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Post00284 TECHNET STRATEGIC FRAMEWORK PART 4 6 October 2000 CONTENTS 1. 1. Re: Post00271 TECHNET STRATEGIC FRAMEWORK 2. TECHNET '99 DRAFT RECOMMENDATIONS 1. Re: Post00271 TECHNET STRATEGIC FRAMEWORK A Technet Strategic Framework is needed to fully incorporate the Technet process with the WHO providing and maintaining the Technet Secretariat. In todays posting Alasdair Wylie asks if a response to the earlier Technet Recommendation postings was invited or expected. We need to turn the recommendations into a strategic framework. The moderator offers some clarification: * The answer is Yes, a response from Technet subscribers is invited! Alasdair also asks " Has it [Technet] been specifically accepted, at whatever level is needed this sort of thing within the new structure? Julie Milstien, WHO/V&B/ATT, replies with a summary of progress since the Technet '99 meeting and the information that the recommendations of the internal WHO meeting that "strongly recommended" " continued location of a Technet secretariat within WHO,specifically within V&B/ATT" was accepted. The Technet recommendations that came out of the global Technet meetings of 1999, 1998, and 1996 were posted in Technet Forum Post00271 on 8 August 2000, Post00274 on 15 August 2000, Post00276 on 21 August 2000. The 1999 recommendations are posted below in item 2 of this posting. ATT is the Access to Technologies unit within the World Health Organization Department of Vaccines and Biologicals ___________________________________________________________________________ From: "Alasdair Wylie" To: "Technet Moderator" Cc: "Julie Milstien" Subject: Re: Post00271 TECHNET STRATEGIC FRAMEWORK - PART 1 Date: Mon, 2 Oct 2000 Allan 1. This as posted is a draft meeting report/recommendations. Are/were comments invited/expected? Not clear from the posting. 2. Who is taking it forward? Kris Engstrom and John Lloyd who drafted it [The draft Technet '99 report] are both doing other things, neither involved with V&B/ATT. Julie Milstien's piece "The Future of Technet" (Technet post0222, 27 January 2000) said that an internal WHO meeting had "strongly recommended" "continued location of a Technet secretariat within WHO...... specifically within V&B/ATT". The recommendation was presumably made to WHO itself. Has it been specifically accepted, at whatever level is needed this sort of thing within the new structure? If so, will the function actually be any more than planning and organising of future Technet meetings, which is said to be in the post description JL's replacement - though I didn't see it in the one posted (Post0234, 21 March 2000) - which leads me to 3. Have you had any other comments on the "Future" proposals in 0222? I think there needs to be some discussion (particularly as "capacity building" is on the table in a big way in the GAVI context, following recent TFCC meeting): Especially about the central proposal about not having a workplan at global level (if I read it correctly) but leaving it to regional level workplans. The implications of this are considerable and I could write a lot but won't now. First things first. Alasdair --- From: Allan Bass To: Alasdair Wylie ; Technet Moderator Cc: Julie Milstien Sent: 03 October Subject: Re: Post00271 TECHNET STRATEGIC FRAMEWORK - PART 1 Dear Alasdair, Comments were invited - see the intro to the piece. I think we need to take it forward - at least to achieve some consensus on taking things forward into the new WHO organizational structure . We would be in a better position to carry this process forward if John's replacement were in situ at WHO/V&B/ATT. I do however think that the GAVI process is leaving this all to one side - as you know - our key criteria effective/safe EPI logistics see not to be criteria in funding for vaccine introduction. We still need the strategic framework. regards, and thanks, allan --- From: "Alasdair Wylie" To: "Allan Bass" Subject: Re: Post00271 TECHNET STRATEGIC FRAMEWORK - PART 1 Date: Tue, 3 Oct 2000 Thanks Allan. I have a few comments on the meeting record and will send but probably better to remind members who attended Technet 99 that you do want them. I think things are moving in the right direction with the GAVI business, particularly given the apparent interest of certain working group members to listen to feedback from field assessment experience, but it needs pushing and I think that Technet has a key role to play. V&B/ATT needs to be seen to be doing something while waiting JLs successor (have they recruited yet?). Best Alasdair --- From: To: ; Sent: 03 October Subject: Technet Dear Alisdair and Allan, Thanks letting me see these notes. Let me try to clarify our position here. 1. As soon as I read the recommendations of the draft Tech Net report (done by Kris Engstrom), I asked John Lloyd to work with us on setting up a meeting to draft a framework. He agreed. He then suggested I ask Allan to help. So I did. Allan has published the recommendations and asked input. Little response. So I spoke to John in great depth on 8 September. We decided to ask Technet Forum members whether they saw a need the Forum, and to see whether the Technet still existed, and what they would like us to help them do. I drafted that before mid-Sept and