Herd immunity was in everyone’s plan at first

Something else that seems very significant looking back. The whole paradigm we had in the beginning, of having a “contain” phase that is fairly quickly abandoned and moving on to a “delay” phase. This apparently was developed in planning for a flu pandemic:

Scientists are used to seeing flu spread through populations very fast, then become milder as it mutates, and to seeing people indeed develop immunity and populations become resistant.

[The flu strategy’s] first “detection and assessment” phase (seemingly an analogue for the “contain” phase of the coronavirus response) describes how the focus would shift away from “actively finding” and isolating confirmed and suspected cases, and instead turn to treatment of the disease once there was “evidence of sustained community transmission of the virus”. It even anticipates that detection and assessment could itself be a “relatively short” phase, depending on the circumstances. The flu strategy bluntly concludes: “It will not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so.”

It wasn’t just the UK that used this concept – it was everywhere. That cute animation gif showing the curve flattening – that was from New Zealand! (Full article) And wrapped up in that curve-flattening, peak-delaying concept is all the stuff that became abhorrent and governments had to distance themselves from – herd immunity, letting the infection spread in a managed way, accepting that people will die. It was all there in the world’s pandemic flu preparations. (Maybe a pandemic flu instead would have been a bit slower to spread and a bit less deadly. Would that have meant societies did not reject this paradigm? It’s hard to imagine.)

Clearly, New Zealand moved on from that model pretty quickly. Our government was one of the slowest to let it go. But we all moved on to suppression (and I think East Asian countries basically started there, having had the experience of SARS 1). Even Sweden doesn’t talk much about herd immunity.

I guess those countries that moved on to suppression fastest, were able to have the option of actually eliminating the virus and then closing borders / setting up managed quarantine to keep it out. In one of my earlier posts, I sort of dismissed this idea as “having its own problems”. I’m sure New Zealand tourism and economy as a whole has taken a massive hit, but as a price to pay for keeping the population safe AND getting to live relatively normally, I’m sure most would agree that it now looks like the best of a bad bunch of choices.

Wouldn’t it be great if we had all started from a point of view where we believed it could be stopped and eliminated? Maybe it could have been! I guess we can only hope that these lessons will save us all this pain the next time.

Because of course once it’s spread so far, we start to face these awful dilemmas between the harms of letting it spread and the collateral harms of the humongous heavyweight and continuous measures it now takes to suppress it. A lot of my frustration with our governments in 2020 has been the lack of transparency – and lack of public debate – on where we position ourselves in this balancing act. Sweden at least was clear that its measures were designed to be evidence-based to avert disaster and be sustainable for a long time. Here, we seem to have flip-flopped all over the place. In the summer the Scottish government was talking about pursuing elimination – yet they aren’t able to close Scotland off, and they have allowed cases to rise an awful long way in the autumn before putting in heavy restrictions… so I guess they don’t really know what they are trying to do.

Then again, why should I expect them to? In the early months it felt impossible to stomach either option: letting it spread, or the prospect of indefinite continuous suppression. At least now, there seems to be light at the end of the tunnel with these vaccines being rolled out.

And the vaccines will help us get back to normal, but not everyone will be able to get them, not everyone will want to get them, and they will not work for everyone – and even when they work, the immunity perhaps won’t last forever. Endemic equilibrium seems the inevitable (and relatively benign) end-point but how much more pain before we get there?

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Covid pandemic, 9 months in

I’ve been looking back over my posts through this pandemic year, trying to make some sort of sense of where I stand after everything I’ve learned. Not that it really makes any difference what I think… but I like to see how much my understanding has changed over time, and how consistent or otherwise my views have been.

Public opinion seems to range from “only zero covid is acceptable” to “this is all a big fuss about nothing”, and neither of these extremes are a tiny wacky minority. SARS-CoV-2 is so sweepingly diverse in its actions in humans that it has supported massive polarisation of views on its management, which is perhaps one of its more sinister (and less talked-about) outcomes – the furthering of fractures in society. As I’ve mentioned before, at times I’ve felt unstable and confused in my own thinking, pulled in different directions – which is why I’m craving clarity, I guess – but perhaps it’s better in some ways to remain open and uncertain.

