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Karemere J, Nana IG, Andrada A, Kakesa O, Mukomena Sompwe E, Likwela Losimba J, Emina J, Sadou A, Humes M, Yé Y. Associating the scale-up of insecticide-treated nets and use with the decline in all-cause child mortality in the Democratic Republic of Congo from 2005 to 2014. Malar J 2021; 20:241. [PMID: 34051817 PMCID: PMC8164747 DOI: 10.1186/s12936-021-03771-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To reduce the malaria burden and improve the socioeconomic status of its citizens, the Democratic Republic of Congo scaled up key malaria control interventions, especially insecticide-treated nets (ITNs), between 2005 and 2014. Since then, the effects of these interventions on malaria mortality and morbidity have not been assessed. This study aimed to measure the impact of the National Malaria Control Programme's efforts and to inform future control strategies. METHODS The authors used data from the Demographic and Health Surveys 2007 and 2013-2014 to assess trends in all-cause childhood mortality (ACCM) against trends in coverage of malaria interventions at national and subnational levels. The authors used the plausibility argument to assess the impact of the malaria control interventions and used Kaplan-Meier survival probability and Cox proportional hazard models to examine the effect of ITN ownership on child survival. Contextual factor trends affecting child survival were also considered. RESULTS Countrywide, household ownership of at least one ITN increased, from 9% in 2007 to 70% in 2013-2014. All provinces experienced similar increases, with some greater than the national level. ITN use increased between 2007 and 2013-2014 among children under five (6% to 55%). Severe anaemia (haemoglobin concentration < 8 g/dl) prevalence among children aged 6-59 months significantly decreased, from 11% (95% confidence interval [CI] 9-13%) in 2007 to 6% (95% CI 5-7%) in 2013-2014. During the same period, ACCM declined, from 148 (95% CI 132-163) to 104 (95% CI 97-112) deaths per 1000 live births. The decline in ACCM was greater among children aged 6-23 months (relative reduction of 36%), compared to children aged 24-59 months (relative reduction of 12%). Cox regression indicated that household ownership of at least one ITN reduced the risk of mortality by 24% among children under five (risk ratio = 0.76, 95% CI 0.64-0.90). Contextual factor analysis revealed marginal improvements in socioeconomic indicators and other health interventions. CONCLUSIONS Given the patterns of the coverage of malaria control interventions, patterns in ACCM by province, and marginal improvements in contextual factors, the authors conclude that the malaria control interventions have plausibly contributed to the decrease in ACCM in the Democratic Republic of Congo from 2005 to 2014.
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Affiliation(s)
- Johanna Karemere
- PMI Measure Malaria, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- ICF, Rockville, MD, USA.
| | - Ismael G Nana
- PMI Measure Malaria, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- ICF, Rockville, MD, USA
| | - Andrew Andrada
- PMI Measure Malaria, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- ICF, Rockville, MD, USA
| | - Olivier Kakesa
- PMI Measure Malaria, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- ICF, Rockville, MD, USA
| | - Eric Mukomena Sompwe
- National Malaria Control Programme, Ministry of Health, Kinshasa, Democratic Republic of Congo
- University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Joris Likwela Losimba
- National Malaria Control Programme, Ministry of Health, Kinshasa, Democratic Republic of Congo
- University of Kisangani, Kisangani, Democratic Republic of Congo
| | - Jacques Emina
- University of Kinshasa, Kinshasa, Democratic Republic of Congo
- Population and Health Research Institute, Kinshasa, Democratic Republic of Congo
| | - Aboubacar Sadou
- President's Malaria Initiative/U.S. Agency for International Development, Washington, DC, USA
| | - Michael Humes
- President's Malaria Initiative/U.S. Agency for International Development, Washington, DC, USA
| | - Yazoumé Yé
- PMI Measure Malaria, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- ICF, Rockville, MD, USA
