The COVID-19 Vaccination program and barriers of vaccination: а Review and comparison. Evidence from Iran and Russia


The vaccination is a global issue of controlling infection agents and non-infectious diseases that require modern technologies and scientific knowledge. During the COVID-19 pandemic the work is continuously implemented to control the situation. The vaccination can affects controlling outbreaks all around the world. Besides, applying several types of vaccines in various countries to control second peak of the pandemic can be considered as significant factor that positively impacts host immune response. However, there are different barriers to vaccination programs worldwide in areas of economy, technology, politics, demography, psychology, especially in countries with low economic level. Although vaccination program started in many countries, developing mass immunity in society is essential for pandemic termination. Iran and Russia also are involved in COVID-19 pandemic disease since January 2020, and they are still working to achieve mass immunity. The actual study was carried out to compare vaccination extent between Russia and Iran countries to evaluate vaccination impact on the COVID-19 pandemic and to review some main factors that influence vaccination to understand main barriers of vaccination in both countries.

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Introduction The novel coronavirus caused COVID-19 pandemic disease all around the world. The novel coronavirus is officially named SARS-CoV-2 because of its genomic homology to SARS-CoV [1]. Coronaviruses are positive-sense single-stranded RNA viruses (+ssRNA) that can infect a wide range of vertebrates. They belong to the Coronaviridae family as characterized as giant and enveloped viruses [2]. In the last 20 years, three epidemics have been made by Coronavirus, and our capability to prevent future likely sudden viral epidemics will be determined by how sincerely we studied and understand SARS-CoV-2 scientific details [3]. In Wuhan, in 2019, SARS-CoV-2 provoked an acute respiratory syndrome epidemic in humans (COVID-19 disease) and has since become a pandemic worldwide [4]. Pandemic developed in a direction that sad to say, till 5th July 2021, Globally, 183,560,151 confirmed cases of COVID-19 disease, including 3,978,581 deaths, were reported to the world health organization (WHO). Though, as of 4th July 2021, a total of 2,988,941,529 vaccine doses have been injected[5]. Iran and Russia, like other countries, have also been affected by COVID-19 disease. In Russia, from 3rd January 2020, till 5th July 2021, there have been 5,635,294 confirmed cases of COVID-19 disease, with 138,579 deaths reported to the world health organization. And as of 6th July 2021, a total of 42,830,589 vaccine doses have been administered. Likewise, in Iran (the Islamic Republic of), from 3rd January 2020 till 5th July 2021, the number of confirmed cases of COVID-19 disease increased to 3,254,818, with 84,792 deaths and a total of 5,717,914 vaccines injected reported to the world health organization. Emphatically, the cumulative total cases per 100000 populations in Russia is 3,861.52 and in Iran is 3,875.11; this means the approximate epidemical situation in both countries is almost the same. Yet, the rate of Deaths (the cumulative total per 100,000 population) in Russia is 94.96 and in Iran is 100.95, which shows a meaningful difference [5]. Though, multi-factorial reasons cause this difference in the rate of Deaths (the cumulative total per 100,000 population). Still, the percentage of vaccination in both countries, Russia and Iran can lead to this vital difference. Vaccination is the principal success of public health programs universally. Vaccines are efficient in preventing disease and mortality. Since 1924 vaccines have prevented more than 100 million cases caused by eight infectious diseases [6]. The first reaction of states to the COVID-19 outbreak was to apply quarantine and social preventive measures, such as wearing masks or social distancing. With the presence of carriers without apparent symptoms in society and a lack of antiviral drugs and vaccines, traditional public health appliance measures will be significantly less effective. An essential human requirement is socializing, and social distancing blocks it, sequentially affecting our mental wellness. Thus, while the physical distancing may appropriately be enforced when necessary, still in the long term, it can influence public mental health [7]. Vaccine study and development accomplishments bring hope to people and our societies to cope with the COVID-19 pandemic and return to routine life. Although people know that the production and development of a vaccine are not rapid and easy, the world is continuously working hard to defeat coronavirus. After all, some countries could pass all steps of vaccine development against coronavirus disease and start vaccine distribution after about one year of work. The development of effective vaccines on the viral pathogen coronavirus-2 occurred rapidly in some countries to control the epidemic situations, and analytical studies determined the safety of candidate vaccines [8]. Russia was also one of the first countries to produce a COVID-19 vaccine named Sputnik V. However, Russian vaccine development has been criticized for indecent rapidity, but scientific papers prove the vaccine’s safety and effectiveness. Moreover, some countries began their vaccination