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Year : 2017 | Volume : 5 | Issue : 1 | Page : 31 - 35  


Original Articles
A Study on the Prevalence of Sexually Transmitted infections among Women of Reproductive age, in urban slums of Guntur city

Suhasini Vasireddy

Assistant professor, Department of Community Medicine, Siddhartha Medical College, Vijayawada

Email: dr.suhasiniv@gmail.com

ABSTRACT:

Background: Sexually transmitted infections are a major health problem affecting women, a study conducted by National AIDS control Organization (NACO) estimated Andhra Pradesh to be having the highest percentage of individuals (22.8%) affected with HIV among those attending STI clinics, so the study conducted to know the prevalence of Sexually transmitted infections among women of reproductive age in the community.

Objective: The objective of the study was to assess the prevalence of sexually transmitted infections among women of reproductive age through a syndromic approach and the various socio demographic factors associated.

Materials and methods: community based cross- sectional study conducted in urban slums of Guntur city. A pre tested questionnaire was administered for information regarding socio- demographic profile and symptoms of sexually transmitted infections. Women who had symptoms of sexually transmitted infections as per the syndromic approach were examined clinically, treated and referred to government general hospital for further follow-up.

Results: 520 women participated in the study. The prevalence of sexually transmitted infections in the total sample was 32.69% (n-170 of 520). The prevalence of vaginal discharge syndrome was 27.88 % (n-145of 520), genital ulcer syndrome was 1.34 %( n-7), and pain lower abdomen was 3.46 %( n-18).The prevalence of symptoms in women with STI was – 156 (91.76%, n-170) had vaginal discharge. 18(10.58%) had pain lower abdomen. 4 (2.35%) had lymphadenopathy, 4(2.35%) had burning micturition, 2(1.17%) had dyspareunia and 18(10.58%) had backache. The prevalence of STIs by clinical diagnosis on per speculum examination of the 170 women were – Bacterial vaginoses- 98(57.65%), Trichomonas vaginalis- 28(16.47%), Candidiasis- 18 (10.59%), cervicitis with PID- 9(5.29%), Herpes- 5(2.94%), syphilis- 2(1.18%) and Venereal warts- 1(0.59%).

Conclusion: The prevalence of RTI/STI on the basis of self- reporting and clinical examination was 32.69%. The most common symptom was vaginal discharge 91.76%. The most common infection was bacterial vaginosis 57.65%. The younger age groups, 15- 19yrs- 53.84%were the most affected followed by the age group 20- 34yrs-33.8%. The infections were more common in women working as agriculture labor 50.55%, illiterate women 40.97%, and women of low social status,-Scheduled tribe- 63.64% & scheduled caste – 40.96%.

Key words: Sexually transmitted infections, Syndromic approach, Social profile, demographic variables.

INTRODUCTION:

Sexually transmitted infections are those infections which are primarily transmitted through sexual contact. Sexually transmitted infections present a major health problem with vast social and economic consequences in the society. The distribution of sexually transmitted infections is dependent on the behavior of the individuals and also on the efficiency of transmission and duration of infectiousness of the organism which causes the infection. Each year nearly 1.3 million die due to reproductive health problems that are largely preventable and one out of 20 teenagers contact a sexually transmittable disease, of which some infections may cause lifelong disability, infertility and certain times even death. The possible consequences of untreated reproductive tract and sexually transmitted infections in women include tubal infertility, ectopic pregnancies, still births, abortions, neonatal deaths, congenital defects and infections in the new born, recurrent urinary tract infections, dyspareunia, dysmenorrhea, menorrhagia, chronic pelvic infections and at times maternal death.[1] The World Bank (1993) estimated that for those aged 15yrs – 44yrs, STI (excluding HIV) were the most common cause of healthy life lost in women after maternal morbidity and mortality. The National AIDS Control Organization estimated that 12%of females and 6% of males attend Primary health centers for complaints related to STIs and prevalence of STIs among sexually active adults is about 5-6%.[2]

