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Canada Diseases
Weekly Report
Rapport hebdomadaire des
maladies au Canada,.
Data of Publicatioo: July 22, 1989
Data de pubifoation: 22juillel 1989
ISSN 0382-232X
?- ..
v·
Vol.15-29
Contained In this Issue:
Contenu du present numero:
Update on Measles in Quebec . . . . • • • • . . • • • • • . • . • • • . . 147
Measles In Ontario -Overview of 1989 Cases . • . • . • • • • . . . . • . 148
La rougeola au Quebec: mise ajour .•....••••.•••••.•.••••••• 147
Announcement . . . . . • . . • • . • . • • . • . . . . . . . • . • . • . • 150
Annonce . • . . • . • • . . . . . . . . • . . . . . . . . • • . • • • • • • • • • • • • . 150
UPDATE ON MEASLES IN QUEBEC
LA ROUGEOLE AU QUEBEC: MISE AJOUR
La rougeole en Ontario - synthase des cas de 1989 • • • • . • • . . . • • • . • • • • 148
Quebec is .experiencing the most important measles epidemic
to occur in that province in over 10 years. From the beginning of
the year to 13 July 1989, approximately 9 800cases of measles
have been notified. In contrast, only 1 284 and 3 672 cases were
reported in the 2 epidemic years 1984and1980, respectively.
This epidemic is already responsible for 4 deaths (3 from
pneumonia and 1 from myocarditis), and is also associated with
the death of a fifth case. Moreover, 4 cases of encephalitis and 1
case of meningitis have also been observed..
Le Quebec conna1t sa plus grave epidemic de rougeole depuis au moins
10 ans. Du debut de 1989 au 13 juillet, environ 9 800 cas ont en effet ere
signales comparativement aux 1 284 et aux 3 672 cas recenses
respectivement au cours des 2 annees d'epidemie 1984et1980. Deja
responsable de 4 deces (3 par pneumonie et 1 par myocardite), l'epidemie
en cours est aussi liee un cinquieme. On a en outre observe 4 cas
d'encephalite et 1 cas de meningite rubeoleuse.
a
The epidemic began on the west island of Montreal in late
December 1988 and gradually spread throughout the province
over the next 6 months. The municipalities bordering the greater
metropolitan region of Montreal have been the areas most
affected. A trend towards decreasing incidence has been observed
in most regions of the province since mid-June.
La poussee epidemique a debute dans l'ouestde l'ile de Montreal
ala
fin de decembre 1988, et s'est graduellement propagee a toute la province
au cours des 6 mois suivants. Les vitles voisines du Grand Montreal ont
ete les plus touchees. Depuis la mi-juin, l'incidence a tendance a diminuer
dans la plupart des regions de la province.
A preliminary analysis carried out on epidemiologic data
available on 2 709 cases residing outside metropolitan Montreal
and 1182 cases from Montreal indicated that the age distribution
of cases is similar in the 2 areas (fable 1).
D' apres l' analyse preliminaire des donnees epidemiologiques
concernant 2 709 cas de l'exterieur du Grand Montreal et 1182 cas de
Montreal, la repartition par groupe d'age est analogue dans des 2 regions
(Tableau 1).
Table 1/Tableau 1
Distribution of Measles Cases In Quebec by Age Group
La rougeole au Quebec: repartition des cas par groupe d'age
Age Group,/
Grouped
age
%
<1 year/an
1-4 years/ans
5-9 {.ears/ans
10- 4 years/ans
16-19 years/ans
20-30 years/ans
> 30 years/ans
Total
MontreaU
Montreal
Number/nombre
Outside Montreal/
Hors de Montreal
%
Number/nombre
5.2
17.2
15.5
38.9
13.8
7.8
1.7
61
213
123
460
163
92
20
3.2
10.9
14.5
50.9
17.1
3.1
0.5
86
295
392
1378
462
83
13
100.0
1182
100.0
2709
These results indicate that the age group primarily affected by
this epidemic has been those 10 to 19 years of age. About 33% to
50% of these cases had no prior history of measles immunization.
It, therefore, appears that the presence of a substantial pool of
non-immune subjects, especially among those 10 to 19, has been
an important factor in this epidemic.