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Ashton RA, Prosnitz D, Andrada A, Herrera S, Yé Y. Evaluating malaria programmes in moderate- and low-transmission settings: practical ways to generate robust evidence. Malar J 2020; 19:75. [PMID: 32070357 PMCID: PMC7027277 DOI: 10.1186/s12936-020-03158-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/09/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many countries have made substantial progress in scaling-up and sustaining malaria intervention coverage, leading to more focalized and heterogeneous transmission in many settings. Evaluation provides valuable information for programmes to understand if interventions have been implemented as planned and with quality, if the programme had the intended impact on malaria burden, and to guide programmatic decision-making. Low-, moderate-, and heterogeneous-transmission settings present unique evaluation challenges because of dynamic and targeted intervention strategies. This paper provides illustration of evaluation approaches and methodologies for these transmission settings, and suggests how to answer evaluation questions specific to the local context. METHODS The Roll Back Malaria Monitoring and Evaluation Reference Group formed a task force in October 2017 to lead development of this framework. The task force includes representatives from National Malaria Programmes, funding agencies, and malaria research and implementing partners. The framework builds on existing guidance for process and outcome evaluations and impact evaluations specifically in high transmission settings. RESULTS The theory of change describes how evaluation questions asked by national malaria programmes in different contexts influence evaluation design. The transmission setting, existing stratification, and data quality and availability are also key considerations. The framework is intended for adaption by countries to their local context, and use for evaluation at sub-national level. Confirmed malaria incidence is recommended as the primary impact indicator due to its sensitivity to detect changes in low-transmission settings. It is expected that process evaluations provide sufficient evidence for programme monitoring and improvement, while impact evaluations are needed following adoption of new mixes of interventions, operational strategies, tools or policies, particularly in contexts of changing malaria epidemiology. Impact evaluations in low-, moderate-, or heterogeneous-transmission settings will likely use plausibility designs, and methods highlighted by the framework include interrupted time series, district-level dose-response analyses, and constructed control methods. Triangulating multiple data sources and analyses is important to strengthen the plausibility argument. CONCLUSIONS This framework provides a structure to assist national malaria programmes and partners to design evaluations in low-, moderate- or heterogeneous-transmission settings. Emphasizing a continuous cycle along the causal pathway linking process evaluation to impact evaluation and then programmatic decision-making, the framework provides practical guidance in evaluation design, analysis, and interpretation to ensure that the evaluation meets national malaria programme priority questions and guides decision-making at national and sub-national levels.
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Affiliation(s)
- Ruth A Ashton
- MEASURE Evaluation, Center for Applied Malaria Research and Evaluation, Tulane School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2300, New Orleans, LA, USA.
| | | | | | - Samantha Herrera
- MEASURE Evaluation, ICF, Rockville, MD, USA.,Save the Children, Washington, DC, USA
| | - Yazoumé Yé
- MEASURE Evaluation, ICF, Rockville, MD, USA
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Effects of insecticide-treated net access and use on infant mortality in Malawi: A pooled analysis of demographic health surveys. Prev Med 2019; 127:105790. [PMID: 31398410 DOI: 10.1016/j.ypmed.2019.105790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 11/21/2022]
Abstract
Malaria continues to be among the top causes of death in children and insecticide-treated nets (ITNs) are considered among the most effective malaria control methods. However, information on the association between universal ITN coverage and infant mortality is limited. A Cox proportional hazard model was applied to Malawi Demographic and Health Surveys to determine the association between ITN access and use and infant mortality between 2004 and 2015-2016. The overall infant mortality rate for the entire period was 47.9/1000 live births. Infants from the ITN-user households exhibited a lower risk of mortality [adjusted Hazard Ratio (aHR) = 0.61, 95% Confidence Interval (CI) = 0.44-0.85] than those from the ITN-nonuser households. Similarly, the infants from the high-access households exhibited a lower risk of death (aHR = 0.63, 95% CI = 0.46-0.86) than those from the no-access households. Infants from the ITN-user and high-access households exhibited a significantly lower risk of death (aHR = 0.57, 95% CI = 0.40-0.82) than those from the ITN-nonuser and no-access households. The relationship between ITN access and use and infant mortality was significant among female infants with a second or higher birth order and interval of ≥2 years. The findings of the present population-based study emphasized the importance of ITN access and use in providing optimal protection against malaria to infants in Malawi. Malaria control programs should ensure high ITN access and use in Malawi to reduce infant mortality.
