scholarly journals Risk stratification as a tool to rationalize quarantine among health care workers exposed to COVID-19 cases – Evidence from a tertiary healthcare centre in India

2020 ◽  
Author(s):  
Ravneet Kaur ◽  
Shashi Kant ◽  
Mohan Bairwa ◽  
Arvind Kumar ◽  
Shivram Dhakad ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Risk Stratification ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
Healthcare Services ◽  
Low Risk ◽  
Contact Tracing ◽  
List Type ◽  
Care Workers

AbstractBackgroundQuarantine of healthcare workers (HCWs) exposed to COVID -19 confirmed cases is a well-known strategy for limiting the transmission of infection. However, there is need of evidence-based guidelines for quarantine of HCWs in COVID -19.MethodsWe describe our experience of contact tracing and risk stratification of 3853 HCWs who were exposed to confirmed COVID-19 cases in a tertiary health care institution in India. We developed an algorithm, on the basis of risk stratification, to rationalize quarantine among HCWs. Risk stratification was based on the duration of exposure, distance from the patient, and appropriateness of personal protection equipment (PPE) usage. Only high-risk contacts were quarantined for 14 days. They underwent testing for COVID-19 after five days of exposure, while low-risk contacts continued their work with adherence to physical distancing, hand hygiene, and appropriate use of PPE. The low-risk contacts were encouraged to monitor for symptoms and report for COVID-19 screening if fever, cough, or shortness of breath occurred. We followed up all contacts for 14 days from the last exposure and observed for symptoms of COVID-19 and test positivity.Results and interpretationOut of total 3853 contacts, 560 (14.5%) were categorized as high-risk contacts, and 40 of them were detected positive for COVID-19, with a test positivity rate of 7.1% (95% CI = 5.2 – 9.6). Overall, 118 (3.1%) of all contacts tested positive. Our strategy prevented 3215 HCWs from being quarantined and saved 45,010 person-days of health workforce until June 8, 2020, in the institution.We conclude that exposure-based risk stratification and quarantine of HCWs is a viable strategy to prevent unnecessary quarantine, in a healthcare institution.SummaryWhat is already known about this subject?Quarantine of HCWs is a well-known strategy for community and HCWs to prevent the transmission of COVID-19.Though success stories of prompt contact tracing and quarantine to control COVID-19 are available from countries like South Korea, Singapore, and Hong Kong, there is a scarcity of evidence that could guide targeted quarantine of HCWs exposed to COVID -19 in India.What does this study add?Only 14.5% HCWs exposed to COVID-19 cases were stratified “high risk” contacts, and the most common reason for high-risk contacts was non-formal workplace interactions such as having meals together.The overall test positivity rate among the high-risk contacts was 7.1%, while it was higher in symptomatic high-risk contacts as compared to those who were asymptomatic (10.2% vs. 6.3%).How might this impact on clinical practice?Contact tracing and risk stratification can be used to minimize unnecessary quarantine of COVID-19 exposed health care workers and prevent the depletion of healthcare workers amidst the pandemic to continue the healthcare services optimally.

scholarly journals Development of an Objective Risk Stratification Tool to facilitate workplace assessments of healthcare workers when dealing with the CoViD-19 pandemic

2020 ◽  
Author(s):  
W David Strain ◽  
Janusz Jankowski ◽  
Angharad Davies ◽  
Peter MB English ◽  
Ellis Friedman ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Risk Stratification ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
List Type ◽  
Care Workers ◽  
Increased Risk ◽  
Objective Risk ◽  
Risk Stratification Tool

