Automated external defibrillators in West Virginia schools.
Abstract: Introduction: Sudden death, particularly when occurring in children and adolescents, is a traumatic event not only for the victim's family, but for the entire community. It has been shown that school-based automated external defibrillator (AED) programs provide a high survival rate for both students and nonstudents who suffer sudden cardiac arrest (SCA) on school grounds. The use of AEDs is becoming increasingly more common in schools in the United States. In West Virginia middle and high schools, we analyzed the prevalence and use of AEDs, barriers to obtaining a device, and cases of sudden death on school grounds.

Methods: A mailed survey distributed to West Virginia high schools and middle schools collected general demographic data, AED data, and occurrences of sudden death on school grounds. Schools reporting a death were contacted to obtain details regarding the event. For schools with a device, the number of AEDs, length of possession, reasons for and means of obtaining the AED, personnel trained to operate the AED and the number of device uses were determined. For schools without an AED, barriers to and interest in obtaining a device were determined.

Results: Two hundred and twenty-five of 312 surveys (72%) were returned. One hundred and fifty-two schools (68%) currently have at least one AED and 73 schools (32%) do not have an AED. Public high schools had the highest prevalence of AEDs (76%) compared to public middle schools (62%) and private schools (67%). Sixty-nine percent of schools obtained their devices by donations or grants and 32% obtained them using school funds. Barriers to obtaining a device included cost (82%), lack of trained personnel (45%), unfamiliarity with AED (22%), and liability issues (19%). There were a total of 23 deaths on school premises reported by 20 schools. There was one reported occurrence of an AED being used to save a life.

Conclusion: Over two thirds of West Virginia middle schools and high schools currently have at least one AED on their premises. An AED is an effective way of preventing death following sudden cardiac arrest, and has saved at least one life in a West Virginia school. While most schools without AEDs cite cost as the main deterrent, the majority of schools with a device received them via donation or grant. We submit that a number of sudden deaths on West Virginia school grounds could possibly have been averted by use of an AED.
Article Type: Report
Subject: Cardiac arrest (Care and treatment)
Cardiac arrest (Prognosis)
Defibrillators (Usage)
Defibrillators (Health aspects)
Defibrillators (Access control)
Mortality (Prevention)
Mortality (West Virginia)
Authors: Mercer, Christopher W.
Rhodes, Larry A.
Phillips, John R.
Pub Date: 07/01/2012
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: July-August, 2012 Source Volume: 108 Source Issue: 4
Topic: Event Code: 350 Product standards, safety, & recalls
Product: Product Code: 3841541 Defibrillators NAICS Code: 334510 Electromedical and Electrotherapeutic Apparatus Manufacturing SIC Code: 3845 Electromedical equipment
Organization: Organization: American Heart Association
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 310150681
Full Text: Introduction

Sudden death of a child or young adult has a devastating effect on the victim's family, school and community. The most important factor in determining survival following sudden cardiac arrest (SCA) is time from collapse to defibrillation. (1-3) Survival benefit has been demonstrated with the use of school-based automated external defibrillators (AED) for both students and nonstudents suffering SCA. (1) In instances where early defibrillation can mean the difference between life and death, education and training of school based AED programs are of utmost importance.

The use of AEDs is becoming increasingly more common in schools in the United States. To date, there are at least 15 states with legislative mandates requiring or supporting AED placement in schools. (4) West Virginia is not yet one of those states. The American Heart Association and other national organizations have set guidelines for the implementation of school-based AED programs. (3) These mandates, in concert with parental and community efforts, coincide with an increased prevalence and utilization of AEDs in the nation's schools.

With this in mind, we aimed to assess the prevalence of AEDs in West Virginia schools, examine barriers to obtaining them, and analyze occurrences of sudden death that occurred on school premises in West Virginia. We also reviewed current American Heart Association recommendations on AED program implementation in schools.


