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Published in final edited form as: Cancer Causes Control. 2021 Apr 28;32(8):793–802. doi: 10.1007/s10552-021-01431-3

Arguments in favor of and against the HPV vaccine school-entry requirement in Puerto Rico: a content analysis of newspaper media

Coralia Vázquez-Otero 1, Dinorah Martinez Tyson 2, Cheryl A Vamos 2, Nancy Romero-Daza 3, Jason Beckstead 2, Ellen M Daley 2
PMCID: PMC8575176  NIHMSID: NIHMS1746708  PMID: 33913078

Abstract

Purpose

Vaccine requirements are effective population-based strategies to increase vaccination rates. In 2018, Puerto Rico’s DOH announced that the HPV vaccine would be required for school entrance. This study explored arguments in favor of and against the HPV vaccine school-entry requirement in PR.

Methods

We conducted a content analysis of two Puerto Rican newspapers. Articles (n = 286) published between 1/1/2015 and 7/31/2018 containing the Spanish terms for “HPV” and “human papillomavirus” were included. Data were summarized using descriptive statistics. Articles that mentioned the HPV vaccine school-entry requirement (n = 33) were reviewed qualitatively using applied thematic analysis.

Results

The top five primary focus areas were education about HPV and the HPV vaccine, advertisements promoting the HPV vaccine, general vaccine information, cervical cancer and screening information, and the HPV vaccine school-entry requirement. Of the 33 articles that mentioned the requirement, 61% presented arguments in favor, 15% presented arguments against, 12% presented both arguments, and 12% only mentioned the existence of the requirement or were the DOH announcement. Arguments in favor centered on cancer prevention, high rates of HPV-associated cancers, and population wellness. Arguments against included worries about sexual transmission of HPV, HPV vaccine’s side effects, issues related to the policy (e.g., mandatory), and lack of education.

Conclusion

Understanding reasons people support or oppose an HPV vaccine school-entry requirement is important for the policy processes to be successful. Education efforts must continue to change the HPV vaccine narrative. Messages should be crafted to educate and gain support among parents and stakeholders towards this population-based cancer prevention strategy.

Keywords: HPV vaccine, HPV vaccine school-entry requirement, Vaccine requirements, Cancer prevention, Puerto Rico

Introduction

Vaccine interventions have contributed to the improvement of the overall health of our society. Consequently, the reduction of vaccine-preventable diseases through vaccination is celebrated as one of the ten greatest public health achievements [1, 2]. Among vaccine interventions, vaccination mandates for school entrance are recommended by the Community Preventive Services Task Force [3] as a highly effective strategy commonly used in the U.S. to increase adolescent vaccine uptake [4-6]. For instance, while education-only requirements do not increase meningococcal conjugate and human papillomavirus (HPV) vaccine coverage, middle-school vaccine requirements are associated with higher coverage of vaccines such as tetanus/diphtheria (Td) or tetanus/diphtheria/pertussis (TdaP) [7, 8]. Moreover, these mandates have been found to be effective in reducing racial/ethnic disparities in vaccine uptake [9].

In the case of the HPV vaccine, a primary prevention strategy for HPV-associated cancers, there has been considerable resistance towards it. Such resistance derives from the framing of HPV prevention as a women’s only issue (i.e., feminization) and the emphasis on the mode of transmission (i.e., sexual contact) [10, 11]. Thus, a limited number of states and territories have made the HPV vaccine a requirement for school entrance [12]. In 2007, Virginia was the first state to enact an HPV vaccine requirement, implementing it in 2009, and only requiring girls to receive the vaccination [12, 13]. Washington, D.C. first required the HPV vaccine for girls in 2009 and later included boys in 2014 [1]. The Department of Health (DOH) of Rhode Island implemented the HPV vaccine school-entry requirement for both sexes during the fall of 2015 [10, 14]. Hawaii’s DOH adopted the HPV vaccine school-entry requirement on July 1, 2020 (to be implemented on July 2021) for adolescents entering seventh grade [15].

During the summer of 2018, Puerto Rico’s DOH Secretary announced that the HPV vaccine was going to be required for school entrance for boys and girls between the ages of 10 to 12 for the start (fall) of the 2018 academic year [16]. This created an opportunity to investigate the arguments in favor of and against the HPV vaccine school-entry requirement in Puerto Rico (PR) presented in the newspaper media.

