New York Stop CMV (cytomegalovirus) - Who we are and why we care.




New York Stop CMV (cytomegalovirus) families and health professionals work together to prevent congenital CMV, or test it, through legislation on testing and education, and though awareness campaigns. We believe it's a woman's right to be educated about CMV ( "significant racial and ethnic differences exist in the prevalence of cCMV", Racial and Ethnic Differences in the Prevalence of Congenital Cytomegalovirus Infection", 2018). (Watch: "CMV Racial Disparities").


Most mothers, like myself, were unaware how to prevent contracting CMV before getting pregnant, the ideal time to make any necessary changes  to our occupation or habits, because half of pregnancies are unplanned

While many medical professionals will say that "Good hand washing is important," there are several specific changes a person can make to protect their current for future pregnancies.  
Many of us write letters to the editor asking them to publish specific steps one can take to reduce changes of contracting CMV. Sample:

Dear Editor:

Thank you for covering the topic of cytomegalovirus (CMV), the leading viral cause of birth defects. According to the Centers for Disease Control and Prevention (CDC),  someone may be able to lessen the risk of getting CMV by "not sharing food, utensils, or cups with a child" (CDC.gov/CMV). Downloadable CDC flyers are available in English or Spanish

The National CMV Foundation recommends: "Do Not Put a Pacifier in Your Mouth. Avoid Contact with Saliva when Kissing a Child. Do Not Share a Toothbrush. Wash your hands often with soap and water for 15-20 seconds, especially after the following activities:

The National CMV Foundation provides "Educational Downloads".

Many women caring for toddlers (their own or professionally), including myself, have admitted to using diaper wipes to wipe off urine or saliva to save time. Diaper wipes do not effectively remove CMV from hands (Stowell et al., 2014). 

Thank you. 

Lisa Saunders

New York Stop CMV

LisaSaunders42@gmail.com


Dr. Sallie Permar, Chair, Department of Pediatrics, Weill Cornell Medicine, and pediatrician-in-chief, New York-Presbyterian Komansky Children's Hospital, stated that CMV is "'a virus that has a PR problem. It's the most common congenital infection in every population...It's a virus we have recognized for over 60 years as the cause of birth defects and brain damage in infants...'" (“Dr. Sallie Permar’s Work Protecting Mothers, Infants from HIV, CMV Lands Her Among ‘Giants’”, Weill Cornell Medicine, 2021).

Since CMV is the leading viral cause of birth defects, why aren't most women educated about it?  The following reasons provide some answers: 

1) Doctors don’t want to frighten, worry or  burden” patients: 
New York Times: "Guidelines from ACOG [American College of Obstetricians and Gynecologists] suggest that pregnant women will find CMV prevention 'impractical and burdensome,' especially if they are told not to kiss their toddlers on the mouth — a possible route of transmission.” (Saint Louis, 2016). 

2) Fearmongering: "Nearly half of surveyed healthcare professionals (HCPs) hesitate to discuss CMV, citing concerns of fearmongering among their patients."(Panther, MD, "Moderna Addresses Awareness Gap, Builds Community Trust To Boost CMV Trial Recruitment," Sept. 20,2023)

3) Medical training downplays the dangers. Pediatrician Megan Pesch, M.D., of the University of Michigan’s C.S. Mott Children’s Hospital, whose third daughter was born with congenital CMV and a progressive hearing loss, said, "I went back and looked at my notes at what I’d learned in residency and medical school, and what we learned was so rudimentary and basic...I waver between feeling guilty and feeling furious. I have spent — how many years of my life in developmental pediatrics? — how could I not have known?”(Washington Post, "How a common, often harmless virus called cytomegalovirus can damage a fetus," May 15, 2021.)

4) Caregivers/Teachers at greater risk, but there are no federal laws governing CMV education policies: Although U.S. workers have the right to “receive information and training about hazards” (Occupational Safety and Health Act of 1970), the Department of Labor states, "Education and training requirements vary by setting, state, and employer."

5)"Infection is usually asymptomatic in both mother and infant, and when symptoms do occur, they are non-specific, so most CMV infections go undiagnosed” (Cannon and Davis, 2005). (This is why testing all newborns for CMV is important.)


