Health Advisories for Consumers of Great Lakes Sport Fish: Is the Message Being Received? John Tilden,1 Lawrence P. Hanrahan,2 Henry Anderson,2 Charles Palit,3 Joseph Olson,2 William Mac Kenzie,1 and the Great Lakes Sport Fish Consortium 1Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta GA 30333 USA; 2Bureau of Public Health, Wisconsin Division of Health, Madison, WI 53703 USA; 3Wisconsin Survey Research Laboratory, University of Wisconsin, Madison, WI 53703 USA Nationwide, 45 states issue health advisories for sport fish consumers. Ch cal coninnts in some Great Iakes (GL) sport fish include compounds suspeted of causing advese reproductve and developmental effects. Although advisories to reduce consumption of contaminated fish, espeially by women, have been issued by GL states (.e., Illinois, Indiana, Mich n, Minnesota, New York, Ohio, Penyani, and Wison) ce the mid-1970., l i about ad- sory awarness and GL sport fish cons pion in the general population. To estimate the preva- lence of GL sport fish ptio an health advisory awarenes, we otd a pulation- based teephone survey of 8,306 adult residents of the eight GL ste We information concerning respondents' d a fish consumption during the p greeding year, and sport fish coadvisory aw nss. The se was 69%. GL sport fish were eaten during the p iyear by 8A4% [95%c i id 9.2] of adults in the GL sates, tely 4.7 million persons. Wo n a 439% (CI, 39.4-48.4) of consumers. Alhouh 49.9% of GL sport fish cse of a health advisory, awareness varied significanty by se 58.2% (CI, 51.7-64.7) of males and 39.1% (CI, 32.645.6) of females were aware. Using logistic regrsion, we found awaree associated with male sex [odds ratio (OR) = 2.3; CI, 1.5-3.5), white race (OR - 4.2; CI, 1.9-9.1), college degree (OR = 3.1; CI, 1.3-7.6), and couns i 224 GL sport fish meals/year (OR - 2.4; CI, 1.4-4.3). Only half of GL sport fish coum reported aness of a health advisry ning tg GL sport fish. Awarns was ep l low ng women, s the need ofae risk communication prga f f le . I work e G health adsories, Illinois, Indi , Mihi i New r Oo ion-based random-Jigit-dial svy s t fish i Environ Healh Perpn10 3 (199T hap/.Iehks ihsi.ge: Great Lakes (GL) sport fish consumption advisories were first issued in the 1970s after extensive testing detected chemical contami- nants in fish tissue. Of particular concern were environmentally persistent lipophilic pollutants such as polychlorinated biphenyls (PCBs) and DDT. These compounds are often found in the highest concentrations in the older and larger predatory fish, which are sought and preferred by many sport anglers. In 1991, an estimated 2.55 million licensed anglers fished on one or more of the Great Lakes (1). Thus, the popularity of this sport presents a significant potential for human exposure to chemical residues in fish tissue. Although two decades of environ- mental regulation have substantially reduced chemical residues (2-3), some sport fish still contain levels thought to be potentially harmful to human health (Anderson et al., unpublished data). Studies of long-term consumption of GL sport fish confirmed an association between contaminated fish consumption and increased PCB or DDT\DDE body burdens (47). The potential adverse health effects of these contaminants have been studied extensively (8-10). The EPA has classified PCBs and DDT\DDE as probable human carcinogens. Consistent with low exposure effects observed in nonhuman primates, some human epidemiologic studies have found associations between maternal/fetal PCB levels, Lake Michigan sport fish consump- tion, and adverse reproductive and develop- mental effects (11-13). These studies are not conclusive, however, and scientists dis- agree regarding interpretation of their find- ings (14-17). This level of uncertainty complicates the process of communicating risk information to sport fish consumers. Current GL sport fish consumption advisories seek to 1) inform the public about the chemical contaminants contained in some sport fish, 2) educate consumers as to how they can minimize their exposure to contaminants, 3) remind consumers of the health benefits of fish consumption (18,19), and 4) present advisory information in a manner conducive to maximal voluntary compliance (Anderson et al., unpublished data). Because of potential adverse repro- ductive and developmental effects, all cur- rent advisories make specific consumption frequency recommendations for women of childbearing age. GL advisories seek to help individual consumers make informed deci- sions regarding sport fish consumption. In the GL states, the level of advisory awareness among licensed anglers has been