The problem of morbidity and mortality in women due to reproductive tract and sexually transmitted is largely ignored because women themselves are reluctant to discuss due to stigma associated with sex and sexually transmitted infections , cultural taboos, illiteracy, socio – economic factors and low status of women in the society. Many a times the sexually transmitted infections are asymptomatic (gonococci and chlamydia infections).[3] The importance of treating sexually transmitted infections has been widely recognized since the advent of the HIV epidemic. Worldwide most adults acquire atleast one sexually transmitted infection and many remain at risk of complications. Community based surveys showed that about 6% of adult population suffers from sexually transmitted and reproductive tract infections.[4] WHO has suggested that, annual total of 333 million new infections occur out of which 160million occur in South and Southeast Asia. The most common sexually transmitted bacterial infections are: Gonorrhea- 62 million, Genital chlamydial infection-92 million, Syphilis – 12 million, Chancroid- 7million, Viral infections are Genital Herpes- 20 million, Human papilloma virus- 30million. The estimates indicate that about 40% of women have STI/RTI at any given point of time out of which only 1% complete full treatment of both partners.[5]

World Health organization has advocated use of syndromic approach in primary health centre level where the prevalence is high and lab facilities are not available. Introducing, prevention and management of RTI/STIs as one of the goals of reproductive and child health programme is a step forward to achieve the goal of health for all. Syndromic case management is providing impressively high cure rates (95%) for individuals sexually transmitted infections.[6] The Syndromic approach to case management is the corner stone for treatment of reproductive and sexually transmitted infections as women are treated at a single visit and counseled for partner treatment and condom use, to prevent transmission. The syndrome identified to be treated in women are; ‘vaginal discharge syndrome, lower abdominal pain, genital ulcer syndrome, and inguinal bubo syndrome’. Vaginal discharge is most often caused by bacterial vaginoses, Trichomonas vaginalis, Neisseria gonorrhea and candidiasis with characteristic discharge revealed by simple speculum examination and treated accordingly. Lower abdominal pain syndrome is caused by infection by Neisseria gonorrhea, Chlamydia trachomatis, anaerobic bacteria, Gardnerella and mycoplasma. Genital ulcer syndrome is caused by Treponema pallidum (Syphilis), Heamophilus ducreyi (chancroid), Klebsiella granulomatis (granuloma inguinal) Chlamydia trachomatis (lympho granuloma venerum), Herpes simplex (genital herpes) and inguinal bubo syndrome caused by Chlamydia trachomatis and Haemophilus ducreyi. Essential strategies of treatment are Case detection, case holding, epidemiological treatment, personal prophylaxis, counseling and health education.[7]

Rationale of the study:The International Conference on population and development, Cairo in 1994 and Fourth World Conference of women, Beijing 1995, India launched Reproductive and Child health program in 1997 with promoting Sexual health as one of the priority to improve maternal health. Traditional approaches of etiological diagnoses and treatment were available only at certain specialty clinics and tertiary hospitals which was unavailable at primary care levels. This has led to the introduction of Syndromic management of sexually transmitted and reproductive tract infections which has led to better cure rate and decreased transmission in the community.Objectives: Theobjective of the study was to assess the prevalence of sexually transmitted infections among women of reproductive age through a syndromic approach and the various socio demographic factors associated.

MATERIAL & METHODS:

Study Design: A community based cross-sectional study.

Study area: urban slums of Guntur city.

Study population: population of five urban health centres of Guntur Municipal Corporation. Total population of Guntur City is 7, 43,354 as per 2011 census with males 3, 71,727 and females 3, 71,612. There are a total of 187 slums with population of2, 48,850.

Sample Size: sample size was calculated based on a study conducted by Deoki Nandan of department of Social and preventive medicine, S.N. Medical college Agra( published in IJCM- Sep 2002) which showed a prevalence of 35.2%, of which rural area showed 49% and urban areas –27%. The lower prevalence of 27% was taken with an allowable error of 15% and sample size 480.

Study subjects: 520 women of reproductive age group (15- 49yrs).

Sampling design: multi stage simple random sampling of urban health centres and slums under these centres. Guntur city has 22 urban health centers out of which five urban health centers and three slums under each health center were chosen by lottery method.Women for study where selected by simple random method of every nth women of reproductive age, who has consented, until the sample is achieved.

Study variables: sexually transmitted infections, syndromic diagnosis, clinical diagnosis, demographic variables.