programs to achieve herd immunity which is essential for society and public health. Still, the vaccination program expansion is not the same in different countries, as fast as required. Indeed, vaccination program development is not just about the production of the proper vaccine. It is about all aspects of a country’s infrastructure, such as cultural infrastructure or economic infrastructure. Iran and Russia are also still far from Herd immunity achievement. According to the capabilities and infrastructure of each country and the society, every country has its main barriers against coronavirus vaccination. Surveys among people report that there is a special rate of distrust against vaccines. Therefore, a wide array of research has started, suggesting various procedures in aiding authorities to deal with vaccine hesitancy, such as proper and effective strategic communication [9]. Vaccine hesitancy is not a new issue in vaccinology, and in the last decade, many people, especially parents of newborn children around the world, were involved in it. By the onset of the coronavirus disease epidemic and consequently the rapid development of vaccination programs against novel coronavirus, vaccine hesitancy these days reached its peak. In between, social media can play a proactive role to affect positively or negatively to decrease or increase vaccine doubt. The inadequate supervision of false information on the internet can lead to people misunderstanding vaccination advantages and finally publish misinformation. However, many countries cannot provide sufficient vaccines and meet their people's needs due to a lack of proper scientific or economic infrastructure. The financial barrier is one of the biggest problems for vaccination. Many developing countries, including, Iran has an economic problem with vaccination. The United Nations news published on April 9th, 2021, that rich countries received more than 87 percent of vaccine doses. Within this situation, doubt about vaccination is nonsense because people cannot accept or decline the vaccination, which does not exist. This review will concentrate on COVID-19 vaccination programs and their barriers in Iran and Russia, and according to their statistics, we will investigate the vaccination effects on the COVID-19 disease. Furthermore, the study will review the circumstances influencing the rate of vaccination in these countries. Literature review Vaccination is one of the numerous issues in medicine and the pharmacological industry. According to the importance of people immunization in the public health and pharmacological sector, many countries, including developed and developing countries, entered this science and industry. Each year globally, about 2.5 million deaths are prevented against infectious diseases by vaccination [10]. In contrast, regretfully, from January 2020, till 5th July 2021, about 3.9 million deaths outcome of coronavirus diseases have been reported to the World Health Organization [5]. Though non-infectious conditions are also nowadays in the vaccinology area, vaccination has got more attention in many countries during the COVID-19 diseases pandemic due to the rapid increase of SARS-CoV-2 infections [11]. Producing and developing a considerable amount of a vaccine quickly in global pandemic conditions is challenging. For this purpose, appropriate activities should follow, such as preclinical tests, clinical trials, planned production, and organized distribution. These fundamental activities usually take decades-long and lead to a significant elevation of mortality, morbidity, and finally, financial risk [12]. However, some countries, including Russia, during the last year passed all developing vaccine’s steps rapidly to prepare the COVID-19 vaccine as soon as possible and decrease all these negative factors. Still, this rapidity has caused a significant rate of distrust against COVID-19 vaccines among societies. Vaccines are especially appropriate for developing herd immunity since people who get vaccinated are exposed significantly to viruses, such as healthcare employees. And we can prevent the death of vulnerable populations by vaccination, including older people with certain underlying medical conditions. Herd immunity is essential for society and is determined as the Immunity of the broad segment of a population (the herd) to disease, which makes the spreading of the illness improbable [13]. Herd immunity protects the whole society indirectly from infectious disease, even those who cannot be vaccinated and are not immune, including very young or immunocompromised persons. Moreover, there was little evidence that herd immunity can be created naturally by spreading coronavirus diseases among the population. Still, we cannot risk to loss of people’s life and property to incur to achieve this natural herd immunity, and we are not sure how long that immunity would last. Establishing herd immunity is not simple work according to the barriers of vaccination programs. This should be noted that it requires a comprehensive large-scale vaccination program [14]. It is evident, an efficient vaccine with global immunization inclusion is essential to bring the global situation back to normalcy considering the rapid transmission and asymptomatic spread of COVID-19; however, the duration of vaccine-induced immunity is still mostly unknown [15]. Vaccination programs can influence public health, although multifactorial challenges and barriers impact vaccination [16]. In this