used to assess the adequacy of advisory com- munication programs (20). Licensed anglers are a relatively easy-to-identify group of GL sport fish consumers who can be surveyed by mail (5,21-22). One drawback of this approach is that the results of surveys con- ducted solely on anglers with fishing licenses might not be generalizable to all persons who eat GL sport fish. To overcome this limita- tion, we conducted a random-digit-dial tele- phone survey of the general population. We surveyed adult residents of the eight GL states to characterize the types of fish eaten by the general population, the demographic characteristics of persons who ate GL sport fish, and the level of advisory.awareness among these GL sport fish consumers. Materials and Methods Survey design. From April 1993 through February 1994, trained interviewers from the University of Wisconsin Survey Research Laboratory conducted a population-based random-digit-dialed telephone survey (23-25) of adults (i.e., persons >18 years of age) residing in Indiana, Illinois, Michigan, Minnesota, New York, Ohio, Pennsylvania, and Wisconsin). One randomly selected adult from each participating household was interviewed. Interview dates were scheduled so that approximately equal numbers of interviews were completed during each of the four seasons. Informed consent was obtained before the start of the interview, and the data acquisition procedures main- tained complete respondent anonymity. Interviewers used a standard question- naire to collect information regarding demo- graphic characteristics, the types of fish eaten Address correspondence to L.P. Hanrahan, Bureau of Public Health, Wisconsin Division of Health, Room 138, 1414 E. Washington Avenue, Madison, WI 53703 USA. The Great Lakes Sport Fish Consortium includes James Boddy, Marvin Budd, Mandy Burkett, Claire Falk, Beth Fiore, Grace Lee, Bob Johnson, Marty Kanarek, Susan Monaghan, Dan Reed, Tracy Shelley, William Sonzogni, Greg Steele, and Dollis Wright. This work is a result of research sponsored by the U.S. Public Health Service, Agency for Toxic Substances and Disease Registry under grant 75/ATH598322-03. Received 11 February 1997, accepted 2 September 1997. Volume 105, Number 12, December 1997 * Environmental Health Perspectives 1360 Articles * Awareness of sport fish health advisories during the preceding 12 months, and an estimate of the average number of fish meals eaten during a time interval selected by respondents (e.g., during a week, month, or year). Respondents were characterized as persons who either 1) ate no fish, 2) ate only commercially purchased fish, 3) ate sport fish not caught in a Great Lake, or 4) ate some GL sport fish. Respondents who reported eating GL sport fish provided addi- tional information, including estimates of the number of GL sport fish meals they consumed during the preceding 12 months, whether they had heard of their state's health advisory for sport fish consumers, and if they had followed specific advisory recommendations (e.g., cleaning and cook- ing practices). They provided consumption estimates for six GL sport fish groups: lake trout, carp/catfish, brown trout, rainbow trout/chinook salmon/coho salmon, perch/smelt/walleye, and all other GL sport fish. These fish species were grouped according to the level of chemical contami- nants reported by federal and state monitor- ing programs. These groups are listed in approximate rank-order, from highest to lowest, by level of chemical contaminants detected. We defined advisory awareness as a self-report of having heard of the health advisory. Compliance was defined as a self- report of always or usually following an advisory recommendation. None of the self- reported information was independently verified. Analytic methods. We calculated overall and state-specific response rates using stan- dard procedures (26) (see Appendix 1). To obtain population-based estimates, we weighted each respondent's information (27,28). Appendix 2 describes the case weighting methodology. The low number of respondents with less than a high school degree was insufficient to weight separately; thus, only two categories of educational attainment were used to calculate weights. These categories were persons with a high school degree or less and persons with at least some post-high school education. In all analyses, respondent age was coded as a three- level categorical variable (i.e., 18-34 years, 35-44 years, and 45 or more years of age) based on the likelihood of childbearing. We initially explored the data through univariate and stratified analysis. Using SUDAAN statis- tical software (Research Triangle Institute, Research