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ISSN 0382-232X
Rapport hebdomadaire des
maladies au Canada
Canada Diseases
Weekly Report
Date of publication: 14 September 1991
Date de publication: 14 septembre 1991
Vol. 17·37
Cohtenu du present numero:
Contained In this Issue:
Hepatitis A Outbreak in Grand Forks, British Columbia, 1990
201
Epidemie d'hepatite AaGrand Forks, Colombie-Britannique, 1990
201
EPIDEMIE D'HEPATITE A AGRANP FORKS,
COLOMBIE·BRITANNIQUE, 1990
HEPATITIS A OUTBREAK IN GRAND FORKS,
BRITiSH COLUMBIA, 1990
Introduction
Avant-propos
From March to July 1990, 14 cases of hepatitis A were identified
in the Grand Forks area ofBritish Col\ltnbia, an area with a population
of approximately 7,000. Ten of these 14 cases occurred in the month
of July.
De mars ajuillet 1990; 14cas d'hepatite A ontete signales dans la region
de Grand Forks en Colombie-Britannique, qui compte environ 7 000 habitants.
Dix de ces 14 cas sont survenus en juillet.
For the purpose of this investigation, a confirmed C!ISe was defined.
as someone with symptoms suggestive of hepatitis whose serum was
found to contain anti-HAV-IgM any time in 1990. Clinical cases were
defined as persons known to have experienced in 1990 an episode of
malaise and/or lethargy with jaundice or darkened urine suggestive of
hepatitis and who had known eontact with a confirmed case.
Pour les besoins de preserite enquete, nous avons classe dans Ia categorie
cas confirmes les personnes presentant des synipromes evocateurs de l 'Mpatite
dont le serum contenait des IgM anti-VHA aun moment OU aun autre en
1990. Un cas est considere comme ~ si la personne a c6nnu en 1990 un
episode de malaise OU d' abattement accompagne d'ictere OU d 'urines foncees
evocateur de l'hepatite et qu'elle avaiteu des contacts avec un cas confirme.
As each case became known to the health unit, contact traeing was
undertaken. Data were collected on the water supply, sewage disposal,
and possil;ile fo9d .expo!)UI4'1J of each case. Because of the period of
time over whlch this outbreak occuned, detailed food histories were
not collected. Local physicians were alerted to the outbreak and were
encouraged to report all subsequent cases as soon as possible. The last
case was identified on 31 July, 1990.
Des la declaration de chaque cas au bureau de sante, on a entrepris de
retracer ces contacts et di? s'informer sur les approvisionnements en eau, les
egouts et les sources alimentaires possibles. Mais vu la duree de cette
epidemie, on n'a pas etabli d'anamnese detailiee des aliments consommes. Les
medecins de l 'endroit ont ete. avises de l' epidemie et pries de declarer tous les
cas ulterieurs le plus t8tpossil:ile. Le demier cas a ete signale le 31juillet1990.
The Outbreak
L'epldemle
In the 5-month period beginning in March, 1990, there were 11
serologically confumed and 3 clinical cases of hepatitis A reported.
Two of the clinical cases were children. The epidemic curve is shown
inFigure 1.
Au cours de la periode de 5 mois del:mtant en mars 1990, on declare i 1 cas
confirmes serologiquement et 3 cas cliniques d'h6patite A. Deux des cas
cliniques sont ceux d'enfants. L'histogramme de I' epidemique est illustre ala
figure 1.
The index family included a 31-year-old male who was ill on
return froiµ Mexico where he had been on a 3-month trip with his wife
and5 children. By 28 March, 1990, he W!IS jaundiced and serologic
examination revealed the pre8ence of a4ti~HAV-IgM. At the same
time, 2 of his children experienced lethargy and darkened urine of
several days duration. None of this family had received hepatitis A
inununoprophylaxis prior to travel. On 26 June, 1990, a parent of the
children's friends was diagnosed withl).epatitis A,.Six other adults,
direct contacts of the index case and his children, became ill with
hepatitis A during the month of July.
