Immunization Schedule

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This schedule is constantly changing due to new developments in how to use old vaccines and the release of new ones. I will try to keep this schedule as up to date as possible. When you review the schedule keep in mind that there are numerous special situations that may require us to alter your child's vaccine schedule. The following is only a guideline and you should read about each individual vaccine to find the details about scheduling that vaccine. Also see the page on how to tell if your child's vaccines are up to date.

 Routine Schedule: (click here to see the schedule I am currently using)

When a number is given more than once, then that dose may be given at any of those times.
AGE HepA Hep B DT, or aDPT Hib Rotavirus Polio MMR Chicken Pox Pneumococcus Tetanus Menningococcal Influenza
Birth   #1                    
2 months   #1 or #2 #1 #1 #1 #1     #1      
4 months   #2 #2 #2 #2 #2     #2      
6 months   #3 #3 #3 #3 #3     #3     #1 (#2 4 weeks later, then yearly)
12 months #1     #4   #3 #1 #1 #4      
15 months   #3 #4 #3 or 4   #3 #2          
18 months #2                      
4 years travel   #4 or 5     #3 or 4 #2 #2        
9 years travel             #2 if not had illness   Maybe read text    
11-12 years travel   #5 or 6         #2 if not had illness     #1  
16 years travel             #2 if not had illness   and every 10 yrs #2  
Pre-college               #2 if not had illness     #1 or 2  

Special consideration: Premature babies, Pneumovax after 2 years, Influenza after 6 months of age and Travel.

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Individual Vaccines and Special Considerations

Chicken Pox DT, DPT and aDPT Haemophilus influenza type B
Hepatitis B Influenza MMR
Pneumovax Polio Premature Babies
Rotavirus Travel New Vaccines (aDPTHib, Nasal influenza vaccine, Hepatitis A, Lymes Disease, HibHepB)
Prevnar / Pneumococcus 7    

For each vaccine I will try to cover the timing of the vaccines, how to prevent or help certain reactions and any special concerns my patient's parents have had about the vaccines. I cannot include all of the possible side effects and legal information required to give consent for the vaccine.

Hep B: ( Hepatitis B vaccine, Engerix, Recombivax )

Hepatitis B is an extremely important vaccine that will be required for school entrance within the next few years across the country and should not be confused with Haemophilus influenza B. The first dose should be given within 12 hours of birth with Hepatitis B immune globulin if the mother has hepatitis B ( all pregnant women are now routinely test for this during the pregnancy). The first dose should be given later to a premature or small baby because it won't work as well, not because it may hurt them (except if the mother has hepatitis B, then the child will get the vaccine). I choose to recommend that the first dose be given at 2 months because 1 to 6 percent of recipients will get a small fever and this fever may cause us to think a newborn is sick. The second dose should be given from 28 days to 6 months after the first, and the third dose from 6 to 12 months from the second. I recommend to give the last dose 12 months after the second for two reasons. First, studies show two doses alone give excellent protection in children. Second, the third is mainly a booster and studies show it works best for this about a year after the second dose. The schedule may be accelerated should an exposure to Hepatitis B occur before the series is completed. The vaccine works extremely well in children and a blood test to ensure it worked is not routinely recommended as it is in adults. Adolescents are especially prone to hepatitis B as they may now have intimate friends and should be started on the vaccine ASAP, if they have not already had it. Remember about 16 to 20% of US citizens have had hepatitis B and 25% of us get hepatitis B from sex, 25% from a needle stick and the rest are UNKNOWN. Are you at risk also? ( hint: YES!!!!!!)At a conference in early 1997 a speaker noted that "more people die of Hepatitis B in this country in 1 day than die in 1 year from AIDS". As of 1/2000, the Hepatitis vaccine is required for daycare and school attendance in West Virginia.