Methods

Overview

The data presented here are part of an exploratory sequential mixed-methods study [17] that entailed two phases. Details of Phase 1 of this study have been published elsewhere; briefly, Phase 1 consisted of interviews with stakeholders from PR who participated in the adoption process of the HPV vaccine school-entry requirement [18]. These interviews informed Phase 2 (analysis reported here) which included a content analysis of two newspapers from PR. The University of South Florida Institutional Review Board approved this study.

Data collection

The methodology of Phase 2 was guided by the seven steps for a content analysis presented by Bernard & Ryan [19]. Additionally, guidelines from Neuendorf [20] on the design of descriptive quantitative content analysis (i.e., the addition of a second coder, the recommendation for coder training, and the calculation of Kappa for the assessment of inter-rater reliability) were used. Also, previously published content analyses about the HPV vaccine [21-23] and the HPV vaccine school-entry requirement newspapers’ coverage [24] informed this study. The information included in the protocol is described below.

Unit of analysis and key terms

We reviewed two of the most circulated Puerto Rican newspapers and their respective websites [25, 26]: El Nuevo Diía and El Vocero. Both newspapers are available online. Each article was considered a unit of analysis. The words ‘VPH’ and ‘virus del papilloma humano,’ Spanish for ‘HPV’ and ‘Human Papillomavirus,’ were the key terms used to search the articles on each of the newspapers’ search engines and websites.

Inclusion and Exclusion criteria.

We included articles published from January 1, 2015 to July 31, 2018 that had at least one of the key terms. We chose the year 2015 as the starting date because in May 2015 the VOCES HPV Panel Report was published [27] by VOCES (PR’s vaccine coalition). This report, among other things, summarizes HPV and HPV-related cancers epidemiological data, and HPV vaccination uptake and completion rates, all in the context of PR. It also included the HPV vaccine school-entry requirement as one of the strategies to help achieve the goals of Healthy People 2020. Additionally, the report was mentioned by the stakeholders who participated in the interviews as an important document that guided the process of adoption of the HPV vaccine school-entry requirement [18]. We reviewed the titles and dates of articles to eliminate articles that were not relevant or could be excluded based on the date. We also excluded repeated articles and unrelated advertisements from the content analysis. The remaining articles were accessed in full. Figure 1 shows the screening and selection processes.

Fig. 1.

Fig. 1

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Article selection process for the content analysis

Instrumentation

We created the variables abstracted for this study based on previous research and findings from Phase 1. A data collection form was developed, and two coders tested the form with a sample of 10% of the articles. This step allowed for revisions to the data collection form [19]. The final version of the data collection form was transformed into a case-by-variable matrix in Excel.

Data abstraction

Data were abstracted from the articles and entered into the case-by-variable matrix. The primary researcher (CVO) and a second coder independently coded a random sample of 10% of the articles. An inter-coder agreement Kappa score of 0.80 was achieved and coding of the rest of the articles was completed by the first author. As an additional assurance of reliability, intra-coder reliability, or stability reliability [20] was assessed when the primary researcher coded the first 100 articles. A randomly selected sample of 10% of these articles was coded a second time by the primary researcher. An intra-coder Kappa score of 0.95 was achieved. Both inter- and intra-coder Kappa scores were calculated using SPSS version 25.

Data analysis

We summarized the data from the 286 articles using descriptive statistics (i.e., frequencies and percentages). Articles (n = 33) that specifically mentioned the requirement were also analyzed qualitatively to identify the arguments presented in favor of and against the HPV vaccine school-entry requirement. This qualitative analysis was conducted following techniques of applied thematic analysis [28], such as coding, categorization, summarization, and the selection of exemplary quotes. Quotes that illustrated the arguments were selected and translated into English.

Results

Sample description

After removing the duplicate articles, there was a total of 286 news articles that included the key terms (Fig. 1). News articles were classified by year to get a perspective on publication activity. On average, most articles were published in 2016 (n = 92, x¯ = 7.67), followed by 2017 (n = 82, x¯ = 6.83), then 2018 (n = 47, x¯ = 6.71), and lastly 2015 (n = 65, x¯ = 5.42). Note that the average number of articles per month by year is provided because data for 2018 only covers the first seven months of the year.