Method of data collection: Interviewing of women by predesigned, pretested questionnaire.The women were interviewed at their house hold by explaining them the purpose of study and creating awareness regarding sexually transmitted infections and the necessity of treatment. The women were approached with the help of ANMs and AWW working in the concerned health center and the anganwadi centers. The questionnaire was administered at their homes during the day time when most of the men folk were out for their daily work.The women with symptoms were motivated to come to the place of examination. They were examined at the urban health centre where the center is nearby, and MCH centers were immunization and antenatal checkups were being carried out.The treatment was given as per National guidelines of a syndromic approach. [8]The drugs were given by the respective urban health centers with directions from the Chief Municipal health Officer. The ANMs and AWW had the list of women given treatment and were advised to approach the medical officers at the urban health centers if necessary to the gynecology department. No list of follow up was maintained as it was a cross- sectional study.

Analysis of data: data computerized in the Microsoft excel sheets and statistical analysis done by percentages and Chi square tests.

Ethical clearance of the study obtained from the Ethical committee of Guntur medical college and consent for participation taken from every individual participant.

RESULTS:

A sample of 520 women were administered the pretested questionnaire and women who have symptoms were examined per speculum at the urban health centre and treatment given as per NACO guide lines. The women were counseled for partner treatment, condom use and to attend gynecology outpatient department for further follow up. The data was analyzed in Microsoft excel and percentages and chi square were calculated. The prevalence of sexually transmitted infections in the total sample was 32.69% (n-170 of 520). The prevalence of vaginal discharge syndrome was 27.88 % (n-145of 520), genital ulcer syndrome was 1.34 %( n-7), and pain lower abdomen was 3.46 %( n-18).The prevalence of symptoms in women with STI was – 156 (91.76%, n-170) had vaginal discharge. 18(10.58%) had pain lower abdomen. 4 (2.35%) had lymphadenopathy, 4(2.35%) had burning micturition, 2(1.17%) had dyspareunia and 18(10.58%) had backache. The prevalence of STIs by clinical diagnosis on per speculum examination of the 170 women were – Bacterial vaginoses- 98(57.65%), Trichomonas vaginalis- 28(16.47%), Candidiasis- 18 (10.59%), cervicitis with PID- 9(5.29%), Herpes- 5(2.94%), syphilis- 2(1.18%) and Venereal warts- 1(0.59%).

Prevalence of STIs in relation to the socio- demographic profile of study population: Sexually transmitted infections were highly prevalent in the age group 15- 49yrs-53.84%, followed by the age group 20- 34yrs- 33.83%, 35- 39yrs- 31.32%, 40- 49yrs- 20%. Chi square is- 10. 03 and‘p’value-<0.11. STIs were highly prevalent in the illiterate- 40.97%, primary school- 33.78%, middle school- 28.92%, secondary and intermediate-23% and graduation and above- only 6.25%.Chi square- 18. 41 and ‘p’ value <0.002. Prevalence of STIs by occupation; agriculture labour- 50.55%, house wife- 27.87%, unskilled labour- 27.87%, and skilled- 28.5%.Chi square-16.02 and ‘p’ value- <0.001. Prevalence of STIs in relation to percapita income per month is -> Rs 675/pm- 38.12%, Rs 675- 2054/pm- 31.18%, Rs 2025- 3374/pm- 16.6%, decreasing prevalence with increasing income. Chi square= 8.18 &‘p’ value is <0.085. Prevalence of STIs by religion: Christian- 37.77%, Muslim- 34.83% and Hindu- 27.98%. The Chi square was- 4.83 and ‘p’ value - <0.08. Prevalence of STI by social status; Scheduled tribe- 68.64%, scheduled caste- 37.09%, backward castes- 34.48%, and other castes – 24.44%.The Chi square is-12.39, and ‘p’ value - <.006, which is highly significant. Prevalence of STI in relation to parity: couple with 1 child- 27.4%. 2 children – 30.43%, 3 children – 33-7%, 4 and more children- 50%.The Chi square is- 6.28 and ‘p’< 0.17%. Prevalence of STI is 83.06% in women undergone normal vaginal delivery and 28% in women who had LSCS. Chi square- 0.93 and p- 0.03. STI was 46.08% in women who had home delivery and 26.25% in in women who had institutional delivery. Chi square is 15.06 and p- <0.0001. Prevalence of STI by menstrual history is; in women with dysmenorrhea- 100%, menorrhagia – 93.33%, oligomenorrhea- 30.33% and normal menstrual cycle- 30.95%. The Chi-square is - 38.38‘p’-< 0.00002.

