COVID-19 indicators and situational analysis; Update on vaccine roll-out
Adhoc Committee on Covid-19 (WCPP)
25 August 2021
Chairperson: Ms M Wenger (DA)
The Committee met virtually for a follow-up briefing by the Western Cape Provincial Department of Health on COVID-19 health update, as the Committee held regular briefings with the Department for this purpose. The Western Cape Provincial Minister of Health and the Provincial Head of Department of Health were present, with the latter presenting the comprehensive report, which touched on the Department’s surveillance and response update; expectations of the third wave; triggered third wave response; vaccine implementation update; and lessons learnt from the third wave.
With a probable decline in the number of cases in the province based on the reproduction rates, Members raised concerns about the high number of cases involving children and young people; testing protocols that exposed potentially positive people to even more people, thereby contributing to the further spread of the virus; impact of the current wave on healthcare workers; credible statistics on the number of reported cases versus actual cases; and the probability of a fourth wave alongside other variants.
Discussions also centred on the collaboration of the Department with the Department of Education to contain the spread of the virus among children and young people, especially because the relaxed restrictions in the current wave coincided with the opening of schools. Members also raised concerns on the increase in the number of cases in Khayelitsha, to which the Department clarified that the township only experienced a marginal increase and not a widespread outbreak.
Concerns were also raised on the changing indicators of early detection of COVID from fever as seen in the first and second waves. The Head of Department clarified that recent research found fever to be an insufficient and less sensitive criterion for early detection of the Delta variant of the third wave, which came with more symptoms of cold and flu.
The Department emphasised the continuous need to take protective measures seriously, while noting its numerous innovations aimed at getting more people vaccinated and tested for COVID, including the opening of a drive-through vaccination site at Athlone Stadium in September and the launch of Department’s hospitality industry vaccination site in Grand West in the previous week.
The Chairperson opened the virtual meeting, welcoming all the Members, support staff as well as the delegation from the Department of Health (DoH). She then highlighted the rules of engagement for virtual meetings. The Committee’s main tenets of order emanated from Directors for Sittings of the House and meetings of Committees by electronic means, which were ATC’d on Friday, 17 April 2020.
The Department of Health (DoH) would brief the Committee on the dominance of the third wave; its behaviour, which differed completely from the first and second waves; and what to expect. The ‘Delta variant’ was the fastest and the fittest variant the country has had to face till date. The Western Cape had witnessed some prolonged waves with uncertainty on when it could reach the peak, especially in the last few weeks.
Dr Nomafrench Mbombo, Western Cape Provincial Minister of Health, and Dr Keith Cloete, Head of Department, Western Cape Provincial DoH, would do the briefing.
Introductory Remarks by the Minister of Health (WCPP)
Dr Mbombo reiterated the purpose of the Department’s briefing, which was to update the Committee on the state of the province in relation to the third wave of COVID-19. The report, which would be presented by Dr Cloete, would touch on the number of cases as part of indicators; the number of deaths and hospitalisation; statistics of oxygen usage; healthcare workers’ infection rates, and so much more. The report featured statistics for districts, sub-districts, comparison with townships, as well as lessons learnt by the Department from the data gathered.
The report on vaccines would see Dr Cloete making a judgment based on the evidence of how far the Department had come in the third wave, in order to determine if cases were increasing or decreasing.
Monies received for vaccinations would be tabled, alongside the number of people who have registered and/or vaccinated according to the various categories and age groups, as specified by the National Policy.
The report would also speak to how the Department was able to navigate challenges and prepare to mitigate the effect of a possible fourth wave.
One of the roles of the Minister as a provincial head was to assist the Department to troubleshoot some of the challenges facing it. For instance, the Department had to come up with innovative ways of getting vaccines to the people. It was not only about the number of people who get vaccinated; you may get excited about the increased number of vaccinated people but you do not want to leave a (hypothetical) ‘Auntie Sarah’ behind. Now there are 18-year-olds, including Auntie (hypothetical) Sarah’s son, Gatiep – who is part of those who do not want to be left behind from vaccinations, hence, the ‘jabs before ‘mjolo’ (‘no dating before vaccination’) awareness campaigns on social media. It is well-known that young people do not like to be perceived as being sickly; they have thus been taken outside the mainstream of health services. The Department has gone to the Central Karoo to bring as many young people and had other upcoming outreaches, which the next one targeted at clubs. Minister Mbombo was excited about the upcoming outreach coming up in the first week of September. Other upcoming events included the opening of the drive-through vaccinations, which was another method of getting more people vaccinated.