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Rowe AK. Assessing the Health Impact of Malaria Control Interventions in the MDG/Sustainable Development Goal Era: A New Generation of Impact Evaluations. Am J Trop Med Hyg 2019; 97:6-8. [PMID: 28990917 PMCID: PMC5619937 DOI: 10.4269/ajtmh.17-0509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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The President's Malaria Initiative contributed to reducing malaria burden in sub-Saharan Africa between 2004 and 2014: Evidence from generalized estimating equation analysis. PLoS One 2019; 14:e0217103. [PMID: 31125380 PMCID: PMC6534374 DOI: 10.1371/journal.pone.0217103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/03/2019] [Indexed: 11/27/2022] Open
Abstract
The President’s Malaria Initiative (PMI) launched in 2005 as a key player in malaria prevention and treatment in sub-Saharan Africa (SSA). Several country-specific evaluations have demonstrated great progress in reducing under-five mortality associated with scaling up malaria interventions in PMI priority countries. Documentation of PMI’s specific contributions was limited, until the publication of Jakubowski, et al., which used difference-in-difference analysis to show a higher reduction of under-five mortality in PMI-supported countries than in others. To generate more evidence, this study used rigorous statistical analyses to assess the reduction in mortality attributable to PMI support. The study used generalized estimating equations and a series of matching procedures to evaluate the impact of PMI on under-five mortality and on population coverage of insecticide-treated nets (ITNs), indoor residual spraying (IRS), and artemisinin-based combination therapy (ACT) in SSA. The analyses used country-level secondary data and controlled for several country-level characteristics assumed to influence outcome measures of interest, PMI program participation, or both. The Mahalanobis distance metric, with 1:1 nearest neighbor matching adjusting for bias in population size in the particular country, showed a reduction in under-five mortality by approximately 12 per 1,000 live births (95% Confidence Interval [CI]: 20.6–3.1; p = 0.012). There were statistically significant increases in the population coverage of ITNs, IRS, and ACTs in PMI countries over the implementation period. ITN use in the population was 0.23% higher (95% CI average treatment effect on the treated: 0.17–0.30; p<0.001) in PMI-recipient countries than in non-PMI countries. The findings show that PMI contributed significantly to increasing the coverage of malaria control interventions and reducing under-five mortality in SSA.
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Yé Y, Eisele TP, Eckert E, Korenromp E, Shah JA, Hershey CL, Ivanovich E, Newby H, Carvajal-Velez L, Lynch M, Komatsu R, Cibulskis RE, Moore Z, Bhattarai A. Framework for Evaluating the Health Impact of the Scale-Up of Malaria Control Interventions on All-Cause Child Mortality in Sub-Saharan Africa. Am J Trop Med Hyg 2017; 97:9-19. [PMID: 28990923 PMCID: PMC5619929 DOI: 10.4269/ajtmh.15-0363] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Concerted efforts from national and international partners have scaled up malaria control interventions, including insecticide-treated nets, indoor residual spraying, diagnostics, prompt and effective treatment of malaria cases, and intermittent preventive treatment during pregnancy in sub-Saharan Africa (SSA). This scale-up warrants an assessment of its health impact to guide future efforts and investments; however, measuring malaria-specific mortality and the overall impact of malaria control interventions remains challenging. In 2007, Roll Back Malaria's Monitoring and Evaluation Reference Group proposed a theoretical framework for evaluating the impact of full-coverage malaria control interventions on morbidity and mortality in high-burden SSA countries. Recently, several evaluations have contributed new ideas and lessons to strengthen this plausibility design. This paper harnesses that new evaluation experience to expand the framework, with additional features, such as stratification, to examine subgroups most likely to experience improvement if control programs are working; the use of a national platform framework; and analysis of complete birth histories from national household surveys. The refined framework has shown that, despite persisting data challenges, combining multiple sources of data, considering potential contributions from both fundamental and proximate contextual factors, and conducting subnational analyses allows identification of the plausible contributions of malaria control interventions on malaria morbidity and mortality.
