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Anthrax:
essential data

Bacterial weapon acting on
humans and livestock

Synopsis, Diagnosis, Symptoms,
Countermeasures, Properties and Uses, Terrorist Interest,
History and natural history, IDC Codes,
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Safety Precautions for Anthrax Casualties

Standard Precautions  defined by the 1996 CDC guidelines should be adopted for handling patients 
 
After invasive procedures, instruments and the operating area should be decontaminated using either disinfectant strength iodine disinfectants or chlorine as calcium or sodium hypochlorite. 

Biosafety level 2 practices should be adopted for handling of samples. 

Corpses should be cremated.

Anthrax is a reportable disease in the United States.

State and federal health authorities must be notified within 24 hours of diagnosis.

 

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Synopsis of Agent Properties

Causative organism:
(Systematic name in 1997)
Bacillus anthracis
Older names: Bacterium anthracis
Alternative disease names:
  • Malignant carbuncle
  • Malignant pustule
  • Woolsorter's disease
  • Rag-picker's disease
  • Charbon
US Army Code N
Properties: Gram-positive, aerobic bacillus, non-motile, spore-forming.

(Cells stain blue in the Gram stain, they require oxygen for growth, are rod-shaped, do not move by their own power, and spread by forming spores that are resistant to extremes of the environment.)

Antibiotic treatments:
  • Penicillins
  • cephalosporins
  • erythromycin
  • tetracyclines
  • fluoroquinones
  • gentamicin
  • chloramphenicols (as a last resort)
Vector involvement: There is no significant vector transmission of the agent. Occasional transmission by the bite of horseflies (Tabanidae) is known and this gives rise to cutaneous anthrax.
Epidemiology of natural outbreaks: Natural outbreaks of anthrax show a point source of origin. The commonest outbreaks in the year 2000 were typhoidal anthrax that came from eating contaminated meat and rarely involved more than a dozen cases. This was common in rural areas of former Soviet Central Asia. Handling carcasses or herding infected animals are also risk factors.

 

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Key Diagnostic Tests.

Physical findings are often not very specific.
 

Staining and cultural behavior

Follow this link. to a page of images of photomicrographs and of colonies of Bacillus anthracis.

Differential Diagnosis

Other disease or conditions that need to be eliminated
Other infectious diseases Other problems
  • Abdominal aneurysm
  • Pleural effusion;
  • Subarachnoid hemorrhage.
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Symptoms and effects.

Anthrax is an acute (rapidly developing) infection of the skin, lungs, and gastrointestinal tract. Skin infection can be caused by direct contact with contaminated wool, hides, or tissues. Infection of the skin results in dry scabs forming at the point of contact. This form is known as cutaneous anthrax (CA) or malignant pustule or malignant carbuncle and occurs most frequently on the hands and forearms of people who work with livestock. The swelling and ulcerated sores associated with CA may develop into systemic (throughout the body) infections. Pulmonary (lung) or inhalation anthrax results from inhalation of Bacillus anthracis spores with passage into the lungs result in fever, shock, and eventually death.

 

A typical example of the black lesions seen in cases of cutaneous anthrax.

In the event of the use of anthrax as a weapon, the appearance of these lesions may be one of the first signs.

 

Infection first appears with the sudden onset of flu-like symptoms that appear within 1-6 days after infection. After 2-4 days, victims exhibit a range of more severe symptoms ranging from essentially similar to upper respiratory tract syndrome: mild fever, general malaise, myalgia to difficulty breathing, exhaustion, tachycardia, cyanosis, and terminal shock. Death usually occurs within 36 hours after the patient first experiences difficulty breathing. In cases of pulmonary anthrax, up to 80% fatalities can be expected without treatment. Historically, treatment has been considered ineffective after the appearance of symptoms of inhalation anthrax. However, aggressive treatment with antibiotics at the earliest diagnosis was effective in treating a number of those developing inhalation anthrax in the 2001 anthrax mail attack

Edema and necrosis in victims arises from the actions of a toxin called anthrax toxin that has three components:

The protective antigen is responsible for binding of the toxin to target cells and passage through the cell membrane. Edema factor interferes with one of the regulatory signaling pathways in the cell, it is an adenylate cyclase. Lethal factor disrupts a second key regulatory system by inactivating an enzyme called MAPKK (mitogen activated protein kinase kinase). The disruption of these central processes kills the cell. The widening of the mediastinum, which is the area behind the breastbone, seen in inhalation anthrax is due this cell death. Bacteria arising from the inhaled spores accumulate in lymph nodes in the area and as the tissue is destroyed (necrotic mediastinitis), the opening widens.