CMV prevention education has been proven effective (studies analyzed in, "The Role of Prenatal Counseling in Preventing Congenital CMV," Massachusetts cCMV Coalition, Colleran, C., 2020). In fact, recent newborn screening for CMV has seen a decrease in congenital infections. "The hygienic precautions we all have engaged in during the pandemic -- masking, hand-washing and infection prevention behaviors -- were almost certainly responsible for the reduction in CMV transmission, which in turn protected mothers and newborns from the potentially devastating effects of the CMV virus," Schleiss said in a school news release. Researchers also attributed the reduction to stay-at-home initiatives and the closing of group child care centers during those months."(Pandemic Silver Lining: Drop in Infections That Cause Birth Defects, USNews.com, Sept. 12, 2022).

Please see below my signature and personal story for more contacts regarding CMV prevention.

Sincerely,

Lisa Saunders, New York Stop CMV, Baldwinsville (near Syracuse), NY. Featured in USA TODAY, "This virus is a leading cause birth defects. Why isn't it screened more?"(Eduardo Cuevas, 2023)


My CMV story: Our daughter Elizabeth was born with brain damage in 1989 because I contracted CMV just prior to or during my pregnancy while living in Maryland as an "in-home," licensed child care provider. I might have prevented her disabilities had I known to lessen my "risk of getting CMV by reducing contact with saliva and urine from babies and young children...not sharing food, utensils, or cups with a child" (CDC.gov/CMV). I should have never used diaper wipes, which are not effective at removing CMV, to clean off surfaces and my hands after when cleaning up after toddlers.  In 2015, when living in Connecticut, I helped the state pass a law requiring the testing of newborns for CMV who failed their hearing screen. Now living in New York, I was thrilled when "Elizabeth's Law" passed in 2022 because it requires providing CMV prevention information ("The passing of ‘Elizabeth’s Law’: A priceless gift”, River Reporter, 2022). 

    I continue to contact newspapers hoping they'll cover CMV (Boston Sunday Globe, "Caregivers and teachers are also at risk”, 2023). My husband and I are walking across New York State between Albany and Buffalo on the Erie Canal Trail, leaving behind #Stop CMV rocks (see one-minute videoto comply with Congress' recommendation that "more effort be taken to counsel women of childbearing age of the effect this virus can have on their children" (112th Congress, 2011). Congress established the Erie Canalway National Heritage Corridor in 2000 because it “facilitated the movement of ideas …like…women's rights…across upstate New York to the rest of the country”(106th Congress). I believe women have the right to know about CMV. Many women across the country have signed my document, "Declaration of Women's CMV Rights and Sentiments," based on the 1848 Women's Rights "Declaration of Sentiments" signed in Seneca Falls. The song, "Had I known (about CMV)" by Debra Lynn Alt expresses how many of us mothers feel when we don't learn about CMV prevention until after our baby is born disabled by it.


To learn more about CMV prevention, I suggest contacting: 


Brandi Hurtubise B.A., New York National CMV Alliance Chair, 

nationalcmvny@gmail.comnationalcmv.org


Amanda Devereaux RN, BSN

National CMV Foundation, Program Director, 

952-201-6289, amanda.devereaux@nationalcmv.orgnationalcmv.org


CMV Reduction in the Workplace

Nellie Brown, MS, CIH
Director of Workplace Health & Safety Programs

Lead Programs Manager

Certified Industrial Hygienist

ILR Outreach Statewide

And

Buffalo Co-Lab

617 Main St. – Suite 300, Buffalo, NY 14203

 ILR School

Cornell University
t. 716 852 1444 x111
njb7@cornell.edu | www.ilr.cornell.edu


New York's CMV Timeline
2018Senate Bill S2816, which requires testing newborns for CMV if they fail their hearing screen, was passed in New York.  The bill was authored by Assemblymember Linda B. Rosenthal who read the 2016 New York Times article, "CMV Is a Greater Threat to Infants Than Zika, but Far Less Often Discussed," and thought something should be done. 
2022: “Elizabeth’s Law,” named in memory of our daughter, Elizabeth Saunders, was passed in New York. It requires the provision of CMV educational materials to child care providers and pregnant women. 
2023 
1)  "The New York State Department of Health announced that effective October 2, 2023, all babies will be screened for Congenital Cytomegalovirus (cCMV), making New York the second state in the nation, after Minnesota, to screen all babies for the virus" (NY Dept. of Health, Sept. 29, 2023). The NY Newborn Screening Program is provisionally adding congenital CMV (cCMV) to its "screening panel for a period of one year" using dried blood spot (DBS) (NY Dept. Health, Wadsworth Center, Sept 1, 2023).  

