Policy Development Fosters Collaborative Practice

This article provides an example of interprofessional collaboration for policy development regarding environmental global health vis-à-vis the Minamata Convention on Mercury. It presents an overview of mercury and mercury-related environmental health issues; public policy processes and stakeholders; and specifics including organized dentistry’s efforts to create global policy to restrict environmental contamination by mercury. Dentistry must participate in interprofessional collaborations and build on such experiences to be optimally placed for ongoing interprofessional policy development. Current areas requiring dental engagement for interprofessional policy development include education, disaster response, HPV vaccination, pain management, research priorities, and antibiotic resistance.

Key points

  • The oral health community has responsibilities in interprofessional policy development that affect the general and oral health of the public.

  • Dentistry must assure involvement in science-based responses, with recognized expertise and advocacy, albeit without governmental standing.

  • Professional dental organizations can work to optimally respond, find common ground, and cooperate regarding complicated interprofessional health issues.

  • Establishing interprofessional partnerships enables collaboration on health issues and ensures that those outside of dentistry understand the importance of oral health.

  • The development of the Minamata Convention on Mercury showed the significance of the commitment by oral health stakeholders, sustained longevity of effort, science-based evidence, understanding of policy development ranging from local to global levels, and the dental profession working effectively in interprofessional collaborations.

Introduction

This article provides an example of interprofessional collaboration concerning policy development based on the impact of a global public health problem resulting from environmental accumulation of mercury. Contained are an overview of mercury and the environmental health issues related to mercury, a brief primer of policy and policy stakeholders, and a description of the collaborations including dentistry specifically concerning the Minamata Convention to create global policy to restrict environmental contamination with mercury.

Introduction

This article provides an example of interprofessional collaboration concerning policy development based on the impact of a global public health problem resulting from environmental accumulation of mercury. Contained are an overview of mercury and the environmental health issues related to mercury, a brief primer of policy and policy stakeholders, and a description of the collaborations including dentistry specifically concerning the Minamata Convention to create global policy to restrict environmental contamination with mercury.

Introduction to the mercury issues warranting global environmental policy development

Mercury in the Environment

Mercury is a chemical element known by the symbol Hg from its former name, hydrargyrum, or liquid silver. It is ubiquitous and found naturally in the environment throughout the world in 3 forms: elemental (or metallic), as part of an inorganic compound (eg, mercuric chloride), or as part of an organic compound (eg, methylmercury and ethylmercury). In its pure, elemental form, mercury is the only metal that is a liquid at room temperature. Mercury has been used to create alloys or amalgams with other metals, produce dental fillings, extract gold from its ores, and help extend the life of dry cell batteries. It can be released as the result of production or improper disposal of several mercury-containing products, including electrical applications (eg, switches and fluorescent lamps), paints, batteries, chlor-alkali, seed grain fungicides, scientific instruments (eg, thermometers and barometers), dental amalgam, topical antiseptics, antibacterial salves, and skin-lightening creams.

Global mercury assessment is intended as a basis for decision making, with an emphasis on anthropogenic emissions (mercury going into the atmosphere) and releases (mercury going into water and land); that is, those associated with human activities. An estimated 5500 to 8900 tonnes (1 tonne = 1000 kilograms) are emitted and reemitted to the atmosphere from 3 sources:

  • 1.

    Naturally (10%) from geological weathering and geothermal activity

  • 2.

    Anthropogenic (30%), mostly from artisanal and small-scale gold mining and coal burning

  • 3.

    Reemissions (60%) of previously released mercury that has built up over decades and centuries in surface soils and oceans without a determinable original source

A comparison of percentage of sector contributions to total anthropogenic emissions is shown in Table 1 , including cremation attributable to dental amalgams. North American emissions are notable at roughly 3% of total global emissions. Local and regional mercury depositions throughout the world have gradually increased contamination levels in the environment to the point that countermeasures have been enacted in recent decades to reduce anthropogenic mercury emissions. Because of long-range distribution and transport of mercury globally, nations with minimal mercury releases and other areas remote from industrial activity may be adversely affected. For example, increased mercury levels are observed in the Arctic, far from the sources of any significant releases.

