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ORIGINAL ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 4  |  Page : 278-283  

Does infant feeding method influence the incidence and pattern of morbidities among human immunodeficiency virus-exposed uninfected nigerian infants?


1 Associate Professor, Department of Paediatrics, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
2 Senior Lecturer, Department of Paediatrics, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
3 Registrar, Department of Paediatrics, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria

Date of Web Publication6-Dec-2017

Correspondence Address:
Olusoga Babatunde Ogunfowora
Department of Paediatrics, Olabisi Onabanjo University, Sagamu, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_142_16

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   Abstract 


Background: Human immunodeficiency virus (HIV)-exposed infants enrolled into the prevention of mother-to-child transmission of HIV program generally receive antiretroviral therapy (ARV), but the feeding methods differ based on several socioeconomic and cultural differences. Objective: The objective of the study was to examine the incidence and pattern of morbidities among HIV-exposed uninfected (HEU) Nigerian infants and determine any relationship with infant feeding methods. Methods: A review of the hospital records of all HEU infants attending the Virology Clinic of Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, between July 2013 and June 2015, was done. The recorded data included biodemographic profile, social parameters, feeding methods, anthropometry, and morbidities. The feeding method groups were statistically compared in relation to the various morbidities. Results: Out of 119 children, 81.5% were exclusively breastfed, whereas 18.5% had exclusive breast milk substitute feeding. About half had various morbidities which included upper airway infections (UAIs) (16.8%), malaria (15.9%), malnutrition (8.4%), diarrhea (8.4%), and pneumonia (2.5%). The frequencies of these conditions were similar among infant groups irrespective of feeding method. The infants with and without morbidities were comparable in terms of the frequency of exclusive breastfeeding (80.3% vs. 82.8%). Low family socioeconomic status (SES) (odds ratio [OR] = 7.7) and ARV use (OR = 0.4) among infants were predictors of morbidities among HEU infants. Conclusion: The incidence and pattern of morbidities among HEU infants showed no relation to the mode of feeding. Rather, family SES and the use of antiretroviral drugs were predictors of morbidities among HEU infants.

Keywords: Breast milk substitute, breast milk, diarrhea, highly active antiretroviral therapy, human immunodeficiency virus-exposed, infant feeding, malnutrition


How to cite this article:
Ogunfowora OB, Ogunlesi TA, Adekanmbi AF, Ayeni VA. Does infant feeding method influence the incidence and pattern of morbidities among human immunodeficiency virus-exposed uninfected nigerian infants?. Indian J Public Health 2017;61:278-83

How to cite this URL:
Ogunfowora OB, Ogunlesi TA, Adekanmbi AF, Ayeni VA. Does infant feeding method influence the incidence and pattern of morbidities among human immunodeficiency virus-exposed uninfected nigerian infants?. Indian J Public Health [serial online] 2017 [cited 2019 Sep 15];61:278-83. Available from: http://www.ijph.in/text.asp?2017/61/4/278/220051




   Introduction Top


The prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) aims to reduce the chances of vertical transmission of HIV infection. It entails the use of highly active antiretroviral therapy (HAART) during pregnancy, avoidance of prolonged labor and assisted deliveries, as well as the administration of antiretroviral drugs to the baby.[1] Since additional 10%–18% risk of transmission is attributable to breastfeeding, emphasis has been placed on counseling of mothers to make informed decision with respect to the method of infant feeding to be adopted. Even though exclusive breast milk substitute feeding (EBMSF) eliminates the risk of transmission through breast milk, this may not always be feasible in resource-limited settings where exclusive breastfeeding (EBF) has been shown to reduce infant mortality.[2] Studies within Nigeria have shown the effectiveness of PMTCT; for example, in a retrospective analysis in Sagamu, only 7.1% of infants who received antiretroviral therapy (ARV) at birth and whose mothers had HAART were infected.[3] Similar findings were reported from Jos where only 0.7% of infants perinatally exposed to HIV were confirmed infected.[4] In Nnewi, maternal HAART use, lack of breastfeeding, and ARV use in babies reduced HIV infection rate from 37.5% to 2.8%.[5]

