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Gupta AK, Talukder M, Shemer A, Galili E. Safety and efficacy of new generation azole antifungals in the management of recalcitrant superficial fungal infections and onychomycosis. Expert Rev Anti Infect Ther 2024; 22:399-412. [PMID: 38841996 DOI: 10.1080/14787210.2024.2362911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Terbinafine is considered the gold standard for treating skin fungal infections and onychomycosis. However, recent reports suggest that dermatophytes are developing resistance to terbinafine and the other traditional antifungal agents, itraconazole and fluconazole. When there is resistance to terbinafine, itraconazole or fluconazole, or when these agents cannot used, for example, due to potential drug interactions with the patient's current medications, clinicians may need to consider off-label use of new generation azoles, such as voriconazole, posaconazole, fosravuconazole, or oteseconazole. It is essential to emphasize that we do not advocate the use of newer generation azoles unless traditional agents such as terbinafine, itraconazole, or fluconazole have been thoroughly evaluated as first-line therapies. AREAS COVERED This article reviews the clinical evidence, safety, dosage regimens, pharmacokinetics, and management algorithm of new-generation azole antifungals. EXPERT OPINION Antifungal stewardship should be the top priority when prescribing new-generation azoles. First-line antifungal therapy is terbinafine and itraconazole. Fluconazole is a consideration but is generally less effective and its use may be off-label in many countries. For difficult-to-treat skin fungal infections and onychomycosis, that have failed terbinafine, itraconazole and fluconazole, we propose consideration of off-label voriconazole or posaconazole.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | - Avner Shemer
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Galili
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gupta AK, Talukder M, Carviel JL, Cooper EA, Piguet V. Combatting antifungal resistance: Paradigm shift in the diagnosis and management of onychomycosis and dermatomycosis. J Eur Acad Dermatol Venereol 2023; 37:1706-1717. [PMID: 37210652 DOI: 10.1111/jdv.19217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
Antifungal resistance has become prevalent worldwide. Understanding the factors involved in spread of resistance allows the formulation of strategies to slow resistance development and likewise identify solutions for the treatment of highly recalcitrant fungal infections. To investigate the recent explosion of resistant strains, a literature review was performed focusing on four main areas: mechanisms of resistance to antifungal agents, diagnosis of superficial fungal infections, management, and stewardship. The use of traditional diagnostic tools such as culture, KOH analysis and minimum inhibitory concentration values on treatment were investigated and compared to the newer techniques such as molecular methods including whole genome sequencing, and polymerase chain reaction. The management of terbinafine-resistant strains is discussed. We have emphasized the need for antifungal stewardship including increasing surveillance for resistant infection.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, Ontario, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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Puntervoll H, Jenum P, Høye S, Tollånes M. Throat infections and use of streptococcal antigen test and antibiotic treatment in general practice; a web-based survey. Scand J Prim Health Care 2022; 40:466-473. [PMID: 36633353 PMCID: PMC9848276 DOI: 10.1080/02813432.2022.2144982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the use of streptococcal antigen tests and antibiotic prescription in general practice in Norway in relation to the national guidelines for sore throat. DESIGN This study was based on a web-based survey. SETTING Norwegian general practice. SUBJECTS 4700 members of the Norwegian College of General Practice received the survey by E-mail. MAIN OUTCOME MEASURES General practitioner (GP) adherence to national guidelines. RESULTS In total, 807 GPs responded and were included in the study. According to the guidelines, 20% and 30% of the GPs would perform unnecessary streptococcal antigen testing when presented with mild and severe infections respectively, while 52% would not perform the test at moderate infection. Phenoxymethylpenicillin was recommended by 95% of the GPs. CONCLUSION In this survey of self-selected GPs, we identified some non-adherence to National guidelines for streptococcal antigen testing and antibiotic prescribing. However, when antibiotic treatment was offered, the correct antibiotics were prescribed.Key pointsNorwegian guidelines for diagnosis and treatment of throat infections include the use of Centor criteria as a clinical tool to limit the unnecessary use of antibiotics. In this web-based survey, we investigated the use of streptococcal antigen tests and antibiotic prescription in general practice in relation to the national guidelines.•Streptococcal antigen tests were not always performed according to Norwegian guidelines, causing inappropriate antibiotic prescribing.•National guidelines were followed in the choice of antibiotics for sore throat.