Table 1
Global emission inventory, 2010, by-product/unintentional (B/U) and intentional (I) assessed sectors by percentage of total anthropogenic emissions
Sector Percentage
(I) Artisanal and small-scale gold mining 37
(B/U) Coal burning 24
(B/U) Primary production of nonferrous metals 10
(B/U) Cement production 9
(B/U) Large-scale gold production 5
(I) Consumer product waste 5
(B/U) Contaminated sites 4
(B/U) Primary production of ferrous metals 2
(I) Chlor-alkali industry 1
(B/U) Oil refining 1
(B/U) Mine production of mercury 1
(B/U) Oil and natural gas burning 1
(I) Cremation (dental amalgam) a <1
Adapted from UNEP. Global mercury assessment 2013: sources, emissions, releases and environmental transport. Geneva (Switzerland): UNEP DTIE Chemicals Branch; 2013. Available at: www.unep.org/PDF/PressReleases/GlobalMercuryAssessment2013.pdf ; with permission.

a Does not include preparation of dental amalgam fillings and disposal of removed fillings containing mercury.

Although natural emissions of mercury into the environment continue, human activities have exceeded natural emissions over the last 200 years and need to be controlled. Mercury can be repeatedly mobilized, deposited, and remobilized between air, water, and soil indefinitely. Although many countries have shown reductions of use and release of mercury, mercury can be transported by wind and ocean currents so it can only be controlled effectively by coordinated global programs.

Furthermore, mercury is very noxious to human health, particularly to fetal and childhood development. Each form has its own toxicologic profile, affecting the nervous, digestive, and immune systems, and specific organs such as lungs, kidneys, skin, and eyes. In adults, exposure to excessive levels of mercury has been linked to reduced fertility, brain and nerve damage, and heart disease. Hence, mercury is a global threat to human and environmental health, with organic mercury generally considered the most toxic, followed by elemental mercury, and then inorganic mercury.

Mercury Use in Dental Amalgam

Dental amalgam has been used widely as a restorative dental material since the early 1800s. The clinical properties of amalgam, including its ease of placement, high compressive strength, low cost, and long-term survival rates, remain largely unrivaled. During the past decades, a decrease in the use of dental amalgam and a corresponding increase in the use of tooth-colored restorative materials such as dental composites has occurred, primarily driven by esthetics.

Since the inception of dental amalgam, claims have been made about the possibility of detrimental health effects caused by the mercury in its mix. The health concerns and debates over the use of mercury in amalgam restorations are not new. For more than a hundred years, numerous assertions have implicated dental amalgam for causing or contributing to neurologic diseases, adverse health conditions, and toxic illnesses. No evidence for these assertions has been found by well-designed clinical studies. Two clinical trials sponsored by US National Institutes of Health National Institute of Dental and Craniofacial Research (NIH-NIDCR) involving more than 1000 children in Portugal and the US New England region, evaluating the potential effects of mercury from amalgam, provide sound data supporting the continued use of dental amalgam. These two children’s amalgam trials found no adverse effects in the 5 years following the placement of dental amalgam. Nonetheless, increasing concern over mercury in the environment has led to a worldwide movement against dental amalgam.

Dental Mercury in the Environment

Dental amalgam mercury release from cremated bodies is measurable at the global level (see Table 1 ). Although the amount emitted contributes to less than 1% of the global burden (as measured from cremation), the amount is estimated to be about 3.6 tonnes. Mercury may also be emitted during the preparation and disposal of fillings. In 2005, ENVIRON International Corporation, with funding from the American Dental Association (ADA), prepared a scientific assessment that calculated the amount of mercury attributable to amalgam wastewater that is discharged in effluent from US sewage treatment plants into surface water. This scientific assessment found that a total of approximately 0.4 tons of mercury enters surface water each year. The US Environmental Protection Agency (EPA) oversaw the validation of this approach and principally agreed with ENVIRON’s conclusions. Therefore, dental amalgam represents a small but quantifiable part of the overall mercury burden worldwide.

The EPA, among other efforts to limit human-related environmental contamination with mercury, seeks reduction of mercury release into the environment from dental offices. The Clean Water Act (CWA) was established in 1948 to give federal and state EPA, and even local municipal sewerage authorities, direct legal authority to protect waterways by limiting the discharge of mercury in all its forms, including the mercury in amalgam. The EPA sets broad minimum requirements in which states can elect to be more stringent. Typically, states regulate waste by granting permits to a municipal sewerage treatment plant, often referred to as the publicly owned treatment works (POTW). The permit limits the total amount of chemicals, such as mercury, the plant may discharge. POTW can either remove pollutants that enter the plant or limit their discharge into its sewerage system.

