Category Archives: General

Thinking about neonatal tetanus

I like this definition / description of neonatal tetanus, borrowed from http://www.unicef.org Ehiopia reports ….

When a newborn is infected by tetanus during the first 28 days of life it is called neonatal tetanus (NT). When a woman delivers her baby in unsanitary conditions, a newborn baby may become infected if a contaminated knife, razor or any other sharp instrument is used to cut the umbilical cord. Infection may also occur if cow dung or ash is used to dress the stump; it is contaminated by soil or it enters the baby’s navel. If the hands of the person
delivering the baby are not clean infection may occur. Infants and children may also contract tetanus when dirty instruments are used for circumcision, scarification and skin piercing, and when dirt, charcoal or other unclean substances are rubbed into a wound. Newborns with neonatal tetanus usually die a painful death. Typically, an apparently healthy baby will stop nursing after a couple of days due to lockjaw, developing stiffness,
arching of the body and violent convulsions. Ultimately, breathing becomes difficult, spasms occur more frequently, and in 70 to 100 percent of the cases, infants die a tortuous death.

Neonatal tetanus, an entirely preventable disease, kills about 200,000 infants in the first month of life. Ninety percent of these deaths occur in 27 developing countries, making this disease a leading cause of death in the poorest part of the world. However, the disease is largely invisible, because most of the deaths occur at home before the baby reaches two weeks of age. Oftentimes, neither the birth nor the death is reported. Maternal tetanus is responsible for at least 5% of maternal deaths, approximately 30,000
deaths annually (Faveau, 1991) with an astonishing 100 million women at risk, despite the fact that it can be easily prevented through immunization.  [NOTE: I'm not certain as to what year these numbers are from, as the report from which I borrowed this paragraph did not have a published date on it ... ]

The WHO approach to dealing with neonatal tetanus is to recommend that all pregnant women receive three (with five being optimal) doses of tetanus vaccine.  !!!! WOW !!!!  I love that tetanus is preventable, but I do not love the idea of trying to get every woman multiple doses of a vaccine in pregnancy.  Some areas have been successful in implementing this approach. Kudos!  But, as always, reality reality reality … and going back to the practices of the traditional birth attendants.  Rather than treating the symptom (infection), why not treat the problem (unclean birth practices) … teach TBAs how to severe cords in a sanitary manner, provide them with a method of cutting the cord.   Clean birth kits !!! GET CLEAN BIRTH KITS AND THE TRAINING TO USE THEM INTO THE HANDS OF THE MIDWIVES !!!

Neonatal tetanus (well, tetanus in any person) is a horrible disease. I weep when I think of the pain the babies are in and their inability to understand why they hurt so badly.  Hundreds of thousands of babies are affected by tetanus each year.  How many of those hundreds of thousands could be spared the pain and (typically) death of this disease if we could get the tools and training into the hands of those amazing women and men who are attending the births. Pictures, basic supplies.

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pondering public health capacity building

Apologies for taking the month off from blogging.  I was traveling and just plain busy when at home. Sometimes, it amazes me how quickly time passes. I was astounded to see that it has been a full month since my last post.

On my mind today is public health capacity building. I am working on a paper for a class regarding how public health capacity building can impact my community. I’ve had some problems writing this paper because I do not particularly want to address public health capacity in my rural, North Idaho, USA community. Instead, I am gathering data on different locations: Nigeria and Haiti in particular.

What *is* public health capacity building?  A narrow definition that I like is, “The capacity to deliver specified, high quality services or responses to particular problems.”  A broader definition is, “The capacity of a system to solve new problems and respond to unfamiliar situations.”  [Definitions borrowed from Capacity Building to address the Social Determinants of Health, Stephan Van den Broucke, Department of International Health EU Expert Group on SDHI, Luxembourg, 24 November 2009 presentation.]

In the narrower definition of capacity building, there must be set criteria on particular competencies relating to specific skills, procedures and structures. Additionally, the results are linked to performance standards, competency assessment, and quality improvement.  Alternatively, in the broader definition, capacity building is defined by more diffuse and complex criteria related to the ability of the public health community to think creatively, adapt to change, innovate and solve problems. The success or implementation of capacity building under the broader definition is significantly linked to leadership, service development, and team involvement.

