Antibiotics, Ecoantibiotics
Better Ways to Guard Water in Medical Settings
Mar
Water safety is a critical aspect of infection control in healthcare facilities. Waterborne pathogens can pose significant risks to patients, particularly those with compromised immune systems. Despite advances in water treatment and distribution systems, outbreaks of waterborne illnesses continue to occur in medical settings, highlighting the need for improved water safety measures.
This article explores the importance of water safety in healthcare facilities and discusses best practices for preventing and managing waterborne infections. By implementing comprehensive water safety plans, healthcare professionals can ensure the delivery of safe, high-quality care to their patients while minimizing the risk of waterborne outbreaks. The article also addresses common patient concerns and provides practical guidance for maintaining water safety in medical settings.
The Importance of Water Safety in Healthcare Facilities
Water safety is a critical component of infection prevention and control in healthcare facilities. Waterborne pathogens, such as Legionella, Pseudomonas, and nontuberculous mycobacteria, can cause severe infections in vulnerable patient populations[1]. These infections can lead to prolonged hospital stays, increased morbidity and mortality, and significant healthcare costs.
Waterborne Pathogens and Their Impact on Patient Health
Waterborne pathogens can thrive in the complex water distribution systems of healthcare facilities, including plumbing, cooling towers, and medical equipment. Patients with weakened immune systems, such as those undergoing chemotherapy, organ transplantation, or advanced age, are particularly susceptible to waterborne infections[2]. These infections can manifest as pneumonia, surgical site infections, or bloodstream infections, among others.
Regulatory Requirements for Water Quality in Medical Settings
Healthcare facilities are subject to stringent regulations and standards for water quality, such as those set by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). These guidelines outline best practices for water treatment, distribution, and monitoring to minimize the risk of waterborne outbreaks. Compliance with these regulations is essential for maintaining accreditation and ensuring patient safety.
The Role of Healthcare Professionals in Maintaining Water Safety
Healthcare professionals play a crucial role in maintaining water safety in medical settings. This includes:
- Educating patients and visitors on proper hand hygiene and water safety precautions
- Reporting any signs of water contamination or potential waterborne illnesses
- Participating in regular training and drills related to water safety and emergency response
Economic Burden of Waterborne Illnesses in Healthcare
Waterborne illnesses in healthcare facilities can have significant economic consequences. These include direct costs, such as increased length of stay, diagnostic testing, and treatment, as well as indirect costs, such as lost productivity and legal liabilities[3]. Implementing effective water safety measures can help mitigate these costs and protect the financial well-being of healthcare organizations.
Common Waterborne Pathogens in Medical Settings
Several waterborne pathogens pose significant risks to patient health in medical settings. These pathogens can colonize water distribution systems, medical equipment, and other water sources, leading to healthcare-associated infections (HAIs). Understanding the characteristics and transmission routes of these pathogens is essential for developing effective prevention and control strategies.
Legionella pneumophila and Legionnaires’ Disease
Legionella pneumophila is a gram-negative bacterium that thrives in warm, stagnant water systems. It is the primary cause of Legionnaires’ disease, a severe form of pneumonia that can be life-threatening in immunocompromised patients[4]. Legionella can colonize cooling towers, hot water systems, and decorative fountains, and can be transmitted through inhalation of contaminated aerosols.
Pseudomonas aeruginosa and Its Associated Infections
Pseudomonas aeruginosa is an opportunistic pathogen that can cause a wide range of infections, including pneumonia, urinary tract infections, and surgical site infections. It is particularly problematic in healthcare settings due to its ability to form biofilms and resist disinfection[5]. Pseudomonas can contaminate water sources such as sinks, toilets, and medical equipment, and can spread through direct contact or ingestion of contaminated water.
Mycobacterium avium Complex (MAC) and Its Impact on Immunocompromised Patients
Mycobacterium avium complex (MAC) is a group of nontuberculous mycobacteria that can cause severe infections in immunocompromised patients, such as those with HIV/AIDS or undergoing transplantation. MAC can colonize hospital water systems and contaminate medical devices, leading to disseminated infections with high mortality rates.