The EPA and the ADA are long-time collaborators on seeking means to reduce dental mercury environmental release. The ADA included amalgam separators as part of the ADA best management practices in October 2007. The EPA, the National Association of Clean Water Agencies, and the ADA have common commitments to reduce mercury levels in the environment through voluntary dental amalgam wastewater reduction measures. A key component of the ADA best management practices is recycling. Working with the EPA and recyclers, the ADA has been leading efforts to develop a national consensus standard for the use of amalgam separators to recycle waste amalgam in the dental office. The ADA has tested, according to ISO standards, amalgam separators that are available in the United States and have published peer-reviewed articles in its journal on the qualities of alternative brands and how dentists should choose a separator.

Estimates of mercury consumption include dental applications and are shown in Table 2 . Total consumption seems to be highest in the east/southeast Asia region, where it approaches twice that of the next highest region. The relative contributions to consumption via dental application is around one-third of total consumption for several regions. The North American region, although it has the third highest total, is has a low percentage from dental applications.

Table 2
Percentage of average selected dental applications (estimated from cremation and dental use) of total mercury consumption by world region, 2010, ordered by total mercury consumption
World Region Total Estimated as Dental Application (%)
East and southeast Asia 504 13.3
European Union (27 countries) 253 35.6
North America 213 16.0
South Asia 129 18.6
South America 100 33.0
CIS and other European countries 63 15.9
Middle-eastern states 53 30.2
Central America and the Caribbean 47 36.2
Sub-Saharan Africa 34 17.6
North Africa 20 25.0
Australia, New Zealand, and Oceania 17 23.5
Total 1433 21.4
Adapted from AMAP/UNEP, 2013. Technical background report for the global mercury assessment. Geneva (Switzerland): Arctic Monitoring and Assessment Programme, Oslo, Norway/UNEP Chemicals Branch; 2013. p. vi. 263; with permission.

Patient Care and Economic Considerations

Dental caries, although largely preventable, is the most common chronic disease, reaching across the human lifespan, not only in the United States but also worldwide. For restoration of dental caries, to date, tooth-colored materials are inferior to amalgam as fillings, especially for posterior teeth: they are far more technique sensitive, have lower clinical survival rates, are more expensive, and are far more difficult to adapt to proper tooth form under restricted clinical conditions such as in developing countries. In addition, economically, no adequate alternative for dental amalgam exists. Amalgam’s combination of durability and low cost is unmatched by any other dental restorative material. Chadwick and colleagues, found that, “When the initial cost and the longevity are considered together, resin composite turns out to be from 1.7 to 3.5 times more expensive than amalgam.” Multiple economic evaluations comparing the use of dental materials, including dental amalgam, have shown that dental amalgam is more cost-effective and cost-beneficial than tooth-colored alternatives, and it has a longer functional time and lower theoretic cost per year of function.

Banning the use of dental amalgam globally would have a strong economic impact from a dental perspective, particularly for practice in resource-poor locations. The impact would be most pronounced in low-income countries with limited access to dental materials, underfunded health care delivery systems, and/or inadequate numbers of practitioners trained to provide safe and effective alternatives. Studies have estimated the macroeconomic impact of regulating or banning the use of amalgam restorations in the United States. Beazoglou and colleagues estimated the direct costs of a ban on the use of amalgam restorations: a ban on their use in children and young people aged 0 to 19 years would increase dental expenditures by about $1.1 billion per year (totaling $13 billion from 2005 through 2020). Banning amalgam in the United States is estimated to increase dental expenditures by about $8.2 billion in the first year and lead to an increase of $98.1 billion from 2015 through 2020, based on an estimate of an average increase of $52 per restoration.

