Childhood Pneumonia: current perspectives on Diagnosis, Management and prevention

MODERATOR: DR ADAEZE C AYUK

SPEAKERS: DR ADEFUNKE BABATOLA

DR. MUHAMMAD SHAKUR ABUBAKAR

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OUTLINE

• BRIEF BIO OF SPEAKERS (DR AYUK)
• PART 1: Introduction; Aetiology; Clinical features; Diagnosis; Management; Common complications; Differential diagnosis (DR BABATOLA)
• PART 2: Risk Factors, Prevention, and Vaccination (DR. MUHAMMAD SHAKUR ABUBAKAR)
• KEY TAKEAWAYS (DR OSAROGIAGBON OW)
• QUESTION/ANSWER SESSION (ALL)

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PART 1�Childhood Pneumonia Diagnosis and Management: current perspectives

Dr Adefunke Babatola

EKSUTH, Ado-Ekiti

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Introduction

• Pneumonia is the inflammation of lung parenchyma caused by pathogenic microorganisms.^1-3

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• It presents with fever, respiratory symptoms, and lung involvement, diagnosed through physical examination or chest X-ray infiltrates.^1,2

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Epidemiology

• Leading cause of infectious child deaths – Remains the single largest infectious cause of death in children worldwide.³

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• High mortality rate – Responsible for about 700,000 deaths among children under five in 2019.³
• Regional burden – Most cases and deaths occur in South Asia and sub-Saharan Africa^,3 where healthcare access is limited.

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Burden

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Improved indices but still commonest in sub-Saharan Africa and Asia

Gradual decline, but still significant – Incidence, severe morbidity, and mortality have decreased but remain a major global concern

Highest global burden – Nigeria records the highest number of pneumonia deaths, with about 143,000 children under five dying annually.

Epidemiology

Modes of Transmission

• Airborne – Spread through inhalation of infectious droplets from coughs or sneezes.

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• Hematogenous Route – Infection spreads through the bloodstream from another infected site.

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Classification

• Source of Infection – Community-acquired pneumonia (CAP) and hospital-acquired (nosocomial) pneumonia.

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• Pathogen specific Aetiology – bacteria, viruses, or fungi.
• Anatomical Distribution – Lobar, bronchopneumonia, and interstitial pneumonia.
• Duration – Acute and chronic pneumonia.
• Severity – Non-severe and severe pneumonia.

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More recent subtypes/classifications

• Healthcare-associated pneumonia (HCAP) – A category distinct from hospital-acquired pneumonia, affecting patients with frequent healthcare exposure.
• Aspiration pneumonia – Recognized as a separate entity, caused by inhalation of foreign material into the lungs.
• Ventilator-associated pneumonia (VAP) – A subset of hospital-acquired pneumonia occurring in patients on mechanical ventilation.
• Immunocompromised host pneumonia – A classification focusing on pneumonia in individuals with weakened immune systems, such as those undergoing chemotherapy or organ transplants.

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Aetiology

• Viral Causes (61.4%): RSV, HMPV, influenza, parainfluenza.⁵
• Bacterial Causes (27.3%): S. pneumoniae, H. influenzae, S. aureus, M. pneumoniae, M. tuberculosis.
• Tuberculosis Contribution (5.9%): M. tuberculosis identified as a cause.
• Mixed bacterial and viral infections are common.
• Severe cases show higher bacterial proportions (S. pneumoniae, H. influenzae, S. aureus).
• Pathogen distribution varies by age: RSV and adenovirus more frequent in younger children.

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Aetiology

• Mollendorf et al. (2022) Findings⁵
• Malnourished and HIV-infected children had higher bacterial or tuberculosis-related pneumonia.
• Regional variations: Higher bacterial pneumonia rates in AFRO countries.
• SEARO/WPRO countries had proportionally more viral cases.