On the trends of the pandemic, she noted that there was a time the Department was more worried about people aged 60 and above, and therefore prioritised them. Although the Department was still worried about this age group, it was now aware that risk factors increased with age, hospitalisation and deaths. There were potential super-spreaders that do not necessarily get sick often. There were also cases of increased numbers amongst young people, but research has shown that mutation could be prevented, since no one was sure if the fourth wave would bring another variant. The Department was doing all it could to prevent another severe, highly transmissible variant. It was for this reason that the young people were being targeted, as well as the men. The Department would be going to taxi ranks on 10 September 2021.
Briefing by the Department of Health
Dr Keith Cloete, Head of Department, took the Committee through a comprehensive COVID-19 and Vaccine Update that touched on:
-Surveillance and response update;
-Expectations for the third wave;
-Triggered third-wave response; and
-Vaccine implementation update.
In summary, the Western Cape province was currently at the peak of the third wave, and early signs of a decline has been detected, as there were now 3 000 recoded cases per day. A two-percent, week-on-week decrease in cases was noted in the Metro, while the only rural area experiencing an increase in cases was the West Coast. Although the number of cases was dropping in the Western Cape, there were still quite a lot of active cases and people were still at risk.
Cumulatively, the vaccines administered in the province till date were about 1.7 million, with 70% of it for the public sector and 30% for the private sector. Of this number, 750 654 people have been fully vaccinated as of 24 August 2021, and 444 478 have received the second dose of Pfizer.
The Department recorded a single highest vaccination conducted in the province for the first time, on 20 August 2021. A total of 53 290 vaccines were administered, surpassing the previous highest record by almost 20 000. This was achievable because the vaccination registrations commenced on the said day.
The Department would be opening a drive-through at Athlone stadium in the first week in September. The National Minister of Health, Minister Phaahla, already opened up the Department’s hospitality industry vaccination site at Grand West, in the previous week.
Ms W Philander (DA) thanked and welcomed the opening remarks by Minister Mbombo as well as the very comprehensive report by Dr Cloete. She said that one cannot help but be astounded by the amount of work that the Department was doing to keep the Western Cape Province secure. She congratulated the Department for yet another feather to their cap with the accolade received from the Auditor-General, concerning the Western Cape vaccination programme.
To her questions, she asked if there was a concerted effort or strategy in collaboration with the Department of Education (DoE) to address the high proportions of cases affecting children in the current wave.
The Department’s innovation relating to matric learners, which would be done in collaboration with the DoE, was noted. How are student governing bodies, parents and the wider community being encouraged to be involved in this innovation?
In the Department’s opinion, what is the overall impact of the current stage of the third wave on the healthcare workers, especially in terms of fatigue and their mental wellbeing?
On the question of high number of cases recorded for children in the current wave, Dr Cloete replied that there were three things that gave rise to the specific report of more detected and reported cases for children between the ages of 10 and 14 as well as 15 to 19, in the current wave than in preceding waves. The first reason was that this was the first time that restrictions would be relaxed, as the country was entering the peak of a wave. The relaxation of restrictions meant that people did not need to stay at home, and this resulted in more movement of people. What was discovered is that young people move around more, especially in the current wave where the relaxation of restrictions coincided with the opening of schools. The second reason was because the Department offered more testing (through ‘rapid tests’) in the current wave than preceding waves. The third reason was the nature of the Delta variant, which was a faster spreading virus that presents itself like a flu with a little bit of running nose. These reasons explained the statistics for more reported cases and testing for children within the age groups of 10 to 14 and 15 to 19.
As for the collaboration of DoE and DoH, Dr Cloete said that the DoE worked very closely with DoH right from the beginning of the first wave. In the first and second waves, schools were closed at the peak, but the current wave required a different strategy, as schools were opened towards the peak of the third wave in the Province. DoH worked together with DoE to teach protocols about mask wearing; social distancing; refraining from certain activities like sporting events; what to do in cases of infection detection in a classroom; how to circumscribe; and so on. School governing bodies were part of the training. The Department’s local teams worked well with the DoE and their work relationship was great, to the extent that vaccination programmes for teachers ran smoothly. Now that plans were underway for age groups 18 to 34, the Department can also plan to vaccinate matriculants to work together. The result of the good working relationship between the DoH and DoE has resulted could be seen in more detection and reporting of cases.
