Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Roy Burstein # 1, Nathaniel J Henry # 1, Michael L Collison 1, Laurie B Marczak 1, Amber Sligar 1, Stefanie Watson 1, Neal Marquez 1, Mahdieh Abbasalizad-Farhangi 2, Masoumeh Abbasi 3, Foad Abd-Allah 4, Amir Abdoli 5, Mohammad Abdollahi 6, Ibrahim Abdollahpour 7 8, Rizwan Suliankatchi Abdulkader 9, Michael R M Abrigo 10, Dilaram Acharya 11 12, Oladimeji M Adebayo 13, Victor Adekanmbi 14, Davoud Adham 15, Mahdi Afshari 16, Mohammad Aghaali 17, Keivan Ahmadi 18, Mehdi Ahmadi 19, Ehsan Ahmadpour 20, Rushdia Ahmed 21 22, Chalachew Genet Akal 23, Joshua O Akinyemi 24, Fares Alahdab 25, Noore Alam 26, Genet Melak Alamene 27, Kefyalew Addis Alene 28 29, Mehran Alijanzadeh 30, Cyrus Alinia 31, Vahid Alipour 32 33, Syed Mohamed Aljunid 34 35, Mohammed J Almalki 36 37, Hesham M Al-Mekhlafi 38 39, Khalid Altirkawi 40, Nelson Alvis-Guzman 41 42, Adeladza Kofi Amegah 43, Saeed Amini 44, Arianna Maever Loreche Amit 45 46, Zohreh Anbari 44, Sofia Androudi 47, Mina Anjomshoa 48, Fereshteh Ansari 49, Carl Abelardo T Antonio 50 51, Jalal Arabloo 33, Zohreh Arefi 52, Olatunde Aremu 53, Bahram Armoon 54 55, Amit Arora 56 57, Al Artaman 58, Anvar Asadi 59, Mehran Asadi-Aliabadi 60, Amir Ashraf-Ganjouei 7 61, Reza Assadi 62, Bahar Ataeinia 63, Sachin R Atre 64 65, Beatriz Paulina Ayala Quintanilla 66 67, Martin Amogre Ayanore 68, Samad Azari 33, Ebrahim Babaee 60, Arefeh Babazadeh 69, Alaa Badawi 70 71, Soghra Bagheri 3, Mojtaba Bagherzadeh 72, Nafiseh Baheiraei 73 74, Abbas Balouchi 75, Aleksandra Barac 76 77, Quique Bassat 78 79, Bernhard T Baune 80, Mohsen Bayati 81, Neeraj Bedi 37 82, Ettore Beghi 83, Masoud Behzadifar 84, Meysam Behzadifar 85, Yared Belete Belay 86, Brent Bell 1, Michelle L Bell 87, Dessalegn Ajema Berbada 88, Robert S Bernstein 89 90, Natalia V Bhattacharjee 1, Suraj Bhattarai 91 92, Zulfiqar A Bhutta 93 94, Ali Bijani 95, Somayeh Bohlouli 96, Nicholas J K Breitborde 97 98, Gabrielle Britton 99 100, Annie J Browne 101, Sharath Burugina Nagaraja 102, Reinhard Busse 103, Zahid A Butt 104 105, Josip Car 106 107, Rosario Cárdenas 108, Carlos A Castañeda-Orjuela 109 110, Ester Cerin 111 112, Wagaye Fentahun Chanie 113, Pranab Chatterjee 114, Dinh-Toi Chu 115, Cyrus Cooper 116 117, Vera M Costa 118, Koustuv Dalal 119 120, Lalit Dandona 1 121, Rakhi Dandona 1 121, Farah Daoud 1, Ahmad Daryani 122, Rajat Das Gupta 21, Ian Davis 1, Nicole Davis Weaver 1, Dragos Virgil Davitoiu 123 124, Jan-Walter De Neve 125, Feleke Mekonnen Demeke 126, Gebre Teklemariam Demoz 127 128, Kebede Deribe 129 130, Rupak Desai 131, Aniruddha