Other Emerging Waterborne Pathogens of Concern
In addition to the well-known pathogens mentioned above, several emerging waterborne pathogens are of growing concern in medical settings. These include:
- Acinetobacter baumannii: A gram-negative bacterium associated with ventilator-associated pneumonia and surgical site infections[6]
- Stenotrophomonas maltophilia: An opportunistic pathogen that can cause respiratory tract infections and sepsis in immunocompromised patients
- Naegleria fowleri: A free-living amoeba that can cause rare but fatal brain infections through contaminated water exposure
Water Distribution Systems in Healthcare Facilities
Water distribution systems in healthcare facilities are complex networks that deliver potable water to various points of use, including patient rooms, operating theaters, and diagnostic areas. These systems can serve as reservoirs for waterborne pathogens if not properly designed, maintained, and monitored. Understanding the components and potential vulnerabilities of water distribution systems is crucial for ensuring water safety in medical settings.
Components of Healthcare Water Distribution Systems
A typical healthcare water distribution system consists of several key components:
- Water source: The origin of the water supply, which can be a public utility or an on-site well
- Water treatment: Processes such as filtration, disinfection, and softening to ensure water quality
- Storage tanks: Vessels for holding treated water before distribution
- Piping network: The complex network of pipes, valves, and fittings that deliver water to various outlets[7]
Each component plays a critical role in maintaining water quality and preventing the growth and spread of waterborne pathogens.
Potential Vulnerabilities in Water Distribution Systems
Water distribution systems in healthcare facilities can have several potential vulnerabilities that increase the risk of waterborne pathogen growth and transmission. These include:
- Dead legs: Unused or infrequently used pipes that can lead to water stagnation and biofilm formation
- Inadequate water temperatures: Water temperatures outside the recommended range can promote the growth of pathogens such as Legionella[8]
- Aging infrastructure: Older pipes and fixtures can corrode, leak, or develop biofilms that harbor pathogens
- Cross-connections: Unintended connections between potable and non-potable water systems that can introduce contaminants
Identifying and addressing these vulnerabilities through regular assessments, maintenance, and upgrades is essential for maintaining water safety.
Water Safety Plans and Risk Management
To mitigate the risks associated with water distribution systems, healthcare facilities should develop and implement comprehensive water safety plans (WSPs). These plans should include:
- System assessment: A thorough evaluation of the water distribution system to identify potential hazards and vulnerabilities
- Monitoring and testing: Regular sampling and analysis of water quality parameters, such as temperature, pH, and disinfectant levels[9]
- Corrective actions: Procedures for addressing water quality issues and preventing the spread of waterborne pathogens
- Documentation and communication: Clear records of water safety activities and effective communication among healthcare staff, patients, and visitors
By implementing WSPs and proactively managing water distribution systems, healthcare facilities can significantly reduce the risk of waterborne infections and ensure the delivery of safe, high-quality care.
Water Treatment Methods for Medical Settings
Effective water treatment is essential for preventing the growth and spread of waterborne pathogens in healthcare facilities. Various physical, chemical, and biological methods can be employed to ensure water quality and safety. The selection of appropriate treatment methods depends on factors such as the water source, distribution system characteristics, and specific microbial risks.
Physical Water Treatment Methods
Physical water treatment methods rely on the removal of contaminants through physical processes such as filtration and ultraviolet (UV) irradiation. Filtration techniques, including membrane filtration and sand filtration, can remove particulate matter, microorganisms, and some dissolved contaminants[10]. UV irradiation uses high-intensity light to inactivate microorganisms by damaging their DNA, rendering them unable to reproduce.
Chemical Water Treatment Methods
Chemical water treatment methods involve the addition of disinfectants or other chemicals to inactivate or control the growth of waterborne pathogens. Chlorination is a widely used method, where chlorine compounds such as sodium hypochlorite or calcium hypochlorite are added to the water to maintain a residual disinfectant level. Other chemical disinfectants include chlorine dioxide, which is effective against biofilms, and monochloramine, which provides a longer-lasting residual than chlorine[11].
Biological Water Treatment Methods
Biological water treatment methods harness the power of microorganisms to remove contaminants and maintain water quality. Biofiltration, for example, uses beneficial bacteria to break down organic matter and nutrients, reducing the risk of pathogen growth. Another emerging biological treatment method is the use of bacteriophages, which are viruses that specifically target and kill bacterial pathogens such as Legionella and Pseudomonas[12].