The impact of the current wave on healthcare workers was clearly documented. Healthcare workers have not had a proper break since March 2020 till date. Many are fatigued and many have gone through trauma. The pandemic has taken a toll on their mental well-being. To make matters worse, everyone now has an opinion on the vaccines; everybody is now a scientist; people are constantly contesting the signs and this has made things more difficult for healthcare workers, who wonder why their advice on kidney diseases, heart diseases and the likes, are taken but not for COVID or the vaccines. Doctors feel tired and let down by people, especially because most sick people coming to the hospitals and have had to go into ICU, be placed on oxygen or ventilator, and eventually died, were unvaccinated. The desire of healthcare workers was for more and more people to be vaccinated to prevent a fourth wave.
The Chairperson mentioned that there have been a lot of international reports on the waning efficacy of vaccines, and some countries in the developed world were opting for booster shots for elderly residents. She asked if the Department had plans for boosters for healthcare workers that got vaccines early in the year in the Sisonke trial.
Dr Cloete replied that the conversation around boosters was a first world conversation. The WHO (World Health Organisation) was very clear on this matter. There was no indication or clear signs to justify that boosters should be routinely used. The first-world countries have excess doses and were dealing with that situation. However, there was no science or evidence from WHO that the use of boosters was justified at the moment.
Ms R Windvogel (ANC) also welcomed the presentation from the HOD.
She asked the Department to speak more on the possibility of a fourth wave as some experts have suggested that it would possibly occur in December.
The Department was asked to explain the reason for the increase in the number of cases in Khayelitsha and what strategies have been put in place to deal with the situation. She also asked for the reason behind young people making up higher number of cases in the current wave.
On the question of the possibility of a fourth wave, Dr Cloete said that the natural epidemiology of a virus was in waves going up and down (as illustrated in the slides). Like any other virus, COVID had a seasonal part to it. To further understand the possibility of a fourth wave, he recalled that the first wave occurred in June/July last year; the second wave in November/December last year; the third wave again in June/July this year, which went into August. There was a likelihood of a fourth wave occurring in December, which would possibly go into January. This was the natural behaviour of the virus, and was the same everywhere in the world (COVID comes with a seasonal variation). The only difference was that the Department has been able to gather sufficient data to know what to do in order to achieve less impact in the fourth wave. Hence, the call for vaccinations, which was the single biggest thing that would help mitigate the fourth wave.
As for the increase of cases in Khayelitsha, he explained that the cases in Khayelitsha were smaller in comparison to those in Mitchells Plain, Klipfontein, Tygerberg and other townships. What looked like an increase in Khayelitsha was actually a marginal increase, as they were very few cases compared to the other areas. Khayelitsha still had inherent immunity, and was yet to have a widespread outbreak. Hence, no specific strategies have been put in place in Khayelitsha, as all necessary requirements had been adhered to in the first place. People understood the protective behaviours and protocols to observe in case of clusters. What was left was to ensure that people understood the importance of mask wearing and social distancing.
Mr B Herron (GOOD) referred to the graph showing the progress made by the Department in terms of reducing the reproductive rates (see slide 5 of the attached document) and bringing down the curve. He was, however, concerned that the statistics in the graph presented was different from what he had been seeing on social media and the National Transgraph, which showed a deep uptake of cases in the Western Cape. He sought clarity on this.
He also sought clarity on the protocols around testing and its possible contribution to the fast spread of the virus, while noting that he has been alerted of people being turned away from testing sites if they were under ages, 40 or 45; or were not showing symptoms; or even if they were showing symptoms, were still being turned away. His mother, aged 83, who was exposed to the virus through his father in the hospital, was turned away from a testing site. She then went to a private doctor and tested positive. He was deeply concerned about this reality, and decried the approach as one that contributed to the spread of the virus. He had to close his own private business because one of his staff within the above-mentioned age group was turned away from being tested despite feeling a bit flush. The business was closed for two weeks because it was a training centre and this staff had been exposed to 60 students. He asked the Department to explain the rationale behind this testing approach and whether it was contributing to the rapid spread of the virus.