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Aetiologic agents of CAP among Nigerian children - studies in the last 15 years

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Clinical Symptoms of Pneumonia

• Main symptoms: Cough, difficulty breathing, fast breathing, fever.
• Additional symptoms (older children): Chest pain, abdominal pain.
• Newborns & infants: May present with general symptoms instead of respiratory-specific signs.

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WHO (2014) Classification of clinical features

• Non-severe pneumonia: Fever, cough, fast breathing, difficulty breathing, mild chest wall indrawing.
• Severe pneumonia: Features of non-severe pneumonia + at least one of the following:
• Central cyanosis (oxygen saturation ≤90%).
• Severe respiratory distress.
• Inability to breastfeed or drink.
• Lethargy, unconsciousness, or convulsions.
• Presence of complications/co-morbidities (CHF, severe malnutrition, sickle cell disease).

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Clinical Signs

• Non-specific: Fever, respiratory distress, tachypnoea, cyanosis.
• Signs of complications: Tachycardia, tender hepatomegaly.

Chest Examination

• Normal or reduced chest movement.
• Dull percussion note, increased vocal fremitus.

Auscultatory Findings

• Decreased/absent breath sounds.
• Bronchial breath sounds.
• Crepitations, increased vocal resonance.

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Further Diagnostic evaluation

Radiological Investigations

• Plain Chest Radiograph – Most common imaging, identifies lung opacities.
• Lung Ultrasound – Increasing use, with diagnostic accuracy comparable or superior to chest X-rays.
• Findings:
• Healthy lung – Smooth hyperechoic pleural line.
• Pneumonia – Florid B-lines, air bronchograms, liver-like appearance.
• Pleural Effusion – Anechoic/hypoechoic fluid in pleural space.
• Limitations:
• Requires clinician expertise.
• Limited training among Nigerian healthcare providers.
• Portable machines not widely available.
• Chest CT Scan – Highly sensitive but expensive, with high radiation exposure.

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Diagnosis

Lung ultrasound findings related to pneumonia

• Healthy aerated lung - only the pleural can be directly visualized as a smooth hyperechoic line deep to the ribs

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• Pneumonia- Florid B lines, sonographic air bronchograms, characteristic liver-like appearance

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• Pleural effusion- anechoic or hypoechoic fluid in the pleural space

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A study in Ibadan, Nigeria (2023⁾⁹ reported that ultrasonographic signs of pneumonia were detected in 79.1% of children with clinical diagnosis of pneumonia.

Microbiological Investigations

• Culture: Blood, pleural fluid, nasopharyngeal, sputum, lung aspirate.
• Serology: Mycoplasma spp., Chlamydia spp.
• Molecular Techniques: PCR, multilocus sequence typing.
• LAMP Method: Detects S. pneumoniae, Group B Streptococcus, Pertussis.
• Viral Diagnostics
• Nucleic Acid-Based Tests: PCR for viral antigen detection.
• Rapid Antigen Detection Testing (RADT): RSV, influenza virus.

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Supportive Investigations

• Pulse Oximetry – Determines oxygen saturation.
• Acute-phase Reactants: ESR, CRP, PCT.
• Full Blood Count – Assesses leukocytosis or anemia.
• Serum Electrolytes, Urea & Creatinine – Evaluates metabolic state.
• Random Blood Sugar – Essential for diabetic risk assessment.
• HIV Status Determination – Important in immunocompromised children.

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Management

• Indications for Admission
• Age <2 months.
• Severe pneumonia.
• Severe malnutrition.
• HIV-infected or immunocompromised children.

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Supportive Management

• Oxygen Therapy – If saturation ≤90% or severe respiratory distress.
• Nutrition Support – Ensuring adequate intake.
• Fever Control – Using appropriate antipyretics.
• Monitoring – Regular assessment of vitals and symptoms.
• Management of Complications – Treating co-existing conditions

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Specific Treatment – Antibiotics

• Empiric antibiotic choice depends on:
• Age and likely pathogen.
• Antimicrobial resistance patterns.
• Previous treatment.
• HIV, nutrition, and vaccination status.
• Macrolides – Add if pertussis, Mycoplasma or Chlamydia is suspected.
• Corticosteroids – Used in Pneumocystis jiroveci pneumonia.