Monitoring and Validation of Water Treatment Effectiveness
Regular monitoring and validation of water treatment effectiveness are critical for ensuring water safety in medical settings. This involves:
- Sampling and testing treated water for microbial and chemical quality indicators
- Monitoring disinfectant residuals and other treatment parameters
- Conducting periodic assessments of treatment equipment and processes
- Implementing corrective actions when water quality issues are identified
By consistently monitoring and validating water treatment methods, healthcare facilities can proactively identify and address potential water safety risks, ensuring the delivery of safe and reliable water for patient care.
Monitoring and Testing Water Quality
Monitoring and testing water quality are essential components of water safety management in healthcare facilities. Regular sampling and analysis of water from various points in the distribution system can help identify potential contamination, assess the effectiveness of water treatment methods, and ensure compliance with regulatory standards. A comprehensive water quality monitoring program should include both routine and investigative testing.
Routine Water Quality Testing
Routine water quality testing involves the regular sampling and analysis of water from predetermined locations within the healthcare facility’s water distribution system. This typically includes testing for:
- Microbial indicators: Total coliforms, Escherichia coli, and heterotrophic plate count (HPC) to assess general microbial water quality[13]
- Disinfectant residuals: Free and total chlorine, chlorine dioxide, or monochloramine levels to ensure adequate disinfection
- Physical and chemical parameters: Temperature, pH, turbidity, and conductivity to monitor overall water quality and treatment effectiveness
The frequency of routine testing should be based on factors such as the size of the facility, the complexity of the water distribution system, and the patient population served.
Investigative Water Quality Testing
Investigative water quality testing is conducted in response to specific concerns, such as suspected waterborne infections, water quality complaints, or treatment process failures. This type of testing may involve:
- Targeted pathogen monitoring: Testing for specific pathogens, such as Legionella, Pseudomonas, or Mycobacterium, in areas with high-risk patients or suspected infections[14]
- Expanded sampling: Collecting water samples from additional locations beyond routine testing points to identify the source and extent of contamination
- Enhanced testing methods: Using specialized techniques, such as polymerase chain reaction (PCR) or culture-based methods, to detect and quantify pathogens
Investigative testing requires close collaboration among healthcare staff, infection prevention and control teams, and water quality experts to ensure a timely and effective response to potential water safety issues.
Interpretation and Communication of Water Quality Results
Interpreting and communicating water quality monitoring results is a critical aspect of water safety management. Key considerations include:
- Comparing results to established water quality standards and guidelines
- Identifying trends or patterns in water quality data over time
- Assessing the potential impact of water quality issues on patient safety and healthcare operations[15]
- Communicating results and corrective actions to healthcare staff, patients, and other stakeholders in a clear and timely manner
By effectively monitoring, interpreting, and communicating water quality data, healthcare facilities can proactively manage water safety risks and ensure the delivery of safe, high-quality patient care.
Infection Prevention and Control Measures
Implementing effective infection prevention and control (IPC) measures is crucial for minimizing the risk of waterborne infections in healthcare facilities. IPC strategies should be comprehensive, addressing not only water quality but also the prevention of pathogen transmission through environmental surfaces, medical devices, and healthcare personnel. A multidisciplinary approach involving collaboration among IPC teams, healthcare staff, and facility management is essential for success.
Hand Hygiene and Personal Protective Equipment
Hand hygiene is a fundamental IPC measure for preventing the spread of waterborne pathogens. Healthcare personnel should perform hand hygiene using soap and water or alcohol-based hand sanitizers before and after patient contact, after exposure to body fluids, and after touching potentially contaminated surfaces[16]. The use of personal protective equipment (PPE), such as gloves, gowns, and face shields, can further reduce the risk of pathogen transmission when caring for patients with suspected or confirmed waterborne infections.