On the issue of reproductive rates, Dr Cloete replied that there were two differences to be noted. The first one was that the reported cases from the National Institute of Communicable Diseases (NICD), as well as the reported cases seen in the media and on social media, were reports from when positive results from the laboratory are reported. This report is usually skewed, especially in instances where there is a long public holiday or delay in testing. This meant that a positive result could be gotten at the end of a particular week, whereas the specimen for that result was taken ten days prior to the day of receiving the positive result. The Department, on the other hand, receives batch of test results, and traces the data to the day the specimen was taken before capturing, as some specimens for test results would have been taken two to five days before test results were out. This was why the Department’s reproductive number, based on actual tests, was much smoother than NICD figures or social media reports. More accurate data is captured when the country goes 14 days without a public holiday, but even at that, there could still be variations in the specimen dates. Nevertheless, the Department’s data on reproductive rates showed that the 67% probability would soon drop below the line, and this meant a downward incline in the spread of the virus.
As for the testing protocols, he said that, at the first, second and third wave, there was an agreement on what to expect with COVID-19. However, it would be impossible to test every single person, as no country in the world had such testing capacity to pick up every single positive case – especially at the peak of a new wave. It was for this reason that the Department was conducting smear positivity testing. If a smear positivity was 10%, it meant that, of all the specimens sent to the lab, less than one in ten came back positive, and this meant that the Department was testing sufficient people for the purpose of ensuring that most of cases had been picked. If a smear positivity test was 40%; this meant that four out of every ten tests sent in came out positive; and this meant that probably twice as many cases out there were not detected. This was one of the reasons why the Department developed “limited testing.” If every single person is tested regardless of their symptoms or fitness level (as seen in the first wave), and test results take 14 days to be out, it would mean nothing by the 14th day. It was for this reason that the Department came up with the idea of ‘mitigation’, which meant that only those that need to be tested (for reasons such as being at risk either due to old age; or an outbreak in school; or someone who has symptoms that may necessitate being placed on oxygen or being hospitalised at the very least; or everyone over the age of 45) would be tested. In essence, there was a likelihood that many people who were not tested in the first and second waves had COVID and could potentially infect others. Although this made very little sense for people with symptoms who wanted to know if they could potentially infect others, the unfortunate reality of that time was that many people indeed had COVID. Therefore, the best protection, even in the current wave, is to encourage adherence to COVID-19 protocols of isolating and social-distancing, because a test does not guarantee that one is infected or not. There was a Ministerial Advisory Committee recommendation that justified the way the Department was applying the testing principles in the province.
Mr P Marias (FF+) asked: to what extent does the Department think that all cases are reported so that it can have credible statistics?
Mr Marais highlighted the fact that people still visited hospitals for other non-COVID related issues, and he wanted to know if patients were tested for COVID before being admitted. There were reports of husbands or wives going to the hospital to complain about non-COVID related issues, only to contract COVID in the hospital, but this was not detected till they died. He asked what measures the Department was putting in place to resolve the fear that came with going to the hospitals for fear of contracting the virus and dying.
To what does the Department ascribe the differences in the different waves? If there was going to be a new wave, why should people feel safe after being vaccinated? Will there ever be an end to different variants? Can the scientists tell if there would be an end to the different variants? How many variants exist to begin with, especially because there was news of more than 20 identified variants in England? Was this true or was this fake news? If there were so many variants, was the Department busy with an experiment or has it found a way of stopping the spread of the virus?
He concluded by commenting that it seemed every predicted new wave came with new regulations set to destroy the livelihood of people. Unfortunately, the health sector has no one to appeal to in cases of differing opinions, especially as it relates to vaccines – unlike lawyers who have the appeal court and teachers who have different bodies to appeal to in the event of a dispute.
To answer the question on the number of reported cases, Dr Cloete said that the Department was aware of the fact the reported cases do not reflect the actual number of cases, which would be a lot more. The Department therefore worked with the number of cases in hospitals, as hospitalisations gave a more accurate reflection of COVID cases. Another accurate parameter used is the number of deaths. This was why the Department was certain that the reproduction numbers were dropping, because, even though the reproduction numbers on cases could fluctuate, the reproductive numbers on deaths were more accurate. The Medical Research Council (MRC) Excess Deaths Report was a good external validation of the status of the pandemic. The Department could therefore say with certainty that the Western Cape has passed its peak and the third wave was on its way down.