The lockdown approach has seemed overly destructive to me: Sweden showed in the summer that case numbers could come right down without shutting everything down, possibly through a bit of natural saturation, summer season, and social distancing. It made me think probably our own lockdown (and that of many other countries) had come too late to do much good. It also lasted way too long. We gradually moved towards Swedish levels of openness-with-precautions, which was working fine in Sweden, but we didn’t quite get there before the season changed and cases started going back up. Soft play has been one casualty of that that is close to my heart.

The situation was OK in the summer. I felt there was too much pessimism and fear. Maybe I was wrong about that. Contact tracing clearly hasn’t worked well enough to prevent another big wave (is anyone surprised? – well, it looked hopeful to begin with). But I didn’t think a new wave in the autumn would be as bad as the first, and I guess it wasn’t:

I had definitely hoped things wouldn’t get as bad as they did. We have probably gone into excess deaths* again – but lockdowns also cause deaths, poor mental health, wrecked livelihoods and future prospects, and other harms. Things were at least coming under control without resorting to lockdown. It seemed hospitals were coping. So I still felt we should hold our nerve and keep going with what measures we had in place.

I think there is too much emphasis on counting covid deaths without viewing them in the context of overall mortality. Sometimes it feels as if no-one ever died before. I also want to ask for each intervention: who benefits, and who pays the price for it? And are we comfortable with that?

I didn’t think restrictions should be relaxed at Christmas. Learning about the pandemic’s overdispersion has changed my thinking a lot: “9 percent of cases were responsible for 80 percent of transmission, while 69 percent of cases did not infect another person”. Where people gather indoors, in close contact for prolonged periods with little ventilation, a lot of spread happens. You’re not likely to catch it walking past someone in a shop (if not crowded) or even from surfaces. Why should shops have to shut and meanwhile people are allowed to visit each other at home over the holidays?

Yes it’s hard to forgo our usual social contact, but in most cases doing so is not as harmful as the overall results of people breaking the rules and gathering: full hospitals, deaths, more lockdowns. I feel I’m turning into one of those judgemental types that blames the spread on people’s behaviour. (Not entirely – secondary schools, universities and certain workplaces/work situations are also implicated, and there’s not much individuals can do about any of those.)

Anyway, and now we have this new, ~56% more transmissible strain that throws everything up in the air. A three-week anticipatory lockdown after Christmas has been implemented. Cases seem to be going up again sharply, and I don’t think it can all be explained by the new strain (although the new strain is making up ~40% of cases).

So I don’t know what I think any more. Maybe if it transmits faster now, it will reach a saturation point faster. The autumn wave seemed to reach saturation, so maybe the new saturation threshold (with this new strain) isn’t much higher anyway. Can only hope that between that and the rapid rollout of the vaccines, we’ll hobble through the rest of the winter and soon be OK.

*ETA: I came across this shiny app for excess deaths. They actually don’t look as bad as looking purely at deaths with a recent covid diagnosis. I guess a fair number of the people in the latter category would have likely died over this winter anyway.

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Thoughts on the Great Barrington Declaration

Three epidemiologists have proposed a different approach to managing the covid pandemic, in the form of the Great Barrington Declaration:

“The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection.”

I’ve been happy to see the conversation broadening out a bit in this way, as I’ve long been a lockdown sceptic and feel that the level of fear in our narratives around this virus has reached unhealthy heights.

I haven’t signed it, though. Part of me wants to – there are definitely things I like in it (and in Sunetra Gupta’s commentary) that I’m just not getting from elsewhere:

  • Recognition of the profound harm of lockdowns. A holistic public health perspective rather than one focused solely on the threat of covid. In the case of Sunetra Gupta, a voice in defence of the world’s poor: warnings that lockdowns will lead to starvation, reminders that being able to stay at home away from other people and be OK is a huge privilege that the majority do not have. And even for those that can, there are still harms.
  • The understanding that the end-point of this pandemic is an endemic equilibrium. Nothing else really makes sense to me. This coronavirus is going to be circulating forever – or at least, we can’t realistically think we can ever eradicate it.
  • Hence, an explanation – a ray of hope – for how the virus will become less of a threat. It’s causing a lot of severe disease because it’s novel. In an endemic equilibrium, we won’t see these big overwhelming outbreaks, because at any given time, many people will have immunity. Reinfections are also expected to be generally milder as the immune system still retains some memory of how to deal with it.
  • Interesting to reflect that if this is true, it will never be a significant threat to today’s children or future generations because they will be first exposed during childhood, at which stage of life it’s generally a mild disease. Maybe the other four circulating coronaviruses would also be life-threatening to the elderly if they had never previously been exposed to them. For that matter, probably those viruses are responsible for deaths (I’m sure Prof Gupta has referred to that), and we just don’t hear about it because there aren’t big waves of serious infections (we have an endemic equilibrium)… and the cause of death is probably recorded as “pneumonia”, i.e. it’s the secondary complications that we consider significant, and the primary infection is almost irrelevant (and not even known). With covid we’ve somehow equated the secondary complications with the infection itself, despite the huge number of asymptomatic and mild infections. Fear fear fear. So, this is something I like and find helpful: framing the coronavirus beside its non-threatening cousins where it can best be understood, and so tempering the hysteria around its novelty.

I think the most obvious criticism of the idea is probably the logistical difficulty of shielding “the vulnerable” while letting the rest live normally. Maybe it would be feasible if we had rapid testing, so that care home workers could be tested at the start of each shift, and visitors tested in the same way. As it is, the physical separation of vulnerable people from their loved ones is extremely tough. And where they live in the same household, it’s hard to imagine ways it could be done. Sunetra Gupta has said she expects it would only take about 3 months for game-changing levels of immunity to be reached under the GBD proposals, so that the difficulties of shielding wouldn’t need to be endured for long – but I don’t think anyone can really know that.

And then there’s the question of how much protection would actually result from reaching endemic equilibrium. There’s been a lot of unhelpful shouty noise about herd immunity being impossible because individual immunity wanes. Herd immunity is not an all-or-nothing thing. Even with lifelong immunity and widespread vaccination, as with measles, the probability of a vulnerable person being exposed is not zero. With a coronavirus in an endemic equilibrium, where individual reinfection might occur every few years, the probability of a vulnerable person being exposed is clearly higher than in the measles case. But still, the GBD people are not wrong to say that a level of herd immunity is built up. The question is, is it enough? And how much would we consider “enough”? What do their models suggest the eventual probability of exposure will be, and what is it now? These are the kind of things that should be asked.

The other thing that bothers me is that we still need to recognise this virus can be dangerous to anyone at high viral loads. Young and healthy doctors and nurses have died of it for this reason. There are certain aspects of normal life – nightlife especially – that I don’t see being safely resumed until most of the population is vaccinated.

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Scotland’s covid whack-a-mole

Tayside’s mini second wave was squashed with testing and tracing:

Grampian’s was squashed with a local lockdown:

Glasgow’s is ongoing, and is being tackled with restrictions on gatherings in homes (as well as testing and tracing, of course). Before I added the last data point, it looked pretty bad. I’m not sure if transmission is genuinely tailing off now or the data is affected by recent delays in processing tests. We’ll have to see.

My general impression has been that things are getting out of control, but looking at these data today, it doesn’t look that way. There are success stories here that no-one seems to be reporting. And most other parts of Scotland are doing OK.

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Be more afraid?

I recently read a very disturbing Guardian piece detailing the goings-on in an Austrian ski resort back in March, through interviews with people who had been there. It seems this resort (Ischgl) was a hotbed of transmission at that time and may have played a significant role in the coronavirus’s spread across Europe. Reading it felt like watching a disaster movie. It’s particularly horrifying from a post-lockdown perspective, now that we have (somewhat) normalised the new high standards of hygiene, social distancing, and isolation of ill people, to hear stories like this from the start of the pandemic where none of those precautions were in place. I felt a visceral disgust reading it, and could recognise the “puritanical instinct” the article mentions is being heightened in all of us; the nightlife scenes depicted there would never have been appealing to me before, but now they even feel wrong.