Triangle Park, NC) (29), we calcu- lated overall prevalence estimates for four dif- ferent fish consumption patterns, advisory awareness among GL sport fish consumers, and self-reported compliance among GL sport fish consumers who reported advisory awareness. We conducted a stratified analysis to determine how advisory awareness varied by sociodemographic group and we conduct- ed a multivariable logistic regression analysis (30). Possible interactive effects between sex and other variables were assessed. Models of significant variables were derived by a back- ward model-selection method (31) and by comparison of hierarchical models using like- lihood ratio chi-square statistics. Age group and state of residence variables were kept in all models. To adjust for the study's sampling design, the final logistic regression analysis used SUDAAN software. Results A total of 8,306 persons were interviewed, including over 1,000 adult residents per state. The overall survey response rate was 69% (see Appendix 1). State-specific response rates ranged from 57% in New York to 78% in Wisconsin. Persons who had less than a high school degree were underrepresented, com- prising 14% of our weighted sample com- pared with the 23% indicated by the 1990 census for these states (28). Fish consumption. The estimated per- centages of persons in the eight GL states who ate fish obtained from different sources are shown in Table 1. The median number of total fish meals eaten (from all sources) was not significantly different between groups. An estimated 8.4% [95% confi- dence interval (CI), 7.6-9.2] of adult resi- dents in the GL states had eaten GL sport fish during the preceding year (approxi- mately 4.7 million persons). Ninety-two percent of GL sport fish consumers in this survey were white, the median age was 39 years, 44% were women, and 52% lived in either Michigan or Ohio. Results of the 1990 census indicates that, among adult res- idents of the GL states, 84% were white, 53% were women, and 26% lived in either Michigan or Ohio. The estimated distribution of GL sport fish consumers by fish consumption level and sex is shown in Figure 1. A median of 6.5 fish meals were eaten per year (range, 1-292 fish meals per year). We estimated that 830,000 persons in the eight GL states had eaten ?24 GL sport fish meals per year. Men reported having eaten GL sport fish more frequently than did women. The median consumption levels for men and women were 8.2 (CI, 6.7-9.6)] and 5.8 (CI, 5.0-7.6) meals, respectively. The median number of GL sport fish meals reportedly consumed by whites and nonwhites were 6.4 (CI, 5.8-7.2) and 9.8 (CI, 6.1-18.8), respectively. This difference was not statistically significant because of Table 1. Estimated prevalence and frequency of consumption by adult residents of Great Lakes states", by type of fish consumed during the preceding year (1993-1994) Percent Median Sample estimated fish mealsb Type of fish consumed size prevalence eaten/year Cl Ate commercial fish only 4,825 61.3 33.6 32.4-36.0 Ate non-GLsportfish 1702 18.3 34.8 31.2-37.2 Did not eatfish 872 12.0 - Ate GLsportfish 679 8.4 34.8 31.2-38.4 Total 8,078c 100.0 28.8 27.6-30.0 Abbreviations: GL, Great Lakes; Cl, 95% confidence interval. alllinois, Indiana, Michigan, Minnesota, New York, Ohio, Pennsylvania, and Wisconsin. bFish of all types. clnformation missing for 228 of 8,306 survey respondents. 12 10 0~ a 8 6 4 <5.0 5-11 >35 Figure 1. Number of Great Lakes sport fish consumers by consumption level and sex in eight Great Lakes states (Indiana, Illinois, Michigan, Minnesota, New York, Ohio, Pennsylvania, and Wisconsin) from April 1993 to February 1994). aSport fish caught in the Great Lakes. Environmental Health Perspectives * Volume 105, Number 1Z December 1997 12-23 Sport fish meals8 per year 1361 Articles * Tilden et al. the small number (n = 50) of nonwhite GL sport-caught fish eaters in our unweighted sample. The GL sport fish group eaten by the greatest number of respondents was perch/smelt/walleye (n = 500) followed by rainbow trout/chinook salmon/coho salmon (n = 316), lake trout (n = 254), other GL sport fish (n = 162), brown trout (n = 73), and carp/catfish (n = 64). Sport fish consumption advisory awareness. The prevalence of advisory awareness among adult GL sport fish con- sumers by various sociodemographic charac- teristics is shown in Table 2. Approximately half of all GL sport fish eaters reported that they had heard of their state's health adviso- ry. Advisory awareness varied significantly by race, sex, educational attainment, GL sport- caught fish consumption level, and state of residence. Advisory awareness