Environmental Cleaning and Disinfection
Regular cleaning and disinfection of environmental surfaces, especially high-touch areas such as sinks, faucets, and showerheads, are essential for preventing the growth and spread of waterborne pathogens. Healthcare facilities should establish cleaning and disinfection protocols that specify:
- Approved cleaning agents and disinfectants effective against target pathogens
- Frequency of cleaning and disinfection based on the level of patient care and risk of contamination
- Proper techniques for applying and using cleaning and disinfection products[17]
- Training and competency assessment for environmental services staff
Ongoing monitoring and evaluation of cleaning and disinfection practices can help ensure consistent and effective implementation.
Medical Device Reprocessing and Sterilization
Proper reprocessing and sterilization of medical devices are critical for preventing waterborne infections associated with invasive procedures. Healthcare facilities should develop and implement policies and procedures for device reprocessing that align with manufacturer instructions, professional guidelines, and regulatory requirements. Key elements include:
- Thorough cleaning and disinfection of devices before sterilization
- Use of appropriate sterilization methods, such as steam sterilization or low-temperature methods for heat-sensitive devices
- Monitoring and documentation of sterilization process parameters and sterility assurance
- Safe storage and handling of sterilized devices to maintain sterility until use[18]
Regular training and competency assessment of personnel involved in device reprocessing can help ensure consistent adherence to best practices.
Emergency Response and Outbreak Management
Despite the implementation of preventive measures, waterborne disease outbreaks can still occur in healthcare facilities. Effective emergency response and outbreak management are essential for minimizing the impact of these events on patient safety and healthcare operations. Healthcare facilities should develop and maintain comprehensive plans for responding to waterborne disease outbreaks, including clear protocols for investigation, control measures, and communication.
Outbreak Detection and Investigation
Early detection and investigation of waterborne disease outbreaks are critical for prompt response and control. Healthcare facilities should establish surveillance systems to monitor for clusters of infections or unusual pathogens that may indicate a waterborne outbreak. Key steps in outbreak investigation include:
- Identifying and defining cases using standardized case definitions
- Conducting epidemiologic studies to identify common exposures and risk factors
- Collecting and testing environmental samples, including water and biofilm, to identify the source of the outbreak[19]
- Collaborating with public health authorities and other healthcare facilities to assess the scope of the outbreak and coordinate response efforts
Timely and thorough outbreak investigations can help guide the implementation of targeted control measures and prevent further spread of infections.
Implementing Control Measures
Once the source of a waterborne disease outbreak has been identified, healthcare facilities must rapidly implement control measures to prevent further transmission. These may include:
- Temporarily restricting or suspending water use in affected areas
- Implementing enhanced water treatment methods, such as hyperchlorination or point-of-use filtration
- Conducting remediation of contaminated water systems, including cleaning, disinfection, and replacement of components as necessary[20]
- Enhancing infection prevention and control measures, such as hand hygiene, environmental cleaning, and use of personal protective equipment
The selection and implementation of control measures should be based on the specific pathogen, the extent of the outbreak, and the available resources and expertise.
Communication and Coordination
Effective communication and coordination are essential for managing waterborne disease outbreaks in healthcare facilities. Key stakeholders, including healthcare staff, patients, families, and public health authorities, should be kept informed of the outbreak status, control measures, and any necessary actions or precautions. Communication strategies may include[21]:
- Regular updates and briefings for healthcare staff and leadership
- Notification of patients and families affected by the outbreak
- Coordination with public health authorities for reporting, investigation, and control efforts
- Media communication to provide accurate and timely information to the public
Clear and consistent communication can help maintain trust, reduce anxiety, and ensure a coordinated and effective response to the outbreak.
Advancing Water Safety Standards in Healthcare
Ensuring water safety in healthcare facilities requires ongoing efforts to advance standards, guidelines, and best practices. As knowledge of waterborne pathogens and control strategies evolves, it is essential for healthcare organizations, regulatory agencies, and professional societies to collaborate in developing and implementing evidence-based standards for water safety.
Updating Guidelines and Regulations
Regularly updating water safety guidelines and regulations is crucial for ensuring that healthcare facilities have access to the most current and effective strategies for preventing waterborne infections. This process should involve:
- Reviewing and incorporating new research findings and evidence-based practices
- Engaging stakeholders, including healthcare professionals, infection prevention experts, and water quality specialists, in the development and revision of guidelines
- Harmonizing guidelines and regulations across different agencies and jurisdictions to promote consistency and clarity[22]
- Providing guidance on the implementation and monitoring of water safety programs in healthcare facilities
By actively participating in the development and adoption of updated guidelines and regulations, healthcare facilities can ensure that their water safety practices align with the latest industry standards.