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Clinical guidelines for CAP by PAN (2022)¹

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…..Clinical guidelines for CAP by PAN

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Criteria for Discharge

• Resolution of fast breathing, respiratory distress, and fever for at least 24 hours.
• Child feeding by mouth and tolerating oral medications.
• Caregiver comfortable with discharge and able to administer oral treatment.
• At Discharge
• Follow-up plan to monitor recovery and prevent complications.

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Complications associated with pneumonia in children:

• Congestive Heart Failure – Due to increased cardiac workload.¹¹
• Anaemia – Can contribute to oxygen delivery issues.
• Pleural Effusion – Accumulation of fluid in the pleural space.
• Hypoxaemia – Reduced oxygen levels in the blood.
• Empyema Thoracis – Purulent infection in the pleural space.

• Sepsis – Systemic infection leading to organ dysfunction.
• Febrile Convulsions – Seizures triggered by high fever.
• Acute Kidney Injury – Kidney damage due to severe infection.
• Pneumothorax/Pneumatocele – Air leakage causing lung collapse or cystic formations.

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Differential diagnoses

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PART 2� Risk Factors, Prevention, and Vaccination

Dr. Muhammad Shakur Abubakar

AKTH

Kano

Child-related�Cardiopulmonary Disorders & Other Conditions�

• Congenital & Acquired Immunodeficiency Disorders – Weak immune defenses.
• Malnutrition – Increased susceptibility due to poor nutrition.
• Congenital Heart Disease – Compromised heart-lung function.
• Asthma – Chronic respiratory inflammation increases pneumonia risk.
• Sickle Cell Disease – Predisposes to infections, including pneumonia.
• Neuromuscular Disorders – Especially conditions with depressed consciousness, leading to poor airway protection.

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Child-related

• Bronchopulmonary Dysplasia – Affects lung development in premature infants.
• Cystic Fibrosis – Leads to thick mucus buildup and recurrent lung infections.
• Pre-existing Illnesses – Conditions like symptomatic HIV infection and measles weaken immunity.
• Gastrointestinal Disorders – Gastroesophageal reflux, tracheoesophageal fistula can contribute to aspiration pneumonia.

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Child-related

• Age – Pneumonia can affect all ages, but extremes (infants and elderly) have higher risk.
• Babies & Young Children (<2 years) – Immature immune system increases vulnerability.
• Premature Infants – Greater risk due to underdeveloped lung function and immunity.
• Infants Not Exclusively Breastfed – Lack of immune protection from breast milk.
• Birth Weight – Low birth weight is associated with increased susceptibility.
• Immunisation Status – Unvaccinated children face higher risk of severe pneumonia. (Jokinen et al. 1993)

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Environmental factors (Pelton et al. 2005)

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Environmental factors

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Seasonality

• Occurs year-round but more prevalent in colder months.
• Indoor crowding during winter enhances droplet transmission.
• In tropical regions, infection peaks follow no common pattern, appearing in wet or dry seasons.

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· Temperature & Humidity

• Cold temperatures can weaken respiratory defenses.
• Low humidity enhances viral stability, increasing transmission. (Moriyama et al. 2020)

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Environmental factors

Air Pollution & Exposure to Smoke

• Outdoor air pollution damages lung defenses.
• Indoor smoke exposure from biomass fuel, cigarette smoke, and poor ventilation increases pneumonia risk.

· Sunlight & Vitamin D Deficiency

• Reduced sunlight exposure lowers vitamin D, which plays a role in immune function.