La premiere farnille touchee (famille d' appel) comprend un homme de
31 ans qlii se relrouvemalade asonretour du Mexique, OU il a sejoume
pendant 3 inois avec sa femme et ses 5 enf1µ1.ts. Le 28 mars 1990, il presente
un ictere; l' examen serologique montre la presence d'IgM anti,VHA. Au
meme moment, 2 de ses enfants presentent un abattement et des urines foncees
durant plusieurs jours. Aucun membre de la famille n' a su.bi
d'inununoprophylaxie contre l'h6patite A avant son depart pour le Mexique.
Le 26 juin 1990, on pose le diagnostic d 'hepatite A chez l'un des parents .des
amis des enfants. Six autres adultes, qui ont ete en contact direct avec la
famille d'appel, presenteront des manifestations cliniques d'Mpatite A durant
le mois de juillet.
The index family is one of 10 households (28 people) living a
somewhat secluded existence on a mountain road northwest of Grand
Forks. The ~ouseholds have separate wells or surface sources of
water. Sewage disposal is by separate septic systems or outhouses.
The houses are widely dispersed over a several kilometre stretch of
road. Occasionally, various members of this group attended potluck
dinners together.
Lafamille d'appel.est l'un des 10 menages (28 personnes) vivantun peu a
l' ecart sur une route de montagne au nord-ouest de Grand Forks. Ces menages
disposent de puits separes ou de sources de surface pour· I' approvisionnement
en eau, de meme que de fosses septiques ou de puisards separees. Les maisons
sont Ires qispersees sur une bande de plusieurs kilometres. Divers membres de
ce gtoupe se sont reunis quelquefois pour manger ala fortune du pot.
I Seccnd aa.
Mal l!e!jtlra!lon No. 15670
Health and Welfare
I.I Canada
la
I
Santa et
Canada
Blen~tre
social
201
Canada
Among this group of 28 persons, there were 5 adult cases of
hepatitis A and 2 clinical cases in children. The attack rate for
symptomatic illness among the 17 adults was 29% and 18% among
the 11 children. This latter figure is conservative since infection is
asymptomatic ~~0% of children under 3 and in 50% of children
age 4 to 6 YC\US • Seroprevalence of anti-HAV-lgM was not
measured in the children, so that a more accurate attack rate cannot
be calculated. The overall clinical attackrate in this group of
residents was 7!28 or 25%.
Dans ce groupe de 28 personnes, on denombre 5 cas d'hepatite A chez
Jes adultes et 2 cas cliniques chez les enfants. Le taux de morbidite de
!'affection symptomatique est 29 % chez les 17 adultes et 18 % chez les
11 enfants. Ce dernier chiffre est en de~a du taux reel presume d'infection,
car on sait que celle-ci est asymptomatia~e chez 80 % des enfants de moins
de 3 ans et chez 50 % de ceux 4 a6 ans ; il a ete imposstble de cemer de
plus pres ce taux de morbidite, faute d' avoir rechercM l 'IgM aJi.ti-VHA
chez les enfants. Le taux global de morbidit:C de I 'infection clinique dans
ces families est de 7!28, soit 25 %.
. Seven adult cases, not residents of the mountain road, were
geographically scattei:ecl through the town. of Grand Forl$s and its
outskirts. Three of these were frequent visitors to severhl families
on the mountain road and had attended potluck dinners ihere.
Consequently, they had the opwrtunity for transmission from this
group through ingestion of contaminated ;food or water. A husband
and wife were also diagnosed with the disease, one on 2 July and
the oiher on th~ 15th. A woman who baby-s!lt for this couple on 3
July developed hepatitis A on the 19th. Considering the incubation
period, it is not clear whether these 3 were exposed simultaneously
or whether the later 2 might })ave contr!lcted hepatitis frpm the first.
There is no apparent epidemiologic link between these 3 cases and
those in the mountain road group. The seventh adultcase in this
group had no apparent contact with any of the other cases and was
unavailable for follow-up.
Sept autres adultes qui ont et:C malades n 'habitent pas le long de la route
de montagne, mais vivent eparpilles dans la ville de Grand Foiles et en
periphene. Trois d' entre eux rendaient frequemment visite aplusieurs des
families habitant le long de la route de montagne et mangeaient avec elles a
la fortune du pot, s'exposant ainsi ala contagion soit parles aliments, soit
par l'eau, Dans le cas d'un couple, on pose le diagnostic d'Mpatite A chez
un conjoint le 2 juillet et chez l'autre le 15. Une femine qui a garde I.es
enf1µ1ts de ce couple le 3 juillet presente des signes d 'Mpatite A le 19.