HepA: ( Hepatitis A vaccine, Havrix, Vaqta )

Hepatitis A is a liver infection like Hepatitis B. HepA is much more common and easier to catch than HepB, but it is less likely to cause you harm.  The HepA vaccine was released in 2000 and has proven to be one of the most effective and safest vaccines we have. The vaccine was originally recommended for those children living in states with twice the national average of HepA disease. The vaccine caused a dramatic decreased in HepA disease in those states. At the same time we learned this, we also learned that HepA disease is under-diagnosed and under-reported by over 10 fold. In late 2005, the national committees recommended the HepA vaccine be given to all 1-2 year olds in the country and those known to be at risk from exposure in their environment or via travel to endemic areas of the world (which is pretty much all countries except America, Canada, Australia and western Europe). The vaccine is given is 2 doses 6 months apart. Currently, due to expected shortages, the vaccine should only be started in those children between 1 and 2 years of age. The vaccine may be finished after 2 years of age. This age was chosen because they have the highest risk of contracting and spreading the disease. Those insurance companies covering the vaccine will most likely stick to this schedule until the ACIP/AAP/AAFP recommend the vaccine routinely for other ages.

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

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DT, DPT and aDPT: and Tetanus

Diphtheria, Pertussis and Tetanus has received undeserved bad press mainly because of the Pertussis component. There still is no good scientific evidence to show that the vaccine does or does not cause injury despite decades of studies and dozens of large liability awards. Please ask your grandmother about how she felt about these illness when she had children. She felt about the same way you do about AIDS, Ebola, RSV and others except her children actually had a significant chance of not only getting these illnesses, but of dying or being injured by them. Probably the best testament about the vaccines is to ask your pediatrician if he or she gave the vaccines to their child. I personally gave my kids most of thiers (my wife, an RN, gave the others). The DPT may be given as early a 4 weeks of age (for foreign travel) and the first 3 may be given as early as 4 weeks apart if necessary. We usually don't like giving them less than 6 weeks apart and would prefer 8 weeks. The 3rd and 4th doses should be no less than 6 months apart. The 5th dose should be given AFTER the 4th birthday. Should the 4th happen to be given after the 4th birthday, then this is considered complete protection. Two vaccines that combine DPT and Hib are available (Tetramune and Acel-immune) and are currently given at 2, 4, 6 and 12 to 15 months of age. Should a legitimate reaction to the DPT occur, then the DT would be substituted for the DPT until 7 year of age, and then the Td thereafter. A legitimate reaction is a immediate anaphylactic reaction (severe allergic reaction) or encephalopathy after a previous dose of the vaccine or a undiagnosed progressive neurologic disorder. The following are cause for special consideration, but are not absolutely a reason not to give the vaccine again: febrile seizure, temperature >104.9, a hypotonic / hyporesponsive episode, or a severe inconsolable cry within 48 hours of the vaccine. A high pitched cry may occur and the vaccine may be given again after you have discussed the risks and benefits with your doctor. The high pitched cry appears to be due to pain; ice on the puncture site and Ibuprofen usually resolves this. Some children get a knot at the site of the injection that shows up a few days after the vaccine is given, may last for a week or two, hurts but is not harmful and is treated just like the high pitched cry above. The knot seems to be correlated with how "vigorous" the vaccine was injected, but one study in Taiwan showed that the more vigorous the vaccine was given the better it worked. If you are not sure if the knot is too big or is infected, then call you pediatrician. The Diphtheria component is given in a smaller dosage after 7 years of age with the Tetanus and this is written DT before 7 years and Td after 7 years of age.The aDPT is the same as the DPT, but contains a acellular Pertussis component which generally causes much less side effects.