2) On Sept. 20, 2023, the New York Assembly and Senate introduced bill A07997/S07659: "Requires cytomegalovirus screening for every newborn by administration of a urine polymerase chain reaction (PCR) test."  "State Sen. John Mannion, who sponsors [this] bill that would make the screening permanent, said early diagnosis and treatment are key in mitigating long-term health problems for babies, emphasizing the need for screening. Assemblywoman Linda Rosenthal also sponsors the bill (NYSenate.gov:“Senator Mannion and Assemblymember Rosenthal Announce Addition of Congenital Cytomegalovirus (CMV) to State's Routine,” Sept. 29, 2023).


New York Parents Share  Stories:
Brandi Hurtubise of Buffalo, New York National CMV Alliance Chair for the National CMV Foundation (nationalcmvny@gmail.comnationalcmv.org), told the National CMV Foundation about her second child Samantha, born in  2016 with congenital CMV "No one told me I shouldn't share drinks or food with my toddler while I was pregnant with [Samantha]. Or that I needed to wash my hands after every single diaper change. That I needed to be cautious of his saliva and urine because it could be carrying a virus that would harm my unborn baby. I didn't know because CMV isn't commonly talked about or educated on; even though it is incredibly common."  You can "meet" Brandi in the PAC-B TV, 2021, interview. Brandi hosted a 5 K to raise funds and awareness in June of 2023. Kristin Schuster, myself and Brandi are featured in the article, "How a Baldwinsville mother fought for 30 years to pass a law that might have saved her daughter", The Post-Standard, Vallelunga, E., Jan.1, 2023, Syracuse.com, Dec. 27, 2022 (Facebook). 
Kristin Schuster of Canandaigua, mom to Autumn (born 2015), told me, "Unfortunately, my daughter wasn't diagnosed with congenital CMV until 18 months old--well after the opportunity had passed to receive treatment most effective when given between ages zero to six months. She was not diagnosed with congenital CMV at birth despite failing her newborn hearing screen multiple times, having 'low for gestational age' birth weight, and microcephaly. Autumn received her first pair of hearing aids for bilateral severe hearing loss at 4 months old, glasses for vision impairment at 5 months, an MRI showing brain calcifications, very significant global delays, and received a g-tube for feeding at 15 months of age. Up until then, all of the doctors and specialists we were seeing claimed that her diagnoses were 'unrelated.' It wasn't until I read an article about CMV posted in a Facebook group for Rochester parents of children with hearing loss that I had that 'aha' moment that congenital CMV must be the root cause of all of my daughter's difficulties. When I requested to have her tested for CMV, I was initially given pushback, but when I demanded her newborn blood spot be tested, her neurologist arranged to have it tested from where it was banked in Albany. When the test came back, we finally had our confirmed diagnosis of congenital CMV--too late for her to receive treatment in the optimal first months of life." Kristin's daughter Autumn was her first child, so Kristin assumes she caught CMV from the young children she worked with. Kristin told me, "I was teaching in a pre-kindergarten inclusion classroom while pregnant with Autumn and was unaware of the dangers of CMV exposure." (You can watch Kristin with her daughter Autumn at our June CMV Awareness Month event in the music video, Had I Known, Lyrics and Music by Debra Lynn Alt , 2021.) 

Angela Cote of Buffalo appreciates the 2018 CMV law because it led to the quick diagnosis of why Elise, born in 2019, failed her newborn hearing test (giving her access to early intervention), but Angela wishes she had known about CMV before her pregnancy.  She told Lisa Saunders in a TV interview how shocked she was by the diagnosis. She couldn’t believe she had never heard of CMV, especially since she was surrounded by young children as a nanny and the mother of a toddler  (PAC-B TV, 2021).
Tabitha Rodenhaus of Buffalo. The silver #Stop CMV rocks being left across New York State are painted by Kaia’s mom, Tabitha. Kaia likes to watch her mom paint. Silver is the color of CMV awareness. 

