Prepositioning Antibiotics for Anthrax (2012) / Chapter Skim
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Appendix D: Commissioned Paper: A Cost and Speed Analysis of Strategies for Prepositioning Antibiotics for Anthrax
Appendix D: Commissioned Paper: A Cost and Speed Analysis of Strategies for Prepositioning Antibiotics for Anthrax
Pages 241-318
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to provide background for the deliberations of the Committee on Prepositioned Medical Countermeasures for the Public. The responsibility for the content of this paper rests with the authors, and the paper does not necessarily represent the views of the IOM or its committees and convening bodies.
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. Prepositioning can enable more rapid dispensing of oral antibiotics following an anthrax attack, thus increasing
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Committee on Prepositioned Medical Countermeasures for the Public commissioned this paper to provide background for its deliberations on prepositioning strategies for anthrax antibiotics. PRTM analyzed three prepositioning strategies: • caches in hospitals and pharmacies; • caches in workplaces of different types (e.g., state and local gov ernment, private infrastructure, Fortune 50 companies, small busi nesses)
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This model is the backbone of several MCM dispensing strategies that were reviewed. Whereas the prepositioning strategies are intended to increase the speed with which a 10-day supply of oral antibiotics is delivered, they are intended only as an adjunct to the POD dispensing approach.
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hospitals, Department of Defense (DOD) medical treatment facilities, and some private hospitals that maintain a limited stockpile to provide to their staff and patients in the event of a biological attack.
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Hospitals, pharmacies, and some clinics already have some security measures in place for safeguarding medications, so during nonemergencies they likely would not incur an incremental security cost. However, in the event of a biological attack, additional security would likely be necessary to augment existing security activities during dispensing operations.
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Serving as a closed POD would not necessarily increase speed over the baseline because no prepositioning would be taking place, and the delivery of antibiotics to the workplace would be contingent on the speed of delivery of the SNS assets. Caching in workplaces would effectively decrease the percentage of the population that would have to be serviced by public PODs.
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FIGURE D-5 Depiction of a home MedKit.
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Rather than the pull approach of that model, the postal distribution model serves to push MCM out to the population. The pilot for this model was sponsored by the Cities Readiness Initiative (CRI)
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To accomplish this, the team estimated total costs associated with: • product, • transport, • inventory management, and • dispensing. For each dispensing strategy, the team examined the time required to dispense antibiotics from the cache to the subset of the population served, as well as the total time required to dispense antibiotics to the general public using a combined SNS-RSS-POD and prepositioned cache strategy.
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In addition to enabling initial time savings, prepositioned caches would help alleviate the burden on PODs by decreasing the total number of individuals that would visit PODs to receive their initial dose of MCM. To allow for additional analysis and comparison, the team reviewed cost and speed implications associated with employing the postal model in the Minneapolis-St.
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Pharmacy Cache To determine pharmacy cache requirements, the team assumed that pharmacies would operate as open PODs and would store enough product to cover the remaining population that is assumed to be served by prepositioned caches but that hospitals lack the capacity to handle. The team then divided the total population assumed to obtain MCM through pharmacies by the total number of pharmacies in the Minneapolis-St.
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Product Product costs are incurred when prepositioned caches or MedKits in homes are established or replenished. Cost components and key assumptions related to product costs are shown in Table D-2.
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Inventory Management Once MCM had been purchased and had arrived at storage facilities, hospitals, pharmacies, and workplaces would incur additional costs related to maintaining inventory, including labor, storage, and inventory replenishment costs. While costs related to labor and storage do not apply to the MedKit dispensing strategy, inventory replenishment costs do.
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To determine the total speed associated with dispensing, the team assumed varying throughput estimates per dispensing strategy employed. Key assumptions are shown in Table D-6.
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Additional Security In assessing costs associated with employing additional Measures security measures, the team assumed that hospitals have sufficient such measures in place and would not incur additional security costs, but that pharmacies might employ a security guard at $29.01 per hour, representing the average hourly wage for a police officer in the Minneapolis St. Paul area as indicated by the U.S.
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For the prepositioning strategies, the public POD component has a considerably longer dispensing time than that of hospitals, pharmacies, or workplaces; the same dynamic occurs for the postal model. Figure D-9 depicts the overall cost for each of the dispensing strategies.
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258 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX FIGURE D-8 Comparison of times to dispensing of first 10-day supply for prepositioning strategies.