was not signifi- candy different by age category. Our sample contained small numbers of GL sport fish eaters from some states. This resulted in unstable state-specific estimates of advisory awareness as indicated by wide 95% confi- dence intervals. In Minnesota and New York, the level of awareness indicated by the weighted sample was approximately 10% less than that indicated by the unweighted data. In these states, persons with relatively high weighting (e.g., males 18-34 years of age who did not have a high school degree) tend- ed to report that they had not heard of the advisory. The final logistic regression model for variables associated with advisory awareness among GL sport fish eaters is shown in Table 3. The risk estimates displayed in Table 3 are odds ratios (OR). In the analy- sis, Wisconsin was used as the referent group in the logistic regression model because the level of GL sport fish consump- tion and advisory awareness among Wisconsin anglers had been documented previously. Statistical significance (p<0.05) was assessed by 95% confidence intervals. Parameters with confidence intervals that Table 2. Prevalence of advisory awarenessa among adults who had eaten sport fish caught from the Great Lakes by sociodemographic characteristicsb April 1993-February 1994 Percent prevalence Sample advisory Characteristic size awareness Cl Total 671 49.9 45.2-54.6 Age (years) 18-34 215 46.9 38.7-55.1 35-44 188 56.1 47.9-64.3 >45 268 49.2 41.8-56.6 Racec White 618 52.1 47.2-57.0 Other 50 22.1 9.4-34.8 Sex Male 347 58.2 51.7-64.7 Female 324 39.1 32.6-45.6 Educational attainment 24 fish meals/year 122 62.4 52.4-72.4 State of residence Michigan 184 60.3 52.7-67.9 Ohio 135 37.9 28.9-46.9 Wisconsin 92 65.3 53.7-76.9 Minnesota 67 37.5e 24.4-50.6 Illinois 57 51.3 36.8-65.8 Indiana 50 42.0 26.7-57.3 Pennsylvania 44 47.8 31.3-64.3 New York 42 50.2e 32.2-68.2 Abbreviations: Cl, 95% confidence interval; GLSCF, Great Lakes sport-caught fish. aAwareness defined as having heard of the sport fish advisory; 8 of 679 consumers had missing informa- tion on advisory awareness. bPrevalence estimates based on analysis of weighted data using SUDAAN software (Research Triangle Institute, Research Triangle Park, NC). cThree individuals missing race information. dTwo individuals were missing GLSCF consumption level information. eThis weighted estimate is unstable, being 10% less than the estimate derived from unweighted data. did not include an OR of 1.0 were therefore the ones that were significant. After adjust- ing for other variables in the model, adviso- ry awareness was significantly associated with male sex, white race, having a college degree, and eating ?24 GL sport fish meals per year. GL sport fish consumers in Ohio were significantly less likely than GL sport fish eaters in Wisconsin (the referent state) to be aware of an advisory. None of the interaction terms investigated were statisti- cally significant. Of those GL sport fish consumers who were aware of an advisory, compliance with advisory recommendations differed signifi- cantly between men and women (Table 4). Use of recommended cleaning and cooking methods was the most frequently reported risk reduction practice, reported by 69% of men and 55% of women. Compliance was significantly lower for advisory recommen- dations that required changes in fishing Table 3. Multivariable logistic regression modela for advisory awarenessb among adult Great Lakes states residents who had eaten sport fish caught in the Great Lakes during the preceding 12 months (telephone survey dates: April 1993-February 1994) Characteristic Odds Ratio Cl Age (years) 18-34 Reference 35-44 1.6 0.9-2.6 ?45 1.3 0.8-2.1 Race Other Reference White 4.2 1.9-9.1 Sex Female Reference Male 2.3 1.5-3.5 Education 24 fish meals/year 2.4 1.4-4.3 State of residence Wisconsin Reference Illinois 0.5 0.2-1.2 Indiana 0.5 0.2-1.1 Michigan 0.9 0.5-1.6 Minnesota 0.5 0.2-1.0 New York 0.7 0.3-1.7 Ohio 0.4 0.2-0.7 Pennsylvania 0.7 0.3-1.7 Abbreviations: Cl, 95% confidence interval; GL, Great Lakes. aModel includes 666 out of the 671 total persons for whom complete data was known for all vari- ables in the model; three persons had missing race information and two persons had missing GLSCF consumption level information (see also Table 2 for category frequencies). bAwareness is defined as having heard of the sport fish advisory. Volume 105, Number 12, December 1997 * Environmental Health Perspectives 1 362 Articles - Awareness of sport fish health advisories behavior (e.g., changing fishing locations to catch fish with lower levels of chemical con- tamination). Discussion The popularity of sport fishing