Study Design

This study is a cross-sectional survey distributed to public and private high schools and middle schools in the state of West Virginia. The surveys were mailed to the principals of these schools, to be completed by them or a designated substitute. A second request survey was sent one month later to the schools that did not initially respond. The decision to use mailed surveys instead of electronic surveys via the Internet was made based on the low response rate to electronic surveys in other similar studies. (5,6) Self addressed and stamped return envelopes were included with the surveys.


West Virginia public high and middle schools, as well as private schools with a minimum enrollment of 50 total students grades 5-12 were included in the study. School enrollment data were obtained through the West Virginia Department of Education website. Three hundred and twelve schools met criteria and were included in the study (119 public high schools, 156 public middle schools, and 37 private schools).


The surveys collected general demographic data regarding the school, such as county location, enrollment and grades represented. The presence of a school-based emergency response program and AED was determined. For schools with an AED, the number of devices, length of possession, personnel trained to operate the AED, means of obtaining, reasons for obtaining, and number of times the AED had been used were collected. For schools without AEDs, barriers to obtaining an AED and interest in obtaining a device were determined. Information on any occurrence of sudden death or AED usage occurring on school premises was requested. Schools that reported a death or AED usage were contacted to obtain details.


General Demographics

Of the 312 schools that were sent surveys, 225 (72%) participated representing 54 of the 55 counties in West Virginia. Public middle schools had the highest response rate at 74% (115 of 156), followed by public high schools with 72% (86 of 119) and private middle/ high schools with 65% (24 of 37). In total, enrollment in schools that completed a survey accounted for 125,105 students, an average of 556 per school. The majority of surveys were completed by principals, followed by school nurses and other staff. Two hundred and six schools (92%) responded that they had an emergency response plan in place. Emergency response plans were more likely to be in place in public schools than private: 81 public high schools (94%), 107 public middle schools (93%) and 18 private schools (75%).

Schools with AEDs

Of the responding schools, 68% (n=152) had at least one AED, while 32% (n=73) of schools had no AED. Of the schools with an AED, 68% (n=104) had one device, 22% (n=33) had 2 devices, and 10% (n=15) had 3 or more. Public high schools were more likely to have an AED (76%) than public middle schools (62%) and private schools (67%). Forty-two percent of schools had a device for 2-5 years, 26% had an AED for 1-2 years, 14% for greater than 5 years, and 13% for less than 1 year. Sixty-nine percent of schools (n=105) obtained their device through donations, including grants and those provided by the county, while 32% (n=48) used school funds. Several schools used a combination of donations and school funds. Fifty of 55 counties in West Virginia reported having an AED in at least one of their schools.

The most common reasons for obtaining an AED were donation (34%), nurse recommendation (30%), faculty recommendation (24%), parental recommendation (5%), doctor recommendation (5%), and previous incident at school (5%). Only 55% of devices were reported to be registered with local EMS. Other schools were unsure if their AED was registered with EMS. School nurses were most likely to be trained in AED usage (n=129, 85%), followed by teachers (n=118, 78%), administrators (n=112, 74%), and coaches (n=96, 63%).

Schools without AEDs

In total, 73 of the 225 (32%) schools returning the survey did not have an AED. Barriers to obtaining an AED included cost (n=60, 82%), lack of trained personnel (n=33, 45%), unfamiliarity with AED (n=16, 22%), liability issues (n=14, 19%), and school board policy (n=1, 1%). Fifty of the 73 schools were interested in obtaining an AED, but did not have plans to do so. Seventeen schools were in the process of obtaining an AED. Four schools were not interested in obtaining an AED.

Death Data

Twenty schools (9%) reported a death on school premises of which the person completing the survey was aware. Twenty-three deaths were reported. The authors have personal knowledge of 2 additional deaths on school grounds that were not reported in the surveys. Of the 25 total deaths, further details were attainable for 22 of the cases (Table 2). One death was from a shooting and one death was due to head trauma. Of the remaining 20 cases, 6 were students and 14 were non-student adults. Deaths were reported as occurring as far back as 30 years ago and as recently as the last year. Victim ages ranged from 12 to 60 years of age. Four of the 6 non-accidental deaths in students occurred during physical activity (gym class or sporting event). Eight adults died following sudden collapse and 2 adults died from electrocution. In light of this information, 14 deaths may have been due to fatal arrhythmias that could possibly have been treated with prompt defibrillation and use of an AED.

