{"id":13398,"date":"2020-04-23T14:50:49","date_gmt":"2020-04-23T14:50:49","guid":{"rendered":"https:\/\/www.onlinecprcertification.net\/blog\/?p=13398"},"modified":"2020-04-23T14:50:49","modified_gmt":"2020-04-23T14:50:49","slug":"sharps-needles-and-bloodborne-pathogen-infections-in-a-prison-healthcare-center","status":"publish","type":"post","link":"https:\/\/www.onlinecprcertification.net\/blog\/sharps-needles-and-bloodborne-pathogen-infections-in-a-prison-healthcare-center\/","title":{"rendered":"Sharps, Needles and Bloodborne Pathogen Infections in a Prison Healthcare Center"},"content":{"rendered":"\n<p><strong>Bloodborne Pathogens in Prisons<\/strong><\/p>\n\n\n\n<p>Prisons are scary for many reasons! But many of us\ndo not think of bloodborne pathogens and <a href=\"https:\/\/www.onlinecprcertification.net\/blog\/household-sharps-a-guide-to-your-home-needle-disposal-options\/\">the\nneedlestick risks<\/a> our prison healthcare workers face.<\/p>\n\n\n\n<p>Even worse, sharps are common in prisons, even\nthough officers try to keep them to a minimum. And cases of prisoners using\nsharp objects to harm their mates are not a new thing. This also points to a\nhigh count of people with infection.<\/p>\n\n\n\n<p>Add to the sexual activity in prisons and you have a\nrecipe for disaster because it further escalates the spread of some of\nbloodborne pathogens.<\/p>\n\n\n\n<p>This article will focus on Bloodborne pathogens in a\npenitentiary setting and how to control the spread of infections.<\/p>\n\n\n\n<!--more-->\n\n\n\n<p>OSHA, the body that protects US workers commissioned\na research six years ago (2014). It was done in one prison to determine whether\nthe officers in charge and other workers were at the risk of bloodborne\npathogen exposure. <\/p>\n\n\n\n<p>They also sought to determine if employees are\nexposed to other health hazards at their place of work. The Occupational Safety\nand Health Administration made realized that prison staffs are exposed to\nvarious highly infectious materials such as blood. <\/p>\n\n\n\n<p>They also noted that every employer (prison\nmanagement) should take care and take precautions in order to protect their\nemployees. <a href=\"https:\/\/www.onlinecprcertification.net\/blog\/workplace-safety-bloodborne-pathogens-needlestick-prevention\/\">Prisons\nshould set proper safety guidelines<\/a> when handling health\nhazards and dealing with sick prisoners.<\/p>\n\n\n\n<p><strong>OSHA\u2019s Recommendations to Prisons HealthCare Centers<\/strong><\/p>\n\n\n\n<p>During the study OSHA identified matters that prison\nauthorities failed to address\u2014and which could be potentially hazardous to their\nhealth.<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li><strong>Training on Bloodborne infections.<\/strong><\/li><\/ol>\n\n\n\n<p>Prisons should ensure all their staffs are <a href=\"https:\/\/www.onlinecprcertification.net\/bloodborne-pathogens-training-certification.php\">trained\non Bloodborne pathogens<\/a> and how they can protect\nthemselves. Also, while there is the need to undergo training, prisons should\nensure that the trainers mandated to perform the coaching are conversant with\nthe subject.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Provide personal protective equipment. <\/strong><\/li><\/ul>\n\n\n\n<p>PPEs are a must-have. All healthcare facilities\nshould provide workers with personal safety equipment including gloves, goggles\nand other safety equipment that can help reduce the spread of infections.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Safe disposal of sharps and medical wastes.<\/strong><\/li><\/ul>\n\n\n\n<p>The employees are also mandated to use closed object\ncontainers in order to transport sharp objects or fluids to their disposal area\nwithout endangering themselves. <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Emergency response or first aid training. <\/strong><\/li><\/ul>\n\n\n\n<p>The organization noted and informed the correctional\nfacility that it is a gross violation when a loss of life or even infection to\noccur and could have been prevented. Particularly if it is a result of\nsomething the employer knew or had knowledge.