HIV-infected infants are known to be susceptible to infections, poorer growth and nutritional indices, and other morbidities arising from the primary HIV infection as well as the several opportunistic infections. Compared to HIV-unexposed uninfected (HUU) infants, HIV-exposed but uninfected (HEU) infants have been shown to have poorer anthropometry, more frequent minor illnesses, and lower academic performances after controlling for socioeconomic status (SES).[6] The problems of HEU infants may arise from the effect of the virus on the placenta, effect of the HAART taken during pregnancy, effect of the mode of feeding, effect of maternal illness, effect of family disarray, and effects of opportunistic infections in the mothers on the HEU infants.[7],[8]

Within the PMTCT scheme, all infants with perinatal exposure to HIV share the risk of the effects of maternal HAART and maternal illnesses including the opportunistic infections. The mode of feeding is usually the most prominent difference between HEU infants. Therefore, the present study was designed to examine the pattern of morbidities among HEU infants and determine any relationship with infant feeding methods.


   Materials and Methods Top


The study was conducted at the Olabisi Onabanjo University Teaching Hospital, Sagamu, a tertiary care center located in South-Western part of Nigeria. The hospital runs a virology clinic (established in 2008 in collaboration with a NonGovernmental Organization, the Institute of Human Virology of Nigeria [IHVN]) for the treatment of adults and children infected with the HIV and people living with HIV/AIDS.

At the virology clinic of the hospital, infants born to HIV-infected mothers are registered within 4 to 6 weeks after birth for care and monthly follow-up for the first 6 months and quarterly thereafter, if they were not infected. The management of such infants includes the commencement of Nevirapine prophylaxis within 72 h after birth for a duration of 6 weeks, growth monitoring, supervision of feeding methods, treatment of minor ailments, referral for major sicknesses, and routine immunization. In addition, Early Infant Diagnosis (EID) in the form of deoxyribonucleic acid polymerase chain reaction is carried out on the infant after 6 weeks of age to determine their HIV status.

This record-based retrospective study was a time-bound study covering the period between July 2013 and June 2015 with purposive sampling. The hospital records of all infants of HIV-infected mothers (i.e., HEU) aged 0–12 months attending the virology clinic during the period were reviewed. From the point of enrollment into the program, the infants were followed up, as described above, till the age of 12 months. Infants with poor clinic attendance (<5 clinic visits), those with mixed feeding (MF), and those with positive EID test results were excluded from the analysis.

Relevant data on the infant's biocharacteristics, age at enrollment, mode and place of delivery, and the type of PMTCT the mothers received were obtained. The morbidities present in each infant at the time of clinic visit were determined (using clinical and relevant laboratory evaluation) and recorded. Symptoms occurring in the interval between the clinic visits were not recorded since the diagnoses could not be reliably made in retrospect. Parental education and occupation were recorded for each child. The present occupation and highest education of each parent were used to compute the family socioeconomic classes as earlier suggested.[9] The families were classified into socioeconomic classes I, II, III, IV, and V. Due to the small number of subjects in Class II and none in Class I, the recommended re-grouping of socioeconomic classes into upper (I-II), middle (III), and lower (IV-V) classes was modified for the purpose of this study as follows: Upper (II and III) and lower (IV and V).[9] Maternal use of HAART during pregnancy was also recorded. The method of infant feeding was classified into EBF or EBMSF in the form of infant formula.

Ethical approval for this study was obtained from the Olabisi Onabanjo University Teaching Hospital Research Ethics Committee.

Data management

Data were processed using Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM SPSS Inc (Hong Kong)). The mean value and standard deviations of continuous data were determined whereas categorical data were described in the form of ratios and percentages. Inferential statistics were done using the Student's t-test and odds ratio (OR) with 95% confidence interval (CI). Multivariate analysis was done using binary logistic regression to determine variables with an independent contribution to the risk of morbidities after controlling for confounding variables. Statistical significance was defined by P < 0.05 in two-tailed test or CI excluding unity.