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Moreover, with the exception of the home MedKits model, each of the other prepositioning strategies includes a component that is served by the SNS-RSS-POD model; these options utilize more than one complementary strategy. The SNS-RSS-POD model is the second-least costly of the five scenarios.
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On the other hand, the SNS-RSS-POD model features the longest overall dispensing time. Moreover, the data analysis indicates that the SNS-RSS-POD model's estimated antibiotic dispensing time of 50.49 hours would exceed the CRI goal of 48 hours by roughly 2.5 hours.
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With a 20 percent population burden, the hospital/pharmacy sites would complete dispensing well before the public PODs. Moreover, offloading 20 percent of the population from the public PODs would decrease their dispensing time by nearly 8 hours.
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. FIGURE D-12 Google map depiction of pharmacies in the Minneapolis-St.
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and interviews indicated that 20 percent is a reasonable assumption for the proportion of the population that could be served by prepositioned workplace caches; the team chose the same assumption for the hospital/pharmacy option to allow for an equivalent comparison. An analysis of these two strategies suggests that overall dispensing time for both could be lowered further if a higher proportion of the population could be served by workplaces or hospitals/pharmacies, as opposed to public PODs.
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The postal model is second only to home MedKits in terms of overall distribution speed. Through the postal model, each household would receive one 10-day course of antibiotics in 25.24 hours: 13.24 hours for transporting the medication from SNS to RSS to post office and 12 hours for postal workers to deliver it.
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To conduct this analysis, the team selected representative zip codes that closely reflect the population density of an urban, suburban, and rural setting (see Figure D-13) (Zipskinny, 2000)
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Since the postal model serves only urban and suburban areas, the team selected an alternative zip code within the vicinity of Minneapolis-St. Paul as representative of a rural area.
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ALTERNATIVE DISPENSING STRATEGIES For this study, the team identified the alternative MCM dispensing strategies depicted in Figure D-14. The current strategy for distributing antibiotics relies on the SNS-RSSPOD model, which is a centralized to decentralized model.
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In addition to avoidance of yearly replenishment costs and/or expiry issues, a federally controlled forward-deployed stock would be geographi
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In Minneapolis, the VA hospital is centrally located (see Figure D-15) , and the many clinics located around the city could serve as FIGURE D-15 Location of the Department of Veterans Affairs (VA)
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Any of these forward-deployed stocks could be distributed to traditional public PODs, closed PODs, or alternative dispensing sites. Moving stocks farther downstream pre-event could dramatically reduce overall dispensing time.
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In the home MedKit model, each person receives enough pills to last for 10 days. In the postal model, each household receives 20 pills, regardless of the number of residents.
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This possibility must be considered when one is looking at the number of antibiotics provided overall in an affected area, as must tracking mechanisms for those who have received medications and those who have not. Efficiency • Reliance on Push Packages: Each prepositioning strategy will re quire the use of a Push Package to get the medications to a POD or to the postal service as soon as possible.
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Also, taking time to portion out medications while PODs are running during an event would increase dispensing time and labor costs. Ongoing Prophylaxis • Dispensing Strategy for a 60-Day Courses to Cover the Population: Each prepositioning strategy covers only the initial immediate need for antibiotics.
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Home MedKits, although comparatively expensive, could be appropriate for certain segments of the population for whom immediate availability of antibiotics would be worth the cost, such as essential first responders. In any city or region that chooses to preposition antibiotics, it is likely that a combination of these strategies should be considered.
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Washington, DC: United States Postal Service, http:// www.authorstream.com/Presentation/aSGuest58704-459527-plenary-plessas/ (accessed September 9, 2011)
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277 APPENDIX D Appendix D.1 Detailed Data This appendix provides the calculations that form the basis of the Observations from Strategy Calculations, incorporating the assumptions described in Components of Cost and Speed for Dispensing Strategies. Note that some cells in the following tables have been redacted to protect sensitive information.
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–28.47 24.82 127.00 Postal Model Overall Dispensing Time (hours) 42.9 42.9 0 % Difference in Dispensing Time –15.03 –15.03 N/A vs.