study, we want to focus on some of the factors and compare the COVID-19 vaccination situation in Iran and Russia to evaluate success. For this purpose, according to Dubé Eve et al. vaccine hesitancy research overview, the authors have designed a graph representing the relation of the vaccination programs to the barriers of public vaccination and, therefore, public health [17]. The population is one of the logical reasons for the unavailability of vaccination (fig.1). As the population gets higher, providing vaccine doses in such a large amount gets more complicated. Such as Bahrain has about 1.64 million people and is administered about 2 million vaccine doses. On the other hand, Russia (about 146 million) and Iran (about 84 million) are both countries with a large population which causes vaccine dose providing more difficult in these countries. Although a country like the United States of America, with a vast population (about 331 million) in line with a high level of the economy, technology, and science, has been able to administer nearly 330 million doses of vaccine till 1st June 2021. Meanwhile, Iran and Russia have administered about 5.7 million and 42 million doses, respectively [5, 18].The importance of the economy is determined by the fact that United Nations news announced (on April 9th, 2021) rich countries received more than 87 percent of vaccine doses globally, while this is just 0.2 percent for the low-income countries [19]. Also, the statistics prove the news. We can observe that just two world economic powers, including the United States of America, and China received about 1.5 billion doses of vaccines, half of the global doses administered [5]. Iran's economic situation is mainly affected by the harsh US sanctions, and this has made developing or providing vaccines too difficult and impact the public health in Iran. On the one hand, research budgets have been significantly reduced due to financial problems. On the other hand, international restrictions in transferring funds decreased access to medicines and health diplomacy. Though medicine is not on the list of sanctions, the challenges in the financial transaction and concern of possible U.S. penalties for pharmaceutical companies and international banks led to the shortage of specific drugs and medical facilities in the last months. Also, the preparation of laboratory materials is complicated according to the economic limitation and sanctions. Indeed, sanction shows not only the economic but the political impact on public health [20]. Given the stated reality, it requires a comparison of Iran's and Russia's economics has seen. According to the World Bank statistics of Gross domestic product 2019, Russia has 11th grade while Iran is 25th [21]. A 14 level of difference like this can show one of the main reasons for the delay in vaccine production in Iran. However, due to American sanctions, both countries' economies have been years damaged, and the pandemic situation has made these economies frail during the last year. With all these conditions, as the ethical issues are an essential aspect for developing the vaccine, Russia has accepted to transfer of technology and access of the Sputnik vaccine to Iran during the current pandemic of COVID-19 [22]. It was not only Iran but also India, Palestine, Turkey, etc. Sputnik V, developed by the Gamaleya National Center of Epidemiology and Microbiology of Russia is one of the first vaccines, produced against COVID-19 disease [23]. However, the Sputnik V vaccine development has been criticized for indecent rapidity, but scientific reports clearly prove the vaccine’s safety and effectiveness [24]. Conforming to the survey-based research of potential global acceptance of the COVID-19 vaccine, the Russian participants had the highest amount of negative responses and the lowest ratio of respondents demanding to accept their employer’s recommendation about vaccination [25]. Also, Russian participants in another study, just 41%would be wished to receive the vaccine if it became available. It presents Russian people are involved with vaccine hesitancy though the vaccine is produced and available in Russia. The Russian people are more possible to trust the COVID-19 vaccine if they believe that the vaccine reduces the risk of virus infection [26]. And the point is that Russia produces the Sputnik vaccine; still, some Russian people don’t trust the foreign and indigenous vaccines. Some people weirdly even don’t believe the COIVD-19 viral infection though many people died from it. Vaccine hesitancy is a substantial global issue remarked many times during the last several years [27], which is defined as a “delay in acceptance or refusal of vaccines despite the availability of vaccination services [28]”. The vaccine hesitancy challenge is a multifactorial psychological barrier to vaccination programs, and it includes many aspects. Still, one of the main factors is social media and communication, which are the critical factors of vaccine hesitancy among society, which are influenced by the vaccination directly and effects on it in return [29]. Many people describe receiving vaccine-related information from online sources, while some information is not accurate or neither based on science [30]. The most numerous concern and doubt to the broad community is the protection and the safety of vaccines regarding vaccine’s rapid development [31]. Researches prove that after all talking with family, friends, and surfing the internet, healthcare