   Results Top


The records of a total of 132 infants who were exposed to the HIV were available for review. Two, three, and eight of these were excluded for reasons of positive EID, poor clinic attendance, and MF method, respectively. The remaining 119 infants were included in the analysis, and none of these had changes in their serostatus. The age at enrollment in the clinic ranged between 2 weeks and 4 months with the mean age at enrollment of 2.0 ± 1.5 months. The population comprised 59 (49.6%) males and 60 (50.4%) females giving a male-to-female ratio of 0.9:1.

[Table 1] summarizes that a larger proportion of the infants who were enrolled within the first 2 months of life had EBF whereas the bulk of those who were enrolled after 2 months had BMS. Although there was no consistent pattern between feeding method and family socioeconomic classes, none of the families belonged to the socioeconomic Class I.
Table 1: Sociodemographic and clinical characteristics of the HIV-exposed uninfected children in relation to the method of feeding

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Sixty-one (51.2%) infants had various morbidities during the period of follow-up whereas 58 (48.7%) had none. Thirty-four (55.7%) infants had only one morbidity whereas the remaining 27 (44.3%) had between 2 and 3 morbidities. The recorded morbidities and their frequencies among infants included upper airway infections (UAI) (20; 16.8%), malaria (19; 15.9%), malnutrition (10; 8.4%), diarrhea (10; 8.4%), pneumonia (3; 2.5), oral thrush, diaper rash and impetigo (2; 1.7%) each, and the others (represented by tinea corporis, furunculosis, anemia, seborrhea, otitis media, pyoderma, cutaneous candidiasis, conjunctivitis, and cellulitis) (23; 19.3%). The frequencies of the morbidities among children who received EBF and EBMSF, respectively, were as follows: UAI (18.6% and 9.1%), malaria (13.4% and 27.3%), malnutrition (8.2% and 9.1%), diarrhea (8.2% and 9.1%), pneumonia (2.1% and 4.5%), oral thrush (1.0% and 4.5%), diaper rash (2.1% and 0.0%), impetigo (1.0% and 4.5%), and others (15.6% and 22.7%). Nine of the ten infants with diarrhea had acute watery diarrhea, one had dysentery while none had persistent diarrhea. Sixteen and six infants among the EBF and EBMS groups, respectively, had >1 morbidity.

Most of the infants (97; 81.5%) were exclusively breastfed whereas 22 (18.5%) had EBMSF. The duration of breastfeeding among the 97 infants who were exclusively breastfed was categorized into <3 months (7; 7.2%), 3–6 months (41; 42.3%), and 7–9 months (7; 7.2%), whereas the duration was not precisely indicated for 42 (43.3%) children.

[Table 2] summarizes that age at enrollment, sex, family SES, and places of delivery were comparable for infants who had EBF or EBMSF. However, the use of ARV among the infants was significantly associated with EBF (P = 0.005).
Table 2: Relationship between feeding methods and sociodemographic parameters of 61 HIV-exposed uninfected infants with morbidities

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As shown in [Table 3], there was no statistically significant difference in the proportions of infants with and without morbidities who were enrolled into the study within 2 months of life (47.5% vs. 46.6%), were of male sex (45.9% vs. 53.4%), whose mothers did not receive HAART in pregnancy (26.2% vs. 25.9%) or who were exclusively breastfed (80.3% vs. 82.8%). A significantly larger proportion of infants in the lower socioeconomic class had morbidities compared to the infants in the upper socioeconomic class (P < 0.0001).
Table 3: Sociodemographic and clinical factors associated with the presence or absence of morbidities among the HIV-exposed uninfected infants

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In [Table 4], comparable proportions of children with EBF and EBMSF had diarrhea (8.2% vs. 9.1%) and malnutrition (8.2% vs. 9.1%). Although 18.6% of the EBF group had UAI compared to 9.1% of the EBMSF group and 13.4% of the EBF group had malaria compared to 27.3% of the EBMSF group, these differences lacked statistical significance.
Table 4: Relationship between infant feeding methods and frequency of specific morbidities