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Improve the quality of health care and control the spread of infections.<\/strong><\/li><\/ul>\n\n\n\n<p>Also because many prisons and jails, were built to\nimprove public safety, it means that those offenders are sent to correctional\ncenters.<\/p>\n\n\n\n<p>The standard of living in prisons can move from bad,\nto worse to pathetic. Correctional facilities are not effective in offering\nbasic services like delivering universal health care or even controlling disease\ntransmission. <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Reduce crowding in prisons.<\/strong><\/li><\/ul>\n\n\n\n<p>In these centers, there is a very high probability\nof pathogens infection among the inmates. This can be <a href=\"https:\/\/www.penalreform.org\/issues\/prison-conditions\/key-facts\/overcrowding\/\">caused\nby overcrowding<\/a>, medical evaluation and treatment delays,\nand so on. <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Check health records before inmate transfers.<\/strong><\/li><\/ul>\n\n\n\n<p>Another factor that causes the spread of these\ninfections is the random transfer of inmates.<\/p>\n\n\n\n<p>If an inmate was infected by Bloodborne pathogens\ninfections, their transfer may affect their treatment.<\/p>\n\n\n\n<p>&nbsp;It can also\nendanger other inmates due to the fact such facilities may be holding many inmates\nwho by chance share things in the cells. Such activities can result to outbreak\nof illnesses triggered by bloodborne pathogen exposures.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Streamlining health records management in prisons. <\/strong><\/li><\/ul>\n\n\n\n<p>Many correctional facilities have poor health record\nmanagement systems. The sharing of information among the facilities is poor, or\nsometimes impossible. As a result, prison authorities fail to share crucial\nhealth info concerning a convict.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Address Mental Illnesses.<\/strong><\/li><\/ul>\n\n\n\n<p>In the correctional facilities, there are many cases\nof unaddressed mental illnesses among the inmates. Health workers find it very\nhard to contain contagious diseases in such an environment. In many cases,\nthese facilities do not even think of requesting third-party assistance from outsiders\nlike NGOs organization, well-wishers, among others.<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li><strong> Follow OSHA Safety Guidelines.<\/strong><\/li><\/ol>\n\n\n\n<p>Penitentiaries don\u2019t even follow guidelines that are\nprepared and published by federally-accepted health bodies like OSHA when\ndealing in treatment or diagnosis of such ailments. <\/p>\n\n\n\n<p>Infectious diseases control practitioners have to be\nmore innovative so at to protects the wellbeing of the prisoners as well as the\ncorrectional facility workers.<\/p>\n\n\n\n<p><strong>Challenges Facing Correctional Facilities<\/strong><\/p>\n\n\n\n<p>As we have noted, there is the need to implement changes\nto control outbreaks, but still, there some challenges that can affect the\ncontrol of bloodborne pathogens.<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li><strong> Hand hygiene. <\/strong><\/li><\/ol>\n\n\n\n<p>Clinical areas in correctional facilities lack\nproper hand washing equipment. The prison authorities feels like soap\ndispensers as well as soaps can be stolen by prisoners and they find it hard\nand expensive to replace.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Sharp objects.<\/strong><\/li><\/ul>\n\n\n\n<p>When places for disposing sharp objects such as\nclosed metallic containers are not available, inmates can get hands on such\nitems and use them to injure themselves or others, fueling the spread of infections.