providers’ recommendations are getting more critical in the decision-making process about vaccination [32]. High inquire pressure for information during the pandemic, cultural factors, the ease of distributing wrong information by social networks, and the weak legal supervision of online content are the principal causes for misinformation propagation. This misinformation can lead to psychosocial, economic, health system, and ethical problems outcome. The powerful and efficient attendance of health specialists and experts in social media during the pandemic and the advancement of public health knowledge in the long duration is the most suggested approach for coping with misinformation-related challenges [33]. Actually, social media can play a significant role in both spreading accurate knowledge or misinformation. But revitalizing the culture of health and continue the pathway toward the development of evidence-based information lead to public awareness and decrease the spread and acceptance of COVID-19 related misinformation. Nevertheless, if countries delay the production of vaccine or development of vaccine administration, the advantages of a vaccine program will diminish considerably. Studies prove the immediate requirement for more substantial financial resources investment and attention to vaccine production and distribution programs which can cause to promote public confidence in COVID-19 vaccines and boost excellent adherence to other available controlling approaches even after a vaccine administration [34]. New studies data from various references suggest that readiness to be vaccinated with a novel COVID-19 vaccine is around 60-70 percent of the general population. In some cases, much lower in specific sociodemographic groups, such as people with lower educational attainment or those who live in rural areas. People give many reasons for COVID-19 vaccine hesitancy. Some people are worried about the vaccine's safety, especially about the unprecedented speed of development that COVID-19 vaccines have. Distrust in the government, the medical research community, and pharmaceutical companies are also widespread. Some people may feel they do not need the vaccine, either because they have already had (or believe they have had) COVID-19, they do not think COVID-19 is a severe threat to their health, or they do not believe in vaccination [35]. The policy we can utilize towards COVID-19 vaccination depends on the definite dangers and profits of the vaccine, the pandemic situation, the nature of the options, and especially the public desire for vaccination. Even if the penalty is fit proportionate, obligatory vaccination can ethically be verified depending on the pandemic conditions. Payment for vaccination is also an option. For those concerned about altruism, the vaccinated can be offered the opportunity to donate their fee back to the health service providers. This combined “payment-donation” model would be a happy marriage of ethics and economics [36]. According to coronavirus novel mutation and lack of enough information about COVID-19, we still don’t know how long the pandemic will last. Even if all the society has vaccinated, we should prepare the government, the community, and public minds for any new mutation of coronavirus and new vaccination programs during subsequent years. The main goal of all these studies is not just to review the coronavirus vaccination barrier; indeed, we are into increase human knowledge to prepare our world for probable future potential threats for human world public health. And the adaptation of our life with the situation during the COVID-19 pandemic. Methods Published literature was reviewed to identify vaccination success, and local evidence showed that COVID-19 vaccination has many barriers to deal with. We utilized advanced search in PubMed website as a free search engine, which accessing more than 32 million citations from the MEDLINE database of references and abstracts on life sciences journals and biomedical topics, and online books. The advance searching of [COVID-19] and [vaccine], and [barriers] keywords show 244 results. From 244 works, 60 were review articles. Just four studies included [Russia], and six covered [Iran]. All the studies timeline was in 2020 and 2021. Also, the statistics used in this article about the pandemic situation consist of the cumulative total per 100,000 population numbers of confirmed cases and the deaths were taken from the World Health Organization website, and the graphs were obtained in the report using statistical analysis software. Result It is crucial to study and observe the statistics of COVID-19 disease confirmed cases and deaths in different countries to find out if the vaccination program is efficient and the public health is not at risk. According to the statistics of the weekly changes of confirmed cases in Iran and Russia, we can observe a negative slope of confirmed cases in Russia’s graph of COVID-19 diseases with slight fluctuations from the 4th of January 2021 till May 3rd. Again from May 10th, the number of confirmed cases increased in Russia. This increase showed that the new Indian mutation of coronavirus (Delta) could change the situation, and the pandemic was not wholly controlled in Russia. However, Russia was one of the first countries in coronavirus vaccine production and, as of 6th July 2021, administered about 42.8 million doses. Likewise, in Iran, it has been at an unstable rate since January 2021, and even