II ressort de ces resultats que l 'epidemic a principalement frappe les 1O
a 19 ans. Environ 33 a 50 % des cas n'avaient pas d'antecedents
d'immunisation contre la rougeole. Dans cette epidemie, il semble done
que la presence d 'un bassin considerable de sujets receptifs, surtout chez
les 10 a 19 ans, ait ete un facteur de risque important.
Source: PM Lavigne, MD, Provincial Epidemiologist,
Ministere de la Sante et Services sociaux, Quebec; RS
Remis, MD, Director, Bureau regional des maladies
infectieuses, Montreal, Quebec.
Source: Dr PM Lavigne, epidemiologiste provincial, mi11istere de la
Sante et des Services sociaux, Quebec; D 7 RS Remis, directeur,
bureau regional des maladies i11fectieuses, Mo11treal (Quebec).
I
Seoood Class Mai Re!ishalion No. 5670
l+I
Health and Welfare
Canada
I
Sante et Bien-etre social
Canada
:-
)
I Coorrierde
147
la doo~lmeclasse-Enregisaemoot n' 5670
Canada
),
•
MEASLES IN ONTARIO· OVERVIEW OF 1989 CASES
LA ROUGEOLE EN ONTARIO· SYNTHESE DES CAS DE 1989
AB of 21 June 1989, 390 cases of measles had been reported in Ontario
Au 21juin1989, I' Ontario avait recense 390 cas de rougeole,
compared to only 292 for all of 1988. This recent trend most likely
comparativernent a un bilan total de 292 seulement pour 1988. Il est fort
represents part of the normal cyclical pattern of measles incidence;
probable que cette tendance recente so it l 'expression d 'une partie du cycle
normal de l'incidence de la rougeole; ~l n'en reste pas moins qu'elle a fait
nonetheless, certain questions have been raised with regard to the efficacy
douter de l'efficacite de la vaccination antirougeoleuse en Ontario. Acet
of measles immunization in Ontario. A related question concerns the
relative efficacy of vaccine as administered before versus after 1980. In an
egard, on s'interroge sur l'efficacite relative du vaccin adrninistre avant
effort to address some of the issues related to measles immunization in
1980 par rapport acelle du vaccin adrninistre apres. Pour trouver des
solutions a certains des problemes lies a la vaccination antirougeoleuse, on
Ontario, a case-control study is being undertaken, which should be
a amorce une etude retrospective qui devrait se terrniner cette annee. Le
completed later this year. The following report presents a brief overview
of the results of a preliminary analysis of the data received on measles
rapport qui suit fait la synthese de l' analyse preliminaire des donnees
communiquees jusqu 'ici sur des cas de rougeole.
cases to date.
ll ressort des statistiques sommaires que les nombres des cas masculins
Summary statistics revealed approximately equal numbers of male and
et ferninins sont apeu pres egaux. La majorite (84,4 %) a fait I' obj et d 'un
female cases. The majority (84.4%) were diagnosed on clinical grounds
alone, with 13.8% confirmed by serology, and 1.8% by an unspecified
diagnostic purement clinique, la confirmation ayant ere pratiquee par
serologie dans 13,8% des cas et par
diagnostic method. W eeldy
Flgure I Meellea In Onlarlo, 1009, By Week of OneeU
une methode diagnostique non
totals of cases increased steadily
Larougeo!een Onlarlo, 1900, ""Ion 11 eemalne d'lnalallation
precisee dans 1,8%. Les nombres
during the first 18 weeks of
1989 (Figure 1). Since that time,
hebdomadaires des cas ont augmente
weekly numbers appear to be
regulierementpendant les 18
to
50
premieres semaines de 1989 (Figure
decreasing, although this may in
Ql
to to
1); depuis, ils semblent etre a la
part be an artifact caused by the
~ 40
baisse, mais ce phenomene est
delay in reporting cases from
some areas. Outbreak curves
peut-etre attribuable en partie au
retard de la declaration des cas dans
plotted for individual health
certains secteurs. Les courbes
units have varied, some
graphiques des flambees par service
displaying the characteristic
pattern of a single source
de sante ont affiche des ecarts,
certaines etant caracreristiques d'ooe
outbreak, while others are
flambee a source unique, d'autres
suggestive of propagated
outbreaks.
evoquantdes flambees etendues.
tl
June
April
May
Of the 390 cases, 85.6% are
Il est etabli que 85,6% des 390 cas
Pab,
March
Jan.