As for the question on different variants, he mentioned that there have been various schools of thoughts on the dishonesty of the medical fraternity due to publicised new research as it unfolds. It should be noted that the medical fraternity was extremely honest. When COVID started, it was new and there was little research or science to explain what the exact pattern of the virus was, unlike diseases like diabetes, which had been researched for 100 years and counting. Scientists have only been studying COVID for the last 15 months; researchers were learning on the go; and more research has to come out so that the medical fraternity can understand what they are dealing with. Therefore, whatever research findings scientists come up with may likely change in another two months, and also by then, it may likely change again in another two to three months’ time. The medical fraternity is honest enough to say that they do not know everything about the virus, but whatever is known at a given time is what is publicised in the best interest of everyone. Informed decisions are also made with the best interest of the people’s health at heart.
Mr Herron was still concerned about the testing protocols. Although he understood the explanation around the data statistics presented by Dr Cloete (that four out of 10 will come back positive), the current approach that allowed for people to wander around in the peak of the pandemic, thus infecting others (since they would not know if they were positive) was worrisome. It was difficult to understand the logic of thinking that more positive results are only because of increased testing; it sounded almost Trumpian. The government and, most importantly, the people, need to know as accurately as possible how many people are actually infected to prevent further spread of the virus through continuous interaction. Usually, people only approach the testing centres for valid reasons. For instance, his mother was exposed to the virus through interaction with his father, who she lived with, who had the virus and was currently on oxygen. His mother should have been tested and if she was yet to, she would be at risk of infecting others, as she continued with her normal life that revolved around going to the shops, the library and interacting with people. It does not make sense that people who present themselves for testing are turned away at testing sites. There was no way the country would be able to manage a pandemic without the people infected knowing that they were infected.
Minister Mbombo explained that the President introduced targeting testing after the first wave, but by this time, the Western Cape Province was already conducting targeted testing. This was the time when the “Know your COVID status” slogan was everywhere. However, the issue of testing protocols can be better understood with a consideration of two issues, the first being the fact that there was no viral testing during the first wave. There was only antigen testing, which was based on diagnostic testing. The second issue was that WHO stated clearly what types of interventions should be applied as a health response to COVID, with the first part of the interventions being isolations and quarantine procedures, followed by hospitalisations and other stages. In instances where a high level of community transmission has been identified, everyone in the community is expected to behave as if they were positive. Fortunately, South Africa was able to define the resurgence of the current third wave. This was impossible in the first wave, as there was no data to compare waves like is being done now. The available data is what has enabled the Department to identify what percentage of cases to be expected; what the reproduction and positivity rates would be and so on.
In essence, testing protocols, as prescribed by the WHO, require countries to consider the country transmission rates, as well the number of persons under investigations (PUIs) in developing their own differential strategies. Where there is a high level of country transmission, the health system is expected to prioritise the vulnerable, as opposed to others who can take care of themselves and may not necessarily need the healthcare system.
As for the risk factors that come with COVID in terms of severe symptoms that sometimes may lead to death, age is usually the first determinant factor and that is why the Department prioritises the age criterion. (There was then a network glitch that made it impossible to get the rest of the comments made by the Minister.)
Dr Cloete added that Mr Herron’s 80-year-old mother should have been tested without question. The idea for testing operations was for healthcare workers to make informed decisions based on certain criteria tailored to various categories of people that present themselves for testing. To better explain this, he said that, if he was working in a primary healthcare facility, he would test more people that came with a valid reason because the guidelines provide for everyone to be tested, subject to the healthcare worker’s judgment. Although the Minister already explained that there were indications and reasons behind the preservation of testing, and prioritisation of treatment of the most vulnerable, everyone above the age of 45 should be tested.
Mr A Van der Westhuizen (DA) said that, at the initial phases of COVID-19, measuring a person’s fever was used as the best indication for detecting an infection of the virus instead of having to do a swab. However, the Department and other researchers have said that the Delta variant is more like a cold and a far smaller percentage of people develop a fever. What are the best indicators to confirm COVID positivity without being formally tested, especially since early detection is needed to prevent those that are positive from infecting other people, as noted by Mr Herron?