The "Tetanus shot" we are supposed to get every ten years is actually the Td. The rules for Tetanus shots are: 1) if you get a cut or puncture wound and have had a Tetanus shot in the last 5 years, then you do not need a Tetanus shot now, 2) if you get a cut or puncture wound between 5 and 10 years after the last Tetanus shot, then you need a Tetanus shot at the time of that wound, 3) if you have not had a Tetanus shot in the last 10 years, then you will get one at the next check up. Before 2005, the Tetanus shot did not contain the Pertussis component if given after 7 years of age.  Pertussis causes Whooping Cough in babies. When we get Pertussis after 5-6 years of age, it causes Bronchitis. True Bronchitis is caused by Pertussis a large percentage of the time in adults. True Bronchitis is a significant cough and cold symptoms lasting more than 10 days often associated with coughing fits. Starting in 2005 the Tetanus shot (Td) given after 9 years of age will be replaced with a vaccine containing acellur Pertussis (TdaP). back to top

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Hib:

Haemophilus influenza B is not to be confused with Hepatitis B or Influenza. Hib was the number one cause of meningitis in infants and young children until the vaccine was developed. It is currently the safest vaccine available. There are several Hib vaccines available and each has a slightly different schedule. Just giving Hib itself does not work well, therefore it is linked with another substance and this is where the differences between the brands of this vaccine come from. The brands are: PedvaxHIB (PRP-OMP), HIBTITER (HbOC), ActHIB (PRP-T), OmniHIB(PRP-T) and ProHIBit (PRP-D). There are combination vaccines with the DTP and these are Tetramune (DPT-HbOC) and Acel-Immune (ActHib + DTP). The first dose may given as early as 6 weeks of age. The first 3 doses are generally given with the DPT. Generally the same brand should be used for all of the doses before 12 months and then any brand may be used as the booster after the first birthday. The third dose may be skipped at 6 months if the PedvaxHIB (PRP-OMP) brand is used, but this cannot be combined with the DPT. For travel, the first dose may be as early as 6 weeks and they can be given as early as 4 weeks apart, but this is not optimal for later protection and may require extra doses later. back to top

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Polio:

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Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

MMR:

Measles, Mumps and Rubella must be given on or after the first birthday to be considered part of the primary series for lifelong protection. The Measles vaccine is given as young as 6 months of age in epidemics, but when given this early does not count for the primary series. The second dose of MMR may be given as early as 1 month from the first and if done so is considered the second and final dose. The second MMR, though, is usually recommended after the 4th birthday and before school entrance and is currently required for entrance into most colleges. Please remember that your child may have a fever and or a rash 5 to 12 days after the vaccine and this is normal, not contagious and not harmful.Occasionally some older children have temporary joint aches a few weeks after the vaccine.

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Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Chicken Pox: ( Varivax )

This vaccine has been in development since 1974, was finally released for use in this country in early 1995 and is one of the safest vaccines available. Only 2 doses are needed and may be given starting on or after the first birthday. We used to only give one dose, but starting giving a second dose in 2007. If you have only had one dose, we normally give the second at the 4-5 year check up. If your child is over 5 and has not had the secodn dose or Chicken Pox, then we will give the second dose at teh next check up. Having Chicken Pox after 12 years of age has greatly increased risks. Many parents ask why give a vaccine for something that doesn't hurt anyone and I usually answer with some surprising statistics. Each year about 100 people die of Chicken Pox, 3000 receive permanent brain damage and 9000 are admitted to hospitals and these are not just kids with chronic illnesses. Chicken Pox results in an average of 8 days of missed school for kids and 2 days of missed work for parents. Economically, Chicken Pox costs us hundreds of millions of dollars per year. Do you remember Chicken Pox and how miserable it made you? Currently we feel the vaccine may last for life, but a booster dose cannot be completely ruled out in 10 to 30 years. Proof of the vaccine or the illness will eventually be required for school entrance in a few years. 60 percent of kids have Chicken Pox before reaching school. The vaccine may be given with all of the above vaccines safely, but the Chicken Pox immunity received will not be quite as good if given with the DPT, although the DPT vaccine will work fine. If you are taking aspirin, then please tell your doctor as the vaccine cannot be given within 6 weeks before or 2 weeks after taking aspirin for fear of Reyes syndrome (which has never been associated with the vaccine). As of 1/2000, the Chicken Pox vaccine is required for daycare and school attendance in West Virginia. back to top

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Premature Babies:

In general, premature babies should get their vaccines according to their age from birth, while measurements and development is measured from your original due date. Vaccines should not be delayed until when the child would have been the correct age according to their due date. There are of course exceptions to this. First, the Hepatitis B vaccine does not work as well in smaller babies, therefore that may be delayed until the child is 8 to 12 lbs. Second, the OPV or live polio vaccine should not be given while the child is in the hospital. The NICU (neonatal intensive care unit) doctors will often not give vaccines until the day your baby leaves the hospital, which is routine and acceptable, but you may want to discuss vaccines with your pediatrician or the NICU doctor when your baby is about 2 months old.back to top

Pneumovax: or Pnu-immune (brands of the adult Pneumococcus vaccine) for those over 2 years of age.

This vaccine can only be given after 2 years of age and will help prevent 23 different strains of Streptococcus pneumoniae. Streptococcus pneumoniae is not the cause of strep throat, but rather causes some ear infections, sinusitis, pneumonia's, blood infections, etc. Mainly it is needed be those without a spleen, with sickle cell anemia, special kidney problems, special immune deficiencies and those with chronic infections. In special circumstances the vaccine may be used in children with chronic ear infections to help prevent them. A version of this vaccine for use below 2 years of age finally became available in 3/2000 (Prevnar). back to top

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Influenza:

Influenza is mainly used in those with heart disease, asthma or other lung disease, some immune deficiencies or suppressions, sickle cell disease and other hemoglobinopathies, diabetes, chronic kidney disease, and in children on long term aspirin therapy. The vaccine should also be given to the household contacts of these patients to best protect these patients from influenza. If you are on chronic aspirin, then talk to your doctor about how the vaccine may be given. The vaccine should be given yearly to the above patients, may be given as early as 6 months of age and two must be given the first year separated by 28 days or more if the recipient is less than 9 years of age. The vaccine usually comes out every year in September, while Influenza is usually first seen from November to January and continues until March or April. The vaccine cannot give you Influenza, but you can get minor flu like symptoms for a few days (if you have ever had the flu, then you would definitely know the difference and this is much better than hospitalization or death from the real flu). As of 2004, it is now routine to give all babies under 2 years of age the influenza vaccine. We will also recommend the vaccine for all household contacts of kids under 6 months. back to top

Back to: are my child vaccines up to date
birth to 2 months 2 to 4 months 4 to 6 months
6 to 12 months 1 to 4 years over 4 years

Rotavirus:

Rotavirus is basically every parents nightmare of a stomach flu (after polio has been eliminated of course). Virtually all children contract this illness before reaching age 5. Approximately 2% of children younger than 2 years of age are hospitalized with dehydration and Rotavirus causes 40-60% of these. The Rotashield brand of Rotavirus vaccine was licensed by the FDA in August 1998 and virtually eliminates hospitalization, while dramatically reducing the need for emergency room visits, doctors visits and missed work and school. The vaccine became a routinely given vaccine after finally being recommended by the ACIP and AAP in October 1998. In early 1999, the vaccine adverse event reporting system (VAERS) received reports of a bowel obstruction called intussusception associated with the vaccine. The natural rotavirus infection causes this complication too. While there were a small number of intussusceptions (100), they all occurred within 6 days of receipt of the Rotashield vaccine. Statistically this would appear to be a small price to pay for saving hundreds of lives and preventing so much severity of illness, but the responsible agencies and company officials felt it best to pull the vaccine off the market in July of 1999. If your child received a dose of this vaccine, don't worry as all of the known reactions occurred within 6 days of receiving the vaccine. In 1/2006 , the new Rotavirus vaccine was released by the FDA and is called Rotateq. This vaccine has proven to be just as effective, but with no increased risk of intussusception. It was studied in many times more children than the original rotavirus vaccine.

Pneumococcus: (Prevnar brand) for those under 5-6 years of age.