· Human Behavior Patterns

• Crowded living conditions enhance transmission of respiratory pathogens.
• Poor sanitation increases risk of respiratory infections (Green et al. 1967)

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Socioeconomic

• Poor Healthcare Access – Limited medical resources and delayed treatment.
• Low Maternal Education – Reduced awareness of preventive measures and treatment-seeking behavior.
• Family Size – Larger families may have increased exposure to respiratory infections.
• Resource-Limited Countries – Higher disease burden due to limited healthcare infrastructure.
• Hospitalization Needs – 50 to 80% of children with severe pneumonia require hospital care.
• Case Fatality Rate (<5 years old):
• <1% – In resource-abundant countries.
• 0.3–15% – In resource-limited countries.

(McAllister DA et al. 2019)

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Interplay Between These Factors

• Malnourished children in resource-limited settings may suffer from worsened immunity and exposure to poor environmental conditions.
• Children in overcrowded homes face both increased transmission risks and healthcare access challenges.
• Premature infants with congenital conditions often require specialized care but may have limited access in low-income areas.

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Preventive Strategies

1. General Health Promotion
2. Specific Protection
3. Prompt Diagnosis & Treatment
4. Limitation of Disability
5. Rehabilitation

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Level 1 – General Health Promotion�

· Adequate nutrition – Supports strong immune function.

· Exclusive breastfeeding – Reduces infection risk in infants.

· Good hygiene practices – Handwashing, safe food handling, and clean environments.

• Reducing indoor air pollution – Avoiding smoke exposure from biomass fuels and tobacco.
• Education: Community awareness on respiratory hygiene;
• UNICEF/PAN PNEUMONIA ALGORITHM

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Level 2 – Specific Protection�

• Immunization – Pneumococcal and Haemophilus influenzae type b (Hib) vaccines.
• Influenza and RSV prevention – Seasonal vaccinations where applicable.
• Preventive antibiotic use – For high-risk populations (e.g., HIV-infected children).

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Level 3 – Prompt Diagnosis & Treatment

• Early identification – Recognizing symptoms such as fever, cough, fast breathing.
• Timely medical intervention – Hospital or community-based management.
• Appropriate antibiotic use – Tailored to age, pathogen, resistance patterns.
• Supportive therapy – Oxygen, hydration, fever control, nutrition.

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Level 4 – Limitation of Disability

• Preventing complications – Early treatment of hypoxia, sepsis, empyema.
• Integrated care – Addressing comorbid conditions like malnutrition and heart disease.
• Home-based care – Training caregivers for continued recovery.

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Level 5 – Rehabilitation

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Role of Vaccination in Prevention

• Key vaccines: PCV, Hib, Measles, Influenza, BCG.
• Vaccination significantly reduces pneumonia morbidity and mortality.
• PAN IMMUNIZATION CHAMPIONS!!!

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Pneumococcal Conjugate Vaccine (PCV)

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Current Trends in Pneumonia Vaccination

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Challenges in Implementation

• Vaccine hesitancy.
• Cold chain and logistical issues.
• Funding constraints in low-resource settings.

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KEY TAKEAWAYS

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Thank You

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PART 1 References

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1.Osarogiagbon OW, Ayuk AC, Meremikwu M, Oguonu T, Umar LW, Garba IB, et al. Management of community acquired pneumonia (CAP) in children: Clinical practice guidelines by the Paediatric Association of Nigeria (PAN). Niger J Paediatr. 2022 Oct 26;49(3):210–39

2. .Olowu A, Elusiyan JBE, Esangbedo D, Ekure EN, Esezobor C, Falade AG, et al. Management of Community Acquired Pneumonia (CAP) in Children: Clinical Practice Guidelines by the Paediatrics Association of Nigeria (PAN). Niger J Paediatr. 2015 Sep 17;42(4):283–92.