Introduction to policy development in oral health

The environmental laws that regulate the disposal of mercury from dental amalgam rely on a conservative approach to effluent limits because it is not known what happens to substances in the environment hundreds or thousands of years in the future. Experts do know a lot about the clinical safety of dental amalgam and mercury in patients because of the volume of peer-reviewed scientific studies that have been published over the past several decades. For providers who are not familiar with environmental laws, the use of environmental modeling assumptions of questionable scientific validity, uncertainty factors, safety factors, and the shifting burden of proof to the provider or alleged polluter can be bewildering and seem patently unfair. A review of policy and public policy is presented here before moving to the specifics of the Minamata Convention. It should be noted that the Minamata Convention applies at the global level, pending adoption at the country level, and having implications at local and professional levels.

Overarching Definition and Context of Policy Development for Oral Health

There is no universally agreed-on definition of the word policy. The term is used in different ways in different contexts. The Merriam-Webster dictionary ( www.merriam-webster.com/ ) provides several definitions of policy, including:

  • “A definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions”

  • “A high-level overall plan embracing the general goals and acceptable procedures especially of a governmental body”

Those related definitions capture some of the key attributes of policy making: it involves general agreement on goals and a broad roadmap on the actions that would help achieve those goals. In many ways, policy making can be thought of as a type of decision making. Governments, institutions, and organizations vary in the policy-making processes, but in general policy making comes down to a decision by a governing body. In most situations, policy development involves receiving input from key stakeholders, negotiation, and compromise. Policy making in oral health is no exception to that general rule. The diversity of opinion among stakeholders requires that various constituents within and outside of the oral health community come together to reach mutually agreed-on goals and chart the broad pathway to achieve them.

Public Policy Processes

Governments enact public policies in many domains that directly or indirectly affect population oral health, including but not limited to health care, education, food, water, licensure, and environment. Governmental policy is frequently reflected in legislative and regulatory action (ie, laws and regulations), and the actions supporting a set of agreed-on goals therefore enter the political realm. In the United States, policies that affect oral health are enacted at every level of government. For example, federal policy governs the mechanism of federal funding for dental research, national surveillance of oral diseases, safety of oral health workers, and mandated coverage of children’s dental services under Medicaid. State policies affect domains such licensure and scope of practice of oral health personnel and facilities, support for public universities and oral health training programs, and level and mechanism of reimbursement for Medicaid services. Both federal and state environmental policies affect factors such as the manufacture, use, and disposal of dental materials. Local government policy affects factors such as community water fluoridation, zoning for health care facilities, and school health programs. It is worth mentioning that there are influences on policies in North America from global ministries such as the World Health Organization (WHO) with the Pan American Health Organization as the regional component for the Americas, and the United Nations Environment Programme (UNEP). For oral health issues the organizations involved include the Oral Health Programme at WHO (Headquarters in Geneva, Switzerland; www.who.int/oral_health/en/ ) and the Environment Program at UNEP (Headquarters in Nairobi, Kenya; www.unep.org/About/ ). Both have regional offices as well, in the Americas, Africa, eastern Mediterranean, Europe, southeast Asia, and western Pacific.

The development of a global health treaty, and hence global public policy, requires a detailed process and involvement from the members of the United Nations (UN) and WHO. For example, in this article, the UNEP initiated the policy development because the issue is based on environmental contamination that caused public health concerns from the global production, transport, and release of mercury in the environment. Numerous reports were generated to collect the scientifically valid evidence and a process to develop a legally binding instrument (LBI) with an intergovernmental negotiating committee (INC) established to prepare it ( Fig. 1 ) . The meetings of the INC are numbered to help follow the process; for example, the first meeting is INC1. When the LBI is generated it is reviewed by the global governmental representatives. A convention is held for the signing of the LBI, which is named after the convention, by the representatives. On agreement the representatives take the convention to their countries (parties) for approval, called ratification. On reaching 50 ratifications, the convention becomes a treaty to be enacted by the ratifying parties. The process is enhanced by regional and other subgroup meetings outside of the INC meetings. The LBI can be further modified during the process of ratification. Research archives on treaties can be found at research.un.org/en/docs/law/treaties . Details on the process (eg, of the Convention on the Rights of Persons with Disabilities) can be seen in the Handbook for Parliamentarians on the Convention on the Rights of Persons with Disabilities at www.un.org/disabilities/default.asp?id=212 .