Deshpande 1, Hanna Demelash Desyibelew 132, Sagnik Dey 133, Samath Dhamminda Dharmaratne 1 134, Meghnath Dhimal 135, Daniel Diaz 136 137, Leila Doshmangir 138, Andre R Duraes 139 140, Laura Dwyer-Lindgren 1 141, Lucas Earl 1, Roya Ebrahimi 142, Soheil Ebrahimpour 69, Andem Effiong 143, Aziz Eftekhari 144 145, Elham Ehsani-Chimeh 146, Iman El Sayed 147, Maysaa El Sayed Zaki 148, Maha El Tantawi 149 150, Ziad El-Khatib 151, Mohammad Hassan Emamian 152, Shymaa Enany 153, Sharareh Eskandarieh 7, Oghenowede Eyawo 154 155, Maha Ezalarab 1, Mahbobeh Faramarzi 156, Mohammad Fareed 157, Roghiyeh Faridnia 158, Andre Faro 159, Ali Akbar Fazaeli 160, Mehdi Fazlzadeh 161 162, Netsanet Fentahun 163, Seyed-Mohammad Fereshtehnejad 164 165, João C Fernandes 166, Irina Filip 167 168, Florian Fischer 169, Nataliya A Foigt 170, Masoud Foroutan 171, Joel Msafiri Francis 172, Takeshi Fukumoto 173 174, Nancy Fullman 1, Silvano Gallus 175, Destallem Gebremedhin Gebre 176 177, Tsegaye Tewelde Gebrehiwot 178, Gebreamlak Gebremedhn Gebremeskel 179 180, Bradford D Gessner 181 182, Birhanu Geta 183, Peter W Gething 101, Reza Ghadimi 184, Keyghobad Ghadiri 3, Mahsa Ghajarzadeh 185, Ahmad Ghashghaee 186, Paramjit Singh Gill 187, Tiffany K Gill 188, Nick Golding 189, Nelson G M Gomes 190 191, Philimon N Gona 192, Sameer Vali Gopalani 193 194, Giuseppe Gorini 195, Bárbara Niegia Garcia Goulart 196, Nicholas Graetz 1, Felix Greaves 197 198, Manfred S Green 199, Yuming Guo 200 201, Arvin Haj-Mirzaian 202 203, Arya Haj-Mirzaian 202 204, Brian James Hall 205, Samer Hamidi 206, Hamidreza Haririan 207, Josep Maria Haro 208 209, Milad Hasankhani 210, Edris Hasanpoor 211, Amir Hasanzadeh 212 213, Hadi Hassankhani 214 215, Hamid Yimam Hassen 216 217, Mohamed I Hegazy 4, Delia Hendrie 218, Fatemeh Heydarpour 219, Thomas R Hird 200 220, Chi Linh Hoang 221, Gillian Hollerich 1, Enayatollah Homaie Rad 222 223, Mojtaba Hoseini-Ghahfarokhi 224, Naznin Hossain 22 225, Mostafa Hosseini 226, Mehdi Hosseinzadeh 33 227, Mihaela Hostiuc 123 228, Sorin Hostiuc 229 230, Mowafa Househ 231 232, Mohamed Hsairi 233, Olayinka Stephen Ilesanmi 234, Mohammad Hasan Imani-Nasab 235, Usman Iqbal 236, Seyed Sina Naghibi Irvani 237, Nazrul Islam 238 239, Sheikh Mohammed Shariful Islam 240 241, Mikk Jürisson 242, Nader Jafari Balalami 243, Amir Jalali 244, Javad Javidnia 245, Achala Upendra Jayatilleke 246 247, Ensiyeh Jenabi 248, John S Ji 249, Yash B Jobanputra 250, Kimberly Johnson 1, Jost B Jonas 251 252, Zahra Jorjoran Shushtari 253, Jacek Jerzy Jozwiak 254 255, Ali Kabir 256, Amaha Kahsay 257, Hamed Kalani 258 259, Rohollah Kalhor 