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Inmate hygiene. <\/strong><\/li><\/ul>\n\n\n\n<p><a href=\"https:\/\/www.npr.org\/2018\/10\/12\/656578210\/arizona-prison-denying-basic-hygiene-needs-to-women-say-inmates\">When\nit comes to personal hygiene<\/a>, there are\nrestrictions when accessing shower. Also there are only a few toilets to serve\nthe populations in prisons.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Prison Housing.<\/strong><\/li><\/ul>\n\n\n\n<p>Correctional facilities experience an acute\nshortages of cells to hold inmates, and the few cells must be shared by a crowd.&nbsp; If there is an outbreak, the infections can\nspread very fast due to the congestions in the facilities.<\/p>\n\n\n\n<p>&nbsp;The lack of isolation\ncells that can be used to manage contagious diseases also contributes to more\ninfections.<\/p>\n\n\n\n<p>In conclusion, there significant number of people\nwho stays in the facilities either workers or inmates. In these facilities, infectious\ndiseases are very rampant among the inmates and the condition of the prisons\nand jails does not help to reduce spread of contagious diseases.&nbsp; <\/p>\n\n\n\n<p>Most of the correctional facilities lack experts on\ninfection control and that brings the need of collaborating with other\ninstitutions that can help in prevention of such diseases. Also there have been\nsuggestions in the developing world that training medical practitioners should\nalso study correctional public health.<\/p>\n\n\n\n<p>Such a program will help create and raise a lot of\nawareness on the infection diseases control and prevention in correction\nfacilities.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Understanding Bloodborne Pathogens<\/h2>\n\n\n\n<p>Bloodborne pathogens, are infectious disease-causing\nmicro-organisms that reside in the blood\u2014 and transmit from one person to the\nnext through blood and body fluids. In essence, they are viruses or bacteria\nthat are carried through the blood. <\/p>\n\n\n\n<p>When passed-on from an infected person to the next,\nthey causes diseases in human beings. Unfixed tissues can also be part of blood-spread\ninfections that can cause illnesses in human body.<\/p>\n\n\n\n<p>Some of the bloodborne pathogens that are very\ncommon are hepatitis C (HCV), hepatitis B (HBV) and human immunodeficiency\nvirus (HIV) which caused AIDS. Other Bloodborne pathogens includes syphilis, malaria\nand brucellosis.<\/p>\n\n\n\n<p>Before we address how the pathogens are spread\nthrough human bodies, we will sample some of the diseases they cause. That way,\nwe will be able to understand and learn various ways of spreading, prevention\nand cure in case of infections<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Hepatitis B. <\/h2>\n\n\n\n<p>This chronic disease is a very deadly and life\nthreatening infection that affects the liver. It is caused by a virus called\nHepatitis B. <\/p>\n\n\n\n<p>The effects on the liver are caused by chronic\ninfections and severe cases may threaten an individual\u2019s life. The cause of death\ncan be cirrhosis or liver cancer.<\/p>\n\n\n\n<p><strong>Hepatitis B Transmission.<\/strong><\/p>\n\n\n\n<p>One of the most common and popular ways HBV to\nspread is through mother-child transmission during birth. This type of\ntransmission is referred to as perinatal transmission. Again it can be spread\nto another child who is uninfected through exposure of the blood. <\/p>\n\n\n\n<p>This can be done in the first five years of child\ngrowth. This transmission is called horizontal transmission.&nbsp; These infections have a very high rate of\ndevelopment to chronic ailments to children that are under the age of 5. <\/p>\n\n\n\n<p>This infection can also be transmitted or spread\nthrough many other ways. Such ways includes tattooing, needle stick injury or\neven exposure of infected body fluids. Such fluids are saliva, vaginal, seminal\nor even menstrual fluids.<\/p>\n\n\n\n<p>Many infections can be transmitted through sexual contact.