Kelly Smolar Gerne, a mechanical engineer from Brooklyn told Lisa Saunders, "My daughter Alexis was born in August 2020 with congenital CMV. With the help of Northwell, Dr. Sood and Nurse Stellato, Alexis is thriving because she was diagnosed and treated early following a failed newborn hearing test. While I am angry about the lack of CMV education prior and during my pregnancy, the CMV testing law passed in 2018 meant our family was the recipient of those who had fought before us. I want to continue that forward so all babies in the State of New York will have the option for early intervention."

Jessica Keukelaar of Macedon is the mother of Kyleigh, born with congenital CMV in 2018. She had no other children at home during her pregnancy. She shared with Lisa Saunders the letter she sent to Assemblymember Rosenthal’s office where she stated, “I was a caregiver in a daycare center when I became pregnant with my daughter born with congenital cytomegalovirus (CMV)... I had never heard of CMV or the precautions to take. This bill [Elizabeth’s Law] is important to me because it came as a complete shock when my daughter was born full term, in 2018, with numerous urgent health issues due to CMV. She was transferred to a different hospital to be in the NICU where she spent the first two weeks of her life; she was very ill. My daughter has developmental delays, spastic cerebral palsy which affects her entire body, eating and digestive difficulties, progressive hearing loss, microcephaly, and more. Some of the extra equipment Kyleigh requires on a daily basis are, a wheelchair due to immobility, gastrostomy tube for proper nutrition, cochlear implant for hearing, and special orthotics for her hands, wrists, ankles, and feet. She had surgery for her cochlear implant at 17 months, a double hip reconstruction at two years, and surgery to have her g-tube placed at three years. She also takes numerous medications several times per day, and receives 11 Botox injections quarterly to help with her spasticity. Congenital CMV has affected every aspect of Kyleigh’s life, as well as our whole family. I wish that someone took the time to educate me about CMV since I was at an increased risk of infection.” Images of Jessica with her daughter Kyleigh can be seen in Had I Known) (about CMV), Lyrics and Music by Debra Lynn Alt."


Edel Law of Tappan, discussing "Elizabeth's Law" with Lisa Saunders said, "This bill is important to me because my three-year-old daughter has congenital CMV. It came as a total shock when at 31 weeks pregnant, I found out she had abnormal brain development. Upon further testing, we found out I had contracted and passed CMV onto my daughter. After learning about CMV, it was not shocking that I contracted the virus since I had a toddler in preschool and was an early childhood educator. My daughter has developmental delays, single sided deafness, wears a cochlear implant, and has a form of heart failure."


 Lisa Saunders of Baldwinsville, formerly of Suffern: My story above. Media coverage of my work includes: 

Democrat and Chronicle and Lohud,: “New York begins screening newborns for CMV virus that causes birth defects. What to know” (Robinson, D., Oct. 4, 2023)


USA TODAY: "This virus is a leading cause birth defects. Why isn't it screened more?" (Cuevas, E. Oct. 2, 2023).


The Citizen: “NY to begin pilot CMV newborn screening program” (Harding, R. Sept. 28, 2023).


NYSenate.gov:“Senator Mannion and Assemblymember Rosenthal Announce Addition of Congenital Cytomegalovirus (CMV) to State's Routine,” Sept. 29, 2023.


Public Access Channel Baldwinsville: The Path to CMV Prevention - 03/20/2023 (my 30-year cytomegalovirus journey and laws passed and hoped for).


The Post-Standard: "How a Baldwinsville mother fought for 30 years to pass a law that might have saved her daughter", Emma Vallelunga, Jan.1, 2023, Syracuse.com, Dec. 27, 2022 (Facebook).


CNYCentral.com:”Baldwinsville mom celebrates new law in daughter's name to protect pregnant women, babies”, Megan Coleman, Dec.15, 2022 (Facebook).


The River Reporter: Viral alert: A silent virus that scars for life, Dec.13,2022


New York Family: “Elizabeth’s Law for CMV Education Passed in New York”, Kaitlyn Riggio, Dec. 8, 2022.


U.S. News & World Report: "Editorial Roundup: New York", Associated Press, Dec. 7, 2022 (scroll down to: Auburn Citizen, December 1, 2022.Editorial: Elizabeth’s Law poised to help families avoid heartbreak).