Promoting Research and Innovation
Advancing water safety in healthcare requires ongoing research and innovation to develop new technologies, strategies, and best practices. Key areas for research and innovation include:
- Improving water treatment and distribution systems to minimize the risk of contamination and biofilm formation
- Developing rapid and sensitive methods for detecting and quantifying waterborne pathogens in healthcare settings[23]
- Evaluating the effectiveness of novel disinfection and sterilization technologies, such as ultraviolet light, ozone, and copper-silver ionization
- Investigating the impact of water safety interventions on patient outcomes and healthcare costs
Healthcare facilities should support and participate in research and innovation initiatives, partnering with academic institutions, industry, and government agencies to advance water safety knowledge and practices.
Education and Training
Effective implementation of water safety standards in healthcare relies on the knowledge, skills, and commitment of healthcare professionals. Ongoing education and training are essential for ensuring that staff are equipped to prevent, detect, and respond to waterborne infections. Education and training initiatives should include:
- Incorporating water safety principles and practices into curricula for healthcare professionals, including physicians, nurses, and allied health staff
- Providing regular in-service training and continuing education on water safety topics, such as risk assessment, monitoring, and outbreak management[24]
- Developing and disseminating educational resources, such as guidelines, checklists, and case studies, to support water safety best practices
- Promoting a culture of safety and accountability, encouraging staff to report water safety concerns and participate in quality improvement efforts
By investing in education and training, healthcare facilities can build a knowledgeable and proactive workforce committed to advancing water safety standards.
Frequently Asked Questions
The most common waterborne pathogens in healthcare facilities include Legionella, Pseudomonas aeruginosa, nontuberculous mycobacteria, and various enteric pathogens such as Escherichia coli and norovirus. These pathogens can cause serious infections, particularly in immunocompromised patients.
Healthcare facilities can prevent waterborne infections by implementing a comprehensive water safety plan that includes risk assessment, monitoring, and control measures. This may involve regular testing of water quality, maintaining appropriate water temperatures, using point-of-use filters, and ensuring proper cleaning and disinfection of water-related equipment and surfaces.
In the event of a waterborne disease outbreak, healthcare facilities should immediately notify public health authorities and initiate an investigation to identify the source of the outbreak. Control measures may include restricting water use, implementing enhanced water treatment, and conducting remediation of contaminated water systems. Clear communication with staff, patients, and families is essential throughout the outbreak response.
Healthcare professionals can contribute to water safety by staying informed about waterborne infection risks and prevention strategies, adhering to hand hygiene and infection control protocols, and reporting any concerns about water quality or potential outbreaks to their facility’s infection prevention team. They can also participate in education and training initiatives to enhance their knowledge and skills related to water safety.
Emerging technologies for improving water safety in healthcare include advanced water treatment methods such as membrane filtration, ultraviolet disinfection, and copper-silver ionization. Rapid molecular testing methods for detecting waterborne pathogens are also being developed to enable faster and more sensitive detection of contamination. Smart water systems that use sensors and data analytics to monitor water quality in real-time are another promising area of innovation.
Patients and families can protect themselves from waterborne infections in healthcare facilities by practicing good hand hygiene, avoiding contact with potentially contaminated water sources (e.g., decorative fountains, ice machines), and following any water use restrictions or advisories issued by the facility. They should also promptly report any concerns about water quality or symptoms of waterborne illness to their healthcare providers.
Regulatory requirements for water safety in healthcare facilities vary by jurisdiction but may include standards for water quality testing, maintenance of water systems, and reporting of waterborne disease outbreaks. In the United States, the Centers for Medicare and Medicaid Services (CMS) requires healthcare facilities to have water management plans as part of their infection control programs. Facilities may also be subject to state and local regulations related to water safety.
Reference list
- Anaissie EJ, Penzak SR, Dignani MC. The hospital water supply as a source of nosocomial infections: a plea for action. Arch Intern Med. 2002;162(13):1483-1492.
