Publications by authors named "Chad Zawitz"

17 Publications

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Genomic Update of Phenotypic Prediction Rule for Methicillin-Resistant Staphylococcus aureus (MRSA) USA300 Discloses Jail Transmission Networks with Increased Resistance.

Microbiol Spectr 2021 Sep 21;9(1):e0037621. Epub 2021 Jul 21.

Division of Infectious Diseases, Rush University Medical Centergrid.240684.c/Cook County Health, Chicago, Illinois, USA.

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health care-associated (HA) and community-associated (CA) infections. USA300 strains are historically CA-MRSA, while USA100 strains are HA-MRSA. Here, we update an antibiotic prediction rule to distinguish these two genotypes based on antibiotic resistance phenotype using whole-genome sequencing (WGS), a more discriminatory methodology than pulsed-field gel electrophoresis (PFGE). MRSA clinical isolates collected from 2007 to 2017 underwent WGS; associated epidemiologic data were ascertained. In developing the rule, we examined MRSA isolates that included a population with a history of incarceration. Performance characteristics of antibiotic susceptibility for predicting USA300 compared to USA100, as defined by WGS, were examined. Phylogenetic analysis was performed to examine resistant USA300 clades. We identified 275 isolates (221 USA300, 54 USA100). Combination susceptibility to clindamycin or levofloxacin performed the best overall (sensitivity 80.7%, specificity 75.9%) to identify USA300. The average number of antibiotic classes with resistance was higher for USA100 (3 versus 2, < 0.001). Resistance to ≤2 classes was predictive for USA300 (area under the curve (AUC) 0.84, 95% confidence interval 0.78 to 0.90). Phylogenetic analysis identified a cluster of USA300 strains characterized by increased resistance among incarcerated individuals. Using a combination of clindamycin or levofloxacin susceptibility, or resistance to ≤2 antibiotic classes, was predictive of USA300 as defined by WGS. Increased resistance was observed among individuals with incarceration exposure, suggesting circulation of a more resistant USA300 clade among at-risk community networks. Our phenotypic prediction rule could be used as an epidemiologic tool to describe community and nosocomial shifts in USA300 MRSA and quickly identify emergence of lineages with increased resistance. Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of health care-associated (HA) and community-associated (CA) infections, but the epidemiology of these strains (USA100 and USA300, respectively) now overlaps in health care settings. Although sequencing technology has become more available, many health care facilities still lack the capabilities to perform these analyses. In this study, we update a simple prediction rule based on antibiotic resistance phenotype with integration of whole-genome sequencing (WGS) to predict strain type based on antibiotic resistance profiles that can be used in settings without access to molecular strain typing methods. This prediction rule has many potential epidemiologic applications, such as analysis of retrospective data sets, regional monitoring, and ongoing surveillance of CA-MRSA infection trends. We demonstrate application of this rule to identify an emerging USA300 strain with increased antibiotic resistance among incarcerated individuals that deviates from the rule.
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http://dx.doi.org/10.1128/Spectrum.00376-21DOI Listing
September 2021

Outbreak of COVID-19 and interventions in a large jail - Cook County, IL, United States, 2020.

Am J Infect Control 2021 09 2;49(9):1129-1135. Epub 2021 Apr 2.

Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address:

Background: Correctional and detention facilities are disproportionately affected by COVID-19 due to shared space, contact between staff and detained persons, and movement within facilities. On March 18, 2020, Cook County Jail, one of the United States' largest, identified its first suspected case of COVID-19 in a detained person.

Methods: This analysis includes SARS-CoV-2 cases confirmed by molecular detection among detained persons and Cook County Sheriff's Office staff. We examined occurrence of symptomatic cases in each building and proportions of asymptomatic detained persons testing positive, and timing of interventions including social distancing, mask use, and expanded testing and show outbreak trajectory in the jail compared to case counts in Chicago.

Results: During March 1-April 30, 907 symptomatic and asymptomatic cases of SARS-CoV-2 infection were detected among detained persons (n = 628) and staff (n = 279). Among asymptomatic detained persons in quarantine, 23.6% tested positive. Programmatic activity and visitation stopped March 9, cells were converted into single occupancy beginning March 26, and universal masking was implemented for staff (April 2) and detained persons (April 13). Cases at the jail declined while cases in Chicago increased.

Discussion/conclusions: Aggressive intervention strategies coupled with widespread diagnostic testing of detained and staff populations can limit introduction and mitigate transmission of SARS-CoV-2 infection in correctional and detention facilities.
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http://dx.doi.org/10.1016/j.ajic.2021.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016534PMC
September 2021

Genomic Epidemiology of MRSA During Incarceration at a Large Inner-City Jail.