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Following the exclusion of the 42 infants whose duration of EBF was not known, multivariate analysis of the variables was done using binary logistic regression to determine independent contributions to the presence of morbidities. The variables which were not associated with the occurrence of morbidities among the infants included infant sex (OR = 0.6; CI = 0.28–1.45), age at enrollment <2 months (OR = 1.5; CI = 0.66–3.58), maternal HAART use in pregnancy (OR = 0.8; CI = 0.14–4.98), maternal HAART use for at least 6 weeks in pregnancy (OR = 1.1; CI = 0.24–5.56), EBF (OR = 1.5; CI = 0.26–9.19), EBMSF (OR = 1.4; CI = 0.20–9.84), duration of breastfeeding <3 months (OR = 1.0; CI = 0.05–19.96), duration of breastfeeding <3–6 months (OR = 5.7; CI = 0.63–51.76), and duration of breastfeeding >6 months (OR = 0.2; CI = 0.01–1.76). Low family SES (OR = 7.7; CI = 2.92–20.33; P < 0.001) predicted the occurrence of morbidities whereas the use of ARV in the infants (OR = 0.4; CI = 0.01–0.11; P = 0.07) protected against the occurrence of morbidities.


   Discussion Top


The present study showed that more than three-quarters of the HEU infants were exclusively breastfed for 3–6 months. This observation reflects the wide acceptability of EBF in the population studied. This is not quite different from the report from Ibadan where almost all nursing mothers breastfed their infants at the onset of the PMTCT.[10] Although breastfeeding is the norm in most parts of the country, in the context of maternal HIV infection and with the knowledge of possible HIV transmission through breast milk, the acceptability of EBF for HIV-exposed infants had been shown to decline to as low as 47%.[11] The latter may explain the low proportion of the mothers in the present study who opted for EBMSF. Nevertheless, the role of infant feeding methods has been depicted in a previous Nigerian study which showed that HIV-free survival among HEU is related to the feeding method; the survival rate at 18 months was worst with MF (69.8%) and EBMS (86.2%) and best with EBF (92.5%) in that study.[12] Therefore, the guideline for counseling on feeding method for HIV-exposed infants in resource-poor settings accommodates EBF for the first 4–6 months which is abruptly ended at the introduction of complementary feeding.

The methods of feeding used for the HEU infants in this study appeared generally not influenced by infant characteristics such as age at enrollment and sex or by family characteristics such as family SES or maternal use of HAART in pregnancy. Both EBF and EBMSF were encouraged in the setting of the study center while MF was discouraged. However, it appeared that the bulk of infants delivered in orthodox health facilities had EBF compared to those delivered in nonorthodox facilities. This observation may be related to the infant feeding practices entrenched at those orthodox birthing facilities according to the tenets of the PMTCT in Nigeria. It is important to add that EBF and use of HAART by the mother and the infant during breastfeeding were adopted and encouraged by facilities involved in PMTCT as prescribed in the national government policy on the control of HIV/AIDS in the country.[13] Therefore, the association observed between the use of EBF and the use of ART for infants in the present study was not surprising. Further, there is a need to incorporate the nonorthodox health practitioners into the PMTCT practices as earlier observed and recommended in a previous study.[14]

More than half of the HEU infants in the present study had various morbidities, the bulk of which were infections of the upper airways and malaria. Furthermore, close to half of the infants were observed to have multiple morbidities. It is not surprising that, in spite of their uninfected status, these infants had several morbidities. The generally low immune functions characteristic of infancy may explain their susceptibility to infectious conditions in particular, as observed in the present study, in spite of noninfection with the HIV. Although the present study did not compare HEU with HUU, previous comparative studies in other parts of the developing world have suggested that HEU infants have a greater tendency for morbidities and hospitalization for care.[12],[13] The likelihood of altered immune functions in the infant following prenatal exposure to HAART has been suggested.[12] The prominent roles of acute respiratory infections and malaria may not be surprising since those are the leading morbidities among infants in the general population. It is of interest that contrary to a previous report [14] which suggested a higher incidence of tuberculosis among HEU presumably due to exposure to their mothers who also had tuberculosis as part of their own illness, none of the HEU in this study had tuberculosis. It is plausible that the diligent search for tuberculosis among the adults attending the clinic followed by recommended antituberculosis treatment reduced the exposure of the HEU infants to tuberculosis. The low incidence of pneumonia in the present study agrees with the earlier report among Kenyan infants that high breastfeeding rate contributed to a great reduction in the incidence of pneumonia among HEU infants.[15] This observation may be explained in terms of breast milk supplies of protective immunoglobulins against common etiologies of childhood pneumonia, given the high rate of breastfeeding among the infants in this study.