260, Manoochehr Karami 261, Surendra Karki 262 263, Amir Kasaeian 264 265, Nicholas J Kassebaum 1 266, Peter Njenga Keiyoro 267, Grant Rodgers Kemp 1 268, Roghayeh Khabiri 269 270, Yousef Saleh Khader 271, Morteza Abdullatif Khafaie 272, Ejaz Ahmad Khan 273, Junaid Khan 274, Muhammad Shahzeb Khan 275 276, Young-Ho Khang 277 278, Khaled Khatab 279 280, Amir Khater 281, Mona M Khater 282, Alireza Khatony 3, Mohammad Khazaei 283, Salman Khazaei 261, Maryam Khazaei-Pool 284, Jagdish Khubchandani 285, Neda Kianipour 3 286, Yun Jin Kim 287, Ruth W Kimokoti 288, Damaris K Kinyoki 1 141, Adnan Kisa 289 290, Sezer Kisa 291, Tufa Kolola 292, Soewarta Kosen 293, Parvaiz A Koul 294, Ai Koyanagi 79 295, Moritz U G Kraemer 296 297, Kewal Krishan 298, Kris J Krohn 1, Nuworza Kugbey 299 300, G Anil Kumar 121, Manasi Kumar 301 302, Pushpendra Kumar 303, Desmond Kuupiel 304 305, Ben Lacey 306 307, Sheetal D Lad 308, Faris Hasan Lami 309, Anders O Larsson 310 311, Paul H Lee 312, Mostafa Leili 283, Aubrey J Levine 1, Shanshan Li 200, Lee-Ling Lim 313 314, Stefan Listl 315 316, Joshua Longbottom 317, Jaifred Christian F Lopez 45 318, Stefan Lorkowski 319 320, Sameh Magdeldin 321 322, Hassan Magdy Abd El Razek 323, Muhammed Magdy Abd El Razek 324, Azeem Majeed 197, Afshin Maleki 142, Reza Malekzadeh 325 326, Deborah Carvalho Malta 327, Abdullah A Mamun 328, Navid Manafi 329 330, Ana-Laura Manda 331, Morteza Mansourian 332, Francisco Rogerlândio Martins-Melo 333, Anthony Masaka 334, Benjamin Ballard Massenburg 335, Pallab K Maulik 336 337, Benjamin K Mayala 1, Mohsen Mazidi 338, Martin McKee 339, Ravi Mehrotra 340, Kala M Mehta 341, Gebrekiros Gebremichael Meles 88, Walter Mendoza 342, Ritesh G Menezes 343, Atte Meretoja 344 345, Tuomo J Meretoja 346 347, Tomislav Mestrovic 348 349, Ted R Miller 218 350, Molly K Miller-Petrie 1, Edward J Mills 351, George J Milne 352, G K Mini 353, Seyed Mostafa Mir 354 355, Hamed Mirjalali 356, Erkin M Mirrakhimov 357 358, Efat Mohamadi 359, Dara K Mohammad 360 361, Aso Mohammad Darwesh 362, Naser Mohammad Gholi Mezerji 363, Ammas Siraj Mohammed 364, Shafiu Mohammed 365 366, Ali H Mokdad 1 141, Mariam Molokhia 367, Lorenzo Monasta 368, Yoshan Moodley 304, Mahmood Moosazadeh 369, Ghobad Moradi 370 371, Masoud Moradi 3 59, Yousef Moradi 372, Maziar Moradi-Lakeh 60, Mehdi Moradinazar 59, Paula Moraga 373, Lidia Morawska 374, Abbas Mosapour 354 375, Seyyed Meysam Mousavi 376, Ulrich Otto Mueller 377 378, Atalay Goshu Muluneh 379, Ghulam Mustafa 380 381, Behnam Nabavizadeh 382, Mehdi Naderi 383, Ahamarshan Jayaraman Nagarajan 384 385, Azin Nahvijou 386, Farid