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Medical and Physical Countermeasures.

B. anthracis does not appear to be spread by person-to-person contact.

Vaccination (Immunoprophylaxis).

A vaccine is available from Michigan Biological Products Institute (now BioPort).

It is given as a series of six injections followed by a booster every year. The first inoculation of the series must be given at least four weeks before exposure to the disease. The vaccine is intended to protect against cutaneous infection as an occupational hazard, e.g. in farming, but it is believed that it could be effective against inhaled spores from a biological weapons attack. The Soviet Union (now Russia) has its own effective live vaccine. A new subunit vaccine with improved protection and fewer side effects is under development in the United States.

NOTE: Influenza vaccine does not provide protection against the influenza-like symptoms of anthrax.

Antibiotics.

Unvaccinated individuals must be treated with antibiotics. The preferred treatment is with fluoroquinones ( ciprofloxacin, levofloxacin, or ofloxacin) at 400-500 mg twice daily. Ciprofloxacin has been recommended for the treatment of inhalation anthrax. Tetracyclines can also be used (doxycycline 100 mg, twice daily). Penicillin used to be recommended but resistant strains occur in nature and antibiotic-resistant strains could be developed for weapon use. Antibiotic resistance determination should be a part of the diagnostic process.

 

Recommended Antibiotic Therapy for Patients with Clinically Evident Inhalational Anthrax in a Mass Casualty Event.
Patient group Initial Therapy

Subsequent therapy depending upon demonstrated antibiotic susceptibility

Duration
Adults: including pregnant women and the immunocompromised Ciprofloxacin 400 mg intravenous every 12 h.

Amoxicillin 500 mg every 8 h

Doxycycline, 100 mg by mouth every 12 h

60 days
Children Ciprofloxacin, 20-30 mg/kg per day intravenously in two daily doses. Dosage not to exceed 1 gram/day

20 kg and heavier: amoxicillin 500 mg by mouth every 8 h

Under 20 kg: amoxicillin 40 mg/kg in three doses taken every 8 h.

60 days

Notes:

These recommendations are made by the American Medical Association's Working Group on Civilian Biodefense published in Journal of the American Medical Association, vol 281, issue 18 pages 1735-1749. (12 May 1999). They have not been evaluated by the US Food and Drug Administration. They are presented here for information only and should not be used for self-treatment.

Ciprofloxacin is generally NOT recommended for pregnant women. Therapy with penicillins or tetracyclines should begin as soon as susceptibility to one or the other is demonstrated


 

Recommended Antibiotic Therapy for Patients with Clinically Evident Inhalational Anthrax In a Contained Casualty Setting.
Patient group Initial Therapy

Subsequent therapy depending upon demonstrated antibiotic susceptibility

Duration
Adults: including pregnant women and the immunocompromised Ciprofloxacin 400 mg intravenous every 12 h.

Penicillin G, 4 million units intravenously every 4 h

Doxycycline, 100 mg intravenously every 12 h

60 days
Children Ciprofloxacin, 20-30 mg/kg per day intravenously in two daily doses. Dosage not to exceed 1 gram/day

Under 12 years: penicillin G 50,000 units/kg intravenously every 6h

12 and over: penicillin G 4 million units every 4 h.

60 days

Notes:

These recommendations are made by the American Medical Association's Working Group on Civilian Biodefense published in Journal of the American Medical Association, vol 281, issue 18 pages 1735-1749. (12 May 1999). They have not been evaluated by the US Food and Drug Administration. They are presented here for information only and should not be used for self-treatment.

Ciprofloxacin is generally NOT recommended for pregnant women. Therapy with penicillins or tetracyclines should begin as soon as susceptibility to one or the other is demonstrated.