Compte tenu de la periode d'incubation, on ignore si ces 3 personnes ont
ete exposees simultanement ciu si les 2 dernieres ont contracte l 'hepatite de
la premiere. Il n' existe aucun lien epidemiologiqile apparent entre ces 3 cas
et ceux du groupe vivant le long de la route de montagne. Le septieme
adulte infecte de ce groupe n'a eu apparemment aucun contact avec les
autres cas; elle n' a pu etre suivie.
'Overall, 4 of 12 adult cases required hospitalization because of
their infection. No children were hospitalized, and no deaths
occurred.
Des 12 adultes infect&, 4 ont du etre hospitalises; aucun des 2 enfants
ne l'a ete. On ne signale aucun deces.
,
Sixty-six personal and family contacts of the cases were
identified. Those household contacts identified within 14 days of
the onset of the illness in cases were offered post-exposure
prophylaxis wi~fi11mune globulin (IG) according to BC Ministry
ofHealthpolicy .
0n a retrace 66 ,perspnnes ayant ere en contact pe):sonnel OU familial
avec des malades. A celles qui ont ere retracees dans Jes 14 jours suivant la
survenue de la maladie chez les h¢patitiqu~s, on a offert l' administration
d 'immunoglobuline atitre prophylactique, confo:ruement a la politiqtie du
ministere de la Sante de la Colombie-Britannique .
Figure 1
Epidemic Curve : Hepatitis A Grand Fords, 1990
Hlstogramme de l'epldemle: Hepatlte A, Grand Forks, 1990
8
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Fortnight of Onset of Dlness
P~riodes d'apparition de la m.atadie
(de
-
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~
Confirmed Cases
Cas coofirm&s
202
ClinicalC-
Cas crmiques
Comments
fu the first 3 cases of this outbreak, the hepatitis A virus
probably was acquired in Mexico. Two of these were children.
Three months later, hepatitis A was diagnosed in the parent of one
of their playmates. Knowing that the rate of asymptomatic infection
in children is at le!ISt 50% and that th~ incubation period ranges
from 15-50 days with an average of 28-30 days, it seems
reasonable to assume that the infection was propagated from the
index family by minimally symptomatic or asymptomatic children
who later were the source of infection forother adults. Poor
personal hygiene and close contact among children, as well as lack
ofrunning water for handwashing near some of the outhouses, may
have been factors which contributed to the Spread of disease in this
group.
Commentalres
Les 3 premiers malades ont probablement contracre le virus de
l'h6patite A au Mexique. Deux d'entre eux sont des enfants. Trois mois plus
tard, chez l'un des parents des compagnons de jeu de ces enfants, on pose le
diagnostic d'hepatite A. Etant donne que le taux d'infection
asYt:nptomatique chez Jes eilfants est d'au mains 50 % et que la periode
d'incubation peut <lurer de 15 a50 jours, (moyenne: 28 a30 jol.irs), il
semble raisonnable de penser que I 'infection a ere propagee par la famille
d' appel, peut-etre par des enfants asymptomatiques ou ne presentant que
quelque:S symptOmes, qui auraient par la suite infecte d' au tres adultes. Le
manque d'hygiene, les contacts etroits entre Jes enfants et l' absence d' eau
courante pour se laver Jes mains aproximite des toilettes exteneures ont pu
favoriser la propagation de la maladie clans ce groupe.
for the cases linked to resideQ.ts of the mountain road, several
routes of transmission were possible. Outhouse and septic field
sewage disposal might have led tO viral contamination of the
surface or well sources of drinking water. However, the separation
of dwellings, the depth of wells and the distant location of surface
water intakes, suggests that contamination of the drinking water
supplies was an Unlikely mode of transmission in this outbreak.
Direct person-to-person contact among asymptomatic or minimally
symptomatic children may have contributed to the spread of
disease in this group by the fecal-oral route, although
c..o.ntamination of foods prepared for shared ingestion caruiot be
ruled out.