Najafi 387, Vinay Nangia 388, Duduzile Edith Ndwandwe 389, Nahid Neamati 354, Ionut Negoi 390 391, Ruxandra Irina Negoi 392 393, Josephine W Ngunjiri 394, Huong Lan Thi Nguyen 395, Long Hoang Nguyen 396, Son Hoang Nguyen 396, Katie R Nielsen 397 398, Dina Nur Anggraini Ningrum 399 400, Yirga Legesse Nirayo 401, Molly R Nixon 1, Chukwudi A Nnaji 389 402, Marzieh Nojomi 60 403, Mehdi Noroozi 404, Shirin Nosratnejad 405, Jean Jacques Noubiap 406, Soraya Nouraei Motlagh 235, Richard Ofori-Asenso 407 408, Felix Akpojene Ogbo 409, Kelechi E Oladimeji 304 410, Andrew T Olagunju 411 412, Meysam Olfatifar 413, Solomon Olum 414 415, Bolajoko Olubukunola Olusanya 416, Mojisola Morenike Oluwasanu 417, Obinna E Onwujekwe 418, Eyal Oren 419 420, Doris D V Ortega-Altamirano 421, Alberto Ortiz 422 423, Osayomwanbo Osarenotor 424, Frank B Osei 425 426, Aaron E Osgood-Zimmerman 1, Stanislav S Otstavnov 427 428, Mayowa Ojo Owolabi 429, Mahesh P A 430, Abdol Sattar Pagheh 122, Smita Pakhale 431, Songhomitra Panda-Jonas 432, Animika Pandey 121, Eun-Kee Park 433, Hadi Parsian 354, Tahereh Pashaei 142, Sangram Kishor Patel 434 435, Veincent Christian Filipino Pepito 436, Alexandre Pereira 437 438, Samantha Perkins 1, Brandon V Pickering 1, Thomas Pilgrim 439, Majid Pirestani 440, Bakhtiar Piroozi 371, Meghdad Pirsaheb 3, Oleguer Plana-Ripoll 441, Hadi Pourjafar 442 443, Parul Puri 303, Mostafa Qorbani 444, Hedley Quintana 100, Mohammad Rabiee 445, Navid Rabiee 72, Amir Radfar 446 447, Alireza Rafiei 448 449, Fakher Rahim 450 451, Zohreh Rahimi 452, Vafa Rahimi-Movaghar 453, Shadi Rahimzadeh 63, Fatemeh Rajati 454, Sree Bhushan Raju 455, Azra Ramezankhani 456 457, Chhabi Lal Ranabhat 458 459, Davide Rasella 460 461, Vahid Rashedi 462, Lal Rawal 56 463, Robert C Reiner Jr 1 141, Andre M N Renzaho 464, Satar Rezaei 465, Aziz Rezapour 33, Seyed Mohammad Riahi 466 467, Ana Isabel Ribeiro 468, Leonardo Roever 469, Elias Merdassa Roro 470 471, Max Roser 472, Gholamreza Roshandel 325 473, Daem Roshani 474, Ali Rostami 475, Enrico Rubagotti 476 477, Salvatore Rubino 478, Siamak Sabour 466, Nafis Sadat 1, Ehsan Sadeghi 59, Reza Saeedi 479, Yahya Safari 3, Roya Safari-Faramani 480, Mahdi Safdarian 453 481, Amirhossein Sahebkar 482 483, Mohammad Reza Salahshoor 484, Nasir Salam 485, Payman Salamati 453 486, Farkhonde Salehi 487, Saleh Salehi Zahabi 488 489, Yahya Salimi 387, Hamideh Salimzadeh 325, Joshua A Salomon 490, Evanson Zondani Sambala 389, Abdallah M Samy 491, Milena M Santric Milicevic 492, Bruno Piassi Sao Jose 493, Sivan Yegnanarayana Iyer Saraswathy 494 495, Rodrigo Sarmiento-Suárez 496, Benn