asked Cecilia Aedo to get it sent to all subscribers to the Forum. It is on its way. I have also asked Allan to clarify his role and the need the Forum as a communication tool among (who? - who is the Technet?) So I am still waiting. No one has come forward to volunteer taking the strategic framework forward so I must wait until I have a staff member who has time to do it. (Good news, interviews are scheduled so it should be soon) 2. Meanwhile I have gone through the 1999 recommendations to let you know what has been done, even without staff in place. This is below: R1. Transport sub-group - this has been done by JL, working with Transaid. We have supported some of this work and have a focal point within ATT/V&B, also AFRO. R2. Checklist on assessment of vaccine supply and cold chain - this is really part of GAVI assessment tool that we have helped develop R3. no action mandated R4. generic protocol on cost-benefit of available injection technologies - moving forward with Gordon Larsen R5. TST and sterilizer maintenance - not done, especially since policy is to move away from sterilizables. R6. SIGN activity R7. Revise guidelines on CFC-free refrigerators - not done unless done PIS revision R8. TechNet and PAHO on working group on CLM - not in our workplan R9. Guide on mgt and supervision of vaccine distribution using VVMs - done R10. Country studies on integration of drugs and vaccines distribution - in workplan and funding requested R11. Guidelines managers on pros and cons of different products - being done and will be ready end Oct R12. Subgroup on procurement by UNICEF - done through GAVI FTF, and I represented WHO on procurement subgroup. Group has been very active R13. Data on inserts shelflife - considered and rejected here at WHO R14. Strategic plan on Technet - see above. R15. GAVI logistics TF - decided to deal with this through TFCC R16. GAVI assessments - done R17. Training in vaccine management - ATT has a major new initiative on vaccine management training, now in planning and implementation with AFRO R18. Communications of MOH staff and Technet members - not done Most of the action points have been done as well, although they were TechNet members. So even without staff on board, I think we have been very active in following up on the spirit of the Technet recommendations. I would like to move forward on a strategic framework, but alas, the people I have asked to do it have not yet come through. You may post this if you wish. Julie --- From: "Alasdair Wylie" To: "Allan Bass" Subject: Technet Date: Tue, 3 Oct 2000 Allan, there seems to be more happening behind the scenes than I had realised. Is there a posting coming out from you about "the need the Forum" etc or is this being sent direct to Technet subscribers by WHO? The flavour of a lot of this is different from what Julie Milstien sent out in Post0222 and she has not actually answered the question I asked - was the recommendation approved/agreed in V&B or not? If WHO's position is in essence that Technet (secretariat) related work will get done if and when there is time that seems to be fairly clear writing on the wall, so it is perhaps a good thing that a consultation is under way but as usual it will be important to keep an eye on the terms of the consultation given the known or presumed interest of whoever is conducting it. I think that the update on action/status on the various recommendations is useful - though some obviously raising further questions - and should be posted, perhaps alongside the original draft text with a further call comments. Alasdair --- From: To: Alasdair Wylie ; Allan Bass Sent: 04 October Subject: Re[2]: Tech Net Please Alasdair, what recommendation are you talking about that I did not answer the question about? --- From: "Alasdair Wylie" To: "Julie Milstien" , "Allan Bass" Subject: Re: Re[2]: Tech Net Date: Wed, 4 Oct 2000 Sorry Julie if it wasn't clear: The advice from you about "The Future of Technet" which Allan posted in Post0222 on 27 Jan , and to which I referred in mine of 2 Oct to Allan and you, said that an internal WHO meeting "strongly recommended" " continued location of a Technet secretariat within WHO....specifically within V&B/ATT". * My question was and is whether this recommendation has been specifically accepted in WHO, at whatever level this sort of thing needs to happen these days. I am well aware that everyone now has to account every nanosecond of work time in relation to the content of the V&B Strategic Plan, and one does not see reference to the Technet secretariat/support function in the "products" in that document. Best Alasdair --- From: [email=milstienj@who.ch]milstienj@who.ch[/email] Date: Wed, 4 Oct 2000 Subject: Re[4]: Tech Net To: "Allan Bass" , "Alasdair Wylie" We have accepted it. From the post description JL's replacement, item 2 (30% of time), includes the following: * Co-ordinates and manages all activities in logistics * Sets priorities use of funds in logistics area * Supervises the recruitment of consultants and experts as necessary to implement the work plan * Convenes the meeting of the TechNet * Assures that technical assistance to countries and regions is available related to logistics issues * Oversees the WHO/V&B system of performance specifications and test procedures Note