Although the number of infants in the respective groups was relatively small, malnutrition was more frequently recorded among children fed with other methods apart from EBF. Underweight had been reported to increase the risk of acute respiratory infections by 58% while adequate breastfeeding also reduced the risk of acute respiratory infections by 52% among HEU in Tanzania.[16] Therefore, a combination of high breastfeeding rate and low prevalence of malnutrition in the present study may explain the low prevalence of pneumonia among the infants studied.

The general absence of difference in the rates of morbidities among exclusively breastfed infants and the infants fed by other methods in the present study agreed with the finding from a previous report among another group of African children.[17] However, the risk of serious infectious events was reportedly higher among nonbreastfed HEU infants compared to breastfed HEU infants.[17] None of such serious infectious events was reported among the HEU infants in the present study. The prevalence of diarrhea was comparably low among infants in the comparison groups in the present study, and this may be related to the general education of the mothers on personal and environmental hygiene. Where such observation had earlier been made, it was attributed to micronutrient supplementation of the infants.[18] It is, therefore, attractive to encourage micronutrient supplementation for HEU infants to further reduce the incidence of diarrheal diseases.

It was also observed that high family SES protected HEU infants against morbidities. This may be related to the availability of funds to take measures which would improve personal and environmental hygiene and enhance good healthcare-seeking practices for the infants. While the maternal use of HAART had no significant influence on the prevalence of morbidities, the protective role of ART use among the infants stood out. This protective role of ART in the infants may not have a direct effect on the prevalence of morbidities since the infants were not infected with the HIV. However, the positive role of ART in the infants may reflect, indirectly though, adherence to the other measures of care aimed to ensure the general well-being of the infants according to the tenets of the PMTCT.


   Conclusion Top


The present study has shown that the feeding method for HEU infants has no direct relationship with the incidence or pattern of morbidities among them. Given the various advantages of EBF over EBMSF, it may appear that other measures, particularly counseling of caregivers on hygiene and appropriate treatment of infectious morbidities among the mothers or caregivers, may reduce the occurrence of morbidities among HEU infants. We acknowledge as a limitation in this study, the small size of the population of infants belonging to the EBMS and MF arms of feeding, and the incomplete data on the duration of breastfeeding. Therefore, it is attractive to advocate for a larger scheme of study on the morbidities among HEU infants which would include both the communities and the facilities.

Financial support and sponsorship

The authors wish to acknowledge the financial support provided by the IHVN for the virology clinic during the period of the present study.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organisation. PMTCT Strategic Vision 2010-2015. Preventing Mother-to-child Transmission of HIV to Reach UNGASS and Millennium Development Goals. 2010.  Back to cited text no. 1
    
2.
Adegbehingbe SM, Paul-Ebhohimhen V, Marais D. Development of an AFASS assessment and screening tool towards the prevention of mother-to-child HIV transmission (PMTCT) in Sub-Saharan Africa – A Delphi survey. BMC Public Health 2012;12:402.  Back to cited text no. 2
[PUBMED]    
3.
Odusoga OO, Oladapo OT, Odusoga OL, Olusile O. Perinatal HIV transmission among HIV-positive mothers receiving free antiretroviral therapy in Sagamu, Nigeria. Int J Multidiscip Res 2012;1:81-8.  Back to cited text no. 3
    