Sometimes I feel like we are all being groomed to be more and more afraid. At the start, fear was something they wanted to avoid spreading. We were told the vast majority of people would only get a mild illness with this virus (when was the last time you heard that message?); that we should wash our hands well, avoid touching our faces, and carry on. There would be an epidemic, but that was OK as long as we flattened the curve so hospitals could cope. Then there was the sudden lockdown, and we never heard that hospitals coped, as it became all about the grim death toll competition with our neighbouring countries. And then deaths went back to normal, or even a little lower than normal; but now we’re obsessed even with case numbers. Zero covid is now the only appropriate ambition.

Is it that we underestimated it earlier in the crisis (and didn’t realise it warranted this much fear)? In what way?

As cases rise, now, blaming fingers are pointed at young people hammered by mixed messages and trying to get on with life. Even permitted social contact is inevitably clouded by guilt and fear, as public health bodies tactlessly warn us not to “kill our grannies” (as Carl Heneghan points out, people kill their grannies with viruses every Christmas, but we never give that any thought). For their own benefit and protection, we strip care home residents of the will to live by removing the social contact and activities that make life worth living.

What psychological toll is wrought on us by being asked to constantly behave as if we are infected with something that will kill someone if we don’t stay vigilant and keep it to ourselves? On the face of it, distancing and mask-wearing and hand hygiene are simple things, and I am certainly not against them. But for some, at least, they are a constant stressor, slowly, insidiously, etching fear deeper into our hearts. I don’t see anyone talking about this.

The worst of the burden of fear is borne by those who had been told to shield themselves from the virus due to their preexisting health issues. These people were directed to keep themselves at home behind closed doors for 4 months in fear for their lives, with no organised support to psychologically manage that situation and maintain rational thinking about their risks. Then at the end of July they were callously tossed out to work again, just as we started to talk about a second wave, apply localised lockdowns to squash outbreaks, and while the narrative around the virus shifts to an ever more fearful one.

It feels a bit ironic that I spent months in therapy learning to live with the constant likelihood of illness, the way everyone else apparently does without any problem… and then a new virus comes along and suddenly the rest of the world flips out and decides illness and death are impossible to coexist with. Which was exactly my starting point.

I honestly don’t know what I think or feel about this coronavirus a lot of the time, or how scared I should be. I feel schizophrenic. I can see it so many different ways. I think we have to try to be rational and balance the harms incurred with different actions, and we are not being helped to do that. We should be. This would pave the way for collective kindness. Some of the things that are shooting up out of this fear- and suppression-based approach – rejection of science and reason, conspiracy theories, covid denial – are truly scary.

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Pandemic deaths analysis

I did some analysis of deaths over this pandemic (because I’m morbid like that).

I calculated expected “normal” deaths for every week of 2020, based on 10-year-average age-specific death rates for each specific week of the year applied to the most recent age-specific populations. I also calculated an upper and lower significance threshold as twice the standard deviation. The graphs below compare these with the actual deaths from all causes (so far), in different age groups.

During the first wave of the coronavirus pandemic, excess deaths (defined by me in relation to expected deaths as calculated above) reached 0.98 of a month’s worth of extra deaths in England and Wales. The tally has since come down to 0.86 of a month for 2020 so far, as deaths have been a little lower than expected after the peak. In Scotland, the excess reached 0.57 of a month, and has since come down to 0.47 of a month’s worth.

The recent lower-than-expected death rates seem to indicate that the deaths of some very old or unwell people were brought forward just a little by COVID-19. Certainly it’s in the older populations that the recent death rates are low enough to reach significance.

Conversely, deaths in the 0-44 age range barely reached significant elevation during the peak. In Scotland, the death rate in that age group has not really come down since April and is still skirting significance. This can’t be due to the coronavirus directly but may be due to effects of the lockdown including reduced access to health services. NRS report that a good chunk of the excess deaths over this year were due to causes other than COVID-19, including dementia, genitourinary diseases and diabetes.