Intravenous antibiotics should be substituted by oral antibiotics as soon as the patient is well enough


 

Cutaneous anthrax can also be treated with tetracyclines (chlortetracycline, oxytetracycline), sulfadiazine, and by passive immunization with immune serum and animals can be treated with chloromycetin. Antibiotic treatment should be continued for at least 4 weeks after exposure and medical supervision must continue after treatment is ended. Antibiotic and immune serum treatments are effective against pulmonary and gastrointestinal infections in the early stages, but are less useful after the disease is well established. It may be necessary to support breathing.

Ciprofloxacin and doxycycline can also be used prophylactically, i.e. before exposure to the agent when there is a risk of its use.

 The British have developed a Biological Antibiotic Treatment Set (BATS) to support vaccination that consists of the powerful antibiotic doxycycline procured as self-administered capsules, to be held by individuals and taken on the orders of local commanders. BATS may be useful in responding to attacks with other bacterial agents such as plague.

Antibiotic Resistance.

The genus Bacillus can acquire antibiotic resistance carried by transmissible plasmids. Research has found a large number of antibiotic resistance plasmids that can be carried by Bacillus and related genera. Some studies have been published on the acquisition of plasmid-borne resistance by B. anthracis. Some of these publications originated in the former Soviet Union and it has been claimed that they were successful in creating strains with multiple antibiotic resistances. There is anecdotal evidence that the Iraqi BW project attempted, unsuccessfully, to develop antibiotic-resistant B. anthracis.

Decontamination.

Effective decontamination can be accomplished by boiling contaminated objects in water for at least 30 minutes and by using some of the common disinfectants. Strong oxidizing disinfectants such as hydrogen peroxide, peracetic acid, and iodine are also effective for area decontamination. Chlorine is effective against vegetative (growing) cells. Spores are resistant to heat, sunlight, and disinfectants and are killed with superheated steam or dry heat at >284°F (>140°C) for several hours. Decontamination of areas affected by anthrax spores during the anthrax mail attack of September-October 2001 was accomplished by cleaning with strong solutions of bleach (sodium hypochlorite.)

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Agent Properties and Potential Uses.

The bacterium is relatively easy to culture and the spores are stable in storage under a wide range of conditions.

As an agent, it is expected that anthrax spores would be released at a strategic location to be inhaled.

The spores are very hardy and can survive superheated steam (159° C, 285° F) for 2 hoursand can contaminate soil and water for years or decades. Even though the spores are relatively hardy, they are killed in air by exposure to ultraviolet light. They die off with half lives of about 0.0-1.5 hours depending upon the cloud cover. A weapon system would require a few grams to a few kilograms in a payload. The infectious dosefor a healthy individual is fairly high, typically an individual has to inhale about 10,000 spores to have a 50% chance of dying of pulmonary anthrax (this is the LD50 or lethal dose effective for 50% of the population), anthrax is much more lethal than a chemical weapon. That is, the mass of bacteria needed is far less than that required of a chemical weapon. One gram of B. anthracis contains about 100 million lethal doses, making it about 10,000-100,000 times deadlier than nerve agents. Information derived from fatalities in the anthrax mail attack of late 2001 forced a reassessment of the infectious dose. It is now believed that the infectious dose can be as low as a few tens of spores for the most vulnerable, such as the elderly or those with lung problems.

A 1970 estimate from the World Health Organization estimated that delivery of an aerosol of Bacillus anthracis over a city of five million would kill 100,000 and incapacitate a further 150,000.

Anthrax could be used against livestock as an economic weapon and to deny areas by soil contamination. It was actually used in this way by the white regimes of Rhodesia (now Zimbabwe) and South Africa as they battled against the coming of majority rule. Sporadic outbreaks of anthrax in herds owned by black Africans but not by white Rhodesians were the first sign that this was taking place.

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Terrorist Acquisition and Attempted Use.

 

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The History and Natural History of Anthrax.

Bacillus anthracis is a member of a very large genus of soil microorganisms. Most are harmless and unknown to the general public. Others are known, including B. thuringiensis, which is used as a natural insecticide. Some may know of B. subtilis, which is the source of the enzyme subtilisin that is used in laundry detergents. Only one other member of the genus, B. cereus, is at all well-known as a health hazard as it can cause an unpleasant form of gastroenteritis.