These are the issues prevalent in public health capacity building. When I think through the issues related to maternal and infant mortality and how best to apply public health capacity building on a global basis, I am drawn to my long-standing conviction that the ability to affect public health in this particular subset is through information dissemination. To reach the masses, the public, those aspects of maternity and neonatal care that are performed at the community level must be addressed and strengthened. The capacity to decrease maternal and infant mortality/morbidity rates is in providing education and tools to the families and those most likely to be attending births, the Traditional Birth Attendants.

When we talk about capacity building, so much of the time, we are focused on building infrastructure and increasing the number of “skilled” providers. But, looking at the broader definition of capacity building, and keeping in mind the link to leadership, service development, and team involvement, there is certainly some credence lent to the concept of working from the bottom up to affect maternal and infant outcomes.

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(birth related only) Essential Interventions, Commodities, and Guidelines

From the WHO report in December 2011, priority interventions related to childbirth are:

  • Social support during childbirth (community, primary, referral)
  • Prophylactic antibiotic for caesarean section (referral)
  • Caesarean section for maternal/foetal indication (e.g. obstructed labour and central placenta previa) ( referral)
  • Prevention of postpartum haemorrhage: a) Prophylactic uterotonic to prevent postpartum haemorrhage (community, primary, referral), b) Active management of third stage of labor to prevent postpartum haemorrhage (primary, referral)
  • Induction of labour for prolonged pregnancy (referral)
  • Management of postpartum haemorrhage: a) uterine massage, b) uterotonics (community, primary, referral), c) manual removal of placenta (only by professional health workers) (primary, referral)
  • Initiation or continuation of HIV therapy for HIV positive women (primary, referral)

This report is actually quite interesting and has loads of good links to reference material.

I am particularly interested in the guidelines/interventions that are called out as appropriate at the community level (the report is referring to community health workers). Social support during birth, prevention of postpartum hemorrage, management of postpartum hemorrage.

The major direct causes of maternal morbidity and mortality include haemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labour. (who.int)

Let’s do it! Let’s Train Midwives to Save Lives at the community level! Social support during birth, prevention of postpartum hemorrage, and management of postpartum hemorrage! THAT’s IT!

(stay tuned: tomorrow … the essential interventions, commodities, and guidelines in relation to newborns)

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First, do no harm …

This afternoon, I just want to write from my heart about why I started the Train Midwives Save Lives project and try to lay out some details of how this complex project is progressing, including a little insight into the upcoming trip to Haiti.

Every day, women and babies die in childbirth. A LOT of women and babies die. And a lot of those women and babies don’t need to die. Being born is risky business, no matter where you are. We do not live in utopia. Heaven is not here on earth. But, there are some simple things that can be done at the time of birth to significantly decrease the number of women and babies who die. Simple things, like ensuring that there is a clean birth environment, knowing how to resuscitate a baby, basic newborn care, severing the umbilical cord either by burning or with a clean blade, treating the umbilical cord one time with chlorhexedine, knowing how to deal with maternal bleeding.  The ramifications of getting the health information into the hands of those who are attending births can be astoundingly good. This project is big. It is going to be costly. It will involve many many studies and people. It is complex because we need to study how different populations deal with these issues, we need to build relationships in a lot of different locales, there are languages and customs and belief systems that will impact all of the work.

What isn’t visible on this blog is all of the activity going on in the background.