DISCUSSION:

Prevalence of Sexually transmitted infection in the present study is 32.69% is higher than that in the study done by Deoki Nandan etal in Agra which was 27%.[9] A study conducted by Tapash Roy in rural Bangladesh showed a prevalence of 21.9 to 32.9%.[10] Bacterial vaginosis is the commonest infection 57.65%, followed by Trichomonas vaginalis 16.47%, candidiasis 10.59%, cervicitis with pelvic inflammatory disease 5.29% and only cervicitis 5.29%. The genital ulcers cases were of Herpes 2.94%, syphilis 1.18% and venereal warts 0.59%. Study conducted by L.Patnaik had showed - Candidiasis 41.3%, bacterial vaginosis 17.4%, trichomoniasis 15.2% and gonorrhea 2.2%.[11] Study done by Savitha Sharma in Himachal Pradesh showed a prevalence of Candidiasis 41.3%, Bacterial vaginosis 17.4%, cervicitis 21%, PID 13.1% and genital ulcer 1.78%.[12] The maximum prevalence of sexually transmitted infections were among the women of age group ‘15- 19’yrs- 53.84% and nearly similar 33.85% in the other age groups (20- 39yrs). The study by Deoki Nandan etal 66.5% and by Savita Sharma 63.6% showed a maximum prevalence in the age group 25- 34yrs. Our study showed a maximum prevalence 40.9% in illiterate women followed by primary education 33.78%, middle school 28.92%, decreasing with higher education graduates – 6.25%. Study of Savitha Sharma showed 72.2% and study by Deoki Nandan showed 61%. Our study showed a high prevalence 50.55% in women working as agriculture labor, study by Savitha Sharma showed a prevalence of 61.7% in women working in fields. The prevalence was high in low income group 38.12%, scheduled tribe 68.64%, and scheduled caste 37.09%. Women with more number of children (4 and more) had a prevalence of 49.5%. Women who had delivery at home had high prevalence 46.08%. A study conducted by Roochika Ranjan et al in New Delhi reported a prevalence of 28% [13]. A study conducted by Kulkarni RN [14] reported leucorrhea in 27.4% of females, our study also showed the same -27.8% of study population. The present study showed a prevalence of lower abdomen pain in 10.58% and vaginal discharge in 91.76% where as a study done by L.Patnaik et al in Brahmapur[11] reported lower abdomen pain in 39.28% and vaginal discharge in 96.4%. The present showed a prevalence of genital ulcer in 4.11% and inguinal lymphadenopathy in 2.35%. The study by L.Patnaik showed inguinal swelling in 3.57% and genital ulcer in 1.78%. The study by J.S. Thakur revealed genital ulcer in 0.72%15. The study by Deoki Nandan [9] showed prevalence of genital ulcer in 9% and inguinal swelling in 1%, burning micturition in 18% and dyspareunia in 35% of STI cases, but present study revealed a prevalence of burning micturition in 2.35% and Dyspareunia in 1.17%. Study done by DeLima SoaresV etal in north Brazil[16] in 341 women showed a prevalence of human papilloma virus -26%, bacterial vaginosis-15%, Trichomonas vaginalis-10%, Neisseria gonorrhea and Chlamydia trachomatis in 6%. 51% of women had atleast one STI with vaginal discharge as the predominant symptom- 56%. Syphilis seroreactivity was positive in 3% of women. A community based cross sectional study in married women in rural Vietnam showed a prevalence of 37% RTI/ STI with Candidiasisin 26%, Bacterial Vaginosis- 11%, Hepatitis- 8.3%, Chlamydia Trachomatis- 4.3%, Trichomonas vaginalis 1%, N.gonorrhea 0.7%, and Warts 0.2%[17]. A study of pregnant women in peri urban Harare, Zimbabwe showed aprevalence of HSV-2- 51.1%, HIV- 25.6%, syphilis -1.2%, Trichomonas vaginalis- 11.8%, bacterial vaginosis -32.6% and candidiasis -39.9%. On gynecological examination, 7% of the women had genital warts whilst 3% had genital ulcers and 28% had an abnormal vaginal discharge. 51% of the women had a positive serological STI, whilst 64% had one or more vaginal infections[18]. The prevalence of sexually transmitted infections in reproductive age women is a global phenomenon, except that the prevalence of micro- organisms is different in different places. In our study the most prevalent infection was Bacterial vaginoses- 98(57.65%), followed by Trichomonas vaginalis- 28(16.47%), a study done by Savita Sharma showed Candidiasis41.3%, Bacterial vaginosis 17.4%,study in Brazil showed human papilloma virus -26%, bacterial vaginosis15%,rural Vietnam showed a prevalence of 37% RTI/ STI with Candidiasis 26%, Bacterial Vaginosis 11%,and a study inZimbabwe showed a prevalence of HSV-2- 51.1%, HIV- 25.6%.