Dr Cloete agreed that, at the beginning of the pandemic, fever, loss of taste and loss of smell were part of the symptoms identified to confirm COVID infections. However, with more and more research conducted, fever was identified as not been a sensitive enough criterion to pick up COVID. For this reason, the health sector developed what is called a “case definition” of COVID, which excludes fever as a sensitive criterion to detect infection of the virus. It was therefore incumbent that once people present themselves for testing at health facilities, health providers were expected to ask necessary questions needed to make informed decisions on the status of each person. Although criteria would change from time to time, but there are certain criteria that health providers and individuals are expected to note. The Delta variant, for instance, was more like a common cold, and this necessitated the requirement for health providers to be more vigilant in terms of advising people on their COVID status.
As noted by the Minister, when infections rise to the level of community transmission, it then becomes incumbent for everyone to behave as though they were all potentially infected, and therefore adhere to all COVID precautions and protocols. Such precautions and protocols include mask wearing; social distancing; isolation; avoidance of contact with fewer people, and so on. Testing negative or not getting tested at all does not safeguard one from being potentially infected.
Ms Windvogel was concerned about the reach of testing and vaccinations to the townships and asked if the same strategy used for widespread availability of HIV testing could be used for COVID testing and vaccinations.
Dr Cloete explained that vaccines and testing were now available everywhere, as was done for HIV testing. In fact, the Department’s team of healthcare staff could now be spotted in the malls and shops like Pick ‘N’ Pay, Shoprite, Boxers and the likes, where shoppers are being asked if they have been tested, registered or vaccinated. In cases where shoppers respond in the negative, they would be urged to get tested or vaccinated at the healthcare stand after their shopping. DoH’s teams were available everywhere, including in the townships such as Khayelitsha, Gugulethu, and so on. The Department’s model of care has expanded from being an “only come to our health facility” model to one which vaccination is being taken to the people. The Department welcomes any suggestions that could help in reaching specific geographic sites for the purpose of establishing outreach points.
Mr Marias congratulated Dr Cloete for the hard work the Department and the Premier were doing. He said that he once raised the issue of the availability of ivermectin at the hospitals, in case a doctor wants to prescribe it, and then shared that four of his close family members had used 1ml of ivermectin, three days apart, to treat COVID, and had now completely recovered from COVID. There were increasing levels of oxygen with outcomes from 84% to 95% and now 98% who could breathe in and their lungs were open. He argued that the fact that there had not been enough vaccine testing was not reason enough because sufficient testing could not have been carried out for a disease that the health sector was only introduced to 15 months ago. The same applied to the vaccines; sufficient testing has not been done on them. There were claims that the COVID virus emanated from animals and was manufactured to test if it could be transmitted from animals to people. What is the Department’s honest opinion on COVID, as well as the use of ivermectin to treat COVID, especially its usage by people who prefer to try the drug rather than die?
Dr Cloete replied that the issue of ivermectin was a vexed issue and has been so for a very long time. Regulatory bodies existed for the purpose of making informed decisions on what specific medicines should be used for. The regulatory body in South Africa, the South African Health Products Authority (SAPHRA), has not approved the use of ivermectin for the treatment of COVID. Instead, it has recommended that ivermectin must be subjected to formal clinical trials before use in South Africa. For this purpose, the Department does not advise the use of ivermectin until sufficient data is established to declare it safe for use.
The Chairperson appreciated the Department and the Minister for their presentation and their answers to all questions raised. She also appreciated all healthcare workers for the tremendous work they are doing to save lives and keep everyone safe.
Committee Resolutions and Actions
The Chairperson asked if there were any resolutions emanating from the meeting. With no response, Members were informed of the opportunity to submit any resolutions they may have in writing latest by 12 noon on Monday, 30 August 2021. Such resolutions will then be brought back to the Committee at the next meeting.
Consideration and Adoption of Minutes
The Committee considered and adopted its minutes of 19 and 23 July 2021.
The Committee considered and adopted its Committee Report for the month of July 2021
The meeting was adjourned.
Wenger, Ms MM
Allen, Mr R
Bosman, Mr G
Botha, Ms L
Herron, Mr BN
Lekker, Ms P
Mackenzie, Mr R
Marais, Mr PJ
Mbombo, Dr N
Philander, Ms W
Van der Westhuizen, Mr AP
Windvogel, Ms R
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