that what you had seen was the vacancy notice which is less complete. John wrote the work plan and the input into the strategic plan his replacement. He chose not to explicitly put the TechNet activities in whatever reason, but that does not mean that they are not being done. Basically, the logistics positions (we have 2), all activities support and are supported by TechNet. We will be looking increasingly to TechNet to help us locate consultants and expertise as polio is sucking up a lot of logistics resources. Hope this clarifies. Julie --- Subject: Re: Tech Net Author: Allan Bass Date: 04/10/2000 Dear Alasdair, NO real response from the technet on the strategic framework stuff - other than a few notes saying that this follow-up was overdue. While I volunteered to do some work on the strategic framework - unfortunately I had some delays in posting the Technet recommendations - due to travel - which put the postings into the norther summer holiday season. On the need the TECHNET Forum - I had not planned a special survey - but it is a good idea! I will do the annual survey TECHNET Forum survey next week which will gather some of the technet subscriber opinions on the forum. My personal position is that I would like to see the Technet continue and the forum as a communications and advocacy tool the TECHNET. It would be a shame to waste the loyal Technet forum readership and what has developed. Responses from readers vary from topic to topic - Robert's discussion of DPT1 data on Monday provoked more response than I would have expected - while the dense recommendations must have been too daunting. I'm still recovering from the workload of the trip to Uzbekistan and Oman so the "great Technet postings" are still in development. I'm working on a posting on the use of the Technet in GAVI. Perhaps it should go in sequence with a revival of the strategic framework posting. We also need to look at the cold chain from next year with VVMs on all VAX - the transition may be messy - and moving to the simplified cold chain will be problematical. LTP and freeze indicators is an issue that should be dealt with, particularly with HepB and HIB entering the Cold Chain globally. Thanks again, regards, allan ____________________________________*______________________________________ 2. TECHNET '99 DRAFT RECOMMENDATIONS The key issues are Who? When? How? Resources? The sources of resources? Measuring achievement or completion. Contributions please: [email=technet@acithn.uq.edu.au]technet@acithn.uq.edu.au[/email] or use your reply button ___________________________________________________________________________ TECHNET '99 DRAFT RECOMMENDATIONS These are the recommendations that were agreed upon in a plenary session of the Technet members meeting in Harare in December 1999. They grew from recommendations suggested by those that made and heard presentations during the five technical sessions, by the sub-groups that met during Session 6, and at other times through the meeting. Most of the recommendations are presented under the session headings, except those that are more general in nature, which are placed at the end of this chapter. SESSION 1: REACHING THE UNREACHED Technet members have learned that failure to reach remote populations that is attributed to lack of transport is usually not lack of vehicles per se but lack of transport management. Management tools exist and are in use but not nearly widely enough. Experience with transport management systems needs to be collated, adapted, and disseminated; cost studies must continue; and operations managers need management skills, as recommended below. R 1. A Technet Transport sub-group should be established by March 2000 to: * Collect and evaluate existing transport management tools, modify them where necessary, and disseminate them to Technet members and national managers. * Document experience in using these tools and disseminate achievements and problems. * Prepare transport system indicators and a survey instrument that can be used on its own and also be integrated into the new Immunization Services Assessment Guidelines those instances where an in-depth transport assessment is warranted.Conduct transport availability and cost studies in areas of different population density, both routine outreach and supplementary immunization activities, to better define the basis transport infrastructure budgeting. SESSION 2: LOGISTICS OF DISEASE CONTROL Experience with Acute Flaccid Paralysis (AFP) surveillance has underscored the principle that support logistics is more likely to be obtained when there is a surveillance system. Much of that system relies on logistics, including: * Storage of vaccine in appropriate cold chain conditions at all levels * Distribution of vaccine, syringes, and other equipment and materials * Collection and transport of specimens (reverse cold chain) Planners and policy-makers hope that the investments made and experience gained in polio eradication will contribute to other disease control activities control. One benefit that could be realized relatively quickly is to expand surveillance supervisory visits to include logistics activities. R 2. The WHO Vaccines and Biologicals Department and the Secretariat Technet should prepare a simple checklist to be used during