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Affiliation(s)
- Yazoume Yé
- MEASURE Evaluation, ICF, Rockville, Maryland
| | - Thomas P Eisele
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Erin Eckert
- President's Malaria Initiative, Bureau for Global Health, United States Agency for International Development, Washington, District of Columbia
| | - Eline Korenromp
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Avenir Health, Geneva, Switzerland
| | - Jui A Shah
- MEASURE Evaluation, ICF, Rockville, Maryland
| | - Christine L Hershey
- President's Malaria Initiative, Bureau for Global Health, United States Agency for International Development, Washington, District of Columbia
| | | | - Holly Newby
- Independent Consultant based on Stockholm, Sweden
| | - Liliana Carvajal-Velez
- Division of Data, Research, and Policy, Data and Analytics Section, United Nations Children's Fund, New York, New York
| | - Michael Lynch
- President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ryuichi Komatsu
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | | | - Achuyt Bhattarai
- President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hershey CL, Bhattarai A, Florey LS, McElroy PD, Nielsen CF, Yé Y, Eckert E, Franca-Koh AC, Shargie E, Komatsu R, Smithson P, Thwing J, Mihigo J, Herrera S, Taylor C, Shah J, Mouzin E, Yoon SS, Salgado SR. Implementing Impact Evaluations of Malaria Control Interventions: Process, Lessons Learned, and Recommendations. Am J Trop Med Hyg 2017; 97:20-31. [PMID: 28990921 PMCID: PMC5619934 DOI: 10.4269/ajtmh.17-0064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/30/2017] [Indexed: 11/07/2022] Open
Abstract
As funding for malaria control increased considerably over the past 10 years resulting in the expanded coverage of malaria control interventions, so did the need to measure the impact of these investments on malaria morbidity and mortality. Members of the Roll Back Malaria (RBM) Partnership undertook impact evaluations of malaria control programs at a time when there was little guidance in terms of the process for conducting an impact evaluation of a national-level malaria control program. The President's Malaria Initiative (PMI), as a member of the RBM Partnership, has provided financial and technical support for impact evaluations in 13 countries to date. On the basis of these experiences, PMI and its partners have developed a streamlined process for conducting the evaluations with a set of lessons learned and recommendations. Chief among these are: to ensure country ownership and involvement in the evaluations; to engage stakeholders throughout the process; to coordinate evaluations among interested partners to avoid duplication of efforts; to tailor the evaluation to the particular country context; to develop a standard methodology for the evaluations and a streamlined process for completion within a reasonable time; and to develop tailored dissemination products on the evaluation for a broad range of stakeholders. These key lessons learned and resulting recommendations will guide future impact evaluations of malaria control programs and other health programs.