This vaccine was released by the FDA in 3/2000. Streptococcus if a family name of many bacteria, just like Smith is a family name. Pneumoniae is the species name, just like John would be a name within the Smith family. Its named Pneumoniae because it was the first or most common cause found for bacterial pneumonia. Strep throat is caused by a different bacteria (Streptococcus pyogenes Group A) and is not related to or covered by this vaccine. There are over 70 separate strains of SP. Each of these strains are different, with some being antibiotic resistant, some more likely to cause serious infection, etc.
    In the USA alone, SP yearly causes:
        * 7,000,000 Ear infections
        * 500,000 Pneumonias (5% die)
        * 50,000 Sepsis (blood infections) (20% die)
        * 3000 Meningitis (15% die)
        * 512,000 Ear tubes placed each year (all causes)
        * $5,000,000,000 (that's Billion) estimated yearly cost for antibiotics for fluid in the ear alone
    Of all the bacterial infections in the USA, SP causes:
        * 85% of Sepsis
        * 50% of Meningitis
        * 66% of Pneumonias in <5yr old children
        * 40% of Sinus infections
        * 40% of Ear infections
    SP is commonly found is healthy children and adults noses. We share these bacteria when we shake hands, share food, talk very close, cough, in other words, when we share secretions. Just having the bacteria in your nose does not hurt you. Due to some alteration in your immune system, such as a viral infection, the bacteria invade your blood stream and cause the infections listed above.
What are the risk factors for developing a serious infection by SP?
        * < 5 years of age
        * Daycare attendance within the last 3 months
        * Not breast feeding
        * Recent or frequent ear infections
        * Recent antibiotic use
        * Chronic illness
        * Passive smoking (second hand smoke)
    From the above numbers you can see how serious this bacterium is, how many people it kills or injures and how much it costs our society. The most dangerous strains of SP are also becoming increasingly resistant to antibiotics. A vaccine should greatly reduce illness, suffering and rising health care costs, but can also help reduce drug resistance by decreasing the amount of antibiotics we have to use.
    The current vaccine includes 7 of the most damaging strains to our children under 5 years of age. The strains of SP that infect different ages and different regions of the world are different. The vaccine was last used in a study of 35,000 children in Kaiser Permanente HMO in California. Remembering that in only covers the worst 7 strains, it gave:
        * 3.6-23% less ear infections
        * 50-60% less Meningitis
        * 20% less office visits for pneumonia
        * 20% less hospitalizations for pneumonia
    The vaccine was originally given at the same time as the DTaP vaccine. Most of the side effects were the same as the DTaP:
        * 5-10% local redness
        * 5-10% local mild swelling
        * 15% local tenderness
        * 25% decreased appetite
        * 35% fever up to 3 days
        * 40% drowsiness
        * 70% fussiness
    The vaccine is injected as follows:
        * 6 weeks old is the earliest it can be given
        * The vaccine is not given over 5 years of age
        * Those starting below 6 months of age get 4 doses
        * Those starting from 6-12 months of age will get 3 doses (first 2 >= 4 weeks apart, 3rd after 1st birthday and 2nd and 3rd doses >= 2months apart)
        * Those starting between 1 and 2 year of age get 2 doses (at least 2 months apart)
        * Those starting after 2 years of age only get 1 dose
        * The vaccine can be given as close a 4 weeks apart
        * Doses 3 and 4 should be at least 2 months apart
    The original version of the pneumococcus vaccine was developed for adults with certain medical conditions. It includes 23 strains of SP, but those strains do not cause as much illness in children as the strains included in the new vaccine. There is only one strain in the old vaccine that is also included in the new vaccine (#4). Also the adult vaccine is not effective below 2 yrs of age. The old vaccine is used in kids over 2 years of age who have:
        * Sickle cell disease
        * No spleen or a non-functional spleen
        * Chronic kidney disease
        * Immunosuppression (chemotherapy, etc)
        * Spinal fluid leaks
        * Chronic lung, heart or liver disease

In ealry 2010, the Prevnar vaccine was improved to have 13 strains of Pneumococcus. If your child is still under 15 months, we will simply finish the schedule with the nex version. If your child is between 2-5, even if they completed the 4 dose first series, we will give one additional dose of the new version to better protect your child. If your child is between 5-6 and has special medical problems, we may give an additional dose of the nex version.