there was a 75.15% increase in total confirmed cases recently during one week from the 5th of April 2021. This vast increase in numbers was the start of the fourth peak of pandemic death numbers in Iran. Figure 2 shows the comparative graphs of confirmed cases of COVID-19 disease (weekly changes) derived from the WHO statistics from both Iran and Russia [5].Under graphs, we can distinguish three peaks of increased confirmed cases of the COVID-19 disease since last year from the pandemic's beginning in Russia. There is no similar pattern for the total numbers of confirmed COVID-19 disease cases in Iran. The difference is that since the 15th March 2021, the number of cases in Iran exceedingly increased (about 2 times) more than in Russia. Although, Russia’s population (144.4 million) is 1.74 times more than Iran’s population (82.91 million). ps202203.4htm00003.jpg According to the information of the Iranian civil registration organization, just last summer and spring, about 241,000 deaths are recorded in Iran [37]. In the same period, about 23,700 deaths in Iran have been reported by WHO due to coronavirus disease [38]. The information above means coronavirus diseases caused 9.8 percent of mortality in half of the last year in Iran. However, before the coronavirus pandemic in 2017, out of 353,855 total number of deaths, the notable reasons of death in Iran were “Diseases of the circulatory system” (40.2%), “Cancer and other tumors” (10.8%), “Respiratory diseases” (9.6%) and “Unintended events” (7.3%), which together account for 67.9% of the total number of deaths in the country [18]. Since the early stages of the pandemic, scientists have reported higher mortality rates among COVID-19 patients with pre-existing cardiovascular disease than patients without acquired cardiovascular disease [39]. Figure 3 presents the comparative graphs of death numbers of COVID-19 disease (weekly changes) derived from the WHO statistics from both Iran and Russia. Since the beginning of the COVID pandemic, the number of deaths due to coronavirus disease in Iran has increased within three terms, and each period, the numbers took about two months to decline. Recently, there has been a worrying increase in the coronavirus-related mortality rate in Iran, even more than Russia in April 2021. While in Russia, there were two peaks of total deaths, but the second peak was prolonged for at least three months and showed a slow downturn in the graph till May 10th, 2021. But in June 2021, everything changed, and the mortality rate extremely increased in Russia. Evidence suggests that Russia and Iran have been unable to control and prevent coronavirus disease and mortality rate, according to the spreading of new mutated coronavirus in these countries(fig.3). Russia and Iran have an approximately similar epidemical condition (the cumulative total cases per 100,000 populations in Russia is 3,980.19 and in Iran is 4,040.15). The number of deaths due to coronavirus in Iran and Russia recently significantly increased. Russia, with 42.8 million, and Iran, with 5.7 million vaccinated doses, have a long way to achieve herd immunity in society which is essential for returning to normal life. However, Russia is much closer to the goal in this way than Iran. ps202203.4htm00005.jpg Russia and Iran have different problems in public vaccination programs. Therefore, they require additional policies to expand the general vaccination program. Russia should place procedures to address vaccine hesitancy, given the Russian people's access to adequate vaccines (Sputnik). Because it seems that the Russian people are still skeptical about vaccination against COVID-19 diseases, even though the vaccine is produced in Russia. In between, the healthcare employees can play a significant role in building trust and transparency of vaccine and vaccination programs to remove vaccine hesitancy among Russian society. Also, we shouldn't forget about the critical role of social media and get the help of communications to increase the people's level of awareness about the vaccination programs and the vaccine itself and prevent the spread of false information. Indeed, creating cultural contexts for coronavirus vaccination can be very effective in potential future contagions. In contrast, Iran is in a completely different situation. Slow vaccination in Iran is not due to vaccine doubts but due to a lack of sufficient vaccines. Because Iran has not yet succeeded in producing its national vaccine. Because of the political, economic, international relations conditions and strict American sanctions it is more difficult for Iran to provide vaccines from other countries. However, Russia has shown extensive cooperation in transmitting vaccine production technology and the vaccine itself to Iran. Though medicine is not on the program of sanctions, the difficulties in the financial transaction and concern of possible U.S. penalties for pharmaceutical companies and international banks led to the shortage of specific drugs, vaccines, and medical facilities in the last few months. As we mentioned earlier, for having a high level of public health, the role of the economy is more important than what we think. In fact, as the statistics showed us, a high amount of vaccine doses is administered in countries with a higher level of the economy. And at the second place, the psychological complications include vaccine hesitancy and people’s awareness which can affect the public health situation. Actually all the factors