Sometimes, I think the project is confusing for people because, in general, we are used to people going to one place and working with a select group of people in that one place. Train Midwives Save Lives will be looking for midwives who are already in locales and midwives who are willing to move into locales or visit frequently … but, in the end, Train Midwives Save Lives is not about whether or not we spend the years that it takes to apprentice a midwife to sufficiency, but, instead, it’s about whether or not we are able to come up with a way to address these elemental training issues and SAVE LIVES…. a lot of lives…It is about coming alongside the traditional midwives and providing them in an honoring manner with some basic tools that they can use to save lives.  Are the issues being addressed by Train Midwives Save Lives the only issues that need attention when it comes to maternal and neonatal mortality? Absolutely not. But these are issues that Train Midwives Save Lives aims to address:

  • Get clean birth kits, along with training on how to use them into the hands of those attending births in low-income countries.
  • Analyze current practices regarding neonatal resuscitation by unskilled birth attendants. Develop and deliver appropriate training regarding neonatal resuscitation in an out-of-institution environment.
  • Gather data on effectiveness of including chlorhexidine for umbilical cord care in clean birth kits. Test inclusion of powdered chlorhexidine in birth kits.
  • Analyze current practices regarding treatment of postpartum hemorrhage in out-of-institution care. Evaluate, develop, and test training on treatment of postpartum hemorrhage when medications are not available. Work with local governments to implement transfer of care protocols.
  • Evaluate how to address pregnancy induced hypertension with diet in low-income countries.
  • Develop and train recognition of obstructed labor for unskilled birth attendants. Work with local governments to implement transfer of care protocols.

Accomplish even one of these goals and it will result in a significant decrease in the number of women and babies who die.

Is Train Midwives Save Lives only about going on mission trips? No.

Are mission trips intrinsically part of what we will do? Yes.

It is the opportunity to be in different locales and connect with the people who are living there that will make the end result of basic training achievable.  While gathering the knowledge and data necessary to build the training, we will be privileged and honored to be able to come alongside traditional birth attendants world wide. We will learn much from them … and we hope that one day, they will learn from us.

I’m so excited that your donations have made it possible for Train Midwives Save Lives to put together hundreds of clean birth kits already.  And preparing to go to Haiti and get the birth kits into the hands of the sage femmes who are doing births without even these most essential items is exciting and daunting. I will admit that I am astounded at the amount of money that is needed to make this trip. I would love to spend all of the donations purchasing clean birth kits … but, then who would get them into the hands of the sage femmes?  This is one reason we need to actually go into each locale — to establish a method of getting the clean birth kits and other training into the hands of the midwives.  Depending on the location, this may take several trips or it may take one.

There is a formal and an informal aspect to Train Midwives Save Lives. The formal piece is to systematically assess how to accomplish the end goal of the pictorial training. The informal piece is being ready to and able to provide clean birth kits, neonatal resuscitation training, postpartum hemorrhage training, and essential newborn care training “on-the-fly” to whomever we are able to bless with these skills on a day-to-day basis.

This first trip to Haiti is going to be a whirlwind! We are going to see about helping the sage femmes in Simone Pele as well as in the villages around Port au Prince. We are going to go out to the sewing project and pick up the messenger bags that the ladies there have made and evaluate whether or not to continue making orders through the project.  If you’ve been following this blog from the beginning, then you know that this is a simpler plan than originally presented. As the weeks have marched by, it has become very obvious that the trip needs to be about observation more than imposing.  Do we have many skills that we are anxious to teach the midwives? Yes. But first, we must find out what they already know and how they do things … otherwise, how will we have any credibility when it comes time to present doing new or different things? Will we be prepared to teach if the opportunity presents itself? Absolutely!

But, first, do no harm.

WHO 10 Facts on Maternal Health

Fact 1 – Worldwide, 1000 women DIE every day due to complications during pregnancy and childbirth – up to 358,000 women per year. In developing countries, conditions related to pregnancy and childbirth constitute the second leading causes (after HIV/AIDS) of death among women of reprodutive age.
 
Fact 2 – Four main killers cause around 70% of maternal deaths worldwide: severe bleeding, infections, unsafe abortion, and hypertensive disorders (pre-eclampsia and eclampsia). Bleeding after delivery can kill even a healthy woman, if unattended, within two hours. Most of these deaths are preventable.
 
Fact 3 – More than 136 million women give birth a year. About 20 million of them experience pregnancy-related illness after childbirth. The list of morbidities is long and diverse, and includes fever, anemia, fistula, incontinence, infertility and depression. Women who suffer from fistula are often stigmatized and ostracized by their husbands, families and communities.
 