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Travel:

Travel to most developed countries carries no more risk than travel in this country and no special vaccines should be required. There are of course exceptions to this and there are actually books on the subject of vaccination for foreign travel. Therefore, you should consult your pediatrician, family practice doctor or your local health department about vaccines for travel to the specific areas you are traveling to at least 10 weeks in advance. It is a good idea to get as many of the vaccines as possible before travel, this is why I listed how soon vaccines can be given apart under the individual vaccines, especially those given before one year and the MMR. The Center for Disease Control (CDC) has a 1 800 number that gives recommendations for vaccines for travel. The number is for a voice information system that can either give voice information or fax the information to you. The number is 1 (800) 232-SHOT(7468). You can also call your local health department for assistance, especially since they are the only ones whom have many of the vaccines needed for travel to certain areas. The best site for vaccine information for travel is the Center for Disease Control site at HTTP://WWW.CDC.GOV, chose the travel section and then the region of the world you will be visiting. This site also give information of how to avoid contacting illnesses that can't be vaccinated against.

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Resources

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New Vaccines

Much of the following is gleamed from government publications, medical journals, meetings and talk in the halls around the hospital. Vaccine approval by the FDA is an exacting task that cannot be rushed. Due to the nature of that process, timetables for vaccine release are very difficult to pin down. Also, just because a vaccine is approved does not mean that it will be used. Many doctors wait until the ACIP (American Council on Immunization Practices) and the AAP (American Academy of Pediatrics) make their recommendations. Please take this into account when reading the following.

aDPTHib: A vaccine combining the acellular DPT and the Hib is available for use over 15 months of age. But it is usually not available due to manufacturing issues.

Lymes Disease: A vaccine for this viral illness has been in the works for some time. The vaccine appears safe and effective, but can only be used I those 15 years and above. There have been approximately 13 to 15,000 cases a year reported in this country for the past few years. You do not have to live in the woods to get Lymes. I will add more data as it becomes available.

Influenza Vaccine in a nasal spray: One drawback to recommending the Influenza vaccine is that children under 9 years of age must get 2 shots the first year they receive the vaccine as well as another shot each year. A nasal spray vaccine can only be used in healthy patients above 2 years of age.

 Pentacel: combines DTaP, IPV and the Hib vaccine into one injection. Using this vaccine saves 7 shots. We use this vaccine.

Menactra: This is an improved version of the vaccine given to college students and military recruits to prevent a devastating meningitis. The vaccine was released in the summer of 2005, lasts for life and is recommended for all kids 11 years of age and above. This meningitis kills 30-70% of those who get it quickly and leave many of the survivors with permanent brain damage. This is not a vaccine you want to skip. WV now requires a dose of Menactra and aDPT prior to entering teh 7th grade and a second Menactra after the 16th birthday or prior to entering the 12th grade. Most colleges require it.


The schedule I am currently using in my office 4/2010

 
AGE Vaccine
Birth Hep B
2 months Pentacel (aDPT Hib, IPV) , HepB, Prevnar, Rotateq
4 months Pentacel (aDPT Hib, IPV) , HepB, Prevnar, Rotateq
6 months Pentacel (aDPT Hib, IPV) , HepB, Prevnar, Rotateq
12 months (must be on or after birthday) MMR, Chicken Pox, Prevnar, HepA (may either do this with no vaccines at 15 month check up, or give a few at 12 months and some at 15 months)
18 months aDPT, Hib, HepA
4 years (must be on or after birthday) aDPT, MMR, IPV, Chicken Box
9 years or older Gardasil (HPV vaccine, 3 doses over 6 months)
at first opportunity after 11th birthday Menactra, aDPT
16 years Menactra

Copyright 2015 Joe Matusic, MD. This document may be freely copied and distributed, providing there is no charge for duplication or the material and this copyright notice remains affixed.

revised 5/2015

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