- Kanamori H, Weber DJ, Rutala WA. Healthcare outbreaks associated with a water reservoir and infection prevention strategies. Clin Infect Dis. 2016;62(11):1423-1435.
- Falkinham JO 3rd, Pruden A, Edwards M. Opportunistic premise plumbing pathogens: increasingly important pathogens in drinking water. Pathogens. 2015;4(2):373-386.
- Bédard E, Prévost M, Déziel E. Pseudomonas aeruginosa in premise plumbing of large buildings. Microbiologyopen. 2016;5(6):937-956.
- Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42.
- Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42.
- Bartley JM, Olmsted RN, Haas J. Current views of health care design and construction: practical implications for safer, cleaner environments. Am J Infect Control. 2010;38(5 Suppl 1):S1-12.
- Exner M, Kramer A, Lajoie L, Gebel J, Engelhart S, Hartemann P. Prevention and control of health care-associated waterborne infections in health care facilities. Am J Infect Control. 2005;33(5 Suppl 1):S26-40.
- Friedman H, Berman T, Guggenbichler P, Szabo I, Haber A. Design and maintenance of water systems in healthcare facilities to prevent healthcare-associated infections. Int J Infect Control. 2017;13(1):1-11.
- American Society of Heating, Refrigerating and Air-Conditioning Engineers. ASHRAE Standard 188-2018: Legionellosis: Risk Management for Building Water Systems. ASHRAE; 2018.
- Freije MR. Formulating a risk reduction strategy for waterborne pathogens in hospital water systems. Am J Infect Control. 2005;33(5 Suppl 1):S50-53.
- Lin YE, Stout JE, Yu VL. Prevention of hospital-acquired legionellosis. Curr Opin Infect Dis. 2011;24(4):350-356.
- Demirjian A, Lucas CE, Garrison LE, et al. The importance of clinical surveillance in detecting legionnaires’ disease outbreaks: a large outbreak in a hospital with a Legionella disinfection system-Pennsylvania, 2011-2012. Clin Infect Dis. 2015;60(11):1596-1602.
- Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis. 2002;8(9):881-890.
- Kizny Gordon AE, Mathers AJ, Cheong EYL, et al. The hospital water environment as a reservoir for carbapenem-resistant organisms causing hospital-acquired infections-a systematic review of the literature. Clin Infect Dis. 2017;64(10):1435-1444.
- Kanamori H, Weber DJ, Rutala WA. Healthcare-associated outbreaks linked to water: Update on prevention and control strategies. Curr Infect Dis Rep. 2017;19(8):32.
- Hoelle JM, Voelker S, Sizemore E, Hicks L. Evaluation of a targeted water quality monitoring program for small public drinking water systems in the United States. Int J Environ Res Public Health. 2019;16(21):4127.
- Wang JL, Chen ML, Lin YE, Chang SC, Chen YC. Association between contaminated faucets and colonization or infection by nonfermenting gram-negative bacteria in intensive care units in Taiwan. J Clin Microbiol. 2009;47(10):3226-3230.
- Sax H, Bloemberg G, Hasse B, et al. Prolonged outbreak of Mycobacterium chimaera infection after open-chest heart surgery. Clin Infect Dis. 2015;61(1):67-75.
- Smith SS, Ritger K, Samala U, et al. Legionellosis outbreak associated with a hotel fountain. Open Forum Infect Dis. 2015;2(4):ofv164.
- Centers for Disease Control and Prevention. Vital signs: health care-associated Legionnaires’ disease surveillance and reporting – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(22):584-589.
- Bédard E, Laferrière C, Charron D, et al. Post-outbreak investigation of Pseudomonas aeruginosa faucet contamination by quantitative polymerase chain reaction and environmental factors affecting positivity. Infect Control Hosp Epidemiol. 2015;36(11):1337-1343.
- Proctor CR, Reimann M, Vriens B, Hammes F. Biofilms in shower hoses. Water Res. 2018;131:274-286.
- Gamage SD, Ambrose M, Kralovic SM, Roselle GA. Water safety and Legionella in health care: prioritizing risks and implementing best practices. Curr Infect Dis Rep. 2016;18(6):24.
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