Fact 4 – About 16 million girls aged between 15 and 19 give birth each year, accounting for more than 10% of all births. In the developing world, about 90% of the births to adolescents occur in marriage. In many countries, the risk of maternal death is twice as high for an adolescent mother as for other pregnant women.
 
Fact 5 - The state of maternal health mirrors the gap between the rich and the poor. Only 1% of maternal deaths occur in high-income countries. A woman’s lifetime risk of dying from complications in childbirth or pregnancy is an average of one in 120 in developing countries and compared to one in 44 300 in developed countries. Also, maternal mortality is higher in rural areas and among poorer and less educated communities. Of the 1000 women who die every day, 570 live in sub-Saharan Africa, 300 in South Asia and five in high-income countries.
 
Fact 6 – Most maternal deaths can be prevented through skilled care at childbirth and access to emergency obstetric care. In sub-Saharan Africa, where maternal mortality ratios are the highest, only 46% of women are attended by a trained midwife, nurse or doctor during childbirth.
 
Fact 7 - In developing countries, the percentage of women who have at least four antenatal care visits during pregnancy ranges from 34% for rural women to 67% for urban women. Women who do not receive the necessary check-ups miss the opportunity to detect problems and receive appropriate care and treatment. This also includes immunization and prevention of mother-to-child-transmission of HIV/AIDS.
 
Fact 8 - About 18 million unsafe abortions are carried out in developing countries every year, resulting in 46 000 maternal deaths. Many of these deaths could be prevented if information on family planning and contraceptives were available and put into practice.
 
Fact 9 - One target of the Millennium Development Goals (MDGs) is to reduce the maternal mortality ratio by three quarters between 1990 and 2015. So far, progress has been slow. Since 1990 the global maternal mortality ratio has declined by only 2.3% annually instead of the 5.5% needed to achieve MDG 5, aimed at improving maternal health.
 
Fact 10 - The main obstacle to progress towards better health for mothers is the lack of skilled care. This is aggravated by a global shortage of qualified health workers. By 2015 another 330 000 midwives are needed to achieve universal coverage of mothers with skilled birth attendance.
 
Facts taken directly from the WHO Fact File
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AHA! Moments #1 and #2

World Health Organization Defines a skilled birth attendant as an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. Traditional birth attendants, trained or not, are excluded from the category of skilled attendant at delivery. In developed countries and in many urban areas in developing countries, skilled care at delivery is usually provided in a health facility. However, birth can take place in a range of appropriate places, from home to tertiary referral centre, depending on availability and need, and WHO does not recommend any particular setting. Home delivery may be appropriate for a normal delivery, provided that the person attending the delivery is suitably trained and equipped and that referral to a higher level of care is an option.

Some excellent work has bee done in Nepal to study how and what to train traditional birth attendants (TBAs) in order to “bring them up to speed.”  Due to formal educational expectations for a skilled birth attendant, it is reasonable to say that TBAs will not in the long term fall into the category of skilled birth attendant. However, as the work in Nepal showed, it is indeed possible to provide training for the TBAs that gives them some of the same core skills as a skilled birth attendant.

The lines are hard to draw between those who attend normal births and those who deal with complications. In North America, the North American Registry of Midwives and the Midwives Alliance of North America have done good work of job analysis and defining the skills and competencies necessary for attendance of NORMAL out-of-hospital births.  These competencies, when mastered, prepare a midwife to attend normal birth. Competencies include recognizing complications and knowing how to get the mother/baby into higher level care when necessary.

In North America, this system works fairly well. One reason it works fairly well is that we have higher level (hospital) care and trained obstetricians to deal with complications that require intervention.

In the developing world, not so much. I greatly admire those who are working to increase healthcare and public health capacity in that area.

Somewhere along the line, though, birth has come to be considered not normal … and, as a result, the lines are blurred.  In the developed world, maternal mortality is not necessarily lower because women are birthing in institutions. There are myriad indicators as to why women in the developed world have a much lower chance of dying in the childbearing year. It’s not all pregnancy related. It is not because they are giving birth in hospital. It is largely because the basics requirements for a healthy life aren’t available.
Clean water. Plenty of food. Infrequent disease.