Erie Canalway National Heritage Corridor: “Congratulations to Lisa Saunders, Author/TV Host and her husband, Jim, two Canalway Challengers who have walked half the length of the Erie Canal to raise awareness [of] the impacts of cytomegalovirus (CMV)” Dec. 6, 2022


The Citizen: “Our View: Elizabeth’s Law poised to help families avoid heartache,”The Citizen Editorial Board, Dec. 1, 2022


The Citizen: "Hochul signs 'Elizabeth's Law,' named for Auburn native's daughter, to raise CMV awareness", Robert Harding, Nov. 29, 2022.


NYAssembly.gov: “Assemblymember Linda B. Rosenthal Bill to Educate Childcare Providers, Pregnant Patients on Cytomegalovirus Dangers Signed into Law,” November 28, 2022.


NYSenate.gov: “Senator John W. Mannion’s legislation to protect pregnant women from dangerous viral infection that’s a leading cause of birth defects is signed into law,” November 28, 2022.


The Citizen: "NY lawmakers OK CMV awareness bill named in honor of CNY couple's daughter", Robert Harding, June 1, 2022.


Eagle Newsroom, "Baldwinsville couple advocates for 'Elizabeth's Law' to stop cytomegalovirus: Bill named in memory of their daughter," Dec. 14, 2021.


Spectrum News: "Couple pushes for law in memory of their daughter" (Houghtaling, J., Jul. 01, 2021). Includes an interview with Dr. Sunil Sood.


Finger Lakes Times, "Trail of Hope celebration in Lyons marks CMV Month in New York" (Buchiere, S., Jun 11, 2021).


Finger Lakes Times: "MAKING A DIFFERENCE: Couple brings awareness to threat to infant health: CMV", (Buchiere, S.,June 4, 2021).


The Citizen: "NY Senate passes bill, named for CNY couple's daughter, to boost CMV awareness", (Harding, R., June 2, 2021).


Syracuse Woman magazine, "Fighting CMV One Step at a Time (p.28)", (Vallelunga, E., May 2021)


DeCracker, June CMV Awareness Month Had I Known, Lyrics and Music by Debra Lynn Alt (2021).


The Citizen: "'Elizabeth's law,' named for CNY couple's daughter, would boost CMV awareness", (Harding, R., May 4,2021)


The Citizen, "Challenge for Change: Walking across NY to raise awareness of CMV", (Wilcox, D., Mar 31, 2021)


News 8: National CMV Awareness Month: Lisa Saunders, musician, Debra Lynn Alt, and pediatrician Brenda K. Balch, M.D., “Mystic mother raises awareness of CMV, a risk for pregnant women and their babies”, (Sarah Cody, 2018)


Simsbury Community Television, Inc., Daughters of the American Revolution, The Abigail Phelps Chapter presents: Congenital Cytomegalovirus with guest Lisa Saunders (May 25, 2017).


Sarah Cody, News Reporter, Facebook CMV Prevention video (June 2018)


Connecticut Magazine: Mystic Mom 'Overwhelmed' by Governor Signing Law on ‘Stealth Virus’ That Can Catch Pregnant Women Unaware (OFGANG, E., 2015)


Cornell Alumni Magazine: In Memory of Elizabeth: Her daughter's death from a preventable disability spurs Lisa Avazian Saunders '82 into action (Bond, A., 2015).


Clinical Advisor magazine: “Connecticut passes cytomegalovirus screening law for newborns” (Aiken, B., 2015)


News 8 Medical/Health Report: "Mystic mom raising awareness about potentially deadly virus" (Jocelyn Maminta, 2015)


News 8: Preventing Congenital CMV During Pregnancy (Alex Ceneviva, 2015)


Fox CT, Hartford Courant: “Mother Working to Protect Pregnant Moms From Dangerous Virus“(Sarah Cody, 2014)


Mystic River Press: “Saunders seeks help with CMV ‘silent virus’ prevention bill” (Souza, M., 2014)


The Day: "Loss and love: Author raises awareness about preventable birth defect" (Barry, A. 2013)


Times Herald Record: “What every pregnant woman needs to know” (Botti, D., 2009)



Sample media on just the 2023 pilot study from Google Alerts


New York State Department of Health
Cytomegalovirus (CMV) is a very common virus. A baby can be infected when a pregnant person contracts the virus and passes it to their developing baby ...