Primary focus

For this study, the primary focus refers to the main message the article was providing. Each article could have more than one message, but the main message was captured during data abstraction. To make this decision the researcher was guided by the title and the first paragraph of the article. The most common primary focus categories included educational articles with information about HPV and the HPV vaccine (23.8%), followed by the advertisement category (16.8%). The advertisement category included ads promoting the HPV vaccine (e.g., by VOCES and others by Merck), announcements of health fairs providing the HPV vaccine, and ads about professional and health conferences. The third most common focus was articles providing general information about vaccines (11.2%), such as types available, benefits, and appropriate ages for inoculation. Articles with a primary focus of providing information about cervical cancer and the importance of cervical cancer screening comprised about 11% of the sample. The HPV vaccine school-entry requirement was the primary focus of 19 articles (6.6%). Figure 2 shows the top five primary focus categories by year (using the average number of articles per month because data for 2018 only covers the first seven months of the year). Other areas of focus included general health information (5.9%), cancer information (5.9%), or information on other types of HPV-related cancers such as oropharyngeal, penile, and anal (4.2%). A complete list of the articles, based on their primary focus by year, can be found in Table 1.

Fig. 2.

Fig. 2

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Top five primary focus categories by year. *Note: until July 31st, 2018

Table 1.

Complete list of articles published by primary focus category by year (n = 286)

Primary focus 2015 2016 2017 2018* Total %
Educational/informative about HPV & HPV vaccine 14 25 18 11 68 23.8
Advertisement 4 22 13 9 48 16.8
Vaccines in general 12 7 6 7 32 11.2
Cervical cancer/screening 4 15 9 3 31 10.8
HPV vaccine school-entry requirement 1 0 13 5 19 6.6
Health in general 5 5 5 2 17 5.9
Cancer in general 5 7 3 2 17 5.9
Other HPV-related cancers 3 3 6 0 12 4.2
Scientific/research advancements 4 3 0 2 9 3.1
About STIs including HIV 4 1 3 0 8 2.8
School-entry/other policies 2 1 2 3 8 2.8
DOH/government announcement 2 2 1 2 7 2.4
Salud/obamacare/insurance 2 0 1 0 3 1.0
Contraceptives 3 0 0 0 3 1.0
Rhaiza (a woman from PR who died of cervical cancer) 0 1 1 0 2 0.7
Other 0 0 1 1 2 0.7
Total 65 92 82 47 286 100
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*

Note: until July 31st, 2018

News articles that mentioned the HPV vaccine school-entry requirement in PR.

Of the 286 news articles, 33 newspaper articles (11.5%) mentioned the HPV vaccine school-entry requirement. This category includes all articles that mentioned the requirement, regardless of the primary focus. From the 33 articles, 20 (60.6%) presented arguments in favor of the HPV vaccine school-entry requirement, five articles (15.2%) presented arguments against, and four articles (12.1%) showed both sides of the arguments. Four (12.1%) articles only mentioned the HPV vaccine school-entry requirement (n = 2) or were the DOH’s HPV vaccine school-entry requirement announcement (n = 2). These four articles were grouped in an ‘other’ category. Figure 3 shows the number of articles of each argument category by the year of publication. No articles with the HPV vaccine school-entry requirement as the primary focus or mention were found published during 2016. However, this finding should be considered within the limitations of the content analysis that are discussed later.

Fig. 3.

Fig. 3

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Number of articles of each argument category by year of publication*

Themes

Arguments in favor of the HPV vaccine school-entry requirement in PR

Topics abstracted from the newspaper articles in favor of the HPV vaccine school-entry requirement (n = 35) covered four areas. First, the need for cancer prevention (n = 16/35), which included cervical cancer prevention (n = 8/16), cancer prevention in general (n = 5/16), and the prevention of other HPV-associated cancers (n = 3/16). Second, the increasing incidence of cervical cancer, oropharyngeal cancer, and other HPV-related cancers (n = 9/35). Third, the importance of overall wellness and protection of the population (i.e., minors) (n = 6/35), and fourth, arguments related to the HPV vaccine (n = 4/35). Table 2 includes exemplary quotes for the arguments in favor of the HPV vaccine school-entry requirement.