Ju in
llai
Avril
Ph,
llaro
emegistres sont vaccines contre la
known to have received measles
rougeole, mais on ne sait trop quelle
immunization but it is unclear
Week Ending/Semaine se terminant le
what proportion received MMR,
est la proportion qui a r6\:u le ROR, le
MR, or monovalent measles
RO, ou le vaccin monovalent
vaccine due to uncertainties in recording this information. An additional
antirougeoleux, des incertitudes s 'etant glissees dans les donnees
consignees ace sujet. Parrni les autres cas, il est en outre etabli que 8,2%
8.2% of cases are known to have never received measles immunization,
n'ontjamais ete vaccines contre larougeole, l'etat vaccinal etantinconnu
while 6.2% have unknown immunization status. The relatively large
number of unknowns represents a cause for some concern, since one of the
chez 6,2%. Le nombre relativement eleve des "inconnus" est quelque peu
inquietant, puisque l 'un des facteurs vises par l' etude retrospective est
factors to be examined in the case-control study is vaccine efficacy.
l' efficacite du vaccin. Le nombre assez important des cas vaccines pour
Another potential source of uncertainty arises from the fairly large number
of vaccinated cases (45 out of the 334 cases known to have been
lesquels la date de vaccination n' a pas ere signalee (45 des 334 cas que
vaccinated), for whom date of vaccination has not been reported. This
I' on sait avoir ete vaccines) pourrait aussi creer des incertitudes. Cette date
serait en effet utile pour bien comparer l 'efficacite relative du vaccin
information would be useful in properly comparing the relative efficacy of
vaccine as administered before versus after 1980, at which time certain
administre avant 1980 par rapport a celle du vaccin adrninstre apres,
modifications were made in the formulation of measles vaccine.
c'est-a-dire ooe fois modifiee la formulation du vaccin antirougeoleux.
Of the 334 cases known to have been immunized for measles, 8.0%
were vaccinated prior to the twelfth month of age. It is likely that some of
these represent coding errors or inaccuracies in reporting the date of ·
immunization. In many cases only the month and year were noted for the
"date of vaccination". These cases were, therefore, coded as having been
immunized on the fifteenth day of the month, which undoubtedly has
resulted in some inaccuracy in calculating age at vaccination. Those
immunized at age 12 months comprised the largest single percentage
(32.2%); an additional 31.5% were immunized during the thirteenth,
fourteenth, or fifteenth month of age. Thus, a cumulative total of 71.6%
had been immunized prior to the age of 16 months, the remainder forming
an extended distribution over several years of age.
Surles 334 cas ~ue l' on sait avoir ete vaccines contre la rougeole, 8,0%
l'ont ete avant le 12 mois de vie. Certains d'entre eux sontprobablement
le fait d'erreurs de codage ou d'inexactitudes dans la date de vaccination
precisee. Souvent, seuls le mois et l' annee ont en effet ere consignes a
"date de vaccination", et ces cas ont ete codes comme ayant ere immunises
le 15e jour de mois, ce qui a sans doute donne lieu a des inexactitudes dans
le calcul de l'age au moment de la vaccination. Les sujets vaccines a 12
mois representaient le pourcentage le plus important (32,2%), ceux qui
I' ont ete au cours de 13e, du 14e ou du 15e mois comptant quanta eux pour
31,5%. Au total, 71,6% des cas ont done ete vaccines avant l'age de 16
mois, le reste etant reparti entre plusieurs ages.
The age distribution of cases (Figure 2) indicates a tendency towards
bimodality with the first peak occurring at age 11.5 years and the second at
13.5-14 years. It is ooclear if this does, in fact, represent 2 distinct case
populations, and if this is so, what the epiderniologic factors are that may
be contributing to this effect.
La repartition des cas par age (Figure 2) revele une tendance a la
bimodalite, un premier pie pouvant etre observe a 11,5 ans et un deuxierne
entre 13,5 et 14 ans. En fait, on ne sait trop s 'il faut y voir 2 populations de
cas distinctes, et, si oui, quels sont les facteurs epiderniologiques pouvant
contribuer cet etat de choses.
a
148
If those cases under 1 year of
age (who are of course unlikely
to have been immunized), are
eliminated, there are no
significant differences in age,
sex, or week of disease onset
between those immunized for
measles and those not so
immunized. Similarly, no
relationship was found between
week of onset and age, the age
groups tending to be relatively
constantly distributed
throughout the course of the
outbreak.
