996803 research- article2021 WMR0010.

1177/0734242X21996803Waste Management & ResearchTs ai

Waste Management & Research

2021, Vol. 39(1) Supplement 27 –33

Analysis of medical waste management © The Author(s) 2021

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and impact analysis of COVID-19 on its sagepub.com/journals-permissions

https://doi.org/10.1177/0734242X21996803 DOI: 10.1177/0734242X21996803

generation in Taiwan journals.sagepub.com/home/wmr

Wen-Tien Tsai

Abstract
Medical waste management in Taiwan is a crucial issue due to its highly environmental and human health risks. The main
objectives of this paper were to analyse the status of medical waste generation and treatment in recent years, and also address the
discussions on the impacts of coronavirus disease 2019 (COVID-19) on its generation in the first half of 2020. It showed that the
reported quantities have slightly increased from 35,747 metric tonnes (Mt) in 2016 to 40,407 Mt in 2019, showing an average
increase by 4.17%. This rate of increase was consistent with the hospital services. When classified by the reported codes, the C-
type waste (infectious waste) accounted for about 89% of the reported quantities, which indicated an annual increase by 4.14%
during the same period. In addition, the medical waste treatment in 2019 was mainly dependent on the commissioned treatment
(80.18%), followed by the recycling (18.53%) and the self-treatment (1.29%). Furthermore, the impact of COVID-19 on the
medical waste generation in Taiwan was not significant in the first half of 2020 compared to the data during the years of 2016–
2019. It was indicated that the consistent trend was observed at the daily confirmed COVID-19 cases in Taiwan during this period.
Obviously, the reduction in the hospital medical services during the COVID-19 outbreak should be offset by the increase in
medical waste generation from the medical services. In order to try to ensure safe and complete destruction of the COVID-19 virus,
all the waste generated from the healthcare facilities should be treated in the incineration plants.

Keywords
Medical waste management, regulatory requirement, trend analysis, COVID-19 impact

Received 18th January 2021, accepted 25th January 2021 by Senior Editor in Chief P Agamuthu.

Introduction clinical or healthcare facilities in Taiwan was as high as 1.0 to 2.0