Table 2.

Arguments in favor of and against the HPV vaccine school-entry requirement in Puerto Rico from the newspaper media

Arguments in favor of the HPV vaccine school-entry requirement
Themes Subthemes Exemplary quotes, source, and year
Cancer prevention Cervical cancer Cervical cancer, as well as other HPV-associated cancers, can be prevented thanks to a vaccine, for this reason, from the next academic year 2018–2019, the vaccine against the human papillomavirus (HPV) will be part of the vaccines required for school-entry for students 11–12 years old.—El Nuevo Día, 2018
Other HPV-related cancers Cervical cancer as well as other cancers associated with the human papillomavirus (HPV), can be prevented thanks to a vaccine.
For this reason, the vaccine against HPV is part of the required vaccines to enter school for students 11 to 12 years old. This decision makes it possible for more young people to be protected against it and associated cancers.—El Vocero, 2018
Increasing incidence Cervical cancer The secretary of health, concerned with the increase of cases of cancer caused by HPV in Puerto Rico (cervical, anal, and oropharyngeal), responsibly decided that beginning on the 2018 school year, the vaccine to prevent the infection with the virus will be required.—El Nuevo Día, 2017
Oropharyngeal cancer Beginning in August 2018, all 11 and 12-year-old students will be asked to be vaccinated against the human papillomavirus (HPV). It was announced by the secretary of health [name], who indicated that this new requirement to the vaccination schedule was motivated by the rise in HPV-associated cancers, such as oropharyngeal.—El Nuevo Día, 2017
Wellness and protection of the population – Puerto Rico must take advantage of this opportunity [the HPV vaccine school-entry requirement] to strengthen prevention by expanding the public health protection arsenal.—El Nuevo Día, 2017
HPV vaccine Not a new vaccination “This is not a new vaccine. It has been recommended for 12 years. In Puerto Rico around a million vaccines have been administered”—said the physician [name], advisor for the Vaccination Program of the DOH.—endi.com, 2018
Cancer prevention “This is the only vaccine in the market that can prevent the development of cancer. […]”—pediatrician, El Nuevo Día, 2018
Arguments against the HPV vaccine school-entry requirement
Theme Subthemes Exemplary quotes, source, and year
Aspects of HPV Sexual transmission What is the reason for a boy or a girl in school-age that has not initiated sexual activity to be protected against a disease that is acquired by sexual contact? […] This is not a disease that a boy sneezing will transmit to another one”, indicated [name], […]”—a member of autism organization, endi.com, 2018
Transient nature [physician leader of a pro-family organization] added that the HPV, in many cases, cures by itself, and not all [HPV types] cause cancer or genital warts.—El Nuevo Día, 2017
Concerns about the HPV vaccine No long-term protection or no protection against all types Although 16 and the 28 types have been associated with 70% of the reported cases of cervical cancer, the [name of feminist organization] emphasized that the vaccine does not offer overall protection.—elvocero.com, 2017
Safety and side effects During March of this year the US official program to overlook vaccine safety, known as VAERS, has reported more than 50,463 adverse reactions to the vaccine. Among those there are 317 deaths; 1,771 kids disabled, 14,299 emergency room visits,
4,606 kids have needed hospitalization, and from those 304 have remained in the hospital for long periods.—[name of concerned mother], El Nuevo Día, 2017
Sexual behavior [name of a member of feminist organization], “[…], the vaccine could result in a lot of people engaging in more risks, falsely assuming that the vaccine protects them from all the HPV types transmitted sexually and that this protection lasts their whole lives”.—elvocero.com, 2017
Issues related to the school-entry policy Infringement on parental rights “The vaccines against HPV are a tool for cervical cancer prevention. However, the vaccine should not be mandated. Each family, after being rightly informed about the advantages and risks of the vaccine, should freely decide which of the strategies they would like to use to protect their health and their family’s health”—a member of a feminist organization, endi.com, 2017
Mandatory aspect The HPV vaccines are a tool for cancer prevention. However, the vaccine should not be compulsory”, said [name], spokeswoman of a feminist organization, in a press release.—endi.com, 2017
Concerns about education and information Lack of unbiased information The organization highlighted that ‘biased’ information publicly provided does not offer the objective judgment tools for men and women, that is the reason why they [feminist organization] required the Department of Health to provide complete information about the vaccine, as well as access to sexual and reproductive health prevention services to young people.—feminist organization, elvocero.com, 2017
The government should provide information and education “[…] it is the Government’s responsibility to guarantee access to complete and objective information about the benefits, risks, and limitations of every preventive option available.” –member feminist organization, endi.com, 2017
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Arguments against the HPV vaccine school-entry requirement in PR