Newborns in NY to be screened for congenital cytomegalovirus - News 12 - Hudson Valley
News 12 - Hudson Valley

All newborns in New York to be screened for Congenital Cytomegalovirus beginning Monday
CNY Central
— New York State has become the second state in the country, after Minnesota, to screen all newborns for Congenital Cytomegalovirus, or cCMV. The ...

All newborns in New York to be screened for Congenital Cytomegalovirus beginning Monday
WRGB
ALBANY, N.Y. — New York State has become the second state in the country, after Minnesota, to screen all newborns for Congenital Cytomegalovirus, ...

This virus is a leading cause birth defects. Why isn't it screened more?
USA Today
Cytomegalovirus, or CMV, infects more than half of adults over their lifetime, typically presenting no symptoms even as it stays within a person's ...

Newborns in NY to be screened for congenital Cytomegalovirus starting today - News 12 - Brooklyn
News 12 - Brooklyn
Starting today, the state will begin testing newborns for a common virus that can cause deafness. The New York Department of Health says all ...

Newborns in NY to be screened for congenital Cytomegalovirus starting today
Cleburne Times-Review
Infants born with CMV can have long-term health complications like hearing and vision loss, seizures and disabilities.

NY baby screenings add test for virus causing deafness - Newsday
Newsday
Starting Monday, newborns in New York will be screened for congenital cytomegalovirus — a virus that can cause deafness or other health ...

Common Virus That Could Cause Birth Defects Will Now Be Screened For - The Messenger
The Messenger
The New York State Department of Health will begin screening all newborn babies in the state for congenital cytomegalovirus (CMV), a virus that is ...

NY Will Begin Screening Newborns For Congenital Cytomegalovirus, Becoming Second ...
Daily Voice
Cytomegalovirus (CMV) is the most common viral infection in newborns and most people infected show no symptoms. However, about 10 percent of infants ...

New York State to start screening newborns for another virus - WETM
WETM
Congenital Cytomegalovirus symptoms in infants include low birth rate, rashes, jaundice, microcephaly (a small head), seizures, damage to the retina, ...

NY to begin pilot CMV newborn screening program - The New York State Senate
The New York State Senate
View the article here. New York will begin screening newborns for congenital cytomegalovirus through a pilot program and two state lawmakers are ...

Senator Mannion And Assemblymember Rosenthal Announce Addition Of Congenital ...
The New York State Senate
Senator Mannion And Assemblymember Rosenthal Announce Addition Of Congenital Cytomegalovirus (CMV) To State's Routine Newborn Screening Panel.

NY to begin pilot CMV newborn screening program - Auburn Citizen
Auburn Citizen
Cytomegalovirus, or CMV, is a common virus, according to the Mayo Clinic. But pregnant women who contract the virus could infect their babies. This ...

Most NY nursing homes already meet federal staffing rule, calling into question whether ...
Crain's New York Business
... startup raises $14M in Series A fundingState receives contract to screen newborns for congenital cytomegalovirus in one-year pilot.

Senator Mannion and Assemblymember Rosenthal Announce Addition of Congenital ...
NYS Senate
SYRACUSE, NY – Senator John W. Mannion and Assemblymember Linda B. Rosenthal today announced the addition of congenital cytomegalovirus (CMV,) the ...

Testing newborns for cytomegalovirus set to begin in New York this fall - WSHU
WSHU
... at Stony Brook Children's Hospital, about how to stay safe from the commonly spread cytomegalovirus, and the dangers the virus presents to infants.

NOTE: after seeing the transcript of an interview on WSHU public radio, I wrote in: Thank you for the story, "Testing newborns for cytomegalovirus set to begin in New York this fall". It states that "WSHU’s Madi Steddick spoke with Dr. Sharon Nachman, the division chief of pediatric infectious diseases at Stony Brook Children’s Hospital, who is leading a year-long pilot program." I'm hoping you can do another piece to explain how women of childbearing age can prevent contracting CMV just prior to or during pregnancy. When WSHU [Madi Steddick] asked:  "All right. And I'm curious, are there any preventative measures that expecting mothers or parents can take seeing as the disease tends to have no symptoms shown?" SN [ Dr. Sharon Nachman] answered: "At this point, there are none. Good hygiene obviously is important. Good hand washing if your children are in school, and when they come home is important...."

I asked that WSHU continue the conversation by adding  specific CMV prevention tips. 

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