Soil microorganisms adapt well to poor growth conditions and the Bacilli have done this by forming spores, very hardy bodies that are inactive until conditions favor their growth. They are actually tough enough to survive dispersal by explosion and this method was tested by the British during World War II. The spores can survive for years in wool or animal hides and for decades or perhaps centuries in soil. One of the common names for anthrax - Woolsorter's disease - refers to the lethal pulmonary anthrax that can be contracted from handling wool from sheep that have been on contaminated soil. A layer of B. anthracis-containing soil can be buried if the land lies undisturbed only to be exposed to air and begin killing livestock if the soil is broken by the plough. Larry Wayne Harris obtained a pathogenic B. anthracis in the 1990's by exhuming cattle that had died of anthrax in the 1950's.

B. anthracis uses the combination of spores and lethality as a dispersal mechanism. When enough spores, or live cells, are taken up by an animal to cause it to develop anthrax and kill it. The bacterium particularly attacks the spleen, the German name for the disease is Milzbrand or inflamed spleen, but is found throughout the body. The area around the infected animal becomes contaminated as the animal begins to hemorrhage in the final stages of the disease. Carrion flies, birds and animals attack the corpse and take the disease with them and continue to disperse it. Louis Pasteur demonstrated that spores can pass through the digestive tract of earthworms. This would help spread the disease through the soil if the carcasses were simply buried. Although the disease does not readily pass directly between animals, this dispersal mechanism can contaminate large areas of land fairly rapidly. The treatment for diseased animals, especially in the wild, is no better than the disease. They are shot and the corpses burned where they lie.

Of the major diseases, anthrax is arguably the one with the longest confirmed history. It was described as a distinct disease by the ancient Greeks and anthrax is actually the Greek word for charcoal, referring to the deep black sores on the skin found in cutaneous anthrax, the commonest and most survivable form. It is thought that anthrax was the fifth or sixth plague of Egypt described in the book of Exodus.

Unlike most other old diseases seen as potential biological weapons, anthrax was not known for causing large-scale epidemics, but more for its economic effects. It is certainly poorly transmissible between people, but it can be contacted from contaminated surfaces and could easily wipe out flocks of sheep or herds of cattle, and still does today, and be economically devastating to an agrarian society. It was this that brought the minds of two of the great founders of bacteriology - Robert Koch and Louis Pasteur - to focus on the disease. Koch identified the bacterium in 1877 and it help him to formulate his postulates (Koch's postulates) that still guide microbiologists in identifying the agents causing diseases.

Pasteur's contributions to microbiology included the development of a vaccine that protected sheep from the disease, and therefore helped the economic recovery of some areas of France where the disease was common enough to hinder the rearing of livestock. They also included the development of the idea of attenuation - the development of weakened strains of an agent that can be used in vaccines to give protection without causing disease. He managed this by growing the bacterium at 42°C rather than 37°C. Safe and effective vaccines for humans are still not fully developed, underlining the scale of Pasteur's achievement.

Pasteur had achieved something that was so surprising that it took the better part of a century to explain it. The bacterial toxin is not coded for by genes of the bacterial chromosome, but by a plasmid. A plasmid is a small, independent piece of genetic material that does not use the same mechanisms as the host chromosome to maintain itself. This plasmid, known as pXO1, cannot maintain itself at 42°C so is lost from the cells, taking the disease-causing ability with it. There are now known to be two such virulence plasmids (pXO1 and pXO2) and modern diagnostic methods focus on rapid detection of these plasmids.

Anthrax has a long and ignoble history as a biological weapon. The first attempt to use it appears to have been a large-scale German plan to destroy Allied horse power using anthrax and glanders during World War I. Viable B. anthracis spores were recovered in 1997 from a glass ampoule inside a sugar cube that had been taken from a German officer in Norway in 1917.