on the Great Lakes is indicated by our estimate that approximately 4.7 million persons had eaten GL sport fish during the year preceding the survey. Our results indicate that the majority of these persons infrequently ate GL sport fish and that they tended to eat fish species that contain relatively low contaminant levels (i.e., perch/smelt/walleye). The GL sport fish con- sumption levels reported by most respondents were highly unlikely to result in body burden levels previously associated with adverse human health effects. However, the frequency of GL sport fish consumption varied widely, suggesting substantially different potentials for chemical contaminant exposure among individual consumers. Because environmen- tally persistent chemical contaminants are present in some GL sport fish, consumers will probably continue to seek information regarding the risks and benefits of eating GL sport fish. In the United States, state governments are primarily responsible for managing potential risks associated with contaminants in locally caught sport fish (32). As of September 1993, 45 of the 50 states had issued one or more fish or shellfish consump- tion advisories or bans (33). Each of the eight GL states has issued sport fish consumption advisories since the mid-1970s. The overall effectiveness of sport fish advisory programs depends on the effectiveness of both the rec- ommendations made and communication methods used (21,34,35). Unfortunately, inconsistency between state-issued advisories has been recognized as a nationwide problem (32). Inconsistencies in GL sport fish advi- sories have at times confused consumers and limited the effectiveness of advisories in the region. Representatives of the eight GL states have drafted a uniform advisory for the Great Lakes (Anderson et al., unpublished data), but it has not yet been adopted. In this survey, although ability to make inter- state comparisons was limited, state of resi- dence predicted the level of advisory aware- ness, suggesting that significant differences in advisory programs continue to exist. In general, GL sport fish advisories encourage sport fish consumers to eat fewer of the fish species and sizes known to contain ele- vated levels of chemical contaminants and rec- ommend the use of cleaning and cooking methods that can substantially reduce the lev- els of PCBs and other fat-soluble contami- nants contained in a fish meal [Anderson et al., unpublished data; (36-38)]. Since GL advisories were first issued, several studies have documented a decline in GL sport fish con- sumption (22,39,40). In our survey, the most widely accepted advisory recommendation was deaning and cooking methods. The results of a survey of New York anglers indicated that the use of these cleaning and cooking methods was significantly higher among persons who were aware of that state's health advisory (21). These findings support the belief that sport fish consumption advisories can decrease chemical contaminant exposures among sport fish consumers if effective communication programs are used. Communication programs in the GL states have traditionally targeted licensed anglers, who are predominantly white men. Written advisory information (e.g., fishing regulation booklets and advisory brochures) has usually been distributed through the recreational fishing industry and governmen- tal offices. GL sport fish consumers who do not purchase licenses might not have access to information distributed in this way. Because we did not ask respondents if they had purchased fishing licenses, we could not directly assess advisory awareness among licensed anglers and nonlicensed GL sport fish consumers. However, our estimated number of GL sport fish consumers was roughly twice that of the most recent esti- mate of licensed GL anglers, suggesting that a substantial proportion of GL sport fish consumers were not licensed anglers. Only half of the adults in our population-based Table 4. Self-reported compliance with health advisory recommendations by sex of consumers of Great Lakes sport fisha who had heard of the advisory Percentage following recommendations Men Women Area of recommendation Percent Cl Percent Cl Cleaning and cooking methods 68.8 61.5-76.5 54.6 44.6-64.6 Consumption frequency 50.1 41.9-58.3 42.8 33.0-52.6 Fish species and size 50.3 42.1-58.5 29.4 20.4-38.4 Fishing locations 43.6 35.6-51.6 28.2 19.1-37.2 Cl, 95% confidence interval. aAdult residents of Illinois, Indiana, Michigan, Minnesota, New York, Ohio, Pennsylvania, and Wisconsin who reported eating Great Lakes sport fish during the year preceding their interview (survey dates were April 1993-February 