Device Usage

Six schools reported having used their AED once and one school used it on two occasions. One school did not want to discuss details. Four AED uses involved placing pads on conscious persons and were placed as precautionary measures. Another use was on a victim who had likely died several hours earlier and no shock was advised. One school reported use of an AED on a school staff member who suddenly collapsed. The AED successfully terminated ventricular fibrillation and the person survived. The authors also have personal knowledge of a 17 year old male student who developed ventricular fibrillation during basketball practice that was successfully converted with a school-based AED (Figure 1).


Over half of all deaths in young athletes are due to SCA, (1,7,8,9) with the leading causes due to hypertrophic cardiomyopathy, long QT syndrome, and other congenital heart defects. (10,11) These deaths are the result of fatal ventricular arrhythmias in which the best chance of survival depends on early CPR and defibrillation. The concept of early defibrillation is based on several principles. (3) First, ventricular fibrillation is the most frequent initial rhythm in witnessed SCA. Second, the most effective treatment of ventricular fibrillation is electrical defibrillation. Lastly, the probability of successful defibrillation diminishes rapidly over time. Survival from cardiac arrest is strongly dependent on early defibrillation, and the likelihood of surviving a sudden cardiac arrest event decreases by 7-10% for every minute of delay in defibrillation from the onset of cardiac arrest. (3,12)


Studies have shown the use of public access defibrillation programs in such places as casinos and airports has greatly improved survival of out of hospital SCA. (13-15) More recently, a large cross-sectional national survey of over 1700 high schools across the country showed improved survival in high school student athletes and nonstudents who suffer SCA. These schools had Emergency Response Planning and AED access and 23 of 36 SCA victims survived to hospital discharge. Survival was equal for both student athletes and older non-students. The annual incidence of SCA in high school athletes was found to be 4.4/100,000 in this study. (1)

The American Heart Association, the American Academy of Pediatrics and other national organizations endorse the recommendations of the public health initiative: The Medical Emergency Response Plan for Schools. (3,16) These guidelines support and encourage the implementation of lay rescuer AED programs in schools with a documented need. Need is defined by one of the following characteristics:

The frequency of cardiac arrest events is such that there is a reasonable probability of AED use within 5 years of rescuer training and AED placement. This probability is calculated on the basis of 1 cardiac arrest known to have occurred at the site within the last 5 years, or the probability can be estimated on the basis of population demographics; or

There are children attending school or adults working at the school who are thought to be at high risk for SCA (eg, children with conditions such as congenital heart disease and a history of abnormal heart rhythms, children with long-QT syndrome, children with cardiomyopathy, adults or children who have had heart transplants, adults with a history of heart disease, etc); or

An EMS call-to-shock interval of < 5 minutes cannot be reliably achieved with conventional EMS services and a collapse-to-shock interval of < 5 minutes can be reliably achieved (in > 90% of cases) by training and equipping lay persons to function as first responders by recognizing cardiac arrest, phoning 9-1-1 (or other appropriate emergency response number), starting CPR, and attaching/operating an AED.

Based on these recommendations, it is reasonable to assume that many schools in West Virginia meet at least one of these criteria, especially given the rural nature of the state. In our state, many schools are in mountainous areas that may be difficult to access by emergency medical services in the recommended time. (17) Even in urban settings, such as New York City, a call-to-shock interval of less than 5 minutes is difficult to achieve. (18)

With the recent push for AED programs in schools, we report a rise in the number of school based AED programs in West Virginia. The incidence of schools with AEDs in the United States was 32% in 2004. (19) Prior studies have shown that the prevalence of AEDs in Iowa and California high schools in 2001 was 25%, (20) 54% in Washington state high schools in 2007, (5) and 72.5% in North Carolina high schools in 2009. (6) This study demonstrated the 2010 prevalence of AEDs in West Virginia public high schools to be 76%.

