments, larger health organisations and large buying groups have tied up most PPE stock with bulk order purchases primarily for the National Health Service but to which the private dental sector in the UK has extremely limited access. 

 

  • A multitude of websites have sprung up selling FFP2 and FFP3 stock and our inboxes are filled daily with multiple advertisements. However, experience and substantial wasted money has shown that this stock is often not as advertised, delivery dates are inaccurate, and the items once received have been shown not to be those ordered.  

  • We have therefore learned the hard way that great care is required to purchase these products from reputable and established providers within the dental, medical and protective workwear industries. It is no coincidence that all of the reputable providers are having substantial problems procuring adequate stocks required by the dental and medical professions in this country. Therefore, newly established suppliers that claim to have large stocks of quality CE marked products which are often sold at substantial mark-ups should be approached with caution and with the expectation that the product advertised is not necessarily fit for purpose and may indeed in some cases never actually arrive.

  • Whilst our regulators have indicated that dental practices can open with “suitable” or “appropriate” PPE in the form of respirators, they are fully aware that this will not be possible for the vast majority of both private and NHS dental practices who will require substantial stocks of consistent quality fit-tested FFP2 and FFP3 respirators that are simply not available.

  • In the absence of availability of personal protective equipment, Centre of Dental Excellence will follow the guidance set out by Public Health England on Considerations for acute personal protective equipment (PPE) shortages updated on 21 May 2020 for the various items.

4.9.3 Fit testing for religious group

  • Where, for cultural, religious or health reasons facial hair is present which will affect the seal of FFP2/3 masks, CODE consider as an alternative, the use of an FFP2 mask with a Type II fluid resistant surgical mask over the borders, in conjunction with a face shield/visor. A through risk assessment will be implemented at a local level if this suggestion is adopted.

  • We have procured for use the D Respirator Face Mask, Stealth P3R, a reusable P3 Half Mask, with replaceable P3 HEPAC filters. It provides a high filtration efficiency at 0.3 microns -99.999% offering protection against silica dust, weld fumes, asbestos, oils, mists and aerosols. A data sheet and a conformity certificate will be saved into electronic format (Code Folders, Covid 19)

4.9.4 Current recommended PPE for primary dental care

  • The current Recommended Personal Protective Equipment for primary, outpatient, community and social care by setting, NHS and independent sector in the UK endorsed by Public Health England, The Academy of Medical Royal Colleges, Public Health Wales, Health Protection Scotland, Public Health Agency and the National Health Service is given in the table below (please click image for hyperlink to full PDF document)

  • It is our view that it is impossible to know whether any of our patients or indeed staff are infected with coronavirus. Whilst we will go through a screening procedure as detailed below for both staff and patients before they commence work and attend the practice, it is entirely possible that anyone can become infected with coronavirus on the way to the practice or in the 72 hours prior to attending after having completed their updated medical and dental questionnaire. 

  • The following PPE will be used for all aerosol generating procedures: 

    • Single-use disposable gloves

    • Single-use disposable fluid repellent coverall or gown (or high-temperature washable equivalent)

    • A filtering face piece respirator fit-tested 

    • Visor/Faceshield

  • The following PPE will be used for Non Aerosol generating procedures

  • Single use disposable gloves

  • Disposable apron

  • Fluid resistant type IIR surgical mask

  • Visor

  • There has been much discussion about whether and which procedures generate aerosol and which procedures do not generate aerosol. This discussion has several facets that require some thought:

  • Droplet size. Viruses are not transmitted on their own but normally within water droplets from the host carrying the virus. These droplets may be a spectrum of sizes, large and visible or tiny and invisible to the naked eye

  • The larger the particle, the more it behaves as a projectile – a large droplet produced during a sneeze, for example, will be projected based on the force used to create it and gradually arc to the floor. The extent of this arc for exhalation is normally around 1.5 m. Hence the 2-metre social distancing rule to reduce the risk of these droplets landing on and being inhaled by another person which is called “airborne transmission”.