Pour ce q\ii est des cas associes aux residents de la route de montiigne,
plusieurs voiesjde transmission sont possibles: Les effluents des toilettes
exterieures et d,es fosses septiques auraient-ils contamine I' eau potable des
sources de surface ou· des puits? L'isolement des maisons, la profondeur
des puits et l' elojgnement des prises d' eau de surface rendent peu probable
que le virus ait e_re transmis par contamination des approvisionnements en
eau potable. Les contacts personnels directs entre enfants asymptornatiques
ou ne presentant qu 'un minimum de symptomes auront plutOt permis la
propagation de I' infection par la voie feco-buccale, bien que l 'on ne puisse
eciirter I 'hypo these d 'une contamination des alirrients partages lors des repas
ala fortune du
Four cases remain epidemiologically unlinked to those among
residents of the mountain road. Although it is possible that separate
sources of hepatitis A virus were resporuible for these cases, it is
equally likely that a comnion source was operating, but remains
obscure.
Quatre cas demeurent sans lien epidemiologique avec ceux recenses
parmi les habitants de la route de montagne. S 'il est possible que ces
malades aient ere infecres par d' autres sources du virus de l 'Mpatite. A, il est
egalement plausible qu'une seule source ait ere al'origine de tousles cas
mais n' ait pas ere decouverte.
Of the 66 contacts of the 14 cases, 54 were eligible for and
received post-exposure immunoprophyla)(is with immune globulin.
Contacts were also instructed in the importance of haridwashing,
overall personal hygiene, careful diapering, and Cleanliness of food
preparation in breaking the chain of fecal-oral transmission of the
virus. Because one of the cases was a nurse in a long-term care
facility where the elderly and frail residents were deemed to be at
high risk for complications of hepatitis, IG was offered to· all
residents and to some staff. Thirty-two of these people received IG
and no cases occurred in the facility.
Parmi les 66 persbnnes etant entrees en contact avec les 14 malades, 54
ont regu de l'immunoglobuline atitre prophylactique. On les a toutes
instruites de I'importance de !'hygiene particulierement d 'un bonlavage des
mains, des precautions apreIJ,dre ~ changeant Jes couche~ <!es beb6s et clans
la preparation des repas, afm de briser la chaine de transmission
f&o-buccale du virus. Vu qu 'un des sujets infecres etait une infirmiere
travaillant dans Un etablissement de soins prolonges dont Jes pensionnaires
ages et freles sont consideres comme des sujets ahaut risque a1' egard des
complications d'hepatite, on a administre de l'irnmunoglobuline atous
ceux-ci et acertains employes, soit en tout a32 personnes. Onn'a
denombre aucun cas d'infection dans l'etablisserrtent.
Given that the average incubation period for hepatitis A is from
28 to 30 days and that the peak of the Grand Forks epidemic was in
July, another generation of cases might have been expected in late
August or September. No new cases were reported after 31 July.
Whether or not the education of the "at risk" group about personal
hygiene and the administration of IG to contacts of cases were
effective in curtailing further transmission of this virus is difficult
to determine without knowledge of the size of the susceptible
·
group.
Comme la penode moyenne d'incubation de l'hepatite A est de 28 a
30 jours et que l' epidemie de Gi::and Forks a culmine en juillet, une autre
generation de cas aurait du se declarer ala fin d'aofit OU en septemb~e. Or,
aucun nouveau cas n'a ere signale apres le 31 juillet. Sans donnees sur la
taille du bassin de sujets receptifs, on ne peut affirmer que les conseils
hygiemques donnes aux groupes soumis au risque et l' administration
d'irnmunoglobulin.es aux sujets etant entres en contact avec les malades ont
effectivement freine la transmission du virus.
The public health response to this outbreak included increased
surveillance of hepatitis A in this region, serologic confirmation of
cases where possible, communication with local physicians to
encourage case finding and reporting, contac~ tracing, and
education and irnmunoprophylaxis of eligible contacts. However,
several public health practice issues were highlighted during the
review of this outbreak resulting in the following recommendations
being made:
Au nombre des mesures de sante publique prises pour !utter contre cette
citons !'intensification de la surveillance de l 'hepatite A clans
cette region, la confirmation serologique des cas clans la mesure du possible,
la communication avecles medeeins de l'endroitpour leiir demanderde
reperer et de declarer les cas, la recherche des sujets etant en ires. en contact
avec les malades afin de les instruire et d'offrir !'immunisation passive a
ceux chez qui elle etait indiquee. Phisieurs questions se posent c~endant
sur la martiere dont ces mesures ont ete appliques dlirant cette epidemie,
d'ou ce qui suit:
Prior to travel, IG is recommended for immunoprophylaxis
·against h~atitis A~yr those going to countries where the
disease is endemic . It is possible that this outbreak would
have been avoided had the index family received IG prior to
travel.