3. Pneumonia in children [Internet]. [cited 2025 May 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/pneumonia

4. Iliya J, Shatima DR, Tagbo BN, Ayede AI, Fagbohun AO, Rasaq A, et al. Pneumonia hospitalizations and mortality in children 3 – 24-month-old in Nigeria from 2013 to 2020: Impact of pneumococcal conjugate vaccine ten valent (PHiD-CV-10). Hum Vaccines Immunother [Internet]. 2023 Jan 2 [cited 2025 May 5]; Available from: https://www.tandfonline.com/doi/abs/10.1080/21645515.2022.2162289

5. Mollendorf C von, Berger D, Gwee A, Duke T, Graham SM, Russell FM, et al. Aetiology of childhood pneumonia in low- and middle-income countries in the era of vaccination: a systematic review. J Glob Health. 2022 Jul 23;12:10009.

6.Abdulkarim AA, Ibraheem RM, Adegboye AO, Johnson WBR, Adeboye M a. N. Childhood pneumonia at the University of Ilorin Teaching Hospital, Ilorin Nigeria. Niger J Paediatr. 2013 Jul 2;40(3):284–9.

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References

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7. Falade AG, Ayede AI. Epidemiology, aetiology and management of childhood acute community-acquired pneumonia in developing countries--a review. Afr J Med Med Sci. 2011 Dec;40(4):293–308.

8.Bello SO. aetiology and outcome of community acquired pneumonia at a tertiary hospital in Lafia Nigeria. Moroc J Public Heath [Internet]. 2021 [cited 2025 Apr 28];3(2). Available from: https://revues.imist.ma/index.php/MJPH/article/view/27218

9. Akinmoladun J, Atalabi OM, Falade AG, Mortimer K, Ogunniyi A. Point of care lung ultrasonographic findings in patients with clinical diagnosis of severe childhood community acquired pneumonia in the tropics. J Pan Afr Thorac Soc. 2024 Mar 27;5(1):17–25.

10. Zar HJ, Andronikou S, Nicol MP. Advances in the diagnosis of pneumonia in children. BMJ. 2017 Jul 26;358:j2739.

11. Odeyemi AO, Oyedeji AO, Adebami OJ, Odeyemi AO, Agelebe A. Complications of pneumonia and its associated factors in a pediatric population in Osogbo, Nigeria. Niger J Paediatr. 2020;47(4):318-23

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PART 2 References

• Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland. Am J Epidemiol 1993; 137:977.
• Pelton SI, Hammerschlag MR. Overcoming current obstacles in the management of bacterial community-acquired pneumonia in ambulatory children. Clin Pediatr (Phila) 2005; 44:1.
• Moriyama M, Hugentobler WJ, Iwasaki A. Seasonality of Respiratory Viral Infections. Annu Rev Virol 2020; 7:83.
• Green GM, Carolin D. The depressant effect of cigarette smoke on the in vitro antibacterial activity of alveolar macrophages. N Engl J Med 1967; 276:421.
• MacGregor RR. Alcohol and immune defense. JAMA 1986; 256:1474

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References

• McAllister DA, Liu L, Shi T, et al. Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis. Lancet Glob Health 2019; 7:e47
• Global Burden of Disease Child and Adolescent Health Collaboration, Kassebaum N, Kyu HH, et al. Child and Adolescent Health From 1990 to 2015: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study. JAMA Pediatr 2017; 171:573
• Adawe, Mohamed Osman, Alfred Owino Odongo, and John Gachuki Kariuki. 2023. “Risk Factors Associated With Pneumonia Among under 5 Years Children at Banadir Hospital, Mogadishu, Somalia”. Asian Journal of Medicine and Health 21 (8):1-11. https://doi.org/10.9734/ajmah/2023/v21i8832
• Vivi Ninda Sutriana, Mei Neni Sitaresmi, Abdul Wahab. Risk factors for childhood pneumonia: a case-control study in a high prevalence area in Indonesia. Clin Exp Pediatr2021 Mar 15;64(11):588–595. doi: 10.3345/cep.2020.00339

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Key Takeaways

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