SummaryHealthcare workers have a greater exposure to individuals with confirmed SARS-novel coronavirus 2, and thus a higher probability of contracting coronavirus disease (CoViD)-19, than the general population. Employers have a duty of care to minimise the risk for their employees. Several bodies including the Faculty of Occupational Medicine, NHS Employers, and Public Health England have published a requirement to perform risk assessments for all health care workers, however, with the absence of an objective risk stratification tool, comparing assessments between individuals is difficult if not impossible. Using published data, we explored the predictive role of basic demographics such as age, sex, ethnicity and comorbidities in order to establish an objective risk stratification tool that could help risk allocate duties to health care workers. We developed an objective risk stratification tool using a Caucasian female <50years of age with no comorbidities as a reference. Each point allocated to risk factors was associated with an approximate doubling in risk. This tool was then validated against the primary care-based analysis. This tool provides objective support for employers when determining which healthcare workers should be allocated to high-risk vs. lower risk patient facing clinical duties or to remote supportive roles.Strengths and limitations of this studyThere is an increased risk of mortality in the clinical workforce due to the effects of CoViD-19.This manuscript outlines a simple risk stratification tool that helps to quantify an individual’s biological riskThis will assist team leaders when allocating roles within clinical departments.This tool does not incorporate other external factors, such as high-risk household members or those at higher risk of mental health issues, that may require additional consideration when allocating clinical duties in an appropriate clinical domain.This population-based analysis did not explain for the very high risk observed in BAME healthcare workers suggesting there are other issues at play that require addressing. BAME healthcare workers suggesting there are other issues at play that require addressing.

Hospital based contact tracing of COVID-19 patients and health care workers during the COVID-19 Pandemic in Eastern India (Preprint)

2021 ◽  
Author(s):  
Durgesh Prasad Sahoo ◽  
Arvind Kumar Singh ◽  
Dinesh Prasad Sahu ◽  
Somen Kumar Pradhan ◽  
Binod Kumar Patro ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Risk Stratification ◽  
Health Care Workers ◽  
Control Strategies ◽  
Routine Data ◽  
Low Risk ◽  
Contact Tracing ◽  
P Value ◽  
Care Workers

BACKGROUND Contact tracing and subsequent quarantining of Health Care Workers (HCWs) is essential to minimize further transmission of SARS-CoV2 infection. OBJECTIVE In this study, we have reported the yield of contact tracing of COVID-19 cases and risk stratification of HCWs exposed to them. METHODS This is an analysis of routine data collected for contact tracing of COVID-19 cases from 19th March to 31st August 2020 at All India Institute of Medical Sciences, Bhubaneswar, Odisha, India. COVID-19 cases were either admitted patients, out-patients, or HCWs in the hospital. HCWs who were exposed to COVID-19 cases were categorized as per the risk stratification guidelines into high-risk contacts and low-risk contacts RESULTS During contact tracing, 3411 HCWs were identified as exposed to 360 COVID-19 cases. Out of 360, 269 (74.7%) were either admitted or out-patients and 91(26.1%) were HCWs. After risk stratification 890 (26.1%) were categorized as high-risk contacts and 2521 (73.9%) were categorized as low-risk contacts. The test positivity rate of high-risk contact and low-risk contacts were 3.82% and 1.90%, respectively. The average number of high-risk contacts was significantly higher when the COVID-19 case was an admitted patient (6.6) rather than when the COVID-19 case was an HCW (4.0) or outpatient (0.2), p-value = 0.009. Similarly, the average number of high-risk contacts was higher when the COVID-19 case was admitted in non-COVID-19 area (15.8) as compared to COVID-19 area (0.27), p value < 0.001. There was significant decline in mean number of high-risk contacts over the study period. CONCLUSIONS Contact tracing and risk stratification was effective and helped in reducing the number of HCWs going for quarantine. There was also a decline in high-risk contacts during study period suggesting role of implementation of hospital based COVID-19 related infection control strategies. This contact tracing and risk stratification approach designed in the current study can also be implemented in other healthcare settings.

scholarly journals Hospital based contact tracing of COVID-19 patients and health care workers and risk stratification of exposed health care workers during the COVID-19 Pandemic in Eastern India

2020 ◽  
Author(s):  
Durgesh Prasad Sahoo ◽  
Arvind Kumar Singh ◽  
Dinesh Prasad Sahu ◽  
Somen Kumar Pradhan ◽  
Binod Kumar Patro ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Risk Stratification ◽  
Health Care Workers ◽  
Secondary Analysis ◽  
Routine Data ◽  
Low Risk ◽  
Contact Tracing ◽  
P Value ◽  
Care Workers