Clin Infect Dis 2021 Jan 4. Epub 2021 Jan 4.

Section of Infectious Diseases, Rush University Medical Center/Cook County Health, Chicago, IL, USA.

Background: Congregate settings, such as jails, may be a location where colonized detainees transmit MRSA. We examined MRSA acquisition during incarceration and characterized the genomic epidemiology of MRSA entering the jail and isolated during incarceration.

Methods: Males incarcerated at the Cook County Jail were enrolled within 72 hours of intake and MRSA surveillance cultures collected. Detainees in jail at Day30 were re-cultured to determine MRSA acquisition. A survey was administered to identify acquisition predictors. Genomic sequencing of surveillance and clinical isolates was integrated with epidemiologic and jail location data to track MRSA transmission pathways.

Results: 800 males were enrolled; 19% MRSA colonized at intake. Of 184 who reached Day30 visit, 12 acquired MRSA. Heroin use before entering (OR 3.67,p=0.05) and sharing personal items during incarceration (OR=4.92,p=.01) were predictors of acquisition. Sequenced clinical USA300 isolates (n=112) were more genetically similar than diverse intake USA300 strains (p<0.001), suggesting jail transmission. Four acquired colonization isolates were within 20 SNVs of other isolates; 4 were within 20SNVs of an intake isolate, 2 for an acquisition isolate, and 1 for a clinical isolate. Individuals with genetically similar isolates were more likely to have had overlapping stays in the same buildings.

Conclusion: There was a high MRSA burden entering jail. Genomic analysis of acquisition and clinical isolates suggests potential spread of incoming strains and networks of spread during incarceration, with spread often occurring among detainees housed in similar locations. Sharing personal items during incarceration is associated with MRSA acquisition and could be a focus for intervention.
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http://dx.doi.org/10.1093/cid/ciaa1937DOI Listing
January 2021

Identification of Presymptomatic and Asymptomatic Cases Using Cohort-Based Testing Approaches at a Large Correctional Facility-Chicago, Illinois, USA, May 2020.

Clin Infect Dis 2021 03;72(5):e128-e135

Cermak Health Services, Chicago, Illinois, USA.

Background: Coronavirus disease 2019 (COVID-19) continues to cause significant morbidity and mortality worldwide. Correctional and detention facilities are at high risk of experiencing outbreaks. We aimed to evaluate cohort-based testing among detained persons exposed to laboratory-confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to identify presymptomatic and asymptomatic cases.

Methods: During 1-19 May 2020, 2 testing strategies were implemented in 12 tiers or housing units of the Cook County Jail, Chicago, Illinois. Detained persons were approached to participate in serial testing (n = 137) and offered tests at 3 time points over 14 days (day 1, days 3-5, and days 13-14). The second group was offered a single test and interview at the end of a 14-day quarantine period (day 14 group) (n = 87).

Results: 224 detained persons were approached for participation and, of these, 194 (87%) participated in ≥1 interview and 172 (77%) had ≥1 test. Of the 172 tested, 19 were positive for SARS-CoV-2. In the serial testing group, 17 (89%) new cases were detected, 16 (84%) on day 1, 1 (5%) on days 3-5, and none on days 13-14; in the day 14 group, 2 (11%) cases were identified. More than half (12/19; 63%) of the newly identified cases were presymptomatic or asymptomatic.

Conclusions: Our findings highlight the utility of cohort-based testing promptly after initiating quarantine within a housing tier. Cohort-based testing efforts identified new SARS-CoV-2 asymptomatic and presymptomatic infections that may have been missed by symptom screening alone.
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http://dx.doi.org/10.1093/cid/ciaa1802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799274PMC
March 2021

Network Characteristics and Visualization of COVID-19 Outbreak in a Large Detention Facility in the United States - Cook County, Illinois, 2020.

MMWR Morb Mortal Wkly Rep 2020 Nov 6;69(44):1625-1630. Epub 2020 Nov 6.