  • However, it can be seen from the diagram below that large spray droplets from a cough or a sneeze can extend to up to 6m whereas aerosols tend to be confined to less than 1.5 m through direct projection

  • These droplets can also land on objects and stay alive long enough to be picked up by touch and transferred via direct contact to the mucous membranes of the mouth, nose or eyes. This is so called “contact transmission”.

  • To reduce the risk of contact transmission, we are asked to sneeze into a tissue (“catch it, bin it kill it”) directed away from others and also told to wash and disinfect hands regularly in case we have touched a surface that harbours virus from a previous persons’ droplets that can then be passed to the mouth or nose or eyes by touch.  

  • Coronavirus can survive for: 

    • 72 hours on plastic and stainless-steel surfaces

    • 24 hours on cardboard surfaces 

    • 9 hours on copper surfaces 

    • 3 hours in suspended aerosols

  • Items that harbour and allow contact transmission are known as fomites – a fomite may be any object on which the virus can live for long enough to be transmitted by contact transmission.

  • The presence of aerosol droplets on their own is not enough to cause infection. If it were, then the dental and medical literature would have far greater numbers of papers alluding to the possibility that dental practices are a high risk of cross infection through aerosol. Despite the apparent risk it is evident that dental surgeries are not in fact centres for disease transmission due to aerosol even with normal personal protective equipment use daily throughout dental practices around the world.  

  • To transmit the virus requires a viral load and a suitable host whose immune system is not strong enough to fight this viral load, i.e. the number of virus particles within a droplet. It appears that patients with severe manifestations of COVID-19 can have up to 60 times the viral load on nasopharyngeal swabs than those patients with a mild form of disease  (see reference [33]). Therefore, it appears that asymptomatic patients may carry a lower viral load and contribute less of a viral load as aerosol than patients exhibiting overt symptoms.

  • Smaller particles produced by breathing and sneezing tend to stay suspended in the air for some time and can be inhaled or can land on objects further away that are then touched by another person. This is what is normally referred to as aerosol

  • It is assumed that aerosol produced during dental procedures is a vehicle for transmission of coronavirus and that creation of an aerosol will cause infection or increase infection rates. This assumption is not necessarily true – it depends on where the aerosol comes from and what it is made up of and how many virus particles are contained within it. e.g. one cough generated droplet may contain more virus that a large aerosol made up mainly of hypochlorous acid (HOCl)  which is a viricidal solution used in dental chair lines and as a coolant during so called dental aerosol-generating procedures (AGP’s).

  • It is assumed that the medical definition of an AGP is the same as a dental AGP. The aerosol composition differs considerably even amongst medical AGPs: for instance, certain medical AGPs such as anaesthetic intubation in theatre generate aerosols by inducing the patient to cough. It has been shown that coughing emits up to 1,000 times the number of droplets compared to normal breathing and intubation was a significant risk of SARS CoV-1 transmission to health care workers during the last coronavirus outbreak.

  • Dental aerosols have been studied for many years. The tissues and fluids of the oral cavity contain many bacteria and viruses that are contained in the aerosol generated in everyday dental procedures. Indeed, we daily treat patients with undiagnosed potential tuberculosis, HIV, human papilloma virus, herpes virus hepatitis B, SARS COVID-1, influenza A (H1N1 and H3N2), common colds from rhinoviruses, respiratory syncytial virus, other coronaviruses, adenoviruses and Coxsackie viruses, Epstein Barr virus and many hundreds of  bacterial species that live within the oral and pharyngeal cavities.

  • Whilst there are multiple references that dental aerosol does contain microorganisms from the oral cavity, that there is no evidence in the literature that general dental aerosol has resulted in the infection of dental healthcare workers or their patients in any centre or with any disease. Where dental aerosols a significant transmitter of airborne pathogens, this would surely have come to light. The paucity and almost lack of publications in the extensive dental and medical literature on the subject suggests that whilst it is theoretically a high risk activity, dental aerosol does not in fact appear to be a significant source of bacterial or viral cross infection when one considers the millions of aerosol producing dental procedures that are carried out every year in this country let alone the rest of the world.