Of the reported deaths in WV schools, 14 may have been caused by SCA or arrhythmias and may have benefited from early defibrillation. While the main objective of school-based AED programs is to protect young student athletes and students at risk, it has also become apparent that a significant benefit exists for non-students as well. This is evidenced by the successful defibrillation of an adult West Virginian described earlier. Ideally, all West Virginia schools would have access to an AED, but it is equally important for schools to be aware of students and faculty at risk for SCA and for appropriate protocols to be in place to ensure a successful school-based AED program.

While the majority of schools without AEDs cited cost as the main barrier to obtaining a device, our data show that most schools obtained their devices either by donations or grants, and the minority actually used school funds. This was also the case in a study of school-based AEDs in the greater Boston area. (21) This perceived barrier can be overcome, as there are many options for schools to acquire funds to finance an AED program outside of school funds. The National Center for Early Defibrillation gives an in-depth outline on securing donations from local corporations and industries, civic organizations, private foundations, public charities, government grants and traditional fund-raisers (www.early-defib. org). Perhaps most impressive is the ability of parents struck by the tragedy of a child with sudden death to implement change and policy. Parents have spearheaded changes in state legislature and parental and community programs provide material, information, and funds to aid interested groups in obtaining devices for their schools (i.e. Louis J. Acompora Memorial Foundation, KEN Heart Foundation, Project ADAM, Project SAVE). A local West Virginia family started the Matt Valez Save a Life Foundation in memory of their son with congenital heart disease who passed away suddenly in gym class. The foundation has raised funds and placed AEDs in schools throughout West Virginia and Ohio. In fact, one of these devices has already saved the life of an Ohio teenager who collapsed suddenly during basketball practice. A similar foundation in Putnam County (the Maura Rae Kuhl AED Foundation) has facilitated the placement of school-based AEDs in that county.

In our state, training the appropriate people to operate an AED was a significant concern in schools without an AED (45%). The American Academy of Pediatrics and American Heart Association established guidelines for developing emergency response protocols for dealing with medical emergencies in school. (16) These guidelines include training staff and students in first aid, cardiopulmonary resuscitation (CPR) and AED training. For those certified in CPR by the American Heart Association, AED training is included. Along with training, these guidelines also state that school AED programs should be coordinated with local EMS services, the device should be appropriately maintained, there should be medical/healthcare provider oversight and there should be ongoing quality improvement. Therefore, schools complying with these guidelines would have a least several people trained in AED use and a medical emergency-response plan to implement a device. This is particularly important for rural states like ours in that a school nurse may be responsible for several schools yet not always be present on a particular campus.

Our data show there is room for improvement of the present school-based AED programs in West Virginia. Only 55% of schools with AEDs were sure they were registered with local EMS; a requirement in the state of West Virginia. Although most public schools in West Virginia responding to the survey reported having an emergency response plan (94%); only 75% of responding private schools had an emergency plan in place.

Another common perceived barrier to obtaining a device was concerns over liability. All states have "Good Samaritan" laws that protect operators from litigation and, in fact, there is increasing legislature requiring or supporting the presence of AEDs in schools. (4) To date, the investigators found no cases of successful law suits brought against lay users of AEDs. Several suits have been filed when an AED was not present in a public place and resulted in large verdicts or settlements. (22-25) This stresses the importance of a comprehensive and coordinated AED program, not just having the device available. Particularly in states with legislature, the absence of a device may portend more liability than having or using a device.


West Virginia has seen a significant increase in the number of school-based AED programs. While most schools cite funding as a major barrier to obtaining defibrillators, most schools with AEDs obtained them through donations. Death in certain situations can be prevented by timely use of public access defibrillation, and access in