·
•
Post-exposure prophylactic JG is recommended in the
provincial hepatitis A policy<2>for household, close
non-household (especially care-giving), sexual, and day-care
1
:Pot. .
1P.!
I'
epidemi~,
•
Onrecommande l'adrninistrationd'immunoglobuline atitre
prophylactique au voy~~eur qui doit se rendre dans un pays ou la
maladie est endemique . La presente epidemie aurait peut-etre ere
pr~venue silafamille d'appel avaitre~u de l'immunoglobuline avant
de partir en voyage.
L'adrninistration d'irnmunoglobuline atitre prophylactique dans les 2
semaines su~yant l' exposition est recommandee dans la politique
provinciale( ' de lutte contre l'hepatite A pour Jes personnes entrant en
203
contacts of cases within 2 weeks of their exposure. In special
situations, contacts of foodhandling cases, or of those living in
camps or institutions, should be offered lG as well. A decision
to offer IG to elderly contacts in an institution where one of
the caBes worked as a nurse. was made l:!!1$ed on the frailty of
the residents, since the petsoii!tl and proressional activities of
the mrrse posed virtufl}ly no threat as a source of itifeetion. In
another circwnstance this decision might be made differently.
contact avec un malade : sa famille, ses proches (en particulier les
soignants), ses partenaires sex:uels, ses camarades de garderie. Dans
certaines situations, tous les sujets ayant eu des contacts avec un malade qui
manipule des aliments OU qui vit clans Un camp OU un etablissement
devraient recevoir egalement de 1'inununogfobuline. La decision qui a ete
prise, au cours de l' epid6mie en question, d 'en dmmer aux: pensionnaires
ages de I' etablissement OU une persohne infectoo travaillait comme
infirmiere a ete motivee par leilr constitution frele, bar les activites
personnel!es et professionnelles de I 'infinniere ne presentaient presqile
·aucun risque de transmission de I'infection. Dans d' autres circonstances, on
aurait pu en decider autre!hent.
Acknowledgem.elits
Remerclements
Shirley -Hunter-Oglow (i>HN/AQministrator), Marcella
Mugford (PHN/Acting Assistant Administrator), Paul Harl (EHO),
·Grace Ripley (PHN),.and Dr. Arnold Lowden (A/MHO) of the
Central Kootenay Health Unit; staff of the serology section of the
Provincial Laboratory and of the Communicable Disease
Epidemiology Services, BC Centre for Disease Control.
Nous remercionil Shirley Hunter-Oglow (infinniere hygieniste/
administratrice), Marcella Mugford (infirmiere hygieniste/administratrice
adjointe interimaire), Paul Harl (agent d'hygiene du milieu), Grace Ripley
(infirmiere hygi6niste) etl~ 11 Arnold Lowden (medecin hygieniste interimaire)
du Central KootenilY Health Unit. ainsi que les employes de la section de
serologie du Laboratoire provincial et des Communicable Disease Epidemiology
Services. BC Centre for Disease Control.
References
1. American Avademy of Pediatrics. Rep_ort of.the Committee on
Infectious Diseases. 20th ed. 1988:215.
2. British Columbia Ministry of Health. Hepatitis A policy. In:
Communicable disease control manual. 1988:2.
3. National Advisory Committee onlnununization. CGnadian
immunization guide. 3rd ed. Ottawa, Ont: Health and Welfare
Canada, 1989: 138 (Supply and Services Canada, Cat. No.
H49-8/1989E).
Source: Lorraine Thompson, Environmental Health Officer,
Beverly McArthur, Public Health Nurse, Teresa
Dalich•Adair, Public Heal(h/:lurse, Grand Forks
sub-office ofthe Central Kootenay Health Unit, Alison
Bell, MD CM, Federal Field Epidemiologist;
Communicable Disease Epidemiology Service, BC
Centre f~r E)isease Control, Vancouver, British
Columbia.