Figure 2
AQa DlalllbuUon of Meallet caeoa' In Onllllo, 1981l/
R6partition par 6ge detcaa' de rougeolerecen&6aen Onlarlo, 1009
40
to
3&
Si l' on elimine les cas de
moins de 1 an (eviderrunent peu
susceptibles d'etre immunises),
on n'observe aucun ecart
important au niveau de l'iige, du
sexe et de la semaine
d 'installation de Ia maladie entre
les sujets vaccines contre la
rougeole et Ies autres. De meme,
aucun lien n' a ete etabli entre la
semaine d'installation et I'iige, Ia
repartition des groupes d'iige
tendant etre relativement
constante tout au long de la
flamooe.
•includ•• c•••• uochr JO J••r• of •9•
coapreod lu cu d• aoira d• 30 Ul•
Ql
to to
«l «l
uo
30
2&
'H Ql
O'tl
M Ill
Ill M
~~z
lZi
20
11
10
a
•
4
I
I 10 12 M 18 18 20 U 24 20 aD 30
L' etude initiale du lien
Another interesting point
possible entre l' efficacite du
arose during the initial
Age (years) / Age (annees)
vaccin et !'introduction, aux
consideration of the possible
environs de 1980, d'unnouveau
link between vaccine efficacy
stabilisant vaccinal par le fabricant a
and the introduction, around 1980,
fait ressortir un autre point important, savoir: un ecart statistiquement
by the manufacturer of a new vaccine stabilizer. There exists a statistically
significatif entre les sujets vaccines avant 1980 et ceux qui l'ont ete cette
significant difference between those vaccinated prior to 1980, and those
annee-fa OU apres, Ces derniers ayant tendance avoir ete vaccines plus
vaccinated in 1980 and later, in that cases from the latter group tend to
have been immunized at a later age •tJian those from the former group
tard que ceux du premier groupe (Figure 3). Cette situation reflete
peut-etre !'introduction en 1983 de Ia Loi sur l'immunisation des eleves
(Figure 3 ). This may reflect the introduction of the Immunization of
qui precise que le vaccin antirougeoleux doit etre administre apres le 1er
School Pupils Act in 1983 which requires that measles immunization be
anniversaire. On peut peut-etre aussi expliquer Ia chose par une tendance
administered after the first birthday. A second possible contributing cause
may be a tendency on the
de certains practiciens
Figure3 Distribution of Moollet Cal09' By ~e of VacclnaUon, Onlarlo, 198Q/
canadiens appliquer la
part of some Canadian
A6palUUon de9 CO' de rougeole par Age de vac:dnaUon, Onlarlo, 1009
recorrunandation de I'Advisory
practitioners to follow the
Committee on Immunization
recommendation made by
Practices des Etats-Unis
the U.S. Advisory
voulant que l' age de
Committee on Immunization
• C••••
vncclnated befor• 24 •onthe
vaccination contre la rougeole
Practices that measles
Cal Yl!ICC!n9a avant l• aoi•
soit 15 mois plutot que 12. Si
vaccination be carried out at
jamais cet ensemble de
15 months of age rather than
donnees mettait en evidence
at 12 months. In the event
that a significant difference
un ecart significatif au niveau
de l'efficacire relative entre le
in the relative efficacy of
vaccin administre avant 1980
vaccine administered before
et le vaccin adminstre apres,
versus after 1980 were to be
on pourrait soutenir que le lien
observed within this dataset,
ao a1 u n
11 11
such a relationship might
en question est attribuable un
Age at Vaccination (months) / Age a la vaccination (mois)
biais cree par les repartitions
then arguably be attributed
differentes de I' age au moment
to bias arising from the
de I' immunisation entre ces 2
different distributions of age
at immunization between
groupes. L'etuderetrospective
these 2 groups. This
proposee pourra permettre
Year vaccinated
1979 aod !afore
and after
hypothetical relationship
d 'examiner plus fond ce lien
CJ 1980
1979 ou &Tant
1980 ou apr6i1
Annee de vaccination
between age at
hypothetique entre l'iige au
moment de I 'immunisation et
immunization and year of
administration of vaccine
l' annee d' administration de
can be further tested with the
vaccin.
proposed case-control study.
a
a
a
•
a
a
The Immunization of School Pupils Act has placed Ontario in an
advantageous position, both with regard to limiting overall incidence rates
of vaccine-preventable illness and having a sophisticated registry of
immunization data on schoolchildren readily available when needed for
epidemiologic analysis. The proposed study will be greatly facilitated by
the availability of such a database.