England and Wales analysis:

Scotland analysis:

If anyone reading this can help me with data for other countries, I’d love to expand the above analysis.

(Apologies, the y-axis label in each graph should just read “Deaths”, not “Deaths or cases”.)

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How bad will the next wave be?

The prevailing view has seemed to be that the virus has only reached a small fraction of the population, and that lockdown stopped it in its tracks; lifting lockdown will sooner or later result in resurgence that is just as bad as before or worse, unless we can manage to keep it down with distancing and sanitising and testing and tracing.

But there are other views, and there are certainly observations that contradict the above idea: why did Sweden’s infection rate peak and go down without a lockdown? Why has exponential growth tailed off in such a similar way across countries with a diversity of intervention levels and timings?

One suggestion has been that the virus has spread a lot further through the population than it seems; seroprevalence studies aren’t the whole story as there can be T-cell immunity and perhaps other types of immunity post-infection that we’re not detecting. It would mean a very high proportion of cases were asymptomatic. This seems legit up to a point – but I think extensive, unobserved, largely asymptomatic spread would mean that symptomatic cases would pop up all over the place seemingly unconnected to any others, and I don’t think that’s been the pattern.

Another idea is that a large proportion of the population are inherently not susceptible to the virus and won’t be infected. That doesn’t make sense to me either, because it would be much harder in that case to set off the rapid global spread that happened earlier this year.

I think it’s simply that the idea of exponential growth is wrong, as it’s based on a model in which people move around randomly interacting with others like gas molecules bumping into each other. We don’t do that, we have fixed homes and workplaces and social circles. Without hard borders anywhere, the virus will of course keep spreading, but more slowly. When it enters new susceptible communities, spread will take off exponentially again within those areas, and we’re seeing that in localised outbreaks now.

I don’t think a new wave will be as bad as the first, on a national level. I think the spread, as well as being slowed down naturally as before by limited movement of people, will be further slowed down by distancing, sanitising, masks, and some immunity from the first wave.

Reapplying lockdowns is like cracking a nut with a sledgehammer and I fear more for the collateral damage of that. We seem at times to be fixated on achieving “elimination” at a moment in time, which will be meaningless in the grand scheme of things.

The way we’re operating now – Phase 3 of easing – is pretty much what Sweden has been doing throughout. (Maybe a bit more cautious – I don’t think they’re using masks in Sweden.) It feels to me like a balanced approach that will not overwhelm healthcare. We’ve had a good summer with this approach. I hope we can hold our nerve and continue.

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Blogging daily life

So, I’ve got a new blog site for my daily life updates: https://masksandrainbows.wordpress.com/

That’s where I’ll post them from now on. Visitors welcome, as ever, so feel free to go and subscribe there! I just wanted to keep Meaning and Truth for what it used to be – essays and reflections that I put considerable care into; my deep and thoughtful place.

Writing (almost) daily with a quick rundown of each day during the pandemic has been a very different exercise, but I’m enjoying it, even after nearly 5 months. I always used to do a lot of writing during times of change – I remember writing screeds during my first week in Malawi – I think it helps me process things, or avoid feeling overwhelmed. Also, it preserves memories really well and provides a way of sharing those memories or experiences. Maybe one day Eilidh will like to read about the pandemic she lived through, or the third birthday party she had to have online.

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Is lockdown worthwhile?

It’s so strange to find myself philosophically estranged from most of my social circle in the sense that everyone seems to be heavily pro-lockdown while I’m more of a sceptic. Disturbingly, the non-pro-lockdown voices being heard are mostly libertarian / hard right / anti-vaxxers, and they’re having mass gatherings in protest; I don’t exactly want to be associated with that.

For me the scepticism is: we don’t know if there will be a vaccine. Even if there is, how long will it be until it’s not only ready but available in huge quantities to be administered to the majority of the population?

I find it hard to imagine those countries currently considered “successful” can seriously contain the virus until then with testing and tracing, unless they close their borders or impose quarantine, which has its own problems; I think it will take lockdown-type restrictions on and off to keep the infection rate as low as people want it to be, and I think the human cost of that (e.g. this among many other things) is probably going to be too high – especially if there is ultimately no effective vaccine, in which case it’s just delaying the inevitable.