'Tho CanWDisouc• Wooldy Rop<;irt pnioon!J cumnt infoon>tion w infectialll and olhor diaollllC1
for tlll'Willancc puIJ>OOOI and ls i.valliblo fu:<> of chargo upon re quoat. Many-of tho uticl01
COD1aln pIOl!minuy lnfonnatmund l\ulbor crolimntion nay bo obtalmdfrom tho 1oun:c1
quo1od. 'Tho Dopaitrrimt o£Holllh llld Wolfuo.doo1 not iHUID>IOsponiibilily for accuncy ot
authoilticlty. Cootributiclu arc wo!Camod (in tho officUlWigugo of your chol0o) frominycno
woridng in']"' boalth fidd &M will not I<Cclude publication cl10wborc •.
I
Sclcmlifl<>Advis<Ky BOOJ:d:
BdW:r.
A.nirtantilditor: .
~Publlihing
Circo1a tloru
Bore an of Comlmmicablc DiJeuo Bpldemiology
Lab<ntory Omiro for Discuo Colllrd
Tunnoy'• Putnn:i
ClITAWA, OD!ario
Cmada
K1A<L2
Dr.1.Spik&
Dr. K.Rozco
Bleanc.. Paul1on
Nicolo B..udoin
Ioonn> Rllgnior
Gettrudo Tmllff
.(613) 957 4243
(613) 957-1329
(613) 957-1788
(613) 95'7..()841
(613) 957-7845
(613)957-0842
Reference
1. American Academy
of Pediatrics. Report of the Committee on lrifectious
Diseases. 206 ed.; 1988:215•.
2. British Columbia Ministry of ijealth. Hepatitis A policy. Dans:
Commumcable diiease control matiual. ~988:2.
3. Comite consultatif national de I' immunisation, Guide pour l'inununisation
des Canadiens, 3° ed., Ottawa, Ontario: Sante etBien-etre social Canada;
1989 : 138 (Approvisionnements et Services Canada, nume:ro de cat.
H49-8/1989F).
Source : Lorraine Thompson, agent d' hygiene du milieu; Beverly McArthur,
infirmiere hygieniste,· Teresa Dalich-Adair, in[irmier~ hr;teniste,
soils-section de Grand Forks du Central Kootemzy Hea t Unit:
Alison Bell, MD CM, epidemiologiste du gouvernementfederal
rattacM au Commrlnicable Disease Epidemiotoo Service. BC eentte
for Disease Control. Vancouver (Colombie-Britannique).
Lo !Upper! bobdorrudaire der maladies au Cnnada, qul foumit des donn6oa po,.W.,ntes "'1t !01 meladies lnfCctl<:use• ct
101 i)llIC• meladie• dam lo but do facill!Dr lour surveillance, pout Stxc obto nu gratuitoment IJ1ll de mando. Un gr.and
nombm d'uticlo! DO caufu:nnoat quo des dannecJ s<iillIIUlirol mll de• ro"!"'ignom<DIJ compJ6montairo1JlCUl'Oilt6tm
obtenU1ona'a&hessant awt 101UCC1 ci1£<>1.to minlstm do la Sant6 nationalo ct du Blon-etm 100tal no peutStm
rotpomablo do l 'o""ctiturlo, do I'.authontleit6 doi articlc1. Touto pononno ocuVrant d.nJ lo dooi.ino do la 110.11t6 ort
invit6o l. cdlalnor (duis la languo oflieiollo do son ehob<) ctla publlcatlon d'un uticlo dMJJ lopresent Rapport n'on
cmpBcho pu la publicatiw aillcur..
Oroupo do eaJJOllJcn aclcnlifiqwm
D' I.Spika
(613) 95742113
D'K.Rozco
(613) 957-1329
~ie<>onehof!
Eloanq: Pauli on
(613) 957-1788
Nicclc Beaudoin
(613) 957-0841
R6dadrl"' adjointo :
Joaruxo Regnier
&!itlquo:
(613) 957-7845
(613) 957..()842
Dlstributioo:
CJortrudo Tudiff
ru
Buzo au d'6pid6mlolop dol mlladlo1 !nnmliniblol
Labonloirc do lutto con!ro I• mlladlo
·
Pr6Tunnoy
O'ITAWA(Ontario)
Cam.da
K1AOL2
204
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