EPIDEMIOLOGY <<Back
 
 
018
A COMPARISON BETWEEN LONGITUDINAL AND TRANSVERSE DIAMETERS OF TUBERCULIN TEST INDURATIONS
Kul Bhushan, MN Mukherjee, SP Chattopadhya & KT Ganapathy: Indian J Med Res 1972, 60, 1724-30.

In the epidemiological surveys carried out by the National Tuberculosis Institute (NTI), Bangalore, instead of reading the tuberculin reactions (indurations) by measuring their transverse diameters as is done conventionally, the longitudinal diameters were read. Later on, as the longitudinal diameters were observed to be larger than the transverse diameters, an investigation was carried out to study whether this difference would affect the estimation of infection rates. Out of 1,240 tuberculin tested persons, for 1,189 both transverse and longitudinal diameters were read by each of two readers, one accustomed to read the longitudinal diameter and the other, the transverse diameter. All care was taken to avoid bias on the part of the readers. All four reading were available for 1,075 persons (87%).

It was found that longitudinal diameters were larger than the transverse diameters for all ranges (of sizes) of reactions when either diameter for each reader was taken as standard. The prevalence of infection, considering 10mm+ reactions as the minimum level for those infected, were almost the same for both the diameters and for both the readers. Analysis according to age sex gave similar results. Variations between the readers are known to be of much higher magnitude than those observed between the diameters in this study. The levels of post-vaccination allergy calculated on the basis of longitudinal diameters, however, will be larger than those for transverse diameters. In view of the above results, the findings of the NTI epidemiological surveys wherein longitudinal diameters of tuberculin reaction are read, will not only be comparable with other studies conducted by NTI but also with studies done by other organizations-national or international.

KEY WORDS: TUBERCULIN, INDURATION SIZE, TRANSVERSE DIAMETER, LONGITUDINAL DIAMETER.

028
FIVE YEAR INCIDENCE OF TUBERCULOSIS AND CRUDE MORTALITY IN RELATION TO NON SPECIFIC TUBERCULIN SENSITIVITY
GD Gothi, SS Nair, AK Chakraborty & KT Ganapathy: Indian J TB 1976, 23, 58-63.

The study was undertaken in a sample of 103 villages of 3 sub-divisions of Bangalore district as a part of the 5 year study of epidemiology of tuberculosis between 1961-68. The follow ups were done at 1.5, 3 & 5 years after the first survey. The entire population was offered tuberculin test with 1 TU RT 23, a second test with 20 TU RT 23 to those persons who were having reactions of 0-13 mm to 1 TU. All aged 5 years or more were offered 70mm photofluorograms at each survey. Two specimens of sputum were collected from persons having abnormal X-ray shadows for examination of tubercle bacilli. Procedures were uniform at each survey. The population was divided into three groups on the basis of their tuberculin reactions: (a) reactors to 1 TU (infected with M.tuberculosis), b) non-reactors to 1 TU but reactors to 20 TU (infected with atypical mycobacteria), c) non-reactors to both 1 TU & 20 TU (not infected with either M.tuberculosis or other mycobacteria). Incidence of disease and crude mortality were studied separately among these groups.

The five year incidence of culture positive disease was the highest among 1 TU reactors and the least among reactors to 20 TU. In the younger age group (5-14 years) the five year incidence of culture positive disease among reactors to 20 TU was significantly lower compared with that among 20 TU non-reactors. The reduction of incidence of culture positive cases in the former group over that in the latter was 75% for culture positive cases and 61% for combined culture positive and negative disease. As regards crude mortality, the overall rate was significantly lower among 20 TU reactors compared with non-reactors. Even if the significance of the finding on crude mortality is debatable, it could be concluded that non-specific infection provides some protection against development of tuberculosis, at least in younger age groups.

KEY WORDS: INCIDENCE, DISEASE, MORTALITY, NTM, RURAL POPULATION.

029
PREVALENCE OF NON-SPECIFIC SENSITIVITY TO TUBERCULIN IN A SOUTH INDIAN RURAL POPULATION
AK Chakraborty, KT Ganapathy, SS Nair & Kul Bhushan: Indian J Med Res 1976, 64, 639-51.

The data from a tuberculosis prevalence survey carried out in three taluks of Bangalore district in south India during 1961-68 were analysed to study (i) the prevalence of non-specific sensitivity in the community i.e., prevalence of infection with mycobacteria other than M.tuberculosis, as found by testing the population with tuberculin RT 23 of a lower strength (1 TU) and higher strength (20 TU), both with Tween 80 and (ii) additional boosting if any, resulting from testing with higher dose of tuberculin, immediately following a test with 1 TU RT 23.

The level of demarcation between infected and uninfected with 1 TU was 0-9 mm induration size and this negative group tested with 20 TU dose induration of 8 mm or more was considered positive. Prevalence of infection with M.tuberculosis in the community were 2.1% in 0-4 years, 7.9% in 5-9 years, 16.5% in 10-14 years, 33.2% in 15-24 years and overall 14.5% in 0-24 years of age group. Infection rate with other mycobacteria were 12.9%, 44.9%, 66.2%, 62.4% and 45.7% respectively in the above stated different age groups.

Testing the population with 20 TU RT 23 following a 1 TU test was found not to boost the tuberculin reactions over that observed on a single test with 1 TU only.

KEY WORDS: NTM, PREVALENCE, INFECTION, BOOSTING, TUBERCULIN REACTION, RURAL POPULATION.

033
USE OF 20 TU RT 23 AND 5 TU BATTEY ANTIGEN FOR ESTIMATION OF PREVALENCE OF NON-SPECIFIC TUBERCULIN SENSITIVITY
GD Gothi, AK Chakraborty, MJ Jayalakshmi & KT Ganapathy: Indian J Med Res 1977, 66, 389-97.

Estimates of prevalence of non-specific tuberculin sensitivity in south Indian population are based on studies using large doses of tuberculin prepared from Mycobacterium tuberculosis. In the present study, comparison of tuberculin test done on 2168 children aged 0-9 years with 20 TU RT 23 and 5 TU Battey antigen, belonging to rural areas, have been done. The distribution of induration to 20 TU RT 23 test has been compared to that of 5 TU Battey test, to see whether estimates of prevalence of non- specific tuberculin sensitivity based on the former could be compared with those based on tests with antigen derived from other mycobacteria.

It was seen that distributions of reactions, mean size of indurations as well as percentages of positive reactors to either test were not significantly different in the two randomly selected groups i.e., one tested with Battey antigen and the other with 20 TU RT 23. The prevalence of non-specific sensitivity in 0-4 years age group based on Battey test was 18.4 per cent and that with 20 TU test, 16.6 per cent. In the age group 5-9 years corresponding rates were 54.2 and 60.1 per cent. From these observations, it is suggested that if other antigens are not available, 20 TU RT 23 could be used for estimation of non-specific sensitivity.

KEY WORDS: BATTEY ANTIGEN, PREVALENCE, NON SPECIFIC INFECTION.

042
EFFECT ON TUBERCULIN ALLERGY OF TUBERCULIN TESTS GIVEN 18 MONTHS EARLIER
Raj Narain, GD Gothi, KT Ganapathy & CV Shyama Sunder: Indian J Med Res 1979, 69, 886-92.

Enhancing effect of tuberculin allergy as a result of repeat tests with 1 TU RT 23 on groups tested with I TU, 20 TU and placebo was studied by random allocation among population not vaccinated with BCG in 8 villages. In all, 2357 persons were tested with 1 TU and 759 with normal saline at first round. Based on testing at three rounds the study population could be divided into eight different groups and were labelled with alphabets 'a' to 'h' having been tested once, twice or thrice. The groups 'a', 'c', 'e' & ’g' were tested at 2 months, round two with 1 TU RT 23 and remaining half were not tested. However, all available persons in the 8 groups were retested at the third round, 18 months after the initial test. Thus, eight groups cannot be treated as independent samples but representative of the whole population.

The study did not show enhancing effect due to previous tuberculin test with 1 TU alone among groups tested once, twice or thrice after an interval of 18 months. Part of population was tested with 20 TU at round one; boosting effect was seen at 2 months when test was repeated. However, it was not seen after 18 months but when exactly the boosting effect disappeared was not known. Thus, there was no increase in reaction even among those who were tested with a higher dose of 20 TU earlier after 18 months. The groups provided the largest number for comparison between tested and the control groups. It is inferred from the study that boosting with high dose or repeat tests with the same dose does not persist after 18 months. Hence, for classifying positive tuberculin reactors, no correction is required to the same individuals/population after an interval of 18 months or more, as no boosting effect after 18 months has been observed, on the basis of this analysis.

KEY WORDS: TUBERCULIN TEST, TUBERCULIN ALLERGY, BOOSTING.

043
PREVALENCE OF INFECTION AMONG UNVACCINATED CHILDREN FOR TUBERCULOSIS SURVEILLANCE
AK Chakraborty, KT Ganapathy & GD Gothi: Indian J TB 1980, 72, 7-12.

A survey was carried out among 12,535 children in the age group 0-9 years of 90 villages in Doddballapur sub-division of Bangalore district to study the possible variation in the prevalence of tuberculous infection among the unvaccinated children in a village depending upon the varying prevalence of BCG scars in the same population. In each village, all the children in the age group of 0-9 years were registered and examined for the presence or absence of the BCG scar. Of the 12,535 children, 6269 (50%) who did not have BCG scars were eligible for tuberculin test, while 6045 were actually tested. Each child without BCG scar was tuberculin tested with 1 TU RT 23 with tween 80 and the reaction read between 72 and 96 hours. Two proportions were calculated in each village viz., a) the proportion with BCG scars and b) that of infected children among those without scar and the villages were distributed by these two proportions.

On the basis of distribution of tuberculin reactions, 10 and 12 mm induration was the demarcation between positive and negative reactors. Prevalence of infection among 0-9 years was 4.9%, 2.6% among 0-4 years and 8.9% among 5-9 years. Distribution of villages according to two variables i.e., prevalence of BCG scars and prevalence of infection among unvaccinated children did not show any correlation with the prevalence of infection among the unvaccinated in the same villages.

It is seen from the study that exclusions of various proportions of children with BCG scars did not have any correlation with the prevalence of infection among the unvaccinated in the same villages.

In non-e of the villages any association was seen between these two. In view of this finding, it is felt that the simple method of periodic tuberculin testing of the population in younger age groups could be developed into a method of tuberculosis surveillance even in areas where direct mass BCG vaccination is given. This would appear to be the cheapest, practicable and technically appropriate method of studying the overall tuberculosis situation.

KEY WORDS: PREVALENCE, INFECTION, BCG SCAR, SURVEILLANCE.

046
EFFECT OF NUTRITIONAL STATUS ON DELAYED HYPERSENSITIVITY DUE TO TUBERCULIN TEST IN CHILDREN OF AN URBAN SLUM COMMUNITY
AK Chakraborty, KT Ganapathy & R Rajalakshmi: Indian J TB 1980, 27, 115-19.

Prevalence of tuberculous infection in young children is an important surveillance measure. However, the hypersensitivity may be depressed by malnutrition and thus interfere with the interpretation of tuberculin test leading to underestimation of the infection rate. Objective of this investigation was to study the relationship between tuberculin reaction with 1 TU RT 23 and nutritional status of children. The study was carried out in 1974 among children aged 1-9 years of age living in an urban slum area of Bangalore city and who were not given BCG vaccination.

Of the 1151 registered children aged 0-9 years, 482 in the age group 1-4 and 526 in 5-9 years formed the study group. Of these 1008 children, 980 had both clinical evaluation and anthropometric measurement for nutritional status and 963 had both tuberculin test readings and anthropometric measurements carried out for them. Of the 482 children aged 1-4 years, 230 were classified as suffering from Protein Calorie Malnutrition (PCM) and of the 498 in the 5-9 years of age, 227 were classified as suffering from PCM. Distribution of tuberculin test indurations in mm among the normals and the undernourished were compared; no significant difference in the mean size of tuberculin indurations as well as in the distributions of these indurations was observed, regardless of the method used for arriving at the classification.

KEY WORDS: NUTRITIONAL STATUS, TUBERCULIN REACTION, SLUM COMMUNITY, INFECTION.

050
DOES MALNUTRITION AFFECT TUBERCULIN HYPERSENSITIVITY REACTION IN THE COMMUNITY
KT Ganapathy, AK Chakraborty: Indian J Pediatrics 1982, 49, 377-82

Distribution of tuberculin test indurations were studied in relation to nutritional status of 930 rural children aged 1-4 years and 796 aged 5-9 years. Using Quetlet's Index, it has been observed that the distribution of indurations were similar in normal and malnourished children. By following Jelliffe's criteria of grading nutrition, no correlation was observed between the size of induration and degree of malnutrition. It is concluded that malnutrition in the community may not influence the prevalence rates of tuberculin infection based on such testing.

KEY WORDS: MALNUTRITION, TUBERCULIN REACTION, COMMUNITY.

053
ARE THE ABSENTEES FOR EXAMINATIONS IN THE EPIDEMIOLOGICAL SURVEY OF TUBERCULOSIS DIFFERENT FROM THOSE EXAMINED?
VV Krishna Murthy & KT Ganapathy: NTI Newsletter 1989, 25, 15-21.

It is a common observation that in epidemiological surveys all those eligible for various examinations (tuberculin, X-ray and sputum examinations) do not attend them. If the 'non-attenders' differ from the 'attenders' the true situation of the problem may not be known. In this paper, the prevalence of infection, bacillary cases and suspect cases at II survey for both attenders and non-attenders of the I survey from longitudinal study conducted by National Tuberculosis Institute, Bangalore, are compared.

It was observed that in spite of repeated attempts, nearly 1/5th of the population did not attend examinations. The non- response group during I survey was examined at the subsequent survey and both response and non- response groups at the preceding survey were compared. It was found that in respect of prevalence of infection and bacillary disease, the two groups did not differ, but the mortality and emigration was higher among the non- response group. Higher mortality among non-attenders may be due to the fact that the group contained more sick people. The higher emigration among non-attenders due to small error even to the extent of 0.5% at the stage of census taking by registering a non-resident as permanent resident of the village would highly boost the rate of emigration among non- attenders. The difference in the indices of crude mortality and emigration rates becomes narrower and narrower as coverages for examinations increase. The analysis indicates that every attempt should be made to obtain as high a coverage as possible in order to obtain valid estimates of epidemiological indices in a population survey.

KEY WORDS: SURVEY, ABSENTEES, CRUDE MORTALITY, EMIGRATION.
 

 
  BCG  
 
 
128
ASSESSMENT OF POST-VACCINATION ALLERGY AMONG THOSE BCG VACCINATED WITHOUT PRE-VACCINATION TUBERCULIN TEST
Kul Bhushan, SS Nair & KT Ganapathy: Indian J TB 1970, 17, 18-31.

The conventional methods of assessment of post-vaccination allergy by doing tuberculin testing among the vaccinated group are inapplicable in case of BCG vaccination without prior tuberculin test (Direct BCG). Because of obvious technical and operational advantages of direct BCG vaccination a search for a method of technical assessment of BCG vaccination is important. Hence, a study was carried out by the BCG Assessment Team of National Tuberculosis Institute in Tumkur district of Mysore state where Mass BCG Campaign was going on. Four groups of persons aged 0-20 years, each group belonging to two BCG Technicians area and vaccinated one day prior to visit of assessment team, were randomly selected. Besides, persons (0-20 years) from 2 unvaccinated villages of adjacent area were included as control groups. All persons were registered simultaneously tuberculin tested with 1 TU RT 23 and 5 TU RT 22 within 24 hours of BCG vaccination (for pre-vaccination allergy) and retested with tuberculin 5 TU RT 22 at the end of 3 weeks and 3 months (for post-vaccination allergy). The four vaccine groups were vaccinated with vaccine batch Nos. 977, 978, 981 and 984 respectively. Classification of the directly vaccinated persons into previously infected and non-infected by tuberculin test administered within 24 hours of vaccination and about 12 weeks later, elicitation of post-vaccination allergy only among the non-infected, has been considered as the Reference Test for judging the suitability of other methods of assessment studied. The main findings are: (1) The Reference Test showed that the four batches of BCG vaccine used had induced varying levels of allergy. (2) Assessment based on the mean size of post-vaccination reactions among 0-4 years age group, which consists predominantly of previously non-infected persons, showed a different pattern of differences between the four batches of vaccine as compared to the Reference Test. Moreover, to get adequate number of children aged 0-4 years, it will be necessary to cover a comparatively large population. (3) The method of using the mean size of post-vaccination reactions among those classified as non-infected on the basis of vaccination reactions of size 0-13 mm at the site of BCG vaccination on the 4th day of vaccination showed results similar to the Reference Test. But this method has only a marginal operational advantage over the Reference Test. (4) Using size of induration at the site of vaccination on 21st day of vaccination did not give the same results as the Reference Test. Operationally this method would have been most suitable as it involved only one visit to the group. (5) Differences between mean size of post-vaccination tuberculin reactions among directly vaccinated persons and mean size of (natural) allergy in reactors among neighbouring unvaccinated areas showed the same results as the Reference Test. This method has the operational advantage but needs further investigations. (6) Tuberculin testing of all directly BCG vaccinated persons including the natural reactors about 12 weeks after vaccination compared favourably, with the reference method, as the tuberculin reactors contributed less than 1 mm over and above the allergy in the vaccinated non-reactors . This method would be useful when rate of tuberculin reactors is less than 20% in 0-20 years age group and their mean size is also less than 20 mm. Operationally, it is a simpler method next only to No.4 above. Further investigations are considered necessary for final selection of this or any of the other methods.

KEY WORDS: BCG, POST-VACCINATION ALLERGY, ASSESSMENT, DIRECT BCG VACCINATION.

129
A COMPARISON BETWEEN LONGITUDINAL AND TRANSVERSE DIAMETERS OF TUBERCULIN TEST INDURATIONS
Kul Bhushan, MN Mukherjee, SP Chattopadhya & KT Ganapathy: Indian J Med Res 1972, 60, 1724-30.

The purpose of this investigation was to compare the corresponding longitudinal and transverse diameters of tuberculin test and study the influence of reader variations, size of reaction and the age specific infection rates, in order to understand the effect of switching over from the transverse to longitudinal readings. The study was carried out in villages in south India where no BCG or tuberculin testing had been undertaken. A total of 1240 persons were given tuberculin test with 1 TU RT 23 in both longitudinal and horizontal diameters. The indurations were read after 2-4 days by two readers independently. The study showed that though the longitudinal diameters were bigger than the corresponding transverse diameters, these differences did not influence infection rates calculated at 10 mm or more induration level. In National Tuberculosis Institute (NTI), Bangalore the practice of reading transverse diameter was altered to longitudinal diameter in the epidemiological surveys as it was comparatively easier to read the longitudinal diameter. Obtaining almost similar infection rates at the 10 mm or more level of induration in this study, irrespective of readers and diameters has minimized the effect of the changeover from transverse to longitudinal diameter reading in the epidemiological surveys at NTI. This would also not pose any problem in comparing the results of NTI studies with other research studies by any national or international organisation where transverse diameters have been measured.

KEY WORDS: TUBERCULIN TEST, LONGITUDINAL, TRANSVERSE, TUBERCULIN INDURATION SIZE.

130
A COMPARISON OF THE COPENHAGEN AND MADRAS LIQUID BCG VACCINES
Kul Bhushan, SS Nair, KT Ganapathy & Vijay Singh: Indian J TB 1973, 20, 4-9.

Liquid BCG vaccine produced upto 1955 at the BCG Laboratory, Guindy, Madras induced low and variable levels of post-vaccination allergy. However, subsequent to improvement in production, its potency was adjudged as equivalent to Danish BCG vaccine. Later on, lower levels of post-vaccination allergy in Mass BCG vaccination campaign and in research studies were observed. A study was planned to compare the Madras BCG vaccine with Danish vaccine in terms of the potency of the strains, production efficiency of the laboratory and stability on storage. This was done by comparing the allergising capacity and size of vaccination lesions. On a predetermined date in each of four consecutive months, both laboratories supplied to the Research Team one week of fresh vaccines from their respective BCG strains and also fresh vaccine of strains borrowed from the other laboratory. With these six vaccines every month, in two consecutive weeks randomly, vaccinations were given to 2,978 tuberculin non-reactors. post-vaccination allergy was elicited 10 weeks later when size of BCG lesion was also noted. Viable counts on all vaccines were done by Madras Laboratory.

Though the Indian and Danish BCG vaccines induced similar levels of allergy, on further analysis it was found that Madras BCG strain was inferior to the Danish strain and that Madras Laboratory produced better vaccine than Copenhagen Laboratory. The vaccine produced from Copenhagen strain in Madras Laboratory induced the highest level of allergy. The stability of vaccines produced from Madras strain was found to be unsatisfactory. Results according to vaccination lesion size and their correlation with tuberculin reaction more or less confirmed the above findings. They were however not corroborated in terms of viable counts. Considering that the inferior quality of Madras BCG strain was due to mutation over time, seed lots of suitable BCG strain would ensure uniformly potent vaccine from Madras Laboratory.

KEY WORDS: BCG VACCINE, POTENCY, DANISH STRAIN, MADRAS STRAIN.

133
FREEZE-DRIED BCG VACCINE SEALED IN PRESENCE OF NITROGEN
Kul Bhushan, GVJ Baily, SS Nair, KT Ganapathy & Vijay Singh: Indian J Med Res 1975, 63, 1335-43.

The Freeze-Dried BCG vaccine manufactured in India is sealed under vacuum. This though adds to its stability involves expensive production procedures. Sealing in presence of nitrogen is both simpler and economical. Before producing this vaccine for use on a large scale, it was considered necessary, to study the influence of storage at higher temperatures on the allergy inducing capacity on the basis of the size of local lesion and viable counts of Freeze-Dried BCG vaccine sealed either in vacuum or in the presence of nitrogen. For this, half of the ampoules of a batch of vaccine prepared in Madras BCG Vaccine Laboratory were sealed in vacuum and the other in presence of nitrogen. Randomly selected ampoules of both types of vaccine were exposed to 37o and 44o for 2, 6, and 18 weeks and another set at 4oC for 18 weeks. Two batches of liquid BCG vaccine were made as controls: 16 types of ampoules thus obtained were randomly repeated 5 times according to Standard Lattice Design. About 3000 school children without BCG scar, aged 5-14 years In Bundi and Kota districts of Rajasthan were vaccinated as per the study design. post-vaccination allergy with 5 TU RT 22 by measuring the size of vaccination lesions was recorded 3 months later. Viable counts on samples of ampoules from Freeze-Dried BCG vaccines exposed differently were done in the production laboratory after 18 weeks of storage.

The vaccine in 16 types of ampoules was significantly different. Liquid BCG vaccine resulted in higher level of allergy and larger vaccination lesions than Freeze-Dried BCG vaccine sealed under either method. The study has shown that Freeze-Dried BCG vaccine sealed under either method vacuum or nitrogen, gave satisfactory level of post-vaccination allergy and induration size of vaccination lesions, provided the vaccine was preserved at 4oC. Storage at 37o for more than 2 weeks and even 2 weeks storage at 44oC affected both types of vaccine badly as shown by post-vaccination allergy and viable counts. However, decrease in viable count with time and temperature was more pronounced in vaccine sealed in presence of nitrogen. Hence, there is a need to provide cold chain facility for Freeze-Dried vaccine all throughout the period.

KEY WORDS: LIQUID BCG, FREEZE-DRIED BCG.
 

 
  BACTERIOLOGY  
 
 
148
EVALUATION OF SPUTUM SMEARS PREPARED BY DIFFERENT METHODS
N Naganathan, KT Ganapathy & R Rajalakshmi: Indian J Med Res 1979, 69, 893-900.

Sputum microscopy is the main casefinding tool in tuberculosis control programmes. The technique of smear preparation is an important step which needs to be simple for wide applicability. It is often stressed that smear should be prepared from the purulent portions of the sputum as they are likely to have more number of bacilli. It may not be possible for the microscopist/paramedical worker at the periphery to strictly follow this procedure. Hence, a study was conducted to compare the sensitivity of 4 methods of sputum smear preparation viz., direct smear prepared (i) blindly without making any selection of portions of sputum specimen, (ii) from portions of sputum material likely to contain the bacilli, (iii) after mixing up the sputum specimens thoroughly, and (iv) from centrifuged deposit after homogenization of sputum with sodium hydroxide and concentration by centrifugation. Culture was also done for Mycobacterium tuberculosis.

A total of 549 specimens were employed. Positivity rates by four methods were: 79.6% by method (i), 80.3% by method (ii), 80.7% by method (iii) and 77.2% by method (iv). There was no statistically significant difference in the number of positives obtained from different methods. Centrifuged deposit smears proved to be in no way better than the direct smears. The differences in the methods lay only in the classification of positive smear as of a low or high grade.

KEY WORDS: SMEAR EXAMINATION, SENSITIVITY METHODS, CENTRIFUGATION, EVALUATION.
 
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