4.
Sagay AS, Ebonyi AO, Meloni ST, Musa J, Oguche S, Ekwempu CC, et al. Mother-to-child transmission outcomes of HIV-exposed infants followed up in Jos North-central Nigeria. Curr HIV Res 2015;13:193-200.  Back to cited text no. 4
[PUBMED]    
5.
Ikechebelu JI, Ugboaja JO, Kalu SO, Ugochukwu EF. The outcome of prevention of mother to child transmission (PMTCT) of HIV infection programme in Nnewi, Southeast Nigeria. Niger J Med 2011;20:421-5.  Back to cited text no. 5
[PUBMED]    
6.
Nicholson L, Chisenga M, Siame J, Kasonka L, Filteau S. Growth and health outcomes at school age in HIV-exposed, uninfected Zambian children: Follow-up of two cohorts studied in infancy. BMC Pediatr 2015;15:66.  Back to cited text no. 6
[PUBMED]    
7.
Filteau S. The HIV-exposed, uninfected African child. Trop Med Int Health 2009;14:276-87.  Back to cited text no. 7
[PUBMED]    
8.
Chen JY, Ribaudo HJ, Souda S, Parekh N, Ogwu A, Lockman S, et al. Highly active antiretroviral therapy and adverse birth outcomes among HIV-infected women in Botswana. J Infect Dis 2012;206:1695-705.  Back to cited text no. 8
[PUBMED]    
9.
Ogunlesi TA, Dedeke IO, Kuponiyi OT. Socio-economic classification of children attending specialist health facilities in Ogun State. Niger Med Pract 2008;54:21-5.  Back to cited text no. 9
    
10.
Brown BJ, Oladokun RE, Osinusi K. Situation analysis of the existing infant feeding pattern at the commencement of the prevention of mother to child transmission (PMTCT) of HIV programme in Ibadan. Niger J Clin Pract 2009;12:421-8.  Back to cited text no. 10
[PUBMED]    
11.
Balogun FM, Owoaje ET. How acceptable are the prevention of mother to child transmission (PMTCT) of HIV services among pregnant women in a secondary health facility in Ibadan, Nigeria? Ann Ib Postgrad Med 2015;13:17-22.  Back to cited text no. 11
[PUBMED]    
12.
Anígilájé EA, Dabit OJ, Olutola A, Ageda B, Aderibigbe SA. HIV-free survival according to the early infant-feeding practices; a retrospective study in an anti-retroviral therapy programme in Makurdi, Nigeria. BMC Infect Dis 2015;15:132.  Back to cited text no. 12
    
13.
Federal Ministry of Health (Nigeria). National Policy on HIV/AIDS. Abuja, Nigeria: Federal Ministry of Health; 2009.  Back to cited text no. 13
    
14.
Sotunsa JO, Amoran EO, Abiodun OA, Ani F. Traditional birth attendants' understanding and perceived roles in the prevention of mother to child transmission of HIV in Ogun State, Nigeria. Ann Health Res 2015;1:24-9.  Back to cited text no. 14
    
15.
Afran L, Garcia Knight M, Nduati E, Urban BC, Heyderman RS, Rowland-Jones SL, et al. HIV-exposed uninfected children: A growing population with a vulnerable immune system? Clin Exp Immunol 2014;176:11-22.  Back to cited text no. 15
    
16.
Slogrove A, Reikie B, Naidoo S, De Beer C, Ho K, Cotton M, et al. HIV-exposed uninfected infants are at increased risk for severe infections in the first year of life. J Trop Pediatr 2012;58:505-8.  Back to cited text no. 16
[PUBMED]    
17.
Cotton MF, Schaaf HS, Lottering G, Weber HL, Coetzee J, Nachman S, et al. Tuberculosis exposure in HIV-exposed infants in a high-prevalence setting. Int J Tuberc Lung Dis 2008;12:225-7.  Back to cited text no. 17
    
18.
Ásbjörnsdóttir KH, Slyker JA, Weiss NS, Mbori-Ngacha D, Maleche-Obimbo E, Wamalwa D, et al. Breastfeeding is associated with decreased pneumonia incidence among HIV-exposed, uninfected Kenyan infants. AIDS 2013;27:2809-15.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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