kg/bed/day. In order to handle medical waste properly, it is
Medical waste, also called healthcare or healthcare waste (World
necessary to predict its generation rate beforehand. In the study by
Health Organization, 2014), refers to all the waste generated by
Tesfahun et al. (2016), the authors developed the predictive model
healthcare activities and related sources, including hospitals, clinics,
for the medical waste generation rate, revealing that this rate has a
nursing homes for the elderly, animal research and testing
strong linear correlation with the number of inpatients. Because of
laboratories, blood banks and collection services, and biomedical
its health and environmental risks, medical waste should be
research centres and laboratories. Regarding the medical waste
separated into hazardous or non-hazardous wastes for the purposes
management, there were significant differences between
of collection, storage and treatment. According to the report by the
lowincome, middle-income and high-income countries (Caniato et
World Health Organization (2018), about 85% of the total
al., 2015). In general, high-income countries may generate on
quantities of waste generated by healthcare activities was general,
average up to 0.5 kg of hazardous medical waste per hospital bed
non-hazardous waste. The remaining 15% was considered to be
per day (World Health Organization, 2018). This quantity was
hazardous due to its infectious, toxic or radioactive characteristics.
different from the local study by Cheng et al. (2010), showing that
In particular, hazardous medical waste could contain potentially
the overall average value of infectious waste generated from the
 28 Waste Management & Research 39(1) Supplement
harmful microorganisms that can infect hospital patients, healthcare modern societies across the world (Fan et al., 2021; Peng et al., 2020;
workers and the general public. In addition, the percentage of Yang et al., 2021; ZambranoMonserrate et al., 2020). Although there
plastic waste (one of combustible materials) in medical waste may was no evidence that the coronavirus can be transmitted in any way
be as high as about 20% to 30% (Huang and Lin, 2008; Lee et al., through medical waste (World Health Organization, 2020b), the safe
2002). Based on the sustainability assessment of medical waste management of the used PPE such as masks and protective clothes
treatment systems (Makan and Fadili, 2021), the rotary kiln system must be implemented rigorously to prevent the spread of COVID-19
was often adopted by high-temperature incineration facilities to (Rhee, 2020).
control the emissions Obviously, medical waste management is a high priority public
health and environmental concern issue. In the past, medical waste,
Graduate Institute of Bioresources, National Pingtung University of Science and especially generated from small healthcare facilities, was often mixed
Technology, Pingtung County with municipal solid waste (MSW) and thus disposed of in sanitary
landfills or MSW incineration plants in many countries such as Korea
Corresponding author:
Wen-Tien Tsai, Graduate Institute of Bioresources, National Pingtung University of (Jang et al., 2006) and Taiwan (Huang and Lin, 2008; Kuo et al.,
Science and Technology, No.1, Shuehfu Road, Neipu, Pingtung County, 911. 1999). In Taiwan, the regulatory measures for the issues of medical
Email: [email protected] waste management are based on the Waste Management Act (WMA).
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License In the Act,
(https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the waste
the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages is grouped
(https://us.sagepub.com/en-us/nam/open-access-at-sage). into two
categories: general waste; and industrial waste. The former is
equivalent to the scope of MSW (Rhyner et al., 1995), but it
additionally incorporates the waste generated by the employees in the
industries into this type of waste in Taiwan. The latter, including
medical waste, is divided into general industrial waste and hazardous
industrial waste. In 2019, the reported quantity of industrial waste
(about 19.8 million metric tonnes (Mt)) in Taiwan was about 2.0
times as great as general waste generation (about 9.8 million Mt)
(Environmental Protection Administration, 2020a). Among the
industrial waste, the reported quantities of medical waste in 2019 only
accounted for about 40,000 Mt, including 35,723 Mt for those
hazardous and 4684 Mt for those non-hazardous.
Regarding the overview of medical waste management in
Figure 1. Daily confirmed COVID-19 cases in Taiwan during the period of
31 December 2019 to 31 August 2020 (Our World in Data, 2020). Taiwan, almost no relevant reviews have been published in recent
years. In the study by Huang and Lin (2008), it was revealed that the
majority of medical waste was general industrial waste based on the
of toxic air pollutants (e.g., dioxins, heavy metals and acidic air data between 2003 and 2005, accounting for about 78% of total