supervisory visits AFP, neonatal tetanus, or measles surveillance the assessment of vaccine supply and cold chain in health facilities. This checklist should be disseminated to countries their review and adaptation. SESSION 3: SAFETY OF INJECTIONS Safety of injections is a growing concern the public, as well as health care providers and those who advise and support them. Among the many technical and management issues that need further work before injection safety can be ensured are: * Development of effective, yet inexpensive equipment disposal and destruction of sharps and other infectious waste * Development of decision-making tools selection of injection technologies * Evaluation of sterilization practices * Research and development of auto-disable syringes curative use Technet members agreed that the Safe Injection Global Network (SIGN) should play the major role in co-ordinating research, promotion, and planning on injection safety in curative as well as preventive settings. It should participate in or take the lead in implementing the four Technet recommendations below. R 3. Technet endorses the recommendations of the Almaty Technet sub- committee, 28-30 April 1999, on the disposal and destruction of sharps and other infectious waste. R 4. On the basis of the WHO three-country study (Ekwueme, Larsen, et al.), the Technet secretariat should develop, field test, and disseminate a generic protocol countries to use to compare the cost-benefit of available injection technologies. R 5. The prevalence of the use of time-steam-temperature (TST) sterilization indicators and of adequate sterilizer maintenance in each country using sterilizables should be urgently evaluated. The evaluation should identify the causes of good and bad performance and should be followed by plans of action to ensure sustainability of injection safety. R 6. SIGN should convene a working group to define specifications auto- disable (A-D) syringes curative injections and then evaluate the potential of A-D syringes curative settings in two stages: * First, studies should be conducted under ideal circumstances to evaluate the safety and effectiveness of A-D technology curative syringes in these settings. * Subsequently, A-D syringes should be evaluated in the field to evaluate their effectiveness in preventing re-use where resources and supplies are limited. SESSION 4: THE COLD CHAIN Policies concerning the cold chain, cold chain supplies and equipment, and tools the management of vaccine supply, distribution, and storage continue to be topics of discussion Technet members. As with transportation, injection safety, and other logistics issues, the technology may be available but the execution is not. In their recommendations the cold chain, Technet members focused on filling gaps in technology and management tools and in providing training that ensures high quality performance. Problems of implementation are addressed more globally in the last section on Other Recommendations. R 7. The current guidelines on the introduction of CFC-free refrigerators into the cold chain should be revised to include HFC and HC gases, which are now more widely used. R 8. Technet and PAHO should convene a working group to guide the revision of the commodities and logistics management software (CLM), including the transition to the Windows platform by March 2000. R 9. WHO should prepare a guide on the management and supervision of vaccine distribution using Vaccine Vial Monitors (VVMs) by July 2000. Existing training materials should be included in this guide as appropriate. Special efforts should be made to disseminate these materials widely and to promote their use in training. R 10. Technet should conduct more country studies on the integration of the distribution of drugs and vaccines by the end of 2000. SESSION 5: INTEGRATION OF HEPB, HIB & VITAMIN A Just as decision-making tools are needed the selection and implementation of transport systems, waste disposal systems, and injection equipment, they are needed the selection of vaccines and different renditions of the same vaccine, especially when new vaccines are becoming available integration into immunizations services. Technet recommendations focused on these needs. R 11. Technet should produce guidelines managers that will help them compare advantages, disadvantages, and costs of different vaccine products. Guidelines should include information on monovalent and polyvalent presentations, single- and multi-dose presentations, requirements for syringes, training needs, and cold chain requirements at each level. R 12. By June 2000, a Technet sub-group should be prepared to advise WHO and UNICEF on procurement specifications for different vaccine presentations. WHO and UNICEF should work with vaccine manufacturers to optimize the storage volume and packing of vaccine. R 13. By June 2000, WHO and UNICEF should request vaccine manufacturers and National Regulatory Authorities to include data in their inserts on the shelf life at designated tropical temperatures for the more stable vaccines that are supplied with VVMs. OTHER RECOMMENDATIONS Technet members made other recommendations that apply generally to all of the topics of interest or that address Technet itself. R 14. A Technet sub-group should be formed to develop