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Affiliation(s)
- Hanne Puntervoll
- The Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Bergen, Norway
- CONTACT Hanne Puntervoll Noklus, Haraldsplass Diconal Hospital, Bergen, Norway
| | - Pål Jenum
- The Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Bergen, Norway
| | - Sigurd Høye
- The Antibiotic Centre for Primary Care, Oslo, Norway
| | - Mette Tollånes
- The Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Bergen, Norway
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Goff DA, Gauthier TP, Langford BJ, Prusakov P, Ubaka Chukwuemka M, Nwomeh BC, Yunis KA, Saad T, van den Bergh D, Villegas MV, Martinez N, Morris A, Ashiru‐Oredope D, Howard P, Sanchez PJ. Global Resilience and New Strategies Needed for Antimicrobial Stewardship during the COVID‐19 Pandemic and Beyond. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022; 5:707-715. [PMID: 35572210 PMCID: PMC9087764 DOI: 10.1002/jac5.1622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/20/2022]
Abstract
Resilience is having the ability to respond to adversity proactively and resourcefully. The coronavirus disease 2019 (COVID‐19) pandemic's profound impact on antimicrobial stewardship programs (ASP) requires clinicians to call on their own resilience to manage the demands of the pandemic and the disruption of ASP activities. This article provides examples of ASP resilience from pharmacists and physicians from seven countries with different resources and approaches to ASP—The United States, The United Kingdom, Canada, Nigeria, Lebanon, South Africa, and Colombia. The lessons learned pertain to providing ASP clinical services in the context of a global pandemic, developing new ASP paradigms in the face of COVID‐19, leveraging technology to extend the reach of ASP, and conducting international collaborative ASP research remotely. This article serves as an example of how resilience and global collaboration is sustaining our ASPs by sharing new “how to” do antimicrobial stewardship practices during the COVID‐19 pandemic.
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Affiliation(s)
- Debra A. Goff
- The Ohio State University Wexner Medical Center The Ohio State University College of Pharmacy Columbus Ohio
| | | | | | - Pavel Prusakov
- Nationwide Children's Hospital, Department of Pharmacy Columbus Ohio
| | - M Ubaka Chukwuemka
- Department of Clinical Pharmacy and Pharmacy Management University of Nigeria, Nsukka Enugu Nigeria
| | - Benedict C. Nwomeh
- Department of Pediatric Surgery Nationwide Children’s Hospital Columbus Ohio
| | - Khalid A. Yunis
- American University of Beirut, Lebanon, Department of Pediatrics, Division of Neonatology Cape Town South Africa
| | - Therese Saad
- American University of Beirut, Lebanon, Pharmacy Department Cape Town South Africa
| | - Dena van den Bergh
- Division of Infectious Diseases & HIV Medicine Department of Medicine University of Cape Town Cape Town South Africa
| | - Maria Virginia Villegas
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque. Bogotá Colombia
| | | | - Andrew Morris
- Sinai Health System‐University Health Network Toronto Canada
| | - Diane Ashiru‐Oredope
- UK Health Security Agency, London, England; Commonwealth Pharmacists Association; London
| | - Philip Howard
- NHS England and NHS Improvement Quarry House, Quarry Hill Leeds England
| | - Pablo J. Sanchez
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Nationwide Children’s Hospital Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Perinatal Research Columbus Ohio
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Saatchi A, Reid JN, Povitz M, Shariff SZ, Silverman M, Morris AM, Reyes RC, Patrick DM, Marra F. Appropriateness of Outpatient Antibiotic Use in Seniors across Two Canadian Provinces. Antibiotics (Basel) 2021; 10:antibiotics10121484. [PMID: 34943696 PMCID: PMC8698544 DOI: 10.3390/antibiotics10121484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/21/2023] Open
Abstract
Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Jennifer N. Reid
- Institute for Clinical Evaluative Sciences, London, ON N6A 5W9, Canada; (J.N.R.); (S.Z.S.)
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
| | - Marcus Povitz
- Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Salimah Z. Shariff
- Institute for Clinical Evaluative Sciences, London, ON N6A 5W9, Canada; (J.N.R.); (S.Z.S.)