La Loi sur I 'immunisation des elev es a place I' Ontario dans une bonne
position, lui permettant de limiter l'incidence globale d'atteintes evitables
par un vaccin et de se doter d'un registre complexe grace auquel des
donnees sur I' immunisation des ecoliers sont, le cas echeant, faciles
obtenir pour une analyse epidemiologique. Une telle base de donnees
facilitera beauoup l 'etude proposee.
Acknowledgement
Remerciements
The assistance and cooperation of Medical Officers of Health and staff
of Health Units in reporting cases are greatly appreciated.
Nous tenons remercier de leur aide et de leur collaboration Ies
medecins-hygierustes et le personnel des services de sante qui ont sigrtale
les cas.
a
a
149
Source: David Assaf/, MD, VivekGoel, MD, George Pasut, MD,
Community Medicine Residents, University a/Toronto, Toronto,
Ontario (initially published in ODSR, VoIJO, No 14, 1989).
Source~
Comment
Commentalre
A review of measles and measles vaccination policy in Canada for both
routine and outbreak situations will be made by the National Advisory
Committee on Immunization as soon as data from the current outbreaks in
Quebec and Ontario have been analyzed. Until this review and analysis
have been completed, the Committee recommends that no change in
routine measles immunization in Canada 1Je made at this time. The current
recommendation is a single dose of MMR for all children on, or as soon as
practicable after, their first birthday.
Des que les donnees sur les flambees actuellement emegistrees au
Quebec et en Ontario auront ete analysees, le Cornite consultatif national
de I 'immunisation se penchera sur la rougeole et la politique de
vaccination centre cette maladie au Canada - tant pour les situations
courantes que pour les flambees. D'ici la, le Comite recommande de ne
rien changer aux pratiques de vaccination antirougeoleuse en vigeur au
Canada, c 'est-a-dire: administration d 'une dose unique de vaccin ROR a
tous les enfants, le jour de leur premier anniversaire ou des que possible
apres.
Source: National Advisory Committee on Immunization.
Source: Comite consultatifnational de I' immunisation.
Announcement
Annonce
Drs David Assaf/, Vivek Goel, George Pasut, residents en
medecine sociale, Universite de Toronto, Toronto, Ontario (deja
publie dans: ODSR, vol JO, n°14,1989).
LIGNES DIRECTRICES CANADIENNES A. L'INTENTION
DES DISPENSATEURS DE SOINS DE SANTE POUR
L'EXAMEN DES ENFANTS SOUP<;ONNES D'AVOIR ETE
VICTIMES D'ABUS SEXUELS • 1989
1989 CANADIAN GUIDELINES FOR HEALTH
CARE PROVIDERS FOR THE EXAMINATION OF
CHILDREN SUSPECTED TO HAVE BEEN
SEXUALLY ABUSED
These guidelines, recently published by the Laboratory Centre for
Disease Control, are the third in a series devoted to controlling the spread
of sexually transmitted disease (STD) in Canada. The previous 2
documents presented guidelines for the diagnosis, management and
treatment of STD in children, adolescents and adults.
Cette recente publication du Laboratoire de lutte contre la maladie est le
troisieme document d'une serie consacree au controle de la propagation
des maladies atransmission sexuelle (MTS) au Canada. Les 2 premiers
presentaient des lignes directrices pour le diagnostic, la prise en charge et
le traitement des MTS chez les enfants, les adolescents et les adultes.
Although the current guidelines are directed at primary health care
providers, they would also be beneficial to social workers and law
enforcement groups. These guidelines should be used in conjunction with
examination and forensic protocols. Following these guidelines should
make the examination more humane, more appropriate to the situation,
and more therapeutic.