The bacterium has been prepared for use as a weapon by the United Kingdom, the Soviet Union, and Iraq. The British prepared anthrax-impregnated cattle cake as a biological doomsday weapon for use against Germany in World War II. At the time, the United States prepared extensive facilities for the manufacture of B. anthracis (known as Agent N) on behalf of the British (Canada was involved to some extent) but demurred from developing it as an agent for itself.

In order to determine whether or not anthrax was a viable weapon, in the summer of 1942 British researchers went to Gruinard Island, off the coast of Scotland, and conducted a series of tests with anthrax-containing bombs. The tests were successful from the point of view of the weapons designers, demonstrating that the weapons could effectively disseminate the anthrax pseudospores; however, they left the island heavily contaminated. The cost of decontamination was originally thought to be too high, and the island was simply abandoned and placed off limits, its only sentinels warning signs.

The island became a bit of an embarrassment, however. Some authorities suggested that anthrax outbreaks in Scotland might be resulting from spores from the island, apart from which the simple fact that the testing had forced the abandonment of the island was continually embarrassing to the government (as when, as noted above in the section on terrorism, soil supposedly from Gruinard was used as a threat). Finally, in the 1980's, the British government undertook to decontaminate the island, conducting a survey to determine where the anthrax was and then studying means to decontaminate the soil.

After some experimentation, it was determined that a solution of formaldehyde 5% in seawater applied at a rate of 50 liters per square meter was effective in killing the anthrax spores without causing the soil to become infertile. During the summer of 1986, the areas on the island which had been found to be still contaminated were treated, samples were collected to see if spores had survived, and areas where viable spores were found were retreated until no anthrax was found. A flock of sheep was then settled on the island and watched. In 1990, when no anthrax had been seen, the British Ministry of Defense declared the island safe, returning it, in 1990, to the heirs of its original owners.

The Sverdlovsk Incident

On or about April 2, 1979, an anthrax aerosol was released from a laboratory, known as Military Compound 19, in Sverdlovsk (now Yekaterinburg) in what was then the Soviet Union. On April 4, 1979, the first cases of inhalation anthrax appeared. The outbreak lasted through May of 1979, with official Soviet sources identifying 96 victims, with 64 deaths. Unofficial sources indicate higher tolls, especially regarding infection, while combining various sources suggests at least 68 deaths.

The Sverdlovsk release was the subject of much controversy at the time. The American government felt it represented evidence of a major breach of the 1972 Convention on the Prohibition of Bacteriological and Toxin Weapons. An initial report on the outbreak by the Defense Intelligence Agency is now available in .pdf. The Soviet authorities said it had nothing to do with biological weapons and attributed the anthrax cases to tainted meat sold by "private butcher", with the animal infection arising from "a single 29-ton lot of bone meal (cattle feed) sold in March from a factory in Aramil, 15 kilometers to the southeast of Sverdlovsk." The Soviets also claimed all the deaths were due to intestinal anthrax. (Private butchers are common in the area and anthrax from improperly butchered meat is common in former Soviet Central Asia). Western intelligence sources had a different view, based on the distributions in space and time of human and animal cases.

The spatial distribution was very suggestive, as can be seen from this description:

   Most people who contracted anthrax worked, lived, or attended daytime military reserve classes during the first week of April 1979 in a narrow zone, with its northern end in a military microbiology facility in the city and its other end near the city limit 4 km to the south; livestock died of anthrax in villages located along the extended axis of this same zone, out to a distance of 50 km.   
   - Matthew Meselson, et al; Science 266, 18 Nov., 1994; 1202-1208.   

There were also other indicators that the outbreak was not natural such as the presence of military decontamination teams on the streets and of police guards at the funerals of victims. But, in the end, the Soviet version of events would largely carry the day until 1992, when Boris Yeltsin, then President of Russia and in 1979 Communist Party chief in Sverdlovsk, acknowledged in a newspaper interview that the outbreak was caused by an accident at a biological warfare facility. Even after this admission, little information has been released, and the cause of the incident has not been stated, although Ken Alibek, in his 1999 book Biohazard states that it resulted from a failure to replace a clogged air filter.