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Alternative Strategies SNS-RSS-POD 44% Postal Model; 56% SNSRSSPOD Overall Cost $5,255,680 $7,287,466 Per Capital Cost $3.09 $4.29 Overall Dispensing Time (hours) 50.49 34.18 Replenishment Costs (annual)
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Product Purchase Price - Total Costs for Medication (overall) Transportation Transportation - SNS to RSS to N/A not available Postal Office not available Transportation Costs (overall)
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+ security Dispensing - Total Costs $2,525,058.13 (total) Inventory Management Inventory Management - Labor Inventory Management - Cost of Storage/Pallet (yearly)
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dispensing Total Costs Product Purchase Price Transportation $0.00 Dispensing $2,525,058.13 Inventory Management (without replenishment) Total Cost (without replenishment)
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50.49 SNS to RSS to POD + POD Operating Time Dispensing Time for Strategy - Total (hours)
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× 1.7 million in MSA Costs Product Purchase Price Product Purchase Price - Costs $0.20 $0.10/pill × 2 pills per day $0.20 $0.10/pill × 2 pills per per daily dosage - Prophylaxis, day Doxycycline Product Purchase Price - $0.01 $0.01 Additional Medication Costs Per Daily Dosage (packaging, etc.)
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Transportation Transportation - Shipping $353.02 Source - average estimated $3,310.80 Source - average Medications to Hospitals/ shipping cost of USPS and estimated shipping cost Pharmacies FedEx of USPS and FedEx Transportation (overall) $353.02 $3,310.80 Dispensing Dispensing - Labor - Salaries (per $2,684.16 6 staff × 18.64/hr × 8 hr/shift × $894.72 2 staff × $18.64/hr × hospital/pharmacy, per day)
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is necessary (source: Georgia Tech paper) Dispensing - Labor - Supplemental Since hospitals and pharmacies Since hospitals and $0.00 $0 Nurses (19 pharmacies/310.1 have trained medical staff, pharmacies have pharmacies)
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+ Dispensing - Total Costs $32,256.89 $79,759.33 training (total) + security (total)
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Inventory Management - $0.00 0 Replenishment - Dispensing (overall) Inventory Management - $0.00 Total costs for product $0.00 Total costs for product Replenishment Costs (total, purchase + total costs for purchase + total costs annual)
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$0.00 $0.00 Total Costs Hospitals and Pharmacies Combined (20%, 340,000 individuals) Product Purchase Price $714,002.10 Transportation $3,663.82 Dispensing $112,016.23 Inventory Management (without $5,712.02 replenishment)
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Product Purchase Price - Total Costs for Medication Per Daily Dosage Product Purchase Price - Total Costs for Medication (per household) Product Purchase Price - Total Costs for Medication (overall)
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$44,736.00 300 staff per POD/day (source: interview with state public health official) × 8 hours/day × $18.64/hr (source: Zaric et.
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Inventory Management Inventory Management - Labor Inventory Management - Cost of Storage/Pallet Inventory Management - # of Bottles/Pallet Inventory Management - # of Pallets Required Inventory Management - Storage (total) Inventory Management - Total Costs (excluding replenishment costs)
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SNS to RSS to POD transportation time + POD Dispensing Time - Total (hours) 42.9 Operating Time Total Costs - POD (80%, 955,000 doses/individuals, 418,859.65 heads of household)
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$4,377,366.46 Replenishment Costs (SLEP) Total Costs - Hospital/Pharmacy Component + POD Component Product Purchase Price Transportation $3,664 Dispensing $2,304,879 Inventory Management Total Cost (without replenishment)
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3.88 Dispensing Time for POD Component (hours) 42.9 Rate-Limiting Step (hours)
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Product Purchase Price - Total Costs for $357,000 (170,000 individuals × $357,000 (170,000 individuals × Medication (overall) one 10-day course per one 10-day course per individual × $2.10 per individual × $2.10 per 10-day course)
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workplaces workplaces Dispensing - Labor - Supplemental $29,433.12 cost/day × 10 $490,555 × 3 hours $12,263.80 $61,319 Nurses (total for 17 large/ 566.67 small hours operating time × 1 operating time × 1 day/24 workplaces) day/24 hours hours 297 continued
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Inventory Management Inventory Management - Labor 0 not available 0 not available Inventory Management - Cost of Storage/ $14 Average of interview data $14 Average of interview data Pallet per month Inventory Management - # of Bottles/Pallet 10,000 Interview 10,000 Interview Inventory Management - # of Pallets 17 170,000 bottles × 10,000 17 170,000 bottles × 10,000 Required bottles/pallet bottles/pallet Inventory Management - Storage (total/ $2,856 17 pallets × $14/month × $2,856 17 pallets × $14/month × annual) 12 months/1 year 12 months/1 year Inventory Management - Total Costs $2,856 $2,856 (excluding replenishment costs)
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$1,346,283.38 $3,372,738.39 Replenishment Costs (annual) $360,392.18 $365,375.37 Total Costs Large and Small Workplaces Combined (20%, 340,000 individuals)