Fig. 1
UNEP global mercury program (a twin-track approach). GC, governing council; OEWG, open-ended working group.
( From Bayne SC, Petersen PE, Piper D, et al. The challenge for innovation in direct restorative materials. Adv Dent Res 2013;25:12; with permission.)

Regardless of the level of government, policy development is often the result of advocacy, input, analysis, and negotiation. Examples in the United States of resources on policy making and the importance of information to congress include a 2009 review by Stine, and a focus in academic research is a 2015 thesis by Schneiderman. UNEP has developed the Toolkit for Identification and Quantification of Mercury Releases to assist countries in undertaking such work. The toolkit is available at the UNEP Web address ( www.chem.unep.ch/mercury/Toolkit/default.htm ).

Policy Among Several Nongovernmental Stakeholders

Many organizations and institutions enact their own specific policies that reflect their goals, often with a set of supporting recommendations or actions on how to achieve them. Most major dental and public health organizations have a formal policy-making mechanism. Overviews of the major policy-making oral health organizations in the United States involved with the Minamata Convention are presented here.

The American Association for Dental Research (AADR) is a nonprofit organization with more than 3700 members in the United States. AADR’s mission is to advance research and increase knowledge for the improvement of oral health, support and represent the oral health research community, and facilitate the communication and application of research findings ( aadr.org/i4a/pages/index.cfm?pageid=3452#.Vp2l-fkrJdg ). AADR currently has policy statements in effect and is heavily involved in advocacy at the federal level in support of its mission.

The ADA, the largest and oldest member organization representing dentists in the United States, with more than 158,000 members, enacts policy through the input of multiple levels of the organization. ADA’s 11 councils serve as policy-recommending bodies within their specific areas of expertise. The House of Delegates (the 480-member governing and legislative body of the ADA representing the constituent [state] dental societies, the federal dental services, and dental students) has sole authority to formally enact policy for the association (ADA Constitution and Bylaws 2015; www.ada.org/∼/media/ADA/Member%20Center/FIles/ADA_2015_Bylaws.ashx ). The ADA currently has several hundred policies in effect, reflecting the organization’s position on a wide range of topics relevant to oral health and safe practice of dentistry ( www.ada.org/en/member-center/leadership-governance/∼/media/1156718AF2E042D08AA6C3677A604C35.ashx ). The ADA also seeks to influence public policy through advocacy and lobbying.

The American Public Health Association (APHA) champions the health of all people and communities ( www.apha.org/about-apha ). Health policy is a major focus of this organization, which is more than 140 years old and brings together more than 25,000 members from all fields of public health. Through its policy statement proposal process, the various components within APHA work together to establish formal evidence-based position statements on public health issues, which helps guide the organization’s advocacy efforts and enables each community within the larger organization to leverage the capability and visibility of APHA to help achieve its goals. Policy statement proposals are voted on by the APHA Governing Council, the representative legislative body of the association. Successful policy statement proposals generally come about through collaboration and compromise because they must satisfy the goals and perspectives of the general public health community. APHA currently has approximately 1400 policy statements in effect ( www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database ). The APHA Oral Health Section, with nearly 500 members, is one of 31 member sections within APHA, and, as part of a large, diverse public health organization, has unique opportunities to ensure an oral health perspective, as well as challenges when the perspectives within and among various sections and interest groups are not completely aligned, thus making collaboration, negotiation, and compromise key to advancing a dental public health agenda.

All 3 of these US-based organizations are major components in their respective international networks. The AADR is the largest division of the International Association for Dental Research (IADR), whose primary mission is to advance research and increase knowledge for the improvement of oral health worldwide ( www.iadr.org/i4a/pages/index.cfm?pageid=3283#.Vp5QlvkrJdg ). The ADA is the US National Dental Association member of the World Dental Federation (FDI), which represents the global dental profession to international, intergovernmental, governmental, voluntary, and other organizations ( www.fdiworldental.org/about-fdi/mission/the-voice-of-dentistry.aspx#sthash.j8H5Igi7.dpuf ). The APHA is a member of the World Federation of Public Health Associations (WFPHA), whose mission is to promote and protect global public health. The WFPHA is accredited as a nongovernmental organization (NGO) in official relations with the WHO ( www.wfpha.org/about-wfpha ).