Meme si elles s'adressent aux agents de soins primaires, les nouvelles
lignes directrices pourraient aussi aider les travailleurs sociaux et les
services de police. Elles devraient etre utilisees conjointement avec les
protocoles d' examen et de recherches medico-legales. Elles devraient
rendre l 'examen medical plus humain et rnieux adapte la situation, ainsi
qu •en rehausser l' aspect therapeutique.
The impetus for this series of guidelines arose from a recommendation
of the Expert Interdisciplinary Advisory Committee on Sexually
Transmitted Disease in Children and Youths (EIAC-STD). Funding for the
project was provided by the Department of National Health and Welfare's
Child Sexual Abuse Initiative.
L'elaboration de cette serie de lignes directrices fait suite une
recommandation du Cornite consultatif interdisciplinaire d'experts en
maladies transmises sexuellement chez les enfants et les jeunes
(CCIE-MTS). Le projet a ete finance par !'initiative relative aux infractions
sexuelles l'egard des enfants du ministere de la Sanre nationale et de
Bien-etre social.
a
a
a
a
Pour obtenir des exemplaires de ces documents, s' adresser per ecrit la
Copies of these documents may be obtained by writing to the
Division de la lutte centre les MTS (8·7)
Bureau de l'epldemlologle des rnaledles transmlsslblee
Leboretolre de lutte contre la maladle
Direction generate de le protection de le eente
Ottawa (Ontario) K1A OL2
Division of STD Control (B·7)
Bureau of Communicable Dl&01111e Epidemiology
Laboratory Centre for Disease Control
Health Protection Branch
Ottawa, Ontario K1 AOl2
l.c 1Upp<rt bcbdamadairo de. maladic1 au Canada, qui foumit doa donn6ea pertin<mtca aur lt1
maladio1 lnfcctio"""" cl!"" autie> maladies dam lo but do f.acililx>r lour llllVOill1I1CO, pout 8tn>
obtcnU: gratuitcment 11U demando. Un grand nombre d'a.rtlclot no cootlctmeutquo do1 d«lJl6el
10II1Illl.ixe1 mail des tmlSCigncrmnt!I c.ompl6montairc1 peuvcmt. enn obbmUJ en •'a.dmaant amt
Tho Cluwla Diloucl Woolcly Roportpm1entscumml infmmalion an inf'llctioo. and olhor W.C....
Cm IUMlillmoo purpo""' and u availllhlo m,., ot cbarF upon tcqUOlt. Many of tho artklu
conllin pt<llmln.uy infonnation 1Dd further coofirmalloo may bo obtained from tho IOW'OOIJ
quoted. Tho Depu1mcntofN•ticrul Health and Wcllim docl not UIUJDll n:lp<E'lbllity Cm
a.:curu;y or authtnticity. Conlrlbutiam are wclc<IDO (in tho official lan,g111&0 of you.r choice) from
myono working in tho health r.. ld and will not pec!wlo publialioncl10whont.
Sclenttnc Advisor:
Editor:
Dr.S.B.A=s
Eleanor Paul.Jon
DollyRlggim
Clrculattoo:
Debcnh Chapman
D"klop Publishing:
BUn:tau ofCcmnnmicablo Discsso Bpidomiology
Labaatnry c..n1n> for Disoll!O Control
Tunooy'1Puturo
<YITAWA, Ontario
Canad& KlA OL2
(613)
(613)
(613)
(613)
lourccJ ci!Coa. l.c ministtrc dcl&Sant6natlonaloctdu Bicn.atn> 1ocia!Dll pcut8tn>iupomablc de
1'oxactitu.do, n1 do 1'authcnticit6 d,,1 ertlcles. Touto pcnCIUK) ocuvrant dam le da:n.Jdix, do la 1ant6
est invill!o l collnboror (dam lalanguo officicllo do 1ao cboix) ct la publication d'IDl article dam lo
pr611CD1 Rapport n'cncm¢chc pu la publicatkn aillcurs.
Corueillersclenllllque:
D' S.B. A=•
(613) 957-0325
Eleanor Paubcm
(613) 957-1788
RMaclrlce en chef:
DlstrlhuUon:
Dolly Riggins
(613) 957-0841
(613) 957-7845
Edltlqom
Deborah Chapman
BUR>and'6pid6miologic dos maladies lreruml!sibles
Laboratoiro dclut!D contrc l• malndio
PnlTunnoy
Ott..wa (On!Brlo)
Caruuh KIA OL2
957-0325
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