which affect vaccination program and public health are related to each other and are affected by each other. Conclusion The COVID-19 disease is a global epidemic that requires international planning and cooperation. Global organizations, including the World Health Organization, play an essential role in this cooperation. The global development of vaccination is a necessary and ethical step in the fight against the COVID-19 epidemic. Vaccination is currently the only way to keep the community immune. However, we should observe herd immunity for this purpose, and we do not know how long the exemption will last. But achieving a stable global situation requires rapid, extensive vaccination. Vaccine hesitancy should also be addressed and prevented in each country according to cultural and social conditions and, domestic and international policies must be aimed at achieving these goals. In the meantime, we cannot ignore the international organizations' support and essential role of Humanitarian aids of rich countries to provide vaccines or transferring technologies. After all, we should consider that herd immunity across all countries, essential for all populations globally to deal with the COVID-19 disease pandemic. Because we live in the global village and we cannot close country borders for all the time. International organizations need to work more on global health diplomacy. Though some rich countries succeed in producing different COVID-19 vaccines, the ethical aspects of vaccinology emphasize the transfer of vaccines and the knowledge of vaccine production. United Nations and World Health Organization have a significant role in between, but the statistics prove we should work more on ethical aspects of vaccinology. In fact, COVID-19 herd immunity must be global; otherwise, we can never control coronavirus disease. On the other hand, politics shouldn’t effect on the health of people nowhere but we see unfortunately situation in Iran proves the opposite. While pharmacological companies providing vaccine doses in the proper amount for the all people worldwide, we should manage the vaccine hesitancy and distribution of vaccine. Vaccine hesitancy requires more studies in different nations according to their cultural background. Because in some Immigrant countries with multicultural societies we can face to different aspect of vaccine hesitancy. On one hand, the coronavirus showed new mutations which means we cannot predict how long the pandemic will last. On the other hand, we cannot stop routine life for a long time. Because the researches proved that long term quarantine during last year pandemic leads to many different difficulties for people. Therefore, we should learn to live and adapt to epidemic situations and we should prepare people's minds for adaptation to the pandemic situation. One of the most important adaptations is preparing people for the coronavirus vaccination programs for now and probable future programs. Because if the coronavirus shows many mutations, we will need a newly updated vaccine against it. The importance of coronavirus vaccine acceptance among people is how social distancing, quarantine, and deterrent rules in the communities will decrease with achieving herd immunity. Social distancing, long-term quarantine, and deterrent rules made many psychological difficulties among different sections of society; also, economic problems were created for people and governments. In this situation, many jobs were lost, and the consequences will be severe for the community and government in all economic, health, political, and cultural aspects. While some developed countries, already reached herd immunity in 2021 and starting to decrease deterrent rules in the second half of 2021. In between, healthcare employees have a significant role in making people trusts to the vaccination programs. Transparent information and clear explanations about new vaccines are essential for the creation of the public trust. Otherwise, in the case of people's vaccination resistance, using binding rules depend on the pandemic severity is also an ethical option. And at last, after producing and developing different types of coronavirus vaccine, vaccination barriers studying and trying for barrier elimination in any country or at the worldwide level is essential to return to the routine life in future as soon as possible. Also, it can be helpful for action rapidity against probable future epidemics. According to these findings, economic barriers at the first step and psychological and cultural difficulties against vaccination programs can be intense among developing countries. The research was carried out with the financial support of the Grant Council of the President of the Russian Federation for the support of leading scientific schools (grant number NSH-2631.2020.6)

About the authors

Shakeri Ali

The Institute for Demographic Research of the Federal State Budget Institution of Science “The Federal Center of Theoretical and Applied Sociology of The Russian Academy of Sciences”

Afzali Mehdi

The Institute for Demographic Research of the Federal State Budget Institution of Science “The Federal Center of Theoretical and Applied Sociology of The Russian Academy of Sciences”

S. V. Ryazantsev

The Institute for Demographic Research of the Federal State Budget Institution of Science “The Federal Center of Theoretical and Applied Sociology of The Russian Academy of Sciences”



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