AbstractIntroductionContact tracing and subsequent quarantining of Health Care Workers (HCWs) is essential to minimize further transmission of COVID-19 infection. In this study, we have reported the yield of Contact Tracing of COVID-19 Patients and HCWs and risk stratification of exposed HCWs.MethodologyThis is a secondary analysis of routine data collected for contact tracing from 19th March to 31st August 2020 at All India Institute of Medical Sciences, Bhubaneswar, Odisha, India. HCWs exposed to COVID-19 infections were categorized as per the risk stratification guidelines and the high-risk contacts were quarantined for 14 days and tested on 7th day from last day of exposure. The low risk contacts were encouraged to closely monitor their symptoms while continuing to work.ResultsOut of 3411 HCWs exposed to COVID 19 patients (n=269) and HCWs (n=91), 890 (26.1%) were high risk contacts and 2521 (73.9%) were low risk contacts. The test positivity rate of high-risk contact was 3.82% and for low risk contact was 1.90%. Average number of high-risk contacts was significantly higher; for admitted patients (6.6) as compared to HCWs (4.0) and outpatients (0.2), p value = 0.009; for patients admitted in non-COVID areas (15.8) as compared to COVID areas (0.27), p value < 0.001; and when clustering of cases was present (14.3) as compared to isolated cases (8.2); p value < 0.001. Trend analysis (15 days block period) showed a significant decline in number of mean numbers of high-risk contacts during the study period.ConclusionContact tracing and risk stratification was effective and helped in reducing the number of HCWs going for quarantine. There was also a decline in high-risk contacts during study period suggesting role of implementation of hospital based COVID related infection control strategies. This contact tracing and risk stratification approach designed in the current study can also be implemented in other healthcare settings.

scholarly journals Risk Stratification as a Tool to Rationalize Quarantine of Health Care Workers Exposed to COVID-19 Cases: Evidence From a Tertiary Health Care Center in India

2020 ◽  
pp. 101053952097731
Author(s):  
Ravneet Kaur ◽  
Shashi Kant ◽  
Mohan Bairwa ◽  
Arvind Kumar ◽  
Shivram Dhakad ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Risk Stratification ◽  
Health Care Workers ◽  
Care Center ◽  
Contact Tracing ◽  
Self Monitoring ◽  
Health Care Center ◽  
Care Workers ◽  
Evidence Based Guideline

Quarantine of health care workers (HCWs) exposed to COVID-19–confirmed cases is a well-known strategy for limiting the transmission of infection. However, during a pandemic situation in a resource-constraint setting, we require an evidence-based guideline for quarantining HCWs. We developed an algorithm for exposure-based risk stratification and quarantine of HCWs. We did contact tracing and risk stratification of 3853 HCWs, of whom 560 (14.5%) were categorized as high-risk contacts. High-risk contacts were quarantined for 14 days and underwent testing for COVID-19, while low-risk contacts continued their work with adherence to physical distancing, hand hygiene, appropriate use of personal protective equipment, and self-monitoring of symptoms. Overall, 118 (3.1%) contacts tested positive for COVID-19. The positivity rate among high-risk contacts was 7.1% (95% confidence interval = 5.2-9.6). Our strategy of risk stratification prevented 3215 HCWs from being quarantined and thus saved 45 010 person-days of health workforce in the institution.

scholarly journals Incidence of COVID-19 infection amongst the high risk versus low risk health care workers: an audit from a tertiary cancer care centre

2021 ◽  
Vol 8 (7) ◽  
pp. 3474
Author(s):  
Nitin Shetty ◽  
Nivedita Chakrabarty ◽  
Amit Joshi ◽  
Amar Patil ◽  
Suyash Kulkarni ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Health Care Workers ◽  
Cancer Care ◽  
Low Risk ◽  
Care Centre ◽  
Protective Measures ◽  
Care Workers ◽  
Significant Difference ◽  
Treatment Research