\nIn prison, this is particularly common in prison settings because unvaccinated\nmales have sexual pleasures with other men. Outside the penitentiary, it is\ncommon in other heterosexual who have many partners and sexual workers. <\/p>\n\n\n\n<p>Studies have been done and it shows that chronic\nhepatitis that occurs in adulthood is less than 5%\u2014and 95% of the cases happens\nduring infancy or early stages of childhood. <\/p>\n\n\n\n<p>The reuse of needles in the prison hospitals or among\ndrug addicts who share needles is also another cause.<\/p>\n\n\n\n<p>In addition, hepatitis infections can also spread\nduring dental and surgical procedures, tattooing, and use of sharp objects that\ncan be tainted with infectious blood.<\/p>\n\n\n\n<p>This type of infection can even survive out of the\nbody for about seven days. At this time, the infections are still capable of\nhappening to a person who comes into contact with it. Therefore there is need\nfor people to be vaccinated with drugs that prevent Hep B infections.<\/p>\n\n\n\n<p>Hep B can be identified after thirty days to sixty\ndays from the time of infection. Those are the best days for detection since\nthis virus incubate for around seventy days or vary between thirty to a hundred\nand eighty days. If the infections are not detected early enough, they lead to\nchronic hepatitis B.<\/p>\n\n\n\n<p><strong> HBV Symptoms. <\/strong><\/p>\n\n\n\n<p>Symptoms don\u2019t start showing off immediately after\nsomeone is infected. After a period of incubation, <a href=\"https:\/\/www.onlinecprcertification.net\/free-course.php?id=4&amp;page=3&amp;cid=96&amp;type=ch\">several\nsymptoms start showing up<\/a>. It should be noted that\ninfections vary from one individual to the next.<\/p>\n\n\n\n<p>Some people will start experiencing several symptoms\nwhich include eyes turning yellow, fatigue, and urine that turns dark among\nothers. Others will experience acute failure of the liver, and in most cases it\nleads to the loss of life.<\/p>\n\n\n\n<p><strong>Hepatitis B diagnosis. <\/strong><\/p>\n\n\n\n<p>For one to be diagnosed with this type of infection,\nlaboratory confirmation is essential in order to differentiate this infection\nfrom viral agents that causes other forms of hepatitis. <\/p>\n\n\n\n<p>Blood samples are taken and are tested for these\ninfections. <\/p>\n\n\n\n<p><strong>Treatment.<\/strong><\/p>\n\n\n\n<p>An acute hepatitis B does not have a specific\ntreatment. The main treatment is to make the patient as comfortable as he or\nshe can be. This is by replacing fluids that have been lost and maintaining a\ngood diet. Unnecessary medication should be done avoided at all cost.<\/p>\n\n\n\n<p>In chronic hepatitis, medication of this condition\nshould be done through medicines. The treatment slows the progression of this\ncondition and can reduce chances of developing to liver cancer\u2014and even improve\nsurvival rates. <\/p>\n\n\n\n<p><strong>Prevention.<\/strong><\/p>\n\n\n\n<p>The only way this type of disease is prevented is by\na vaccine called hepatitis B vaccine.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hepatitis C (HCV)<\/h2>\n\n\n\n<p>This type of disease causes infections and leads to\nthe liver inflammation. This disease grows when an individual is infected with\nhepatitis c virus.<\/p>\n\n\n\n<p><strong>Transmission.<\/strong><\/p>\n\n\n\n<p>Since this type of condition is blood borne, there\nvarious way it can be transmitted. <\/p>\n\n\n\n<p>It can be transmitted by sharing of equipment used\nto inject drugs, unscreened blood transfusion, sexual contact, and also through\nmedical equipment that are not well sterilized.<\/p>\n\n\n\n<p>Hepatitis C virus can also be from mother to baby\nbut studies show that this type of transmission is not common.<\/p>\n\n\n\n<p>It should be noted that, unlike many beliefs, this\nvirus cannot be spread through a mother breastfeeding a child. Neither can it\nbe spread through kissing or hugging or even by sharing drinks or food with any\ninfected person.<\/p>\n\n\n\n<p><strong>Symptoms.<\/strong><\/p>\n\n\n\n<p>It begins showing symptoms two to six weeks\nincubation. Researches show that about 80% of all the people infected with this\nvirus do not show any symptoms. <\/p>\n\n\n\n<p>Those who exhibit signs include high fever, low\nappetite vomiting and pain in their abdomen. Other sign ranges from nausea,\npain in the joints, skin turning yellow, dark urine among others.