  • In summary, it is our professional opinion that the aerosol generated in dental practice through dental operative procedures is formed mainly of treated water containing potent virucidal components such as hypochlorous acid (HOCl) or other proprietary antibacterial and antiviral chemicals placed to protect dental water lines from bacterial and viral contamination. The aerosol produced from the patient’s mouth during dental operative procedures is therefore substantially diluted and formed mainly of clean water with a virucidal activity and is not, in our opinion from the paucity of evidence over many years, a major risk or source of cross infection of infective agents between patients and dental healthcare professionals. 

  • The bacterial load carried by the aerosol created during dental procedures is also substantially reduced by preoperative mouth rinses, gargles and nasal sprays and the use of dental dam which is already part of our routine as seen below. Thus, we feel that the risk of transmission by dental aerosols in dental practices is the same or even less than the risk outside the surgery, despite the fact that bacteria and viruses are still detectable within these aerosols. 

4.9.5 Staff Requirements

  • Despite the above viewpoint, it is in the interest of all of our staff and patients and our profession that everyone attending our practice is kept as safe as possible with a belt and braces approach 

  • All staff are required to wear personal protective equipment depending on the environment in which they work and the procedures that they are expected to carry out.

  • This list is modified from our normal procedures and should be adopted upon reopening of CODE on 8th June as planned. It is based on the document COVID 19: guidance and standing operating procedure - Delay phase 18 May 2020

  • All staff should comply with the recommendations under item 4.4 upon arrival at the practice.

4.9.5.1

Back office staff

  • Practice Manager is unlikely to have direct contact with patients to the practice. However, Use polycotton scrubs or similar machine washable to be worn only within the practice and laundered at home in half empty drum, with a temperature higher than 60 degrees

 

Front office staff

Where they need to have direct contact with patients or third parties attending the practice then they shall adopt the protocols listed below:

  • Use polycotton scrubs or similar machine washable to be worn only within the practice and laundered at home in half empty drum, with a temperature higher than 60 degrees

  • Normal surgical face masks and face shield/visor to be worn in common areas where social distancing is not possible, changed at least every 1½ hours. No mask is required if alone in a room or if social distancing is possible within the same room as a colleague.

4.9.6  Patient greeting and escort/ runner nurse

This nurse will be responsible for greeting of patients that arrive at the practice, going through patient arrival protocols and escorting the patient to the appropriate surgery directly upon arrival at the practice. This nurse will also be responsible for disinfecting common areas after passage of patients to and from the surgeries. This nurse should not enter operative areas and should be the only nurse wearing full protective gear in common areas. PPE may be removed and placed in a dedicated lidded container when there are likely to be extended periods of time between patient arrival and departure to the practice. This practice member will be responsible for providing enough time to re-don PPE in time for patient departure or patient arrival at the practice. Further details are listed below:

  • Use of polycotton scrubs, protective water-resistant gown, surgical mask and visor, nitrile gloves, hairnet

4.9.7 Norms for clinical staff, dental surgeons, hygienist/therapist and assisting dental nurses

  • Use of polycotton scrubs, protective water-resistant gown, reusable test fitted respirator P3 Stealth half face mask depending on procedure (see below), multiple use disinfectable safety goggles or spectacles (normal loupes for clinical operators), multiple use disinfectable or disposable visor, nitrile or latex single-use disposable gloves, single use hairnet or surgeon hat depending on hair length.   

  • Donning and removal of PPE training for staff at CODE

  • At the moment of writing, arrangements for training the nurses and reception staff has been allocated on Friday, 5th of June 2020

  • As a clinic that regularly carries out surgical procedures, all of our clinical staff are trained and proficient in sterile gown and draping as it is a daily activity within the practice.  

  • Putting on and removing (donning and doffing) of personal protective equipment so that contaminated surfaces are contained within removed gloves, gowns, hoods and disposable visors immediately prior to disposal in clinical waste bags for incineration and good hand hygiene before and after this process is already part and parcel of our daily work. 

  • However, additional training has also been received during fit testing of our FFP3 respirators to revise the procedure to ensure that contaminated surfaces are not allowed to come into contact with clean surfaces or be the source of cross infection following patient procedures. 

We shall be following the following guidelines: NHS / Public Health England / Health and Safety Executive: 

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