1
|
Dhaliwal BK, Weeks R, Huber J, Fofana A, Bobe M, Mbailamen AD, Legge G, Cisse G, Shet A. Introduction of the pneumococcal conjugate vaccine in humanitarian and fragile contexts: Perspectives from stakeholders in four African countries. Hum Vaccin Immunother 2024; 20:2314828. [PMID: 38439691 PMCID: PMC10936592 DOI: 10.1080/21645515.2024.2314828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
Childhood pneumonia causes a significant burden of preventable child morbidity and mortality in Chad, Guinea, Somalia/Somaliland, and South Sudan. Leaders from these countries have committed to reducing this burden and are preparing to introduce the pneumococcal conjugate vaccine (PCV) into their immunization programs. To support long-term sustainability for expected PCV introductions in settings afflicted by prolonged humanitarian crises this research explores national stakeholders' perspectives on contextual factors that may influence optimal vaccine implementation. This qualitative study used purposive sampling to identify and interview stakeholders involved in vaccine decision-making. Interview transcripts were analyzed through the framework method, an approach involving charting data into pre-populated matrices. Findings from interviews with 16 key informants from government, partner organizations, and international health agencies fit within the following four overarching themes: (1) population-level vulnerabilities to pneumonia, exacerbated by climatic risks and low levels of maternal education; (2) disease burden and the interest in enhancing surveillance to monitor vaccine impact and integrate disease control efforts; (3) policy processes, including formalizing vaccine decision-making; and (4) vaccine implementation preparation, including the conduct of robust communication campaigns, training, and cold chain upgrades. This research explores perspectives from leaders in these countries which are at pivotal moments in their journeys toward introducing PCV. Widespread commitment among leaders, in addition to financial support, will facilitate vaccine introduction. Further, fostering a shared understanding among partners about context-specific determinants of program success will help build tailored implementation strategies for each country.
Collapse
Affiliation(s)
- Baldeep K. Dhaliwal
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rose Weeks
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jasmine Huber
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aminata Fofana
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mohamed Bobe
- Somalia/Somaliland Country Office, Save the Children, Mogadishu, Somalia
| | | | - George Legge
- Expanded Programme on Immunisation (EPI), National Ministry of Health, Juba, Republic of South Sudan
- Expanded Programme on Immunisation (EPI), Ministry of Health and Public Hygiene, Conakry, Republic of Guinea
| | - Gassim Cisse
- Expanded Programme on Immunisation (EPI), Ministry of Health and Public Hygiene, Conakry, Republic of Guinea
| | - Anita Shet
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
2
|
Banerjee P, Huber J, Denti V, Sauer M, Weeks R, Dhaliwal BK, Shet A. Closing the pneumococcal conjugate vaccine (PCV) introduction gap: an archetype analysis of last-mile countries. Glob Health Action 2023; 16:2281065. [PMID: 38084434 PMCID: PMC10795629 DOI: 10.1080/16549716.2023.2281065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Pneumonia remains the leading infectious cause of global childhood deaths, despite the availability of pneumococcal conjugate vaccine (PCV) products and widespread evidence of their safety and efficacy. OBJECTIVE To map the landscape of countries that are yet to fully include PCV in their National Immunization Programs, we conducted an archetype analysis of country indicators related to barriers and facilitators for PCV decision-making. METHODS We created a country matrix focused on three key domains - health characteristics, immunisation factors, and policy framework, and identified ten related indicators. We scored countries based on indicator performance and subsequently ranked and grouped them into three archetypes of low-, moderate-, and high-barrier countries with regard to PCV introduction. RESULTS Our results indicated 39 countries (33 low- and middle-income countries [LMICs] and 6 high-income countries) that are yet to introduce PCV. Among LMICs, 15 countries were classified as 'low-barrier,' indicating factors favourable for PCV introduction such as high immunisation coverage of common childhood vaccines, supportive governments, and substantial disease burden and eligibility for Gavi support. Countries classified in the 'moderate-barrier' (12) and 'high-barrier' (6) archetypes demonstrated adequate capacity in immunisation systems but had competing national priorities and cost barriers that impeded policy decision-making on PCV introduction. CONCLUSIONS The current health and policy indicator-based categorisation provides an actionable framework to design tailored PCV advocacy within these last-mile countries. Policy approaches emerging from this framework can lead to strengthened decision-making on vaccine introduction and sustained vaccine access that can enhance child survival worldwide.