<\/p>\n\n\n\n<p><strong>Diagnosis.<\/strong><\/p>\n\n\n\n<p>Hepatitis C virus is generally asymptomatic. This\nmeans that there very few people that can be diagnosed with the virus. <\/p>\n\n\n\n<p>These infections can remain undetected for decades\ndue to the fact that they are asymptomatic. When they will manifest themselves\nthey would have caused serious damages in the liver. Normally, the hepatitis C\nvirus is diagnosed in mainly two steps.<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>By testing anti-hepatitis C virus\nantibodies which is done by serological test, it identifies individuals who are\ninfected<\/li><li>When the tests are positive, certain\ntests have to be done in order to check the extent infection has progressed.\nThis also will try to address the level of treatment that would be used.&nbsp; <\/li><\/ol>\n\n\n\n<p>A study that was conducted shows that at least 30%\nof the individuals that are infected just need a strong immune system. The\nother 70% of individuals would require further tests in order to access the\nextent of infection. And medics can check for damage has done to the liver\nthrough a process called biopsy of the liver.<\/p>\n\n\n\n<p><strong>Treatment. <\/strong><\/p>\n\n\n\n<p>When a person gets infected, some of the pathogens\nare retracted naturally if one has a strong immune system. If the virus becomes\nchronic, treatment is required and is normally through medication.<\/p>\n\n\n\n<p><strong>Prevention. <\/strong><\/p>\n\n\n\n<p>Unlike the Hepatitis B, this condition does not have\nany vaccines that have been developed to act as a prevention mechanism.&nbsp; Therefore, its prevention is by reducing a\nperson\u2019s chances of infection by avoiding risks that would expose one to the\nvirus.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Human Immunodeficiency Syndrome (HIV)<\/h2>\n\n\n\n<p>This is a virus that affects the immune system in\nthe human body. Basically, the immune system in our bodies helps us to fight\ninfections. <\/p>\n\n\n\n<p>When this virus is uncontrolled, it kills immune\ncells which are normally called T cells. The most affected cells are the CD4\ncells. This makes the body to be venerable to many infections as. <\/p>\n\n\n\n<p>When this condition is not treated in advance, it\nleads to a more serious medical condition known as acquired immune deficiency\nsyndrome (AIDS). When this infection reaches that stage, the body becomes very\nweak and unable to fight infections as well as diseases.<\/p>\n\n\n\n<p>AIDS became more critical that if one went untreated\nfor a period of three years, death was imminent. Medical practitioners advanced\ntheir technology and developed ways to deal with this situation through antiretroviral\n(ARVs) drugs. It prolongs life expectancy after HIV infection.<\/p>\n\n\n\n<p><strong> Transmission.<\/strong><\/p>\n\n\n\n<p>It must be noted that anybody can contact this\ncondition because it is transmitted mainly by the fluids in the body.<\/p>\n\n\n\n<p>The fluids that act as a main source of transmission\nare unscreened blood during transfusion, semen and vaginal fluids, mother to\nchild through breast feeding.<\/p>\n\n\n\n<p>HIV spreads mainly via unprotected sexual contact. Also\nthere is sharing of injection equipment among drug users as well as the\nequipment that need sterilization before they are used again <\/p>\n\n\n\n<p>Another common mode of transmission is through\nduring breast feeding. Infected mother can pass the virus through milk. Also,\nduring child birth, there are many risk-factors that could lead to infection in\nnewborns.<\/p>\n\n\n\n<p>Blood transfusion is another way these infections\ncan spread. Sometimes organ transplant can lead to HIV\u2014 though not common in\ndeveloped countries as a mode of transmission.<\/p>\n\n\n\n<p>However, people should note that when a person is\ninfected by HIV and is under treatment, they may have an undetectable viral\nload. In this case HIV transmission is very low.