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Replenishment Costs (annual) $725,767.55 Dispensing Time Large Small Workplaces Workplaces Dispensing Time - Transportation (hours)
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Product Purchase Price - Total Costs for Medication (overall) Transportation Transportation - SNS to RSS to Postal Office N/A not available not available Transportation Costs (overall)
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Inventory Management Inventory Management - Labor Inventory Management - Cost of Storage/Pallet Inventory Management - # of Bottles/Pallet Inventory Management - # of Pallets Required Inventory Management - Storage (total) Inventory Management - Total Costs (excluding replenishment costs)
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42.9 Total Costs - POD (80%, 955,000 doses/individuals, 418,859.65 heads of household) Product Purchase Price Transportation $0.00 Dispensing $2,192,863.06 Inventory Management (without replenishment)
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Total Dispensing Time for Strategy Dispensing Time for Large Workplace Component (hours) 10 170,000 individuals/component × 10,000 individuals/large workplace × 10 work work places × 1,000 individuals/hour Dispensing Time for Small Workplace Component (hours)
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Dispensing - Labor - Hotline 10 days labor for a hotline $18,288 Dispensing Costs (overall) $2,388,288 Inventory Management Excluding replenishment costs, no inventory Inventory Management - Total Costs (excluding 0 management costs for MedKits replenishment costs)
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costs for transportation + total costs for dispensing Total Costs per Dispensing for 10-day course to population Product Purchase Price $8,704,000 Transportation $5,450,000 Dispensing $2,388,288 Inventory Management (without replenishment) $0 Total Cost (without replenishment)
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Product Purchase Price - Total Costs for Medication (total postal dispensing) Product Purchase Price - Total Costs for Postal $42,655.74 [2,540 workers × 2.28 MedKits (for Workers' MedKits household)
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Inventory Management - Total Costs (excluding replenishment costs)
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Inventory Management - Replenishment - Labor - $0.00 Postal workers Inventory Management - Replenishment - Security $0.00 (total) Inventory Management - Replenishment - Total Costs $0.00 for Dispensing Inventory Management - Replenishment Costs (total)
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POD Component Data Calculations Costs Individuals 955,000 Households 418,859.65 Product Purchase Price Product Purchase Price - Costs per daily dosage - Propylaxis, Doxycycline Product Purchase Price - Additional Medication Costs Per Daily Dosage (packaging, etc.) Product Purchase Price - Total Costs for Medication Per Daily Dosage
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Transportation Transportation - SNS to RSS to Postal Office N/A not available not available Transportation Costs (overall) $0.00 Dispensing Dispensing - Labor - Salaries (per POD, per day)
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Inventory Management Inventory Management - Labor Inventory Management - Cost of Storage/Pallet Inventory Management - # of Bottles/Pallet Inventory Management - # of Pallets Required Inventory Management - Storage (total) Inventory Management - Total Costs (excluding replenishment costs)
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Total Costs - Postal Component + POD Component Product Purchase Price Transportation $0.00 Dispensing $4,146,340.35 Inventory Management Total Cost (without replenishment) $6,919,617.69 $42,655.74 Replenishment Costs (annual)
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34.18 Rate-Limiting Step (hours) 34.18 Total Dispensing Time for Strategy (hours)
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PRTM expresses its gratitude to the Committee on Prepositioned Medical Countermeasures for the Public for the opportunity to contribute to its mission. PRTM would also like to thank Kristin Viswanathan for her assistance with the document review and all IOM employees that contributed to this effort.
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Susan Cooper, Tennessee Department of Health Victoria Davey, Department of Veterans Affairs Adele Etheridge, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention (CDC) Matthew Feltman, Kroger/Giant Sue Gorman, Office of Public Health Preparedness and Response, CDC Jayne Griffith, Minnesota Department of Health Roy Herman, Office of Public Health Preparedness and Response, CDC Laura Herrera, Department of Veterans Affairs Jack Herrmann, National Association of County and City Health Officials (NACCHO)
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317 APPENDIX D Jude Plessas, U.S. Postal Service Ken Rapuano, The MITRE Corporation Marjorie Sidebottom, University of Virginia David Starr, Office of Emergency Preparedness and Response, New York City Department of Health and Mental Hygiene Jason Stear, Office of Public Health Preparedness and Response, CDC Thomas Tighe, Direct Relief International Penny Turnbull, Marriott Hotels International James Turner, American College Health Association Representative, Utility Services Provider Michael Valentino, Department of Veterans Affairs
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