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Affiliation(s)
- Christine L. Hershey
- President’s Malaria Initiative, U.S. Agency for International Development, Washington, District of Columbia
| | - Achuyt Bhattarai
- Malaria Branch and President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lia S. Florey
- The DHS Program, ICF International, Rockville, Maryland
| | - Peter D. McElroy
- Malaria Branch and President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carrie F. Nielsen
- Malaria Branch and President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yazoume Yé
- MEASURE Evaluation, ICF International, Rockville, Maryland
| | - Erin Eckert
- President’s Malaria Initiative, U.S. Agency for International Development, Washington, District of Columbia
| | | | - Estifanos Shargie
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Ryuichi Komatsu
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Julie Thwing
- Malaria Branch and President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jules Mihigo
- President’s Malaria Initiative, Centers for Disease Control and Prevention, Bamako, Mali
| | | | | | - Jui Shah
- MEASURE Evaluation, ICF International, Rockville, Maryland
| | - Eric Mouzin
- Roll Back Malaria Partnership, Geneva, Switzerland
| | - Steven S. Yoon
- Malaria Branch and President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S. René Salgado
- President’s Malaria Initiative, U.S. Agency for International Development, Washington, District of Columbia
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Hershey CL, Florey LS, Ali D, Bennett A, Luhanga M, Mathanga DP, Salgado SR, Nielsen CF, Troell P, Jenda G, Yé Y, Bhattarai A. Malaria Control Interventions Contributed to Declines in Malaria Parasitemia, Severe Anemia, and All-Cause Mortality in Children Less Than 5 Years of Age in Malawi, 2000-2010. Am J Trop Med Hyg 2017; 97:76-88. [PMID: 28990920 PMCID: PMC5619935 DOI: 10.4269/ajtmh.17-0203] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/30/2017] [Indexed: 12/01/2022] Open
Abstract
Malaria control intervention coverage increased nationwide in Malawi during 2000-2010. Trends in intervention coverage were assessed against trends in malaria parasite prevalence, severe anemia (hemoglobin < 8 g/dL), and all-cause mortality in children under 5 years of age (ACCM) using nationally representative household surveys. Associations between insecticide-treated net (ITN) ownership, malaria morbidity, and ACCM were also assessed. Household ITN ownership increased from 27.4% (95% confidence interval [CI] = 25.9-29.0) in 2004 to 56.8% (95% CI = 55.6-58.1) in 2010. Similarly intermittent preventive treatment during pregnancy coverage increased from 28.2% (95% CI = 26.7-29.8) in 2000 to 55.0% (95% CI = 53.4-56.6) in 2010. Malaria parasite prevalence decreased significantly from 60.5% (95% CI = 53.0-68.0) in 2001 to 20.4% (95% CI = 15.7-25.1) in 2009 in children aged 6-35 months. Severe anemia prevalence decreased from 20.4% (95% CI: 17.3-24.0) in 2004 to 13.1% (95% CI = 11.0-15.4) in 2010 in children aged 6-23 months. ACCM decreased 41%, from 188.6 deaths per 1,000 live births (95% CI = 179.1-198.0) during 1996-2000, to 112.1 deaths per 1,000 live births (95% CI = 105.8-118.5) during 2006-2010. When controlling for other covariates in random effects logistic regression models, household ITN ownership was protective against malaria parasitemia in children (odds ratio [OR] = 0.81, 95% CI = 0.72-0.92) and severe anemia (OR = 0.82, 95% CI = 0.72-0.94). After considering the magnitude of changes in malaria intervention coverage and nonmalaria factors, and given the contribution of malaria to all-cause mortality in malaria-endemic countries, the substantial increase in malaria control interventions likely improved child survival in Malawi during 2000-2010.
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Affiliation(s)
- Christine L. Hershey
- President’s Malaria Initiative, Agency for International Development, Washington, District of Columbia
| | - Lia S. Florey
- The DHS Program, ICF International, Rockville, Maryland
| | - Doreen Ali
- National Malaria Control Program, Lilongwe, Malawi
| | - Adam Bennett
- Global Health Group, University of California San Francisco School of Medicine, San Francisco, California
| | | | | | - S. René Salgado
- President’s Malaria Initiative, Agency for International Development, Washington, District of Columbia
| | - Carrie F. Nielsen
- President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Peter Troell
- President’s Malaria Initiative, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Gomezgani Jenda
- President’s Malaria Initiative, Agency for International Development, Lilongwe, Malawi
| | - Yazoume Yé
- MEASURE Evaluation, ICF International, Rockville, Maryland
| | - Achuyt Bhattarai
- President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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