Correctional and detention facilities have been disproportionately affected by coronavirus disease 2019 (COVID-19) because of shared space and movement of staff members and detained persons within facilities (1,2). During March 1-April 30, 2020, at Cook County Jail in Chicago, Illinois, >900 COVID-19 cases were diagnosed across all 10 housing divisions, representing 13 unique buildings. Movement within the jail was examined through network analyses and visualization, a field that examines elements within a network and the connections between them. This methodology has been used to supplement contact tracing investigations for tuberculosis and to understand how social networks contribute to transmission of sexually transmitted infections (3-5). Movements and connections of 5,884 persons (3,843 [65%] detained persons and 2,041 [35%] staff members) at the jail during March 1-April 30 were analyzed. A total of 472 (12.3%) COVID-19 cases were identified among detained persons and 198 (9.7%) among staff members. Among 103,701 shared-shift connections among staff members, 1.4% occurred between persons with COVID-19, a percentage that is significantly higher than the expected 0.9% by random occurrence alone (p<0.001), suggesting that additional transmission occurred within this group. The observed connections among detained persons with COVID-19 were significantly lower than expected (1.0% versus 1.1%, p<0.001) when considering only the housing units in which initial transmission occurred, suggesting that the systematic isolation of persons with COVID-19 is effective at limiting transmission. A network-informed approach can identify likely points of high transmission, allowing for interventions to reduce transmission targeted at these groups or locations, such as by reducing convening of staff members, closing breakrooms, and cessation of contact sports.
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http://dx.doi.org/10.15585/mmwr.mm6944a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643900PMC
November 2020

Frequent Methicillin-Resistant Staphylococcus aureus Introductions Into an Inner-city Jail: Indications of Community Transmission Networks.

Clin Infect Dis 2020 07;71(2):323-331

Division of Infectious Diseases, Rush University Medical Center/Cook County Health, Chicago, Illinois, USA.

Background: Jails may facilitate spread of methicillin-resistant Staphylococcus aureus (MRSA) in urban areas. We examined MRSA colonization upon entrance to a large urban jail to determine if there are MRSA transmission networks preceding incarceration.

Methods: Males incarcerated in Cook County Jail (Chicago) were enrolled, with enrichment for people living with human immunodeficiency virus (PLHIV), within 72 hours of intake. Surveillance cultures assessed prevalence of MRSA colonization. Whole-genome sequencing (WGS) identified preincarceration transmission networks.We examined methicillin-resistant Staphylococcus aureus (MRSA) isolates to determine if there are transmission networks that precede incarceration. A large proportion of individuals enter jail colonized with MRSA. Molecular epidemiology and colonization risk factors provide clues to community reservoirs for MRSA.

Results: There were 718 individuals (800 incarcerations) enrolled; 58% were PLHIV. The prevalence of MRSA colonization at intake was 19%. In multivariate analysis, methamphetamine use, unstable housing, current/recent skin infection, and recent injection drug use were predictors of MRSA. Among PLHIV, recent injection drug use, current skin infection, and HIV care at outpatient clinic A that emphasizes comprehensive care to the lesbian, gay, bisexual, transgender community were predictors of MRSA. Fourteen (45%) of 31 detainees with care at clinic A had colonization. WGS revealed that this prevalence was not due to clonal spread in clinic but rather to an intermingling of distinct community transmission networks. In contrast, genomic analysis supported spread of USA500 strains within a network. Members of this USA500 network were more likely to be PLHIV (P < .01), men who have sex with men (P < .001), and methamphetamine users (P < .001).

Conclusions: A large proportion of individuals enter jail colonized with MRSA. Molecular epidemiology and colonization risk factors provide clues to identify colonized detainees entering jail and potential community reservoirs of MRSA.
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http://dx.doi.org/10.1093/cid/ciz818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353325PMC
July 2020

A randomized controlled study of intervention to improve continuity care engagement among HIV-infected persons after release from jails.

AIDS Care 2019 07 10;31(7):777-784. Epub 2018 Oct 10.

b Rush University Medical Center , Chicago , IL , USA.

Short-term stay, multiple jail admissions and social and financial difficulties are significant obstacles for continuity care engagement (CCE) after release among HIV-infected jail detainees. However, data existing on interventions or strategies to increase post-release CCE among this population are limited. We conducted a randomized controlled study among HIV-infected detainees at Cook County Jail during 2011-2014. The intervention group received telephone contact within 2-4 days of release by a continuity clinic coordinator, who scheduled and informed the ex-detainees of their appointment date within 6 weeks post-release plus standard of care, while the control group received standard of care. The standard of care included comprehensive discharge planning, offering substance abuse treatment and provision of information on how to self-schedule an appointment with the chosen clinics. Of the 166 detainees enrolled, 56 were excluded due to being sent to prison or re-incarcerated within 6 weeks. The final cohort included 55 detainees in each of the groups. The rate of CCE within 6 weeks after release was significantly higher in the intervention group compared to the control group (58% vs. 33%; P = .007). In multivariable logistic regression analysis, being in the control group was the only factor associated with no CCE within 6 weeks (adjusted odds ratio 2.66; 95% confidence interval 1.18-6.00; P = .02). The study findings suggest that the simple telephone contact intervention significantly improved CCE among HIV-infected jail detainees.
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http://dx.doi.org/10.1080/09540121.2018.1533236DOI Listing
July 2019

Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: Data from the Seek, Test, Treat, and Retain Harmonization Initiative.