The arguments against the HPV vaccine school-entry requirement (n = 26) abstracted from the newspaper articles were summarized in four broad themes. These included: (1) aspects of HPV (n = 4/26), 2) concerns related to the HPV vaccine (n = 9/26), 3) issues about the school-entry policy (n = 9/26), and (4) concerns related to lack information and education (n = 4/26).

The aspects noted about HPV were its mode of transmission (i.e., sexual transmission) (n = 2/4) and its transient nature (i.e., clears by itself) (n = 2/4). The concerns about the HPV vaccine included the belief that the vaccine does not provide long-term protection or does not protect against all the types of the virus (n = 3/9). Other concerns were the safety and side effects of the vaccine, including the belief that it causes cervical cancer (n = 4/9). The least noted concern was related to the children’s sexual behavior and getting the HPV vaccine (n = 2/9). The issues against the school-entry policy included two areas: (1) the requirement’s infringement on parental rights over their children’s health decision-making process (n = 5/9) and (2) opinions against the mandatory aspect of the policy (n = 4/9). In some newspaper articles, the interviewees noted their concerns on a lack of unbiased information (n = 2/4) and noted that it was the government’s responsibility to provide information about the vaccine and sexual education (n = 2/4) to the population. Themes and subthemes with the corresponding quotes are shown in Table 2.

Discussion

The purpose of this study was to investigate the arguments in favor of and against the HPV vaccine school-entry requirement in PR presented in the newspaper media. Previous research on the arguments supporting HPV vaccine mandates was framed under the umbrella of women’s health and children’s welfare [11]. Moreover, numerous topics represent the various arguments in favor of the HPV vaccine school entrance mandates, including cost-effectiveness, appropriate age for vaccination for best immune response, need for cervical cancer prevention and reduction, the importance of parental participation in health decisions concerning their children, need to increase vaccination uptake, and the need to achieve herd immunity [29, 30]. Conversely, arguments against the need for HPV vaccine school-entry requirements are based on the lack of viral transmission through casual contact, intrusion into parental autonomy, public distrust due to pharmaceutical lobbying during the policy development process, and the potential economic burden on the government and health care system (e.g., health departments and private physicians’ offices) [30-33].

In PR, the framing strategy used was to describe the HPV vaccine school-entry requirement as a tool for cancer prevention, notably based on the need to reduce the high rates of cervical cancer among Puerto Rican women. Additionally, the public health impact on population wellness was found as a common argument in favor of the vaccine requirement. Studies among physicians have reported similar reasons for supporting the HPV school-entry requirement such as its effectiveness in increasing immunization and its public health impact on immunization [34-36]. Among parents or guardians, research has found that arguments in favor of the requirement were about the prevention of cervical cancer and the requirement as a public health intervention that could benefit all [37], having positive views about the HPV vaccine [38], and the overall protection of their child’s health [35].

Findings showed that arguments against the HPV vaccine school-entry requirement were, for the most part, related to the HPV vaccine and the virus. Regarding the HPV vaccine, the concerns focused on its side effects and safety. These reasons have also been discussed in previous research among parents who thought that the vaccine was new and had concerns about its safety and side effects [37, 39-42] and, thus, were more likely to be against the HPV vaccine school-entry requirement. Physicians have also noted similar arguments including concerns about the long-term efficacy and safety of the HPV vaccine [34, 36].