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
| | - Michael Silverman
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
- Faculty of Medicine, Division of Infectious Diseases, University of Western Ontario, London, ON N6A 3K7, Canada
| | - Andrew M. Morris
- Department of Medicine, Sinai Health, University Health Network, University of Toronto, Toronto, ON N6A 3K7, Canada;
| | | | - David M. Patrick
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- Correspondence: ; Tel.: +1-604-822-7898
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. The increasing problem of treatment-resistant fungal infections: a call for antifungal stewardship programs. Int J Dermatol 2021; 60:e474-e479. [PMID: 33729567 DOI: 10.1111/ijd.15495] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Antimicrobial stewardship (AMS) programs have been widely recognized among the public health community. These programs focus majorly on bacterial infections, efficient antibiotic use, and measures to curb increasing antibacterial resistance. AMS programs are successfully established around the globe; however, very few include antifungal stewardship (AFS). The increasing incidence of superficial and invasive fungal infections, combined with delayed or inaccurate diagnosis, has contributed to the overprescribing and overuse of antifungal agents. Such increased exposure to antifungal agents may be a reason for the emergence of increasing antifungal resistance among fungal pathogens. With mounting reports of treatment failures and resistant infections, the evidence to support the need for AFS programs is increasing. AFS is an emerging branch of AMS programs that requires global attention and recognition.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
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Tan C, Graves E, Lu H, Chen A, Li S, Schwartz KL, Daneman N. A decade of outpatient antimicrobial use in older adults in Ontario: a descriptive study. CMAJ Open 2017; 5:E878-E885. [PMID: 29273579 PMCID: PMC5741418 DOI: 10.9778/cmajo.20170100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antimicrobials are frequently prescribed to community-dwelling older adults. Our aim was to examine the prevalence, quantity and indications of antimicrobial prescriptions to older residents of Ontario. METHODS We conducted a population-based analysis of outpatient antimicrobial prescriptions to residents of Ontario aged 65 years or more from 2006 to 2015. Antimicrobial prescriptions, infectious disease diagnoses and prescriber information were determined from linked health care databases. Our analyses were primarily focused on antibiotics, which account for most antimicrobial use. RESULTS We identified 2 879 779 unique Ontario residents aged 65 years or more over our study period. On average, 40.7% (range 40.1%-41.5%) of older adult outpatients in any given year received 1 or more antibiotic prescriptions. Antibiotic use remained stable over the study period, averaging 25.1 (range 24.1-25.6) defined daily doses per 1000 person-days per year. Selection of antibiotics evolved, with increasing use of penicillins and decreasing use of fluoroquinolones and macrolides. For 65.7% of prescriptions, no infectious disease diagnoses were identified within 7 days of the prescription. Among prescriptions with an associated diagnosis, upper respiratory tract infection was most common (18.9%), followed by urinary tract infection (6.2%), skin/soft-tissue infection (4.3%), lower respiratory tract infection (4.2%) and other infection (1.2%). Most antibiotics were prescribed by family physicians. INTERPRETATION Antibiotic use among older adult outpatients in Ontario remained stable between 2006 and 2015. Current methods of measuring use are not capable of accurately determining indication, and, thus, additional data sources to monitor the appropriateness of community antimicrobial use are needed.
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Affiliation(s)
- Charlie Tan
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Erin Graves
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Hong Lu
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Anna Chen
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Shudong Li
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Kevin L Schwartz
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Nick Daneman
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
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Taylor G. The importance of stewardship. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2015; 41:3-4. [PMID: 29769965 PMCID: PMC5868638 DOI: 10.14745/ccdr.v41is4a01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antimicrobial resistance is a growing public health threat that at times may appear to be unsolvable. However, in the last few years, great advances have been made to address this issue in Canada and around the world. Our Federal Action Plan on Antimicrobial Resistance and Use in Canada has identified three pillars to address antimicrobial resistance: surveillance, stewardship and innovation. In this supplement are examples of successful stewardship programs for the community, physicians and health care organizations; there are many more. Given that we know successful stewardship programs are possible, it is important to continue this work across the country. Each success helps and multiple successes can create a synergistic effect that can lead to a change in patient expectations and prescribing patterns. Our antimicrobials are a precious resource. It is well worth the effort to contribute to this synergy and build a culture of stewardship so that antimicrobials will continue to be effective for generations to come.
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Affiliation(s)
- G Taylor
- Chief Public Health Officer, Public Health Agency of Canada, Ottawa, ON
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