<\/p>\n\n\n\n<p><strong>Symptoms.<\/strong><\/p>\n\n\n\n<p>A person with HIV can last several years without\nknowing unless they get tested. <\/p>\n\n\n\n<p>Some of the symptoms that appear are called\nnon-specific symptoms. These are symptoms that do not indicate specific\nconditions. <\/p>\n\n\n\n<p>Such symptoms includes fatigue, vomiting, diarrhea,\nheadaches, skin rushes, pneumonia, recurrent fevers among others<\/p>\n\n\n\n<p><strong> Diagnosis. <\/strong><\/p>\n\n\n\n<p>When diagnosing if someone is HIV infected there\nseveral tests that can be done. The type of test is usually determined the\nmedical practitioner who is conducting the test.<\/p>\n\n\n\n<p>One ways to test is the antibody test. It is the most\ncommon to diagnose HIV. This type of test checks the antibodies\u2014a type of protein\nwhich fights infections\u2014 produced by the body.<\/p>\n\n\n\n<p>The tests are done by use of blood and are very\neffective that they give a result after 30 minutes. Because testing can bring a\nnegative result (even in infected people) and a person is exposed &nbsp;to the virus from time to time, tests should\nbe repeated after ninety days.<\/p>\n\n\n\n<p>Another way testing is done by use of nucleic acid\ntest which is very expensive. It is particularly used to test individuals who\nare known to be in a risk of contracting the virus. These tests focus on the\nvirus itself, that\u2019s why they are very expensive. <\/p>\n\n\n\n<p><strong>Treatment. <\/strong><\/p>\n\n\n\n<p>When one gets tested and the results are positive,\ntreatments should begin immediately. The main form of treatment for this\ncondition is what is referred to as antiretroviral (ARVs) drugs. These are daily\nmedications that <a href=\"https:\/\/www.aidsmap.com\/about-hiv\/diagnosed-hiv-low-cd4-count\">help\nto boost CD4 cells<\/a> by keeping them immune and empowering\nthem to fight diseases.<\/p>\n\n\n\n<p>It also reduces the chances of the HIV infection to\nprogress to AIDS. Furthermore, the treatment can reduce chances of transmitting\ninfections to others.<\/p>\n\n\n\n<p>Medical researchers are still looking for ways to\ndevelop a vaccine that can reduce or stop transmission of the virus. But\nindividual steps and principles can reduce the rate of infection.<\/p>\n\n\n\n<p>Such principles include that a person can decide to practice\nsafe sex, avoid sharing of sharp objects that can lead to infections.<\/p>\n\n\n\n<p><strong>Final\nWords<\/strong><\/p>\n\n\n\n<p>All these are part of Bloodborne pathogens\ninfections, their causes, treatments, diagnosis and how they can be prevented\nfrom spreading.<\/p>\n\n\n\n<p>Correctional centers should use this information to\nimprove the quality of heathcare in their penitentiaries and protect convicts\nfrom infection.<\/p>\n\n\n\n<p>Healthcare workers who are dedicated to serving\nprisoners are even at a higher risk than convicts. That explains why prison\nauthorities should change their approach when it comes to protecting their\nemployees.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Bloodborne Pathogens in Prisons Prisons are scary for many reasons! But many of us do not think of bloodborne pathogens and the needlestick risks our prison healthcare workers face. Even worse, sharps are common in prisons, even though officers try to keep them to a minimum. And cases of prisoners using sharp objects to harm [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-13398","post","type-post","status-publish","format-standard","hentry","category-cpr"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v25.4 (Yoast SEO v25.4) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Sharps, Needles and Bloodborne Pathogen Infections in a Prison Healthcare Center<\/title>\n<meta name=\"description\" content=\"CPR blog for Sharps, Needles and Bloodborne Pathogen Infections in a Prison Healthcare Center\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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