a strategic plan for Technet activities, linked to the WHO/V&B strategic plan, and to identify the appropriate process and modalities of engagement with GAVI by the end of February 2000. R 15. GAVI should consider forming a Logistics Task Force to complement the work being carried out by its other Task Forces (currently, on financing, advocacy, and country coordination). The Logistics Task Force would focus on the revitalization of immunization services, participating in design, field-testing and implementation of country assessments and introducing new vaccines. R 16. Technet should set up a sub-group to collaborate on the development of the instrument for GAVI country assessments by February 2000. R 17. Technet recognizes the importance of training in improving service performance and introducing new policies, strategies, technologies, and vaccines. Considering the poor record of previous training efforts, new training strategies that assure quality and are targeted to those who need the training to do their jobs should be designed, implemented, and evaluated. R 18. Extending the scope of the recommendation of the 2nd Technet meeting, Technet should request Ministries of Health to allow national logisticians and managers to communicate with Technet members and the Technet secretariat on technical issues. Official communications would continue to be conducted through normal channels. ___________________________________________________________________________ ACTION POINTS During the sub-group meetings in Session 6 and thereafter in plenary, participants agreed on actions that they could undertake to support the implementation of the 1999 (or previous) recommendations and to contribute to the improvement of primary health care operations. Some of these actions are new; those that have been brought forward from earlier Technet meetings are so indicated. 1. INJECTION SAFETY Injection safety continues to be of major concern to Technet members and others working in the health sector. 1.1 NATIONAL INJECTION SAFETY PLANNING In 1998, the Copenhagen meeting of Technet included as a priority activity that: Every country should devise or update a national plan of action for injection safety aimed at achieving 100% safe injections by 2000. WHO will continue to monitor the status of these plans and will report to Regional EPI Managers' meetings and the next Technet consultation. At the end of 1999, it was clear that many countries were still not treating injection safety as a high priority. They had not implemented safety measures, e.g., ensuring that re-usable needles and syringes were sterilized, had not developed injection safety plans, and were not monitoring injection and syringe disposal practices. ACTION POINT 1.1. Technet members should continue to remind their colleagues, partners, and clients of the importance of this activity, promote plan development, and provide assistance in monitoring of plan implementation. 1.2 INTEGRATED APPROACH TO SOLVING THE INJECTION SAFETY PROBLEM Although auto-disable syringes offer close to 100% protection against re- use, this protection can never be totally guaranteed. This and other considerations (such as that re-usable syringes will continue to be needed) mean that the provision of auto-disable syringes alone will not work. Health workers need to integrate safe practices into their daily behavior. They must have adequate supplies of auto-disable syringes at all times. They must have adequate disposal facilities to ensure that syringes are rendered harmless after use and then completely destroyed. These points, made in 1998 and earlier, must be continuously emphasized. ACTION POINT 1.2. Technet members should help national managers and partners understand that no guarantees can be made against re-use of auto- disable syringes. Members should help managers plan to provide good training and supervision for health workers, to monitor needle and syringe use, to install adequate storage and disposal facilities. 1.3 EXTENDING THE LIFE OF STERILIZABLE SYRINGES In a study in Zambia, where 50% of injections are given with sterilizable syringes, the life of syringes was significantly lengthened when a vapor purifier filter was used. Hard water pads were useless. TST spots were enthusiastically received because they helped prove that leaking sterilizers were not sterilizing the equipment. ACTION POINT 1.3. Technet members should encourage sponsors to continue the trials of the filters and should continue to promote the use of TST spots and monitor sterilization in practice. 1.4 TECHNOLOGY TRANSFER Availability of funds and technical assistance will not guarantee successful transfer of syringe production to new manufacturers any more than they guaranteed problem-free transfer of vaccine production. Regulation of production and continuing monitoring of product quality are also needed. ACTION POINT 1.4. Manufacturers of auto-destruct syringes should provide information about what is needed to transfer syringe production technology and what assistance they can provide in setting up the production process itself and in dealing with connected issues, such as waste management. 