As for countries (like the UK) that didn’t manage to contain it, I have a hunch that opening up now won’t be as painful as we fear: I think that the infection may have spread a lot further already than official reporting, and / or that the epidemic growth is more self-limiting than Imperial models suggested, so that some places might already have achieved a decent amount of immunity (e.g. London). But what do I know? Nothing really. This is just what makes most sense to me so far.

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Rules and fear

It’s been interesting to see how fully and swiftly a lot of people adopt imposed rules as an entire way of being in this pandemic crisis. I’ve just joined a Facebook group for people shielding (i.e. very high-risk people who are trying to take every possible measure to avoid contracting the coronavirus), and even there, so much discussion is around whether we are “allowed” to do this or that. To my mind, the questions should be, what is the level of risk to me if I do this or that? Some people, simply because they haven’t been told otherwise, are still holding on to a forlorn hope that they will somehow be able to stop shielding after the original 12 weeks is up.

I keep thinking about Sweden, where apparently the citizens are trusted to make their own responsible choices to a large extent, based on transparent information. What has happened in our culture that we have become so dependent on being told what to do?

It sort of reminds me of religious discussions from the blogging days of old. The irony of followers of Jesus reconstructing, from his recorded words, a legalistic religiosity of the very type he tried to dismantle. The realisation that I was never going to fit in to a religious community because I couldn’t fully swallow the rules (although I gave it a good try).

I have some difficulty swallowing the current rules, too. Why can’t I have a picnic or sunbathe in a park, if I can do this without getting anywhere near anyone and evidence indicates transmission risk outdoors is very low anyway? The Scottish Government has already recognised that allowing unlimited outdoor exercise – as opposed to just one spell a day – should make “very little difference” to the infection rate. It seems to me the benefits of outdoor freedoms are huge and the risks are relatively tiny.

As restrictions start to be eased, rules become more and more complicated and harder to make sense of, as this Facebook post (I’ll put a screenshot at the bottom of the post) illustrates well. I’m not saying the UK Government couldn’t have been clearer on Sunday, but it seems obvious we’ll experience more confusion the more we move away from “stay at home” but still expect clear rules for everything.

The current mood in my social media circles is very much one of fear: give us rules, keep up restrictions, clamp down, get this situation fully under control. But what control? As I wrote previously, I’m scared of the fucking virus, but I’m also really scared we will lose too much – outdoor freedoms being the very least of it – by trying too hard to suppress what might be insuppressible. What exactly are we hoping for? As someone wrote in a public post yesterday, “we were never going to social distance this thing into nonexistence”…

I get a great sense of calm from listening to Anders Tegnell and Johan Giesecke. I hear them say the Swedish curve has flattened, even with more moderate social distancing, and this is partly due to the development of some immunity in a significant chunk of the population. I feel that’s good news, if true. And I do feel it makes some sense. Sweden’s deaths per capita aren’t the worst – and Giesecke’s constant refrain anyway is to wait a year before comparing countries (his belief is there will not be much difference by then). Care homes have been a problem everywhere and lockdown hasn’t really helped them.

I also like the UnHerd YouTube channel for its in-depth discussions and interesting variety of interviewees with different expertise. A German virologist gave the most reassuring story I’ve heard about how the virus might become something we can live with, even in the absence of a vaccine (there has been no successful vaccine developed against any other coronavirus) and without necessarily lifelong immunity following infection. He also finds evidence the virus has spread further than official estimates, and the fatality rate is correspondingly smaller.

I suppose I find all this comforting because if they are right, maybe this crisis will all be over sooner than we think. The UK’s horror story of 40,000+ deaths by now – according to these hypotheses – at least reflects enough infections in the population to have produced a decent amount of immunity. So while nothing can take away the tragedy that has happened, maybe the process of opening up will be easier than everyone fears. I certainly prefer that idea to the prevailing conception that our only way to meaningfully un-pause society without risking a horrific flare-up is a vaccine that may or may not be possible to develop.

I guess we all have to find some comfort somewhere, some hope.

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