CONCLUSION:

The prevalence of RTI/STI on the basis of self- reporting and clinical examination was 32.69%. The most common symptom was vaginal discharge 91.76%. The most common infection was bacterial vaginosis 57.65%. The younger age groups, 15- 19yrs- 53.84% were the most affected followed by the reproductive age group 20- 34yrs-33.8%. The infections were more common in women working as agriculture labor 50.55%, illiterate women 40.97%, and women of low social status,-Scheduled tribe- 63.64% & scheduled caste – 40.96%.

REFERENCES:

  1. Greeda Selvareni.Ari – Intervention programme for reproductive tract infections in rural Tamilnadu, India. Southeast Asian Studies Manual, 2000;121-133.
  2. National AIDS control Organization. Ministry of Health and Family welfare operational guidelines for program managers and service providers for strengthening STI/RTI Services. New Delhi NACO- 2011p-9
  3. Yasmin Irfan- Study of Reproductive tract infections and Awareness in Tribal women in Keamari district, Karachi, Pakistan. Southeast Asian Studies Manual, 2000; 141- 142.
  4. Training of Doctors to deliver RTI/STI services, Resource material for trainers, May 2011. http//www.naco.gov.in/upload/publication Handout .pdf.
  5. Management of Sexually Transmitted Infections- Report of inter country workshop- Yongon, Myanmar, 16- 20, July 2001, World Health Organization. Regional Office for South East Asia- Dec, 2001; 10.
  6. Women Empowerment and Development- Vital for achieving reproductive health goals, National Institute of health and family welfare- bulletin, march 2005;1-6.
  7. Sexually transmitted diseases- intervention strategies Chapter V , Text book of Preventive and Social Medicine,21 edition 2011; 306- 311.
  8. National guidelines on prevention, management and control of reproductive tract infections including sexually transmitted infections. Ministry of health and family welfare, Govt.of India; 1-4
  9. Deoki Nandan, S.K.Mishra, Anita Sharma, Manish Jain, Estimation of prevalence of RTI/STI among women of reproductive age, Indian Journal of Community Medicine, Sept 2002; 27:110-113
  10. Tapash Roy, clinic based study to assess the magnitude and knowledge of reproductive tract infection amongst rural women in Bangladesh. Southeast Asian Studies manual 2000; 106-111.
  11. L.Patnaik, Prof.T.Sahu, Dr. N.C.Sahani, Syndromic diagnosis in RTI/STI among women of reproductive age in Bramhapur, W.W.Solution exchange U.N. Net in Health -07, 27.11.06.
  12. Savitha Sharma, B.P.Gupta. The prevalence of RTI and STI among married women. Indian Journal of community Medicine, Oct, 2009; 34: 62-4.
  13. Roochika Ranjan, Sharma AK and Geeta Mehta- Evaluation of WHO Diagnostic Algorithm for Reproductive tract infections among married women, Indian Journal of Community Medicine, 2003;28(8):1-4.
  14. Kulkarni RN, Durge PM, Community based study on Prevalence of STI in city of Nagpur, Indian Journal of Public Health, Oct- Dec, 2005; 49(4): 238-9.
  15. S.Thakur, H.M.Swami, S.P.S.Bhatia- Efficacy of Syndromic Approach in Management of RTI and associated difficulties, Indian Journal of Community Medicine, April- June,2002; 27(2): 77-9.
  16. Lan PT, LundborgCS, PhucHD, Sihavong A, UnemoM etal -Reproductive tract infections including sexually transmitted infections: a population-based study of women of reproductive age in a rural district of Vietnam. PMID:18003708, DOI:1136/sti.2007.027821 [PubMed - indexed for MEDLINE]
  17. Nyaradzai E Kurewa, Munyaradzi P Mapingure, Marshal W Munjoma, Mike Z Chirenje, Simbarashe Rusakaniko etal-The burden and risk factors of Sexually Transmitted Infections and Reproductive Tract Infections among pregnant women in Zimbabwe. BMC- Infectious Diseases,201010:127DOI:1186/1471-2334-10-127
  18. Global Health Sector Strategy on Sexually transmitted infections 2016-2021, WHO June 2016
  19. De Lima Soares, De Mesquita AM, Cavalcante FG, Silva ZP, Hora V. etal -Sexually transmitted infections in a female population in rural north-east Brazil: prevalence, morbidity and risk factors.Tropical Medicine Int Health 2003- July; 8(7):595-603.