PLoS One 2018 22;13(5):e0197730. Epub 2018 May 22.

Department of Biostatistics, University of Washington, Seattle, WA, United States of America.

Background: Transgender persons are highly victimized, marginalized, disproportionately experience incarceration, and have alarmingly increased rates of HIV infection compared to cis-gender persons. Few studies have examined the HIV care continuum outcomes among transgender women (TW), particularly TW who are involved with the criminal justice (CJ) system.

Methods: To improve our understanding of HIV care continuum outcomes and risk behaviors among HIV-infected TW who are involved with the CJ system, we analyzed data from the National Institute on Drug Abuse-supported Seek, Test, Treat, Retain (STTR) Data Harmonization Initiative. Baseline data were pooled and analyzed from three U.S. STTR studies to examine HIV risk and care continuum indicators among CJ-involved HIV-infected TW compared to cisgender men (CM), matched on age (within 5 years) and study at a ratio of 1:5.

Results: Eighty-eight TW and 440 CM were included in the study. Among matched participants, TW were more likely to report crack and cocaine use compared to CM (40%,16% respectively, p<0.001); both TW and CM reported high rates of condomless sex (58%, 64%, respectively); TW were more likely than CM to have more than one sexual partner (OR = 2.9, 95% CI: 1.6, 5.2; p<0.001) and have engaged in exchange sex (OR = 3.9, 95% CI: 2.3, 6.6; p<0.001). There were no significant differences between TW and CM in the percentage currently taking ART (52%, 49%, respectively), the mean percent adherence to ART (77% for both groups), and the proportion who achieved viral suppression (61%, 58%, respectively).

Conclusions: HIV-infected CJ-involved TW and CM had similar use of ART and viral suppression but TW were more likely than matched CM to engage in exchange sex, have multiple sexual partners, and use crack/cocaine. TW and CM had similarly high rates of condomless sex and use of other drugs. TW require tailored risk reduction interventions, however both CJ-involved TW and CM require focused attention to reduce HIV risk and improve HIV continuum of care outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197730PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963777PMC
November 2018

TALES FROM THE INSIDE.

Authors:
Chad Zawitz

Posit Aware 2015 Nov-Dec;27(7):14-5

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August 2016

The Intersecting Epidemics of Human Immunodeficiency Virus, Community-Associated Methicillin-Resistant Staphylococcus aureus, and Incarceration.

Open Forum Infect Dis 2015 Dec 30;2(4):ofv148. Epub 2015 Sep 30.

Rush University Medical Center/Cook County Health and Hospitals System.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) has had a significant impact on human immunodeficiency virus (HIV)-infected and incarcerated individuals. We examined electronic medical surveillance data from 2006 to 2011 and observed that even in a population of currently or recently incarcerated individuals, HIV status was a significant risk factor for MRSA infections and Hispanic ethnicity was protective.
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http://dx.doi.org/10.1093/ofid/ofv148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4631903PMC
December 2015

The dangers of HIV stigma in corrections.

Posit Aware 2014 Sep-Oct;26(6):16-9

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November 2014

Opt-out screening for Chlamydia trachomatis and Neisseria gonorrhoeae in female detainees at Cook County jail in Chicago, IL.

Sex Transm Dis 2014 Mar;41(3):161-5

From the *Rush University Medical Center, Chicago, IL; †John H Stroger Hospital/Cook County Health and Hospital Systems, Chicago Center for AIDS Research, Chicago, IL; and ‡Cermak Health Services, Cook County Jail, Chicago, IL.

Background: In April of 2011, the Cook County Jail initiated opt-out screening of all women for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) at the time of intake. In this retrospective review, we assess the impact of opt-out protocol on rates of testing, diagnoses, and successful treatment.

Methods: We collected the results of all CT and GC tests ordered during intake from April 2011 through December 2012 and reviewed the medical chart of every patient with a positive result for documentation of treatment. Univariable and multivariable analyses were performed to examine the factors associated with receipt of treatment.