The mode of transmission of the virus and its association with sexual activity was another area of concern in this study. Parents have discussed the sexual nature of HPV transmission [13] as a reason to be against the HPV vaccine school-entry requirement, as well as the lack of casual transmission [35, 43]. Similarly, Casciotti et al. (2014) [24] found that, in print media, the encouragement of sexual activity was an argument against the requirement. Moreover, Vercruysse et al. (2016) [35] found that several parents in their study believed that some adolescents are not sexually active; thus, there is no need for the HPV vaccine to be required for school entrance. The concern of HPV not being casually transmitted has been also voiced among physicians [34, 36].

Finally, the parents’ right to decide what is best for their children was a theme noted in the Puerto Rican news articles. This finding is similar to previous research with parents and physicians who reported parents’ choice or decision to vaccinate their children [13, 35, 36, 38, 42-44], as an argument against the HPV vaccine school-entry requirement. Furthermore, Casciotti et al. (2014) [24] found that the government’s imposition of the HPV vaccine over parental autonomy was the most common theme reported in print news media from Texas, Virginia, and Washington, D.C. between 2005 and 2009.

Research has shown that the media plays an important role in influencing the way people think by framing messages and emphasizing issues to the general public [45, 46]. Moreover, this agenda-setting function of the media, based on collaborations with diverse sectors of society, provides opportunities for public health interventions to highlight specific problems [46]. Since support from different stakeholders and the public’s involvement are necessary for the policy process to be successful, targeted messages could be created to raise awareness and educate, not only about the HPV vaccine but also about the societal value of school-entry requirements. Crafting clear informational campaigns about vaccine requirements has been recommended as a way to increase their acceptance [47]. Therefore, engaging the public[48, 49], including policymakers [50], via a variety of media such as social and print media, and using different formats (e.g., narratives) to offer the correct information could contribute to change opinions towards this type of population-based strategy.

Strengths and Limitations

This study has limitations that should be discussed. A limitation specific to the content analysis methodology is that the search process for each of the newspaper’s database differed. Newspapers’ search engines are created for everyday use and leisure reading and are not designed with the rigorous algorithms needed for research [51]. Thus, there is a possibility that not all the published news articles were captured. To address this limitation, two newspaper search engines and websites were used. However, by using these two mainstream sources, news articles from fringe media sources may have been missed. Moreover, this study captured what was presented in online print news media; thus, future research should look at other modes of news transmission such as social media and television, as additional sources of information to get a better understanding of the arguments for and against the HPV vaccine school-entry requirement.

Nonetheless, this study has several strengths. Conducting a content analysis of the newspaper media, an important mean of communication, provided a look at the arguments presented from several different sides or points of view. A unique contribution of the current content analysis is its special focus on the news articles that mentioned the HPV vaccine school-entry requirement in PR. Focusing on the news media provides a deeper understanding of the arguments in favor of and against this policy in the general population. Additionally, data collection of this study was timely because it took place during the adoption process of the HPV vaccine school-entry requirement; therefore, capturing the arguments presented at that moment. Lastly, this study focuses on PR’s newspaper media from a territory with particularly high rates of HPV-related cancers. Therefore, framing the HPV vaccine school-entry requirement as a tool for cancer prevention, as was done in PR, may serve to promote the use of this population-based intervention in other high prevalence areas in the U.S.

Conclusion

The HPV vaccine school-entry requirement provides an opportunity to increase HPV vaccine coverage among adolescents and promote long-term cancer prevention. Educating the public about the HPV vaccine and engaging them in the policy process continues to be an important role for public health practitioners. Thus, understanding the arguments surrounding vaccination mandates and providing the correct information via a variety of media can contribute to allowing our society to continue enjoying the success of vaccine interventions.

Funding

Funding for the completion of this project came from the USF COPH Student Honorary Awards for Research and Practice (‘SHARP’) Award and the USF Office of Graduate Studies Scholarships and Fellowships. Coralia Vazquez-Otero is currently supported by the Cancer Prevention Fellowship from the National Cancer Institute and Harvard T.H. Chan School of Public Health—NIH grant number 2T32CA057711-27. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Footnotes

Conflict of Interest One of the authors, Dr. Daley, previously served on the US HPV Vaccine Advisory Board of Merck Pharmaceuticals. The remaining authors declare no conflicts of interest.

Availability of data and material Available upon request.

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