pollutants) in compliance with the official standards (World Health medical waste and others for infectious industrial waste. In addition,
Organization, 2020a), but poor incineration techniques have been the impacts of the COVID-19 pandemic in Taiwan were relatively
used by Asian developing countries for a long time (Khan et al., minor as compared to other countries. Figure 1 shows the profile of
2019). For example, a comprehensive inspection survey was confirmed cases from 1 January 2020 to 31 August 2020 (Our
performed for 14 hospitals located in Sistan and Baluchestan Province World in Data, 2020). However, the studies on the impacts of
(Islamic republic of Iran) (Bazrafshan and Mostafapoor, 2011), COVID-19 on medical waste generation in Taiwan have not been
showing that medical waste segregation in the hospitals had not been reported in the literature. Therefore, this paper was structured by
conducted properly. three important issues. First, the trend changes on the reported
Since the first outbreak of coronavirus (COVID-19) early in 2020, quantities of regulated medical waste and its current treatment
more than 40 million confirmed cases of COVID-19 have been methods were analysed to compare the hospital medical services in
reported worldwide as of 21 October 2020 (World Health Taiwan. Second, the legal framework and relevant requirements for
Organization, 2020b), causing confirmed deaths of over one million medical waste treatment were updated. Finally, the discussions on
people. The multi-dimensional effects of the COVID-19 pandemic the impacts of the COVID-19 pandemic on medical waste
have happened at all levels (Cheval et al., 2020). More seriously, this generation in the first half of 2020 were addressed to be in response
pandemic outbreak could trigger acute respiratory diseases, which to the expected increase or not.
will further lead to septic shock and kidney failure. It can be expected
that the COVID-19 pandemic has led to a reduction in hospital
medical services, and rates of transmission of influenza and other Methodology
respiratory viruses. Due to the massive use of personal protective To present an overview of the latest knowledge about the medical
equipment (PPE) and related implements during the COVID-19 waste management in Taiwan, the updated data on the statistics of
pandemic, the significant increase of medical waste in large hospital medical waste generation and the status of its treatment methods
services and healthcare centres will be an unavoidable outcome in were gathered from the official yearbook (Environmental Protection
 Tsai 29
Administration, 2020a) and the database (Environmental Protection genetic or bio-technological research. The medical waste generators
Administration, 2020b). These factsheets were surveyed to present that are designated and officially announced by the central
an analytical description about their trend changes in recent years competent authority (i.e., Environmental Protection Administration
(2016–2019). On the other hand, the regulatory requirements for the (EPA)) shall perform the required measures, including the
clearance and treatment of medical waste were reviewed by using submitted industrial waste management plan and the reporting to
the official laws and regulations website (Ministry of Justice, 2020). the local competent authorities via the Internet. The contents of the
According to the official databases established by the central plan included the status of generation, storage, clearance, treatment,
competent authorities (Environmental Protection Administration, reuse, export, transit and transshipment of the waste at issue).
2020a, 2020b; Ministry of Health and Welfare, 2020; Ministry of Furthermore, medical waste treatment, with the exception of that
Justice, 2020), the discussions on the impacts of the COVID-19 subject to reuse methods, shall be generally performed in
pandemic on medical waste generation were also addressed in this accordance with the following options: self-treatment;
study to correlate with the epidemic control and prevention jointtreatment; and commissioned treatment. In contrast, the
measures and the profile of confirmed cases of COVID-19 in specific legislation dedicated to medical waste management is a
Taiwan ( Our World in Data, 2020), and to be in recent practice in most of the countries (Ali et al., 2017).
Table 1. Categories of industrial waste generated from medical organizations (medical waste) in Taiwan. In
Category Code Item Comments order to
promote
Hazardous industrial C-0504 Waste sharp implements Waste implements than can cause stab or cut injuries to the human body,
pollution
waste (infectious including scalpel, injection needle and surgical suture needle Waste
waste) C-0512 Cytotoxic waste carcinogenic cytotoxins or other drugs
C-0513 Infectious waste I It refers to the sources from pathology, blood, contaminated animal
carcasses, residual limbs and bedding
C-0514 Infectious waste II It refers to the sources from contaminated items and implements or
appliances
C-0599 Infectious waste mixture