Collapse
Affiliation(s)
- Preetika Banerjee
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jasmine Huber
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Molly Sauer
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rose Weeks
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Baldeep K. Dhaliwal
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anita Shet
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
3
|
Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification, and testing of strategies, work to achieve sustainability at scale, and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
Collapse
Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
| | | |
Collapse
|
4
|
Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/09/2023] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification, and testing of strategies, work to achieve sustainability at scale, and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
Collapse
Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
| | | |
Collapse
|
5
|
Baqui AH, Koffi AK, McCollum ED, Roy AD, Chowdhury NH, Rafiqullah I, Ahmed ZB, Mahmud A, Begum N, Ahmed S, Khanam R, Harrison M, Simmons N, Hossen S, Islam M, Quaiyum A, Checkley W, Santosham M, Moulton LH, Saha SK. Impact of national introduction of ten-valent pneumococcal conjugate vaccine on invasive pneumococcal disease in Bangladesh: Case-control and time-trend studies. Vaccine 2021; 39:5794-5801. [PMID: 34465471 DOI: 10.1016/j.vaccine.2021.08.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/14/2021] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bangladesh introduced the ten-valent pneumococcal conjugate vaccine (PCV10) into its national immunization program in March 2015 creating an opportunity to assess the real-world impact of PCV on invasive pneumococcal disease (IPD). METHODS Between January 2014 and June 2018, children aged 3-35 months in three rural sub-districts of Sylhet district of Bangladesh were visited every two months to collect morbidity and care-seeking data. Children attending sub-district hospitals with pneumonia, meningitis, or sepsis were assessed for IPD after obtaining informed consent. Blood and cerebrospinal fluid were collected from enrolled children to isolate pneumococcus using culture and molecular test. Children who were age-eligible to receive the PCV and had pneumococcus isolated were enrolled as cases. Four age and sex-matched clinic and community controls were selected for each case within one to two weeks of case identification. Data on immunization status and confounders were collected. PCV coverage was estimated using vaccine coverage surveys. Case-control and incidence trend analyses were conducted to assess the impact of PCV on IPD. RESULTS The community cohort yielded 217,605 child years of observations and 154,773 sick child-visits to study hospitals. Pneumococcus was isolated from 44 children who were age-eligible to receive PCV; these children were enrolled as cases. The cases were matched with 166 community- and 150 clinic-controls. The matched case-control analyses using community-controls showed 83% effectiveness (95% CI: 1.57-97.1%) and clinic controls showed 90% effectiveness (95% CI: -26.0% to 99.1%) of PCV in preventing IPD. Incidence trend analysis estimated vaccine effectiveness at 80.1% (95% CI: 38.4, 93.6). CONCLUSION PCV in this pediatric population in Bangladesh was highly effective in preventing IPD.