Sartorius 141 497, Brijesh Sathian 498 499, Sonia Saxena 500, Alyssa N Sbarra 1, Lauren E Schaeffer 1, David C Schwebel 501, Sadaf G Sepanlou 325 326, Seyedmojtaba Seyedmousavi 502 503, Faramarz Shaahmadi 504, Masood Ali Shaikh 505, Mehran Shams-Beyranvand 63 506, Amir Shamshirian 507, Morteza Shamsizadeh 508, Kiomars Sharafi 3, Mehdi Sharif 509 510, Mahdi Sharif-Alhoseini 453, Hamid Sharifi 511, Jayendra Sharma 512, Rajesh Sharma 513, Aziz Sheikh 514 515, Chloe Shields 1, Mika Shigematsu 516, Rahman Shiri 517, Ivy Shiue 518, Kerem Shuval 199, Tariq J Siddiqi 276, João Pedro Silva 118, Jasvinder A Singh 519 520, Dhirendra Narain Sinha 521 522, Malede Mequanent Sisay 379 523, Solomon Sisay 524, Karen Sliwa 406, David L Smith 1 141, Ranjani Somayaji 525 526, Moslem Soofi 527, Joan B Soriano 528 529, Chandrashekhar T Sreeramareddy 530, Agus Sudaryanto 531, Mu'awiyyah Babale Sufiyan 532, Bryan L Sykes 533, P N Sylaja 534, Rafael Tabarés-Seisdedos 535 536, Karen M Tabb 537, Takahiro Tabuchi 538, Nuno Taveira 539 540, Mohamad-Hani Temsah 541 542, Abdullah Sulieman Terkawi 543 544, Zemenu Tadesse Tessema 379, Kavumpurathu Raman Thankappan 545, Sathish Thirunavukkarasu 546, Quyen G To 547, Marcos Roberto Tovani-Palone 548, Bach Xuan Tran 549, Khanh Bao Tran 550 551, Irfan Ullah 552 553, Muhammad Shariq Usman 276, Olalekan A Uthman 554, Amir Vahedian-Azimi 555 556, Pascual R Valdez 557 558, Job F M van Boven 559 560, Tommi Juhani Vasankari 561, Yasser Vasseghian 465, Yousef Veisani 562, Narayanaswamy Venketasubramanian 563 564, Francesco S Violante 565 566, Sergey Konstantinovitch Vladimirov 567 568, Vasily Vlassov 569, Theo Vos 1 141, Giang Thu Vu 221, Isidora S Vujcic 77, Yasir Waheed 570, Jon Wakefield 571, Haidong Wang 1 141, Yafeng Wang 572, Yuan-Pang Wang 573, Joseph L Ward 574, Robert G Weintraub 575 576, Kidu Gidey Weldegwergs 401, Girmay Teklay Weldesamuel 577, Ronny Westerman 578, Charles Shey Wiysonge 579 580, Dawit Zewdu Wondafrash 581 582, Lauren Woyczynski 1, Ai-Min Wu 583, Gelin Xu 584, Abbas Yadegar 356, Tomohide Yamada 585, Vahid Yazdi-Feyzabadi 586 587, Christopher Sabo Yilgwan 588 589, Paul Yip 590 591, Naohiro Yonemoto 592, Javad Yoosefi Lebni 332, Mustafa Z Younis 593 594, Mahmoud Yousefifard 595, Hebat-Allah Salah A Yousof 596, Chuanhua Yu 572 597, Hasan Yusefzadeh 598, Erfan Zabeh 599 600, Telma Zahirian Moghadam 33 601, Sojib Bin Zaman 602 603, Mohammad Zamani 604, Hamed Zandian 601 605, Alireza Zangeneh 527, Taddese Alemu Zerfu 606 607, Yunquan Zhang 608 609, Arash Ziapour 332, Sanjay Zodpey 610, Christopher J L Murray 1 141, Simon I Hay 611 612