1994). survey who had eaten GL sport fish had heard of their state's health advisory. When contrasted with the overall high levels of advisory awareness found by previous mail surveys of licensed GL anglers (7,21,22), it appears that substantial numbers of nonan- glers are not receiving advisory messages. Our survey results indicate that existing advisory communication programs are less effectively reaching women, nonwhites, and persons with lower levels of educational attainment. The results of previous surveys of licensed GL anglers also support this con- clusion (21,225. Well-accepted principles of risk communication indicate that messages designed for specific audiences are often needed to reach diverse subgroups within a population (41,42). The weight of evidence from the risk communication literature, sur- veys of licensed GL anglers, and this popula- tion-based survey of GL sport fish con- sumers suggests that expanded use of target- ed advisory communication methods are needed. To accomplish this, the EPA has devel- oped a detailed and comprehensive guid- ance document (42) to assist health profes- sionals with the task of fish consumption advisory risk communication. The manual provides specific advice to health profession- als on all aspects of health advisory risk communication, including risk communica- tion as a process of sharing information, problem analysis and program objectives, audience identification and needs assess- ment, communication strategy design and implementation, program evaluation, and methods of responding to public inquiries. By following the principles outlined in the EPA guidance, state jurisdictions can devel- op successful risk communication programs for those who have not been receiving this very important message. In an era of shrinking governmental budgets, individual state agencies must bal- ance the costs of managing potential health risks against the magnitude of the potential health risk. It is unlikely that sport fish advi- sory programs will have sufficient resources to mount extensive communication cam- paigns. However, targeted communication programs designed to reach specific groups are possible. Our results suggest that addi- tional communication efforts are particular- ly needed to reach persons most sensitive to the effects of the chemical contaminants (i.e., women of childbearing age). Greater collaboration between government agencies and risk communication specialists would probably reduce the costs of developing and evaluating new communication programs, and this collaboration would reap the addi- tional benefit of increased consistency among state-issued advisories. Environmental Health Perspectives * Volume 105, Number 12, December 1997 1 363 Articles * Tilden et al. Appendix 1' .. . . , ......... ...... ; - ; ... ;i;~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.. . ... .. .. .. ... RnaI sempi. ...co e .. ....... e., Kriwm fowm1I ... : . hj tWt oreke ds. tic p r. tedy .rt_i .......... . .... .... nu be g, Known eligible nonresponse all! h. Complete inteviwte.el The .CASRO response rate f.oa .. .h (g.+.h. h + b...+.e gI)' `d+f) State April iPa uly t ................. .1. . u. a,y O erl il.i.nois 6;...... 4% 66 69% 67 7 Michigan 65% 66% 73% 76% . 70%. Minnesota 73% 7% 7% 83 7% New York 51% .53%.. 61% 6 57% Ohio 66% 68% 76% ~74% 71 Pennsylvania 60% 56% 74% 74% c7% Weconsin 79%. --.?79% .% . Tot a ..61% 61%. 6I 9 70% 69% .Appendix 2 To obtain population-basedestimates gwe w.eigted ..ach response by he. i.v .r.. the probabily of h s thesate response ktatee the number adults residing i andthe quantiy sof tele- : ,~~~~~~~~~~~ W . .~~~~~~~~~. 1199. eamS."..... A.M.1.0 wereusedtoweight each stasdo the population a g.e,. sex. en duca.tional a.ttainmet ......... distibutio (72.... . T: hus standard tlephone w metos were used in the sdyl (22i. Th'e comput onot finl weiht for each observation is described in the following eqiations. F_W= DWx PSWx 0.25, .where FW= final weight, DW= desgn weight and PSW= poststratifica- *tio weight : : ..~~~~~ ~ ~ ~ ~~~~~~~ E-c. IS . ..... .. !k DWSS..R.R x lISP x NRP)/10 x. NAN), .:. . . . ..:. W.hr S.8 =satep ecificeo rate p ercent:, ; , HP.IS,P husehold unit selctonpobbil ity NR.P= ubroeieta phones in the house.holdd unit, and NAH= number ofadultsinth hu hold .. unit .. .. . . . ~~~.0 . u where CPC= state-specific census population in the statification cell and -DW= sum of the design weights. for te completed sample cases in the ...stratification cell. .The final weight is a product oft deign w.eig9ht and ithe poststratification weight, and the constant.25. 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