Ruling out TBAs as viable providers of care is difficult.

One stumbling block is that the skilled birth attendant category includes “ability to manage normal childbirth and provide basic (first line) emergency obstetric care.” This basic emergency obstetric care, as best as I can tell from WHO resources includes:

  • Hypertension in pregnancy - Hypertension, Assessment and management, Delivery, Postpartum care, Chronic hypertension, Complications
  • Management of slow progress of labour – General principles, Slow progress of labour, Progress of labour, Operative procedures
  • Bleeding in pregnancy and childbirth - Bleeding, Diagnosis and initial management, Specific management, Procedures, Aftercare and follow-up
These requirements, especially the operative procedures piece (which equals vacuum extraction, suturing, etc.) make it clear that TBAs will not fall under the category of skilled birth attendants.

Train Midwives Save Lives aims to consider what training can we get to the TBAs to improve outcomes. Most women worldwide do not see a skilled birth attendant for childbirth. Plain and simple.

By the WHO definitions, I am not a skilled birth attendant. I do not know how to carry out a vacuum extraction. I cannot write prescriptions for antibiotics for postpartum infection nor can I write prescriptions for women who need pharmaceuticals to control high blood pressure.

As a midwife, I serve low-risk women who are having normal births.  When the course of pregnancy or birth results in that woman/baby not being considered low-risk or not having a normal birth, then I refer to higher-level care.

Traditional Birth Attendants should be serving low-risk women who are having normal births. Obviously this is not the case, as evidenced by the astounding number of women and babies who die in the childbearing year each and every year.

AHA! Moment #1: Systematically provide training appropriate for anyone who might be attending a birth (family or community member) to enable them to make good decisions as to which women are low-risk.

AHA! Moment #2:  Provide training to those same people as to how to provide a clean birth environment, what to do when a baby doesn’t breathe at birth (and no resuscitation equipment is available), and a mom  bleeds excessively (and no pharmaceuticals are available).

I hope against hope that Train Midwives Save Lives will be able to complete large and small-scale studies to look into these keys and create the tools to make a difference.  It’s a long road ahead and the journey has just begun!

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Essential Newborn Care. What is it really?

Keep the baby with the mama!

Keep the baby WITH THE MAMA!

Keep the baby WARM!
(if you are in a warm climate, then there’s not a lot to do in this area)

Make sure the baby is breathing!

I’ve been enjoying my research on this topic today. The term “Essential Newborn Care” just sounds so, well, BIG. And, indeed, it *is* big! … But I find it quite humorous that we can’t just use words like

“Keep the baby with the mommy.”

I do have some comments on and appreciation for this directive from the WHO Philippines office…

Essential Newborn Care (ENC) 

The ENC Protocol is a step-by-step guide for health workers and medical practitioners issued by the Department of Health for implementation under Administrative Order 2009-0025.

What are these step-by-step interventions?

Immediate drying

Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front and back, arms and legs.

[COMMENT:  If baby is vigorous, drying and rubbing off all the vernix really isn't such a great idea (see the instructions later in the directive regarding bathing the baby). OTOH, if everyone is taught to dry the baby, then you don't have to worry about differentiating between a vigorous and nonvigorous baby ... because you'll just be stimulating all of them!]

Uninterrupted skin-to-skin contact

Aside from the warmth and immediate bonding between mother and child, it has been found that early skin-to-skin contact contributes to a host of medical benefits such as the overall success of breastfeeding/colostrum feeding, stimulation of the mucosa—associated lymphoid tissue system, and colonization with maternal skin flora that can protect the newborn from sepsis and other infectious disease and hypoglycemia.

[COMMENT: LOVE THIS "Intervention"]

Proper cord clamping and cutting

Waiting for up three minutes or until the pulsations stop is found to reduce to chances of anemia in full term and pre-term babies. Evidence also shows that delaying cord clamping has no significant impact on the mother.

[COMMENT: YES!!! While not my idea of delayed cord clamping, THREE MINUTES is a LIFETIME in the medical world!  It's interesting that three minutes is the time called out here, seeing as the research supports a 4 minute cord infusion ... but, 3 minutes is definitely better than immediate!]

Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in

The earlier the baby breastfeeds, the lesser the risk of death. Keeping the baby latched on to the mother will not only benefit the baby (see skin-to-skin contact) but will also prevent doing unnecessary procedures like putting the newborn on a cold surface for examination (thereby exposing the baby to hypothermia), administering glucose water or formula and foot printing (which increases risk of contamination from ink pads) and washing (the WHO standard is to delay washing up to 6 hours; the vernix protects the newborn from infection). 

[COMMENT:  Non-separating of the newborn from the mother is an intervention?  I do love this recommendation overall, though.]

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Now … the harder part is to figure out just how do you get the basics of essential newborn care ingrained into the heart and hands of everyone who is at a birth?  I think the reality is that for births that take place out of the hospital / birth center, then the chances that these basics are happening are greater.  I am hoping to take a look at this with one of the groups of TBAs … much my hunch is that the report will be that they are indeed practicing these “interventions.”

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Clean Birth Kit Instruction Sheets (warning: Graphic!)

As I researched clean birth kits and their effectiveness, I learned two things (well, actually, I learned a lot more than two things … but two basic precepts):

1. The contents of clean birth kits are standardized and simple: a clean birth surface (trash bag or chux pad), gloves (universal precautions), soap (same), razor to cut the umbilical cord, string of some sort to tie the umbilical cord.

2. Although these contents are very logical and simple, it accomplishes little for someone get the baggie full of goodies if there are not simple instructions included.  Furthermore, I was unable to find a standard set of instructions that could be included in the birth kits.

SOLUTION!  So, I put a note up on my Facebook to see if anyone might be interested in helping me with this little art project. I figured the drawings needed to be simple, black and white, and VERY easy to understand. The idea is to make it so that anyone who might find themself in the presence of a birthing woman and in possession of a clean birth kit could use the contents to potentially improve the outcome.

A sweet friend volunteered to help and we met over coffee one afternoon a few weeks ago. I am super excited to share her excellent work here on the Train Midwives Save Lives blog.

WARNING: THE GRAPHICS (below) are just that — GRAPHIC!

I’m looking forward to comments on how we can improve the pictures / instructions.  Do they make sense? Is it an issue that they read left-to-right? If you had no idea what the baggie was for, would you be able to figure it out?

If you are someone who is making clean birth kits and sharing them with women / midwives in the the developing world and you feel that these graphics would be useful to the people who are receiving your clean birth kits, PLEASE feel free to use them! For the purposes of this post, I am including only the 1-per page version. There is another file available that is sized so that you can print 4-per page. If you’d like this, just email trainmidwives_savelives@yahoo.com and I’ll forward it on to you.

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global blogging

This blog post is absolutely just for fun. I noticed on the Stats page for the blog that it shows the countries from which people have viewed the posts. It is astounding to see that people from the following countries have peeked into the Train Midwives Save Lives vision:

United States, Sweden, Canada, Burkino Faso, United Kingdom, Lithuania, Germany, India, Pakistan, France, United Arab Emirates, Sri Lanka, Hong Kong, Rwanda, South Africa, Ireland, and the United Republic of Tanzania.

Fantastic!  Keep spreading the word!
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chlorhexidine + clean birth kit =

Healthier moms and babies!

Introducing initial plans for a small-scale pilot study on the effects of including chlorhexidine IN clean birth kits.

Chlorhexidine is a chemical antiseptic that is effective on gram-positive and gram-negative bacteria. Latest research shows significant reduction in neonatal infection when umbilical cords are treated even just once with chlorhexidine.

Clean birth kits contain a bar of soap for hand washing, a chux or plastic sheet/bag for a clean birth surface, clean gloves for universal precautions, clean string for tying the umbilical cord, a new razor blade for cutting the cord, and pictorial instructions illustrating the sequence of use of the items.

Chlorhexidine + clean birth kits will evaluate whether or not chlorhexidine is used when included in the kits, if it is used correctly, and the impact on infection rates in a small population.

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