Affiliations

10 January 2019

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doi: 10.1038/s41586-019-1545-0

Abstract

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Conflict of interest statement

This study was funded by the Bill & Melinda Gates Foundation. Co-authors employed by the Bill & Melinda Gates Foundation provided feedback on initial maps and drafts of this manuscript. Otherwise, the funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the final report, or decision to publish. The corresponding author had full access to all of the data in the study and had final responsibility for the decision to submit for publication.

Figures

Fig. 1. U5MR estimates in 99 LMICs. a, U5MR at the second administrative level in 2000. b, U5MR at the second administrative level in 2017. c, Modelled posterior exceedance probability that a given second administrative unit had achieved the SDG 3.2 target of 25 deaths per 1,000 live births for children under 5 in 2017. d, Proportion of mortality of children under 5 occurring in the neonatal (0–28 days) group at the second administrative level in 2017.

Fig. 1. U5MR estimates in 99 LMICs. a, U5MR at the second administrative level in 2000. b, U5MR at the second administrative level in 2017. c, Modelled posterior exceedance probability that a given second administrative unit had achieved the SDG 3.2 target of 25 deaths per 1,000 live births for children under 5 in 2017. d, Proportion of mortality of children under 5 occurring in the neonatal (0–28 days) group at the second administrative level in 2017.

Fig. 2. Geographical inequality in U5MR across 99 countries for 2000 and 2017. a, Absolute inequalities. Range of U5MR estimates in second administrative-level units across 99 LMICs. b, Relative inequalities. Range of ratios of U5MR estimates in second administrative-level units relative to country means. Each dot represents a second administrative-level unit. The lower bound of each bar represents the second administrative-level unit with the lowest U5MR in each country. The upper end of each bar represents the second administrative-level unit with the highest U5MR in each country. Thus, each bar represents the extent of geographical inequality in U5MRs estimated for each country. Bars indicating the range in 2017 are coloured according to their Global Burden of Disease super-region. Grey bars indicate the range in U5MR in 2000. The diamond in each bar represents the median U5MR estimated across second administrative-level units in each country and year. A coloured bar that is shorter than its grey counterpart indicates that geographical inequality has narrowed.

Fig. 2. Geographical inequality in U5MR across 99 countries for 2000 and 2017. a, Absolute inequalities. Range of U5MR estimates in second administrative-level units across 99 LMICs. b, Relative inequalities. Range of ratios of U5MR estimates in second administrative-level units relative to country means. Each dot represents a second administrative-level unit. The lower bound of each bar represents the second administrative-level unit with the lowest U5MR in each country. The upper end of each bar represents the second administrative-level unit with the highest U5MR in each country. Thus, each bar represents the extent of geographical inequality in U5MRs estimated for each country. Bars indicating the range in 2017 are coloured according to their Global Burden of Disease super-region. Grey bars indicate the range in U5MR in 2000. The diamond in each bar represents the median U5MR estimated across second administrative-level units in each country and year. A coloured bar that is shorter than its grey counterpart indicates that geographical inequality has narrowed.

Fig. 3. Estimated number of children under 5 who died within 99 countries in 2017. a, Number of deaths of children under 5 in each country. b, Number of deaths in each first administrative-level unit. c, Number of deaths in each second administrative-level unit. d, Number of deaths of children under 5 in each 5 × 5-km grid cell. Note that scales vary for each aggregation unit.

Fig. 3. Estimated number of children under 5 who died within 99 countries in 2017. a, Number of deaths of children under 5 in each country. b, Number of deaths in each first administrative-level unit. c, Number of deaths in each second administrative-level unit. d, Number of deaths of children under 5 in each 5 × 5-km grid cell. Note that scales vary for each aggregation unit.

Fig. 4. Number of deaths of children under 5, distributed across level of U5MR, in 2000 and in 2017, across 99 countries. Bar heights represent the total number of deaths of children under 5 within all second administrative-level units with corresponding U5MR. Bins are a width of 5 deaths per 1,000 live births. The colour of each bar represents the global region as defined by the subset legend map. As such, the sum of heights of all bars represents the total number of deaths across the 99 countries. a, Deaths of children under 5 in 2000. b, Deaths of children under 5 in 2017. The dotted line in the 2000 plot is the shape of the distribution in 2017, and the dotted line in the 2017 plot represents the distribution in 2000.

Fig. 4. Number of deaths of children under 5, distributed across level of U5MR, in 2000 and in 2017, across 99 countries. Bar heights represent the total number of deaths of children under 5 within all second administrative-level units with corresponding U5MR. Bins are a width of 5 deaths per 1,000 live births. The colour of each bar represents the global region as defined by the subset legend map. As such, the sum of heights of all bars represents the total number of deaths across the 99 countries. a, Deaths of children under 5 in 2000. b, Deaths of children under 5 in 2017. The dotted line in the 2000 plot is the shape of the distribution in 2017, and the dotted line in the 2017 plot represents the distribution in 2000.

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