Governmental Policy Development Specific to the Minamata Convention on Mercury

In parallel with other activities concerning environmental mercury, in 1997, the WHO held a consultation meeting on the use of dental amalgam. The objective of this consultation was to provide more information to the member states. WHO Oral Health was requested to review again the WHO/FDI consensus statement and if necessary draft a relevant document on dental amalgam use, taking into account the benefits but also the risks for individual, occupational, and environmental health of restorative materials. The project was thoroughly scrutinized by the WHO Programmes on Environmental Health and Occupational Health. The consensus statement on restorative dental care also emphasized the need for further research on alternatives to dental amalgam. These actions show that global attention to amalgam predates the Minamata Convention process.

In 2001, UNEP agreed to conduct a global assessment of mercury and its compounds, including information on the health effects, sources, long-range transport, prevention strategies, and control technologies, hence starting the process that led to the Minamata Convention. In 2003, significant evidence was published of large-scale global harm from mercury and its compounds, warranting further international action to reduce the risks to human health and the environment.

In 2009, the UNEP Governing Council mandated the development of a global LBI on mercury because it was determined that voluntary actions to control mercury waste were insufficient and that there was a need for an LBI. An INC was established to prepare an LBI on mercury ( www.unep.org/chemicalsandwaste/Mercury/ReportsandPublications/GlobalMercuryAssessment/tabid/1060889/Default.aspx ).

Also in 2009, the WHO Global Oral Health Program organized a meeting in Geneva, Switzerland, in cooperation with UNEP. From this meeting, a report on dental restorative materials concluded that dental amalgam is an effective restorative material. Consequently, the report Future Use of Materials for Dental Restoration highlights the current scientific evidence on dental materials, including amalgam and nonamalgam restorative materials, and gathered information for future recommendations on the use of dental restorative materials, paying key attention to avoiding environmental pollution. The comprehensive review pointed out that existing alternative materials to dental amalgam are not ideal because of limitations in their durability, fracture resistance, and wear. The report also notes the widespread public health threat from any proposed or impending ban of dental amalgam. Long term, it was critically important for WHO, FDI, IADR, and national dental associations to increase global awareness about the importance of the relationship of oral health to general health and well-being by emphasizing the value of risk assessment, prevention, disease management, and minimal intervention care. Preventing and managing oral diseases diminishes the need to use amalgam and other restorative material alternatives.

During this 2009 WHO meeting, consideration was given to the importance of strengthening oral health promotion and disease prevention as the strategy to reduce the use of restorative dental materials. In the case of tooth decay, the best care possible should be provided to meet patients’ needs. The meeting recognized the variation in dental practice among countries and the challenges faced by middle-income and low-income countries providing dental care, hence likely resulting in different approaches to dental caries management in different countries that need to be considered in oral health policy, training personnel, and development and planning of specific public health programs. It was noted that only a few countries, of high income, had initiatives to phase out the use of amalgam.

Among countries using amalgam, additional costs, especially if not part of their current systems, would be added by requiring systems for waste management to prevent environmental release of mercury to the environment. Following a review of existing evidence and much deliberation, the meeting recognized the huge challenges faced in dental restoration, disease prevention, and oral health promotion globally. As a result, the meeting considered that all currently existing methods and materials to manage dental caries need to remain available to dental professions in the short and medium terms.

Furthermore, the meeting noted that although alternative dental restorative materials may be desirable from an environmental health perspective, a progressive move away from dental amalgam would depend on adequate quality of these materials. Existing alternative dental materials are not ideal because of limitations in durability, fracture resistance, and wear resistance. Therefore, the meeting recognized the need for strengthening of research into the long-term performance, possible adverse effects, and viability of such materials.

Consideration of phasing down instead of targeting to phasing out dental amalgam arose at this 2009 WHO meeting. A multipronged approach with short-term, medium-term, and long-term strategies should be considered. Alternatives to dental amalgam exist but the quality of such materials needs to be further improved for use in public health care. The meeting suggested important strategies that can be put in place while waiting for new materials to be developed. The roles of WHO, UNEP, and NGOs such as the IADR and the FDI, user groups, and industry were seen as critical and it was decided that further meetings must be convened to discuss the way forward and to develop strategies to address issues in both developed and developing countries.

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Oct 25, 2016 | Posted by in General Dentistry | Comments Off on Policy Development Fosters Collaborative Practice
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