Results: Opt-out screening increased the number of diagnoses by more than 4-fold (from 9.3 to 40.8 cases/mo). Among 17,065 women eligible for screening, 3729 (22%) women opted out of screening, and screening was completed in 9265 (54.2%). There were 235 (2.5%) gonococcal infections and 702 (7.6%) chlamydial infections. Of 866 women with a positive test result, 602 (69.5%) received treatment while in jail. In multivariable analysis, older age (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.14-2.63), pregnancy (aOR, 2.51; 95% CI, 1.22-5.18), and longer length of stay in jail (aOR, 18.1; 95% CI, 11.7-28.1) were associated with greater likelihood of treatment.

Conclusions: Women entering the Cook County Jail have high prevalence of GC/CT infections. Opt-out screening increased the number of GC and CT diagnoses made, and a high proportion of women were treated while incarcerated. Significant challenges remain in ensuring that screening is completed for all women who do not opt out and in providing treatment to women with short duration of incarceration.
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http://dx.doi.org/10.1097/OLQ.0000000000000106DOI Listing
March 2014

Money well spent. Opt-out testing in prisons can catch STD cases--and save taxpayers money in the long run.

Authors:
Chad Zawitz

Posit Aware 2012 May-Jun;24(3):23-6

HIV/Infectious Disease Services for Cermak Health Services, Cook County Jail, USA.

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November 2012

Continuity of care in a cohort of HIV-infected former jail detainees.

J Correct Health Care 2013 Jan 27;19(1):36-42. Epub 2012 Sep 27.

Section of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL 60612, USA.

This article describes a retrospective cohort study of HIV-infected jail detainees cared for at the Cook County Jail Clinic (CCJC), Illinois, between January and June 2007. Continuity care engagement (CCE) was defined as being seen at least once within 6 months after release at the designated continuity clinics. Being highly active antiretroviral therapy (HAART) naïve during or prior to detention, no prior HIV care, and detectable viral load at initial CCJC visit were associated with continuity care nonengagement (CCNE), while being HAART naïve during detention was the only independent predictor for CCNE. Identification of at-risk detainees and interventions based on these findings should be considered to improve CCE in this population.
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http://dx.doi.org/10.1177/1078345812458246DOI Listing
January 2013

Community-associated methicillin-resistant Staphylococcus aureus colonization in high-risk groups of HIV-infected patients.

Clin Infect Dis 2012 May 21;54(9):1296-303. Epub 2012 Feb 21.

Rush University Medical Center, Chicago, Illinois 60612, USA.

Background: We examined the epidemiology of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) nasal colonization among 3 groups of human immunodeficiency virus (HIV)-infected and 1 group of HIV-negative outpatients.

Methods: We determined prevalence and risk factors associated with MRSA colonization among women, recently incarcerated, and Hispanic HIV-infected patients and HIV-negative patients; isolates were typed by pulsed-field gel electrophoresis. Relative prevalence was calculated using Poisson regression, and logistic regression was used for multivariate analysis.

Results: Of 601 patients, 9.3% were colonized with MRSA; 11% of HIV-infected and 4.2% of HIV-negative patients were colonized (relative prevalence, 2.6; 95% confidence interval [CI], 1.12-6.07; P = .03). Among HIV-infected patients, recently incarcerated patients had the highest colonization prevalence (15.6%) followed by women (12%); Hispanic patients had the lowest (2.8%). Eighty percent of confirmed MRSA isolates were identified as USA300. On multivariate analysis, history of incarceration or residence in alternative housing (odds ratio [OR], 2.3; 95% CI, 1.1-4.7; P = .03) was associated with MRSA colonization; Hispanic ethnicity was negatively associated (OR, 0.3; 95% CI, .11-.98; P = .045). There was a trend (OR, 1.6; 95% CI, .9-3.0; P = .097) toward geographic location of residence being associated with colonization. After controlling for incarceration, residence, and geography, HIV status was no longer significantly associated with colonization.

Conclusions: The CA-MRSA and HIV epidemics have intersected. Examination of networks of individuals released from incarceration, both HIV positive and negative, is needed to assess the role of social networks in spread of CA-MRSA and inform prevention strategies.
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http://dx.doi.org/10.1093/cid/cis030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404690PMC
May 2012

HIV care in the correctional setting.

Authors:
Chad Zawitz

Posit Aware 2009 Nov-Dec;20(6):30-2

Cermak Health Services, Cook County Jail, USA.

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January 2010
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