Collapse
Affiliation(s)
- Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | - Alain K Koffi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Global Program in Respiratory Sciences, Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | | | - Iftekhar Rafiqullah
- Department of Microbiology and Immunology, University of Mississippi Medical Center (UMMC), Jackson, MS, United States
| | | | - Arif Mahmud
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | - Nazma Begum
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | | | - Rasheda Khanam
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Meagan Harrison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Nicole Simmons
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Abdul Quaiyum
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - William Checkley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States; Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lawrence H Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | | |
Collapse
|
6
|
Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 11/09/2023] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
Collapse
Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
| | | |
Collapse
|
7
|
Population-based incidence and serotype distribution of invasive pneumococcal disease prior to introduction of conjugate pneumococcal vaccine in Bangladesh. PLoS One 2020; 15:e0228799. [PMID: 32053640 PMCID: PMC7018078 DOI: 10.1371/journal.pone.0228799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/23/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Bangladesh introduced the 10-valent pneumococcal conjugate vaccine (PCV-10) in 2015. We measured population-based incidence of invasive pneumococcal disease (IPD) prior to introduction of PCV-10 to provide a benchmark against which the impact of PCV-10 can be assessed. METHODS We conducted population, facility and laboratory-based surveillance in children 0-59 months of age in three rural sub-districts of Sylhet district of Bangladesh from January 2014 to June 2015. All children received two-monthly home visits with one week recall for morbidity and care seeking. Children attending the three Upazilla Health Complexes (UHC, sub-district hospitals) in the surveillance area were screened for suspected IPD. Blood samples were collected from suspected IPD cases for culture and additionally, cerebrospinal fluid (CSF) was collected from suspected meningitis cases for culture and molecular testing. Pneumococcal isolates were serotyped by Quellung. Serotyping of cases detected by molecular testing was done by sequential multiplex polymerase chain reaction. RESULTS Children under surveillance contributed to 126,657 child years of observations. Sixty-three thousand three hundred eighty-four illness episodes were assessed in the UHCs. Blood specimens were collected from 8,668 suspected IPD cases and CSF from 177 suspected meningitis cases. Streptococcus pneumoniae was isolated from 46 cases; 32 (70%) were vaccine serotype. The population-based incidence of IPD was 36.3/100,000 child years of observations. About 80% of the cases occurred in children below two years of age. DISCUSSION IPD was common in rural Bangladesh suggesting the potential benefit of an effective vaccine. Measurement of the burden of IPD requires multiple surveillance modalities.
Collapse
|
8
|
Kaguthi G, Nduba V, Borgdorff MW, Verver S. Predictors of post neonatal mortality in Western Kenya: a cohort study. Pan Afr Med J 2018; 31:114. [PMID: 31037174 PMCID: PMC6462392 DOI: 10.11604/pamj.2018.31.114.16725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction to determine the predictors of mortality in infants in Siaya, western Kenya, ahead of novel tuberculosis (TB) vaccine trials in the same population. Methods in a study to determine tuberculosis incidence, 2900 infants aged 0-45 days, weighing ≥ 1700g were enrolled. Four monthly follow up visits were conducted for at least 12 months. HIV testing was done at six weeks of age. Free ancillary care was provided. Deaths were reported by parents, study staff and community workers. Cox proportional Hazard analysis was used to identify risk factors. The period of analysis commenced at six weeks old and was censored at 12 months of age. Results included in the analysis were 2528 infants with 2020 person years of follow up (pyo). There were 117 deaths (4.6 %). The post-neonatal mortality rate was 58 (95% CI: 48, 69) per 1000 pyo. In multivariate analysis, health facility births were protective against mortality (Hazard Ratio (HR) 0.54; 95% CI: 0.34, 0.84) and infant HIV infection at baseline was associated with increased mortality (HR 10.3; 95% CI: 6.40, 16.7). HIV uninfected infants born to HIV infected mothers had increased hazards of mortality (HR 1.73; 95% CI: 1.03, 2.90). Gender, weight at six weeks, maternal education and occupation were not significant predictors of mortality. Conclusion infant mortality was high and was associated with being born outside a health facility, maternal HIV infection and HIV infection of the infant. Measures to decrease mother to child transmission and other HIV control measures need to be strengthened further to see incremental reductions in infant mortality.
Collapse
Affiliation(s)
- Grace Kaguthi
- Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Nairobi, Kenya.,Academic Medical Centre, University of Amsterdam, the Netherlands
| | - Videlis Nduba
- Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Nairobi, Kenya.,Academic Medical Centre, University of Amsterdam, the Netherlands
| | | | - Suzanne Verver
- Academic Medical Centre, University of Amsterdam, the Netherlands.,Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands.,Dutch Tuberculosis Foundation, the Hague, the Netherlands
| |
Collapse
|