Background: Theoretically, health care workers (HCW) are at increased risk of getting infected with COVID-19 compared to the general population. Limited data exists regarding the actual incidence of COVID-19 infection amongst the high risk and low risk HCW of the same hospital. We present an audit from our tertiary cancer care centre comparing the COVID-19 infection rate between the high risk and low risk HCW, all of whom had been provided with adequate protective measures and health education.Methods: This is a retrospective observational study from 01 April 2020 to 30 September 2020, in which all the 970 HCW of Advanced Centre for Treatment, Research and Education in Cancer were divided into high risk and low risk groups. High risk HCW included all the medical and non-medical staff directly involved with the care of COVID-19 patients, and rest were low risk HCW. Adequate protective measures and classes for infection prevention were provided to all the HCW. We calculated the incidence of COVID-19 infection in both these groups based on the positive real time-polymerase chain reaction (RT-PCR) result and also looked for any significant difference in incidence between these two groups.Results: The incidence of COVID-19 infection amongst the high risk HCW was 13% and that of low risk HCW was 14%.Conclusions: We found no significant difference in COVID-19 infection between the high risk and low risk HCW. Thus, along with protective measures, behavior modifications induced by working in high risk areas, prevented the high risk HCW from getting increased COVID-19 infection compared to the low risk HCW.

scholarly journals Analysis of social interactions and risk factors relevant to the spread of infectious diseases at hospitals and nursing homes

PLoS ONE ◽  
2021 ◽  
Vol 16 (9) ◽  
pp. e0257684
Author(s):  
Frederik Boe Hüttel ◽  
Anne-Mette Iversen ◽  
Marco Bo Hansen ◽  
Bjarne Kjær Ersbøll ◽  
Svend Ellermann-Eriksen ◽  
...  
Keyword(s):  
Health Care ◽  
Nursing Homes ◽  
Social Interactions ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
Contact Tracing ◽  
Future Research ◽  
Care Workers ◽  
The Social ◽  
Using Data

Ensuring the safety of healthcare workers is vital to overcome the ongoing COVID-19 pandemic. We here present an analysis of the social interactions between the healthcare workers at hospitals and nursing homes. Using data from an automated hand hygiene system, we inferred social interactions between healthcare workers to identify transmission paths of infection in hospitals and nursing homes. A majority of social interactions occurred in medication rooms and kitchens emphasising that health-care workers should be especially aware of following the infection prevention guidelines in these places. Using epidemiology simulations of disease at the locations, we found no need to quarantine all healthcare workers at work with a contagious colleague. Only 14.1% and 24.2% of the health-care workers in the hospitals and nursing homes are potentially infected when we disregard hand sanitization and assume the disease is very infectious. Based on our simulations, we observe a 41% and 26% reduction in the number of infected healthcare workers at the hospital and nursing home, when we assume that hand sanitization reduces the spread by 20% from people to people and 99% from people to objects. The analysis and results presented here forms a basis for future research to explore the potential of a fully automated contact tracing systems.

scholarly journals Nonspecific low back pain and associated factors in the professions of health care workers especially the physiotherapist

2021 ◽  
Vol 6 (9) ◽  
Keyword(s):  
Health Care ◽  
Low Back Pain ◽  
Back Pain ◽  
High Risk ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
Associated Factors ◽  
P Value ◽  
Low Back ◽  
Care Workers

Introduction: Low back pain (LBP) is relatively a major cause of disability among the working population and has a significant socioeconomic impact. The study aims were to determine the prevalence and associated factors of low back pain among professions of health care workers especially the physiotherapist. Methods: A total of 225 participants (78,7%female, 21.3% male) among students of Professional and Scientific Master degree in University of Medicine, Faculty of Technical Medical Science and healthcare workers that working in the University and in the tertiary University Medical Center of Tirana "Mother Teresa" were involved to evaluate LBP for a period for more than two years (from Mars 2017 until to November 2019). A standardized Nordic questionnaire for the analysis of LBP symptoms and epidemiological risk factor data was used to collect information from our study participants. Results: Prevalence of LBP in healthcare workers was determined to be 87.5%. Female resulted to be 4.9 times in risk to have LBP compared to male for CI 95% (2.16-11.2) p value<0.001. The average age resulted to be 37 ± 5.9, where the minimum and maximum age were 21 and 55 years old respectively. The participants ≥51 years old were 14 times in high risk for LBP compared to other age groups for CI 95% (5.9-21.6) p value=0.001. It was observed that low back pain was most common among nurses (44.1%) p value<0.0001. Also risk factors such as job position, working condition, long standing and long sitting at desk, health status and also the physical activity demonstrated an association and increasing low back pain risk, p value in all these factors resulted less than 0.05. Conclusion:Our study demonstrated that the prevalence of LBP were higher and healthcare workers especially the nurses are among group with high risk of low back pain.