In recent years, analysis on tissue samples from victims of the outbreak has demenstrated that the anthrax aerosol released from the facility was quite sophisticated, containing at least four separate strains of anthrax. In addition, the large distance it traveled (animal cases appeared some 50 kilometers downwind) suggests that it was well optimized for aerosol dissemination. The Soviets are also reported to have developed blends of B. anthracis strains intended to defeat known vaccines.


Exactly how much effort the Soviet Union poured into its biological weapons program can be seen from these photographs.


The inside of a 20,000 liter fermentor at a plant in Kazakhstan. The metal strips running up the fermentor wall are baffles that are a standard feature of fermentor design. The turbine, the fan-like object near the bottom of the tank appears to be a Rushden turbine. The lower part of one of the four storey-high fermentors from the outside. The hall actually contained 10 of these.
Photographs: Center for Cooperative Threat Reduction

Iraq obtained anthrax for its biological weapons program, in part by buying it from the American Type Culture Collection. This points out one of the great problems in controlling biological weapons proliferation. Biological weapons organisms also constitute standing public health problems and are matters of legitimate research interest. There is a specific clause in the Biological and Toxin Weapons Convention that allows these organisms to be studied for genuine reasons of public good. Furthermore, anthrax is endemic in the Middle east and Iraqi scientists had already obtained at least one isolate of B. anthracis from a woman who had died of anthrax in the northern city of Mosul some years before they bought strains from the ATCC.

Bacillus anthracis strains supplied to Iraq by the American Type Culture Collection
Strain Notes
ATCC 14185
Batch 01-14-80 (3 each)
G.G. Wright (Fort Detrick) V770-NP1-R
Bovine anthrax
Class III Pathogen
Sent May 2, 1986
ATCC 10
Batch 08-20-82 (2 each)
Bacillus Anthracis Cohn
Class III pathogen
Sent May 2, 1986
ATCC 14578
Batch 01-06-78 (2 each)
Class III pathogen
Sent May 2, 1986
ATCC 240
Batch 05-14-63 (3 each)
Class III pathogen
Sent September 29, 1988
ATCC 938
Batch 1963 (3 each)
Class III pathogen
Sent September 29, 1988
ATCC 8705
Batch 06-27-62 (3 each)
Class III pathogen
Sent September 29, 1988
ATCC 11966
Batch 05-05-70 (3 each)
Class III pathogen
Sent September 29, 1988
Materials sent May 2, 1986 were directed to Ministry of Higher Education; Materials sent September 29, 1988 were directed to Ministry of Trade
ATCC 14578 is the type strain for Bacillus anthracis; the ATCC sample was deposited by Paul Fildes, who headed the World War II development of anthrax as a biological weapon in Britain

 

After the Gulf war, the Iraqis were noticeably evasive about their weaponization of anthrax, among other things claiming in 1995 in a "full and final accounting" to have filled 10 Scud missile warheads with weaponized anthrax and later, in 1997, in another "full and final accounting" to have filled only 5 missile warheads with anthrax. Subsequent questioning about this discrepency led some United Nations Special Commission personnel to the conclusion that the Iraqis had produced two different forms of anthrax for use in munitions - a wet slurry (easier to produce) and a dry form (better for dispersion) - and that they had actually filled 15 missile warheads with anthrax.

The threat of anthrax as a biological weapon led some to believe that it was necessary to vaccinate the US military against it. After a heated debate within the US national security establishment about the wisdom or necessity of the action, a vaccination program was begun in the late 1990's. The program was controversial as some believed that it was of limited effectiveness and because some believed it had played a role in the development of Gulf War Syndrome. In addition, Michigan Biologics had received a number of poor reviews of its performance from the US Food and Drug Administration. A small number of soldiers, sailors and airmen refused to take the vaccinations because of these concerns and were disciplined. The search for effective vaccines and protection against this and other agents continues.

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International Classification of Disease Codes for Anthrax
IDC Codes: ICD-9-CM ICD-10
Anthrax 022  A22 
Cutaneous anthrax 022.0 A22.0 
Pulmonary anthrax 022.1 A22.1 
Gastrointestinal anthrax 022.2 A22.2 
Anthrax septicemia  022.3 A22.7 
Other specified manifestations of anthrax 022.8 A22.8 
Anthrax, unspecified 022.9  A22.9 

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