2. INDICATORS OF LOGISTICS PERFORMANCE WHO and UNICEF staff, national staff, and international partners have been conducting assessments, evaluations, and reviews of logistics, the cold chain, and other aspects of immunization operations for many years; and good assessment tools have been developed. Now, new tools are needed to examine the impact of changes in technology and the introduction of new vaccines as well as to continue the review of the performance of health workers in meeting existing standards. They have also called for a common tool that all staff and partners can use. This tool, which includes indicators for all aspects of immunization operations, is now under development. In keeping with Recommendation 16 (see Chapter 3), Technet members have played and will continue to play a role in this development. 3. TRANSPORT FOR OUTREACH Most people involved in the planning and provision of health services are now convinced that it is not how many vehicles you have that counts but how you use them. Recognizing that help in transport systems development is widely needed, participants in this Technet meeting recommended that a working group be formed to select the best management systems tools and disseminate them, with recommendations for technical assistance and training, to national managers. See Recommendation 1 in Chapter 3. 4. INTRODUCTION OF NEW VACCINES With the availability of new vaccines (hepatitis B and Hib) and revived interest in old ones (yellow fever), national managers are faced with new kinds of decisions: Should we put our resources into improvements in the existing immunization programme or into the introduction of new vaccines? To make these decisions, managers need to know: * The extent of improvements that are needed * The capacity of the existing programme to integrate a new vaccine * The operational requirements of the vaccine, e.g., how it is administered and what its storage requirements are. The new Immunization Service Assessment Guidelines will help managers assess their programmes' performance and capacity for expansion. Manufacturers of new vaccines can help by providing information about the new vaccines. WHO, in turn, can continue to collect this information from manufacturers and from regional offices such as PAHO, organize, package, and disseminate this information to national managers. ACTION POINT 4.1: WHO should ask manufacturers of new vaccines to provide the following: * For each vaccine and diluent and each presentation, the size of box in which it comes and its volume in refrigeration. * For each vaccine and each presentation, the number of vials included in the inner package and the number of inner packages in each box. Description of diluent packaging - included in the vaccine box or packed separately? * Photocopies of the labels that the manufacturers place on vials, ampoules, diluents, and boxes. * Photocopies of inserts. 5. INTEGRATION OF VACCINES AND DRUGS In some countries, vaccines and drugs are now being stored, packed, and shipped from a single central-level store. Similarly, integrated transport management is being re-instituted or tried for the first time. Other aspects of operations are also being considered for integration. Logisticians can help managers examine the benefits and constraints of integrating other operational functions, such as maintenance and repair of equipment and supervision, in their efforts to improve services. Technet members particularly, because of their knowledge, experience, and ubiquity, are in an excellent position to provide this assistance. ACTION POINT 5.1: Technet members should help managers systematically consider the short-term and long-term impacts of decisions to integrate and decentralize operational functions. 6. COLD CHAIN The cold chain recommendations of the 1998 Technet addressed requirement for refrigerators to be used for vaccine storage and the activities that were needed to plan for the purchase or repair of equipment that met these requirements. Most of these activities are long-term and were endorsed again in the 1999 meeting. Renewed emphasis was placed on facilitating the integration of VVMs and the multi-dose vial policy (aka opened-vial policy) into daily practice by health workers and managers. Technet members can help by promoting their use and providing training and technical assistance. ACTION POINT 6.1: Technet members should take every opportunity to explain how VVMs work and describe their benefits to health workers, managers, and the public. Similarly, the multi-dose vial policy needs to be explained and promoted. In addition, Technet members should monitor the use of VVMs and the application of the policy in health facilities. ___________________________________________________________________________ The Draft report is available for download in Adobe acrobat format: Technet1999-MeetingDraftReport4-2000.pdf (9kb) Go to the website ftp://ftp.acithn.uq.edu.au/Technet/1-ClickHereForTECHNETfiles/Technets Then double click on the file: Technet1999-MeetingDraftReport4-2000.pdf to start the download. or Send an email to: [email=listserv@acithn.uq.edu.au]listserv@acithn.uq.edu.au[/email] with the message: get technet Technet1999-MeetingDraftReport4-2000.pdf and the file will be emailed to you ____________________________________*______________________________________


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