Table 1: Prevalence of Sexually Transmitted Infections by Syndromic Approach:

Syndrome

STI cases (%of N- 520)

%prevalence (% of n- 170)

Vaginal discharge syndrome

145 (27.88%)

85.29%

Genital ulcer syndrome

7 (1-34%)

4.11%

Pain Lower abdomen

18 (3.46%)

10.58%

Total cases

170(32.69%)

Table 2: Prevalence of sexually transmitted infections by clinical diagnosis on speculum examination:

Diagnosis

No of cases

% of total STI n- 170

Bacterial vaginosis

98

  1. 65%

Trichomonas vaginalis

28

16.47%

Candidiasis

18

10.59%

Cervicitis with PID

9

5.29%

Herpes

5

2.94%

syphilis

2

1.18%

Venereal warts

1

0.59%

Table 3: Prevalence of sexually transmitted infections by age:

Age in years

Study population N- 520

STI cases n- 170

% prevalence of age group

15- 19 yrs.

26

14

52.84%

20- 24 yrs.

136

46

33.82%

25- 29 yrs.

133

45

33.83%

30- 34yrs.

77

23

33.76%

35- 39yrs.

83

23

31.32%

40- 44yrs.

39

8

20.5%

45- 49yrs.

26

4

19.23%

Chi square= 10.33;

p <0.11.

Table 4: Prevalence of Sexually transmitted infections by social profile

Ccategory

Study population-520

STI cases n- 170

% prevalence

Literacy status

Illiterate

227

93

40.97%

Primary

74

25

33.78%

Middle

83

24

28.92%

Secondary

99

22

22.22%

Intermediate

21

5

23.81%

Degree and above

16

1

6.25%

Chi square-18.41

p- <0.002

Occupation

House wife

354

103

29.10%

Unskilled labor

61

17

27.87%

Agriculture labor

91

48

50.55%

Skilled

14

4

28.5%

Chi square= 16.02

p-<0.001.

Income per capita

< 675 Rs / month

181

69

38.12%

675 – 2054 Rs/month

311

97

31.18%

2055 – 3374Rs/month

24

4

16.66%

3375 – 5049 RS/month

4

-

-

Chi square= 8.18

p- <0.085.

Religion;

Hindu

243

68

27.98%

Christian

188

71

37.77%

Muslim

89

31

34.83%

Chi square=4.83

p- <0.08

Social category

Scheduled tribe

11

7

68.64%

Scheduled caste

213

79

37.09%

Backward castes

116

40

34.48%

others

180

44

24.44%

Chi square= 12.39

p< 0.006 highly significant

Table 5: Prevalence of STI as per womens parity, mode and place of deliveryand menstrual history

Category

Study pop

STI cases

% prevalence

No of children

1

91

25

27.4%

2

253

77

30.43%

3

89

30

33.7%

4 and above

39

19

49.2%

Chi square=6.28

p-< 0.17

Type of delivery

vaginal

372

123

83.06%

LSCS

100

28

28%

Chi square=1.93

p-<0.33

Place of delivery

Institution

320

84

26.25%

Home

152

67

46.08%

Chi square=15.06

p- <0.0001.

Menstrual history

Normal

405

123

30.37%

Menorrhagia

15

14

93.33%

Oligomenorrhea

42

13

30.95%

Dysmenorrhea

8

8

100%

Chi square= 38.38

p- <.00002.





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