scholarly journals Prevalence of SARS CoV-2 infection among Health Care Workers of a hybrid tertiary COVID 19 hospital in Kerala

2021 ◽  
Author(s):  
Jessy S J ◽  
Shamha Beegum ◽  
Genga Gopakumar ◽  
Bindu G ◽  
Chntha S ◽  
...  
Keyword(s):  
Health Care ◽  
High Risk ◽  
Health Care Workers ◽  
Risk Group ◽  
Previous History ◽  
High Risk Group ◽  
Low Risk ◽  
Risk Category ◽  
Care Workers ◽  
History Of

Back ground and objectives- This study was undertaken to estimate the prevalence of SARS-CoV-2 infection among Health care workers [HCWs] of a hybrid COVID treatment hospital in Kerala. Methods- The study was conducted during 3rd week of January 2021. Among 3550 HCWs, 979 subjects were selected by stratified random sampling and grouped into high risk and low risk category based on job setting. Demographic details and clinical information regarding previous history of COVID 19 were collected at the time of SARS-CoV-2 IgG testing. Results: From 979 subjects, the data with respect to 940 health care workers were analysed. SARS-CoV-2 IgG was detected in 19.1% of HCWs. Seroprevalence among high risk group was 20.3% and that in low risk group was 7.4% [p=0.005]. In high-risk group, seropositivity was noted in 30.54 % of nurses, 19% hospital attenders, 18.9% resident doctors and 6.4% consultant doctors. In those with past history of SARS-CoV-2 infection, seropositivity was 75.4%. In those who were COVID positive during July2020, 33.3% were still IgG reactive. Interpretation and conclusion- The study reported 19.1% SARS CoV-2 IgG reactivity among health care workers in our hospital. Seropositivity was significantly higher in high risk group compared to low risk group. Antibody decay kinetics in our study is comparable to that in published literature. Infection control challenges in hybrid hospitals account for higher seropositivity in this study compared to overall seroprevalence among HCWs in Kerala.

scholarly journals Rapid environmental monitoring, capture, and destruction activities of SARS-CoV-2 during the Covid-19 health emergency

2020 ◽  
Author(s):  
Roberto Marchetti ◽  
Martina Stella ◽  
Debjyoti Talukdar ◽  
Rosaria Erika Pileci
Keyword(s):  
Health Care ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
Health Workers ◽  
Pcr Analysis ◽  
List Type ◽  
Rt Pcr ◽  
Care Workers ◽  
Polymerase Chain ◽  
Hospital Wards

ABSTRACTObjectivesSARS-CoV-2 pandemic is a health emergency for occupational healthcare workers at COVID19 hospital wards in Italy. The objective of the study was to investigate if U-Earth AIRcel bioreactors were effective in monitoring and improving air quality via detection, capture, and destruction of the SARS-CoV-2 virus, reducing the risk of transmission among healthcare workers.MethodsU-Earth AIRcel bioreactors are a demonstrated effective biomonitoring system. We implemented a methodological approach wherein they were placed at various hospitals treating COVID-19 patients in Italy. The detection of the SARS-CoV-2 virus was achieved through rapid biomonitoring testing of the solutes from the AIRcel bioreactors via SARS-CoV-2 rapid test antigen and consecutive reverse transcription-polymerase chain reaction (RT-PCR) analysis with the multiplex platform (XABT) and the Real-Time PCR Rotor-Gene.ResultsThe marked presence of the SARS-CoV-2 virus was found in multiple water samples via the detection of ORF1ab + N and/or E gene involved in gene expression and cellular signaling of the SARS-CoV virus. The AIRcel bioreactors were able to neutralize the virus effectively as traces of the viruses were no longer found in multiple solute samples after an overnight period.ConclusionsTransmission of COVID-19 via bio-aerosols, transmitted by infected patients, remains a viable threat for health workers. AIRcel bioreactors allow for rapid biomonitoring testing for early virus detection within the environment, reducing the risk of exponential contagion exposure and maintaining good air quality without endangering health workers. This same protocol can also be extended to public spaces as a bio-monitoring tool for hotpots early detection.Key messagesWhat is already known about this subject?Transmission of SARS-CoV-2 virus via bio-aerosols is a threat to health care workers. Only few studies have conducted investigations on how to limit the spread of the virus via air purifiers.Existing studies show a higher risk to health care workers serving at COVID-19 wards with a higher risk of viral transmission.What are the new findings?In this study, SARS-CoV-2 virus traces were captured by U-Earth air purifier bioreactor units placed at several hospitals in Italy.AIRcel bioreactors achieved early detection of the SARS-CoV-2 virus within the environment via rapid biomonitoring testing.AIRcel bioreactors have proved effective in biomonitoring via the detection, capture, and destruction of SARS-CoV-2 virus through reverse transcription-polymerase chain reaction (RT-PCR) analysis with the multiplex platform (XABT) Multiple Real-Time PCR Rotor-Gene.How might this impact on policy or clinical practice in the foreseeable future?This study shows the need for effective surveillance and biomonitoring to contain the spread of the SARS-CoV-2 virus. AIRcel bioreactors, an effective occupational surveillance system, can reduce the transmission of the virus to health care workers serving COVID-19 infected patients at hospital wards.AIRcel bioreactors can also be used in public spaces and other settings, such as schools, to increase the speed of detection of the SARS-CoV-2 virus and improve control of the environment, thereby decreasing the exponential growth of the pandemic.

scholarly journals Evaluation of Occupational Health and Infection Control Practices in Some Federal Medical Centers (FMCs) in Southern Nigeria

2019 ◽  
pp. 1-19
Author(s):  
O. T. Allen ◽  
I. L. Nwaogazie ◽  
K. Douglas
Keyword(s):  
Health Care ◽  
At Risk ◽  
High Risk ◽  
Infection Control ◽  
Health Care Workers ◽  
Healthcare Workers ◽  
P Value ◽  
Chi Square ◽  
Care Workers ◽  
Southern Nigeria

The hospital is a high risk environment for the transmission of infections to health care workers, visitors, patients and the surrounding community. Healthcare workers are exposed to a variety of hazards which predisposes these “indispensable carers” to various life threatening infections and diseases. This study is aimed at evaluating the occupational hygiene and infection control practices in Federal Medical Center (FMC) Owerri and FMC Yenayoa, both located within southern Nigeria. Descriptive cross sectional study using a structured questionnaire and walk-through safety checklist was employed. A total of 379 healthcare workers were selected through disproportionate stratified sampling from the two facilities. The questionnaires were self-administered and analyzed using SPSS Version 22.0. Frequencies, chi-square were computed and multivariable logistic regression analysis was used to identify the predisposing factors to which health workers are exposed; 60.7% of respondents were male, dominant age group; 30 – 39yrs, nurses represented a larger proportion (34.8%) of healthcare workers in this study; 51.7% and 48.3% of respondents in FMC Yenagoa and FMC Owerri respectively had a good knowledge of hazards and controls. There was a significant difference with chi-square as, 9.710 p-Value <0.008. Good level of attitude was 44.7% in Owerri and 21.2% in Yenagoa, chi-square 18.295 p-Value <0.001. Overall level of occupational hygiene and infection control practices was poor in both facilities. Health care workers had a very high level of exposure to ergonomic hazards (88.9%) and biological hazards 47.6% in Owerri and 55.3% in Yenagoa. Nurses were 5 times more at risk of ergonomic hazards (95%CI) – 5.96 (2.19–16.24)  p-Value < 0.001, while Medical Laboratory scientists were 5 times more at risk of chemical hazards (OR = 5.98, 95CI: 3.05–11.69, p-Value <0.001). The checklist revealed that both facilities were of imminent high risk category. Health care workers at FMC Yenagoa had higher exposures to all five categories of hazards than FMC Owerri. Working in FMC Owerri predisposes workers to higher health hazards than in FMC Yenagoa. There was better administrative controls including trainings and immunizations in FMC Yenagoa than in FMC Owerri.

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