General industrial D-2101 Non-infectious industrial waste

waste (after sterilization)
D-2199 General infectious waste The rest of the medical waste that cannot be classified should be mixture
grouped into the D-2199, but not include the general employee domestic waste (D-1801),
radioactive waste and recyclable waste (R-type, including paper, plastics, glass, metals, plaster mold,
developer/fixer and so on)

comparison with their reported quantities in the first half of 2019 and prevention, waste reduction and resource recycling in medical
2020 (Environmental Protection Administration, 2020b). institutions, the central competent authority (i.e., Ministry of Health
and Welfare (MOHW)) commissioned a non-profit organization to
establish the platform (“Medical Waste Treatment Information”).
Table 1 lists the categories of medical waste in Taiwan, which must
Results and discussion Current status
be reported to the competent authority based on the platform
of medical waste generation and information. It can be seen that the medical waste can be grouped into
treatment infectious waste (coded as C-types waste, one of hazardous industrial
In Taiwan, the legal framework for medical waste clearance and wastes) and general industrial waste (coded as D-type waste). Table 2
treatment was authorized by the WMA (Ministry of Justice, 2020). shows the variations of the quantities of medical waste generation in
In the WMA, the wastes are classified into two groups: general Taiwan according the reported codes, using the yearly data for the
waste; and industrial waste. Industrial waste refers to waste that is years 2016 to 2019 (Environmental Protection Administration,
produced from industry activities (but excluding waste generated by 2020a). Some important features were further addressed as follows:
the employees themselves), including “hazardous industrial waste”
and “general industrial waste.” Hazardous industrial waste is (a) total reported quantities of medical waste have slightly increased
produced by industry that is toxic or dangerous with the from 35,747 Mt in 2016 to 40,407 Mt in 2019, showing an annual
concentration or volume sufficient to influence human health or average increase by 4.17%. This rate of increase was consistent
pollute the environment. According to the regulation (“Standards with the hospital medical services, increasing from in 2016 to in
for Defining Hazardous Industrial Waste), medical waste (also 2019 ( Ministry of Health and Welfare, 2020). When classified by
called “biomedical and infectious waste”) refers to waste, which is the reported codes, the C-type waste (infectious waste) accounted
produced in the course of medical treatment, medical testing, post- for about 89% of the total reported quantities of medical waste,
mortem examinations, quarantine inspections, research, or the which indicated an annual increase by 4.14% during the same
manufacture of chemical agents or biological materials by medical period. It should be noted that waste generated by the hospital’s
treatment organizations, medical testing institutions, medical employees themselves is recognized as general waste or
laboratories, industrial and research organization laboratories of recyclable waste (e.g., waste paper and waste plastics), and
biological safety grade two or above, or laboratories engaged in according to the WMA, there is no need to report it by C-type and
 30 Waste Management & Research 39(1) Supplement
D-type codes. Therefore, the fractions of infectious waste as value on dioxins emission around the world (Dopico and Gómez,
shown in Table 2 are so high as compared to the report by the 2015).
World Health Organization (2018); and Table 3. Reported quantities (measured in metric tonnes) based on the
Table 2. Reported quantities of medical waste in Taiwan.* treatment methods of medical waste in 2019.
Code 2016 2017 2018 2019 Code Reuse and Selftreatment Commissioned
recycling treatment
C-0504 2188 2259 2409 2384
C-0504 247 186 1951
C-0512 463 549 592 595
C-0513 1470 1630 1722 1813 C-0512 0 0 595
C-0514 10,748 11,423 12,210 12,887 C-0513 0 36 1777
C-0599 16,759 16,755 17,264 18.044 C-0514 7245 296 5347
Sub-total 31,628 32,616 34,197 35,723 C-0599 0 1 18,041
D-2101 556 471 569 595 D-2101 0 1 623
D-2199 3563 3507 3748 4089 D-2199 1 0 4086
Sub-total 4119 3978 4317 4684 Source: Environmental Protection Administration (2020b).
Total 35,747 36,594 38,514 40,407
*the quantity of medical waste generation (unit: metric tonnes) is equal to the Regarding the methods for the storage of medical waste, the
reported quantity, plus the storage quantity (this year) and minus the storage
quantity (previous year). Source: Environmental Protection Administration
management enterprises shall comply with the following regulations
(2020b). (Ministry of Justice, 2020):

(a) “Waste sharp implements” shall be stored separately from other

(b) regarding the quantities of C-type waste in 2019, reported by the
medical waste, sealed in not readily perforated sturdy containers
rankings, C-0599 occupied 50.51%, C-0514 contributed
for storage within one year.
36.07%, C-0504 constituted 6.67%, C-0513 accounted for 5.08%,
(b) “Infectious waste” shall be stored separately from other medical
and C-512 shared 1.67%. By contrast, D-2199 provided
waste. Those that use thermal treatment methods shall seal the
87.30% of the reported quantities of D-type waste in 2019. infectious waste in leak-proof, non-destructible red plastic bags,
or red combustible containers. Those that use sterilization
On the other hand, Table 3 lists the reported quantities based on treatment shall seal and store the waste in leakproof, non-
the treatment methods of medical waste in 2020 (Environmental destructible yellow plastic bags, or yellow containers. Herein,
Protection Administration, 2020a). Obviously, the medical waste “sterilization” refers to treatment methods involving the use of
treatment was mainly dependent on the commissioned treatment physical (such as microwave treatment) or chemical principles
(80.18%), followed by the reuse and recycling (18.53%) and the self- to sterilize microbes in industrial waste within a certain time
treatment (1.29%). Herein, the self-treatment means that the period. The indicator microbe reduction rate shall attain at least
generators treat medical waste by themselves under the approval of 99.999%. Those using high temperature high pressure steam
the central competent authority (i.e., EPA) in conjunction with the sterilization shall test for Geobacillus stearothermophilus
central industry competent authority (i.e., MOHW) based on the spores. Those using other sterilization methods shall test for
WMA. When classified by the reported waste codes, it should be Bacillus subtilis spores. The storage conditions of infectious
noted that the treatment methods of C-0514 waste (the sources from waste shall comply with the following requirements:
contaminated items and implements or appliances) were provided by – waste producing organizations may store infectious waste
the reuse and recycling (56.21%), the commissioned treatment more than 5°C for a maximum of one day. These medical
(41.49%), and the self-treatment (2.30%) during the years 2016 to organizations may refrigerate it in the range of 0 to 5°C for a
2019. maximum of seven days, and freeze it below 0°C for a
maximum of 30 days;
Regulatory measures on medical waste – clearance organizations may not store infectious waste, but
management in Taiwan those that require transfer shipments due to particular
circumstances may refrigerate or freeze it below 5°C for a
According to the WMA in Taiwan, the medical waste management
maximum of seven days upon approval by the local
enterprises shall be recorded in detail and kept for at least three years
competent authorities; and
in accordance with the regulations governing the operation and
– treatment organizations may not store infectious waste at
monitoring for methods and facilities for its storage, clearance and
more than 5°C. These treatment organizations may
treatment. In addition, the medical waste treatment facilities with
refrigerate it in the range of 0–5°C for a maximum of seven
high-temperature incinerators must control the emissions of toxic air
days, and freeze it below 0°C for a maximum of 30 days.
pollutants (e.g., dioxins, heavy metals and acidic air pollutants) in
compliance with the Air Pollution Control Act in Taiwan. For
Regarding the methods for the clearance of medical waste, the
example, the medical waste incineration plants in Taiwan must
management enterprises shall be in accordance with the following
comply with the dioxins’ emission limit of 0.1 ng/m 3 based on
principles:
toxicity equivalency quantity, which may be the most stringent limit
 Tsai 31
Table 4. Total medical waste generation in Taiwan (Q1/Q2 2020 vs. Q1/Q2 2019).

Medical waste Q1 2020 Q1 2019 Difference Year on Q2 2020 Q2 2019 Difference YoY (%)
category (A–B) year (C–D)
Value (A)* Value (B) (YoY) (%) Value (C) Value (D)
Total 8832 8447 385 4.6 8842 8888 −46 −0.5
C-0504 600 562 38 6.8 611 589 22 3.7
C-0512 150 139 11 7.9 152 151 1 0.7
C-0513** 444 431 13 3.0 428 447 −19 −4.3
C-0514*** 3,254 3,082 172 5.6 3,258 3,184 74 2.3
C-0599 4384 4233 151 3.6 4339 4517 −178 −3.9

*, measured in metric tonnes; **, “Infectious waste I” refers to the sources from pathology, blood, contaminated animal carcasses, residual limbs and
bedding; and ***, “Infectious waste II” refers to the sources from contaminated items and implements or appliances.
Source: Environmental Protection Administration (2020b). excessive use and consumption of PPE (e.g., masks and gloves) and
other plastic-containing articles (e.g., disinfectants and spray
bottles) during the pandemic (Silva et al. 2021). For instance, the
(a) Medical waste that has been stored in differently coloured most commonly used materials in the face masks include nonwoven
containers may not be cleared in a mixed state. fibrous plastics such as polypropylene (O’Dowd et al., 2020).
(b) Medical waste may not be compressed or arbitrarily opened However, it should be noted that polyvinyl chloride (PVC) is still
during the transportation period. the most used plastic material for disposable medical devices due to
(c) Refrigeration measures shall be provided during the its unique properties (Jang et al., 2006). Therefore, adopting
transportation period, and normal operation shall be also effective decontamination for reprocessing of PPEs will reduce
maintained. plastic waste generation and also help to prevent the formation of
(d) The doors of the clearance vehicles shall remain shut and locked dioxins from these disposable medical devices containing
if there are no personnel present during the loading and incinerated PVC (Parashar and Hait, 2021).
unloading processes. It is generally recognized that the increase in the number of
confirmed COVID-19 cases could be positively correlated with the
Regarding the methods for the thermal treatment of medical medical waste generation due to the increased usage of disposable
waste, the management enterprises shall meet the following PPE. For example, a 27% increase in medical waste was reported
standards: following the COVID-19 outbreak in Malaysia (Agamuthu and
Barasarathi, 2020). Although the medical waste generation in 2020
(a) The central temperature of the combustion chamber at the outlet was yet to be availably obtained by accessing on the official database
position shall be maintained above 1000 °C. in Taiwan (Environmental Protection Administration, 2020a), it might
Combustion gas residence time shall be over one second. be roughly observed by the monthly variations of the reported
(b) Combustion efficiency shall be over 99.9%. quantities of medical waste in Taiwan. Table 4 provides the data on
(c) Destruction and removal efficiency (DRE) shall be over 99.99% the reported quantities of medical waste generated during the Q1/Q2
for chlorinated organic compounds, over 99.999% for 2019 and the Q1/Q2 2020 (Environmental Protection Administration,
polychlorinated biphenyls and dioxins (polychlorinated 2020b). Figures 2 and 3 depict the monthly trends of hazardous
dibenzo-p-dioxins/polychlorinated dibenzofurans), and over medical waste (C-type) and general medical waste (D-type)
99.9% for other principal organic hazardous constituents. generation in Taiwan since January 2019, respectively. As compared
(d) Treatment facilities shall possess devices for automatic to the data in the Q1 2019, it showed an increase by 4.6% in the Q1
monitoring and control of combustion conditions, the recording 2020 due to the COVID-19 outbreak. It seemed to be in parallel with
of the output central temperature of the combustion chamber, the trend by the daily confirmed COVID-19 cases in Taiwan (Figure
and emergency response. 1), when the most serious situation occurred in March 2020.
Subsequently, the daily confirmed COVID-19 cases in Taiwan
showed a declining trend since April 2020. In addition, the statistics
Analysis of medical waste generation during the of hospital medical services in the first half of 2020 versus the first
COVID-19 pandemic half of 2019 have decreased by about 10% (Ministry of Health and
Welfare, 2020), which should be attributed to the serious anti-
As described previously, the impact of the COVID-19 pandemic on
epidemic measures in the medical institutions and the successful
waste management due to the epidemic control and prevention
personal health care. When comparing the reported quantities of C-
measures such as lockdown and social distancing has been
type medical waste in Taiwan during
reviewed by several researchers (Eroglu, 2020; Fan et al., 2021;
Kulkarni and Aantharama, 2020; Sarkodie and Owusu, 2020; Silva
et al., 2021; Zambrano-Monserrate et al., 2020). More seriously,
this pandemic could cause acute respiratory diseases, thus
triggering the rapid demand for PPE. As a consequence, the medical
waste containing plastic materials will be generated by the
 32 Waste Management & Research 39(1) Supplement

Figure 3. Monthly trends of hazardous medical waste (C-type) generation

in Taiwan since January 2019 (Environmental Protection Administration,
2020b).
Figure 2. Monthly trends of general medical waste (D-type) generation in
Taiwan since January 2019 (Environmental Protection Administration,
2020b). (a) All the waste generated from the healthcare facilities during the
COVID-19 pandemic should be treated in the officially certified
the first half of 2019 with the first half of 2020, it only showed a incineration plants.
slight increase by 1.95% (17,335 Mt vs. 17,674 Mt, which were (b) The operation temperature at the municipal waste incineration
obtained from the accumulated data shown in Table 4 and Figure 2). plants shall be properly increased to kill viruses effectively
Similarly, the reported quantities of D-type medical waste in Taiwan because urban waste may be mixed with medical waste.
at the same period also indicated a consistent increment by 0.22% (c) In order to reduce the excessive use of single-use plastics,
(2233 Mt vs. 2238 Mt, which were obtained from the accumulated preferably non-plastic personal PPE (e.g., face masks) should be
data shown in Figure 3). In summary, the impact of COVID-19 on the developed.
medical waste generation in Taiwan was not significant in the first
half of 2020 as compared to the annual increase by about 4.1% during Declaration of conflicting interests
the years of 2016 to 2019. Obviously, the reduction in the hospital The author declared no potential conflicts of interest with respect to the
medical services should be offset by the increase of medical waste in research, authorship, and/or publication of this article.
services such as medical services. Due to the effective control of the
COVID-19 outbreak in Taiwan, the findings of the current work were Funding
different from other studies (Agamuthu and Barasarathi, 2020; Rhee, The author received no financial support for the research, authorship,
2020). and/or publication of this article.

ORCID iD
Conclusions
Wen-Tien Tsai https://orcid.org/0000-0002-3697-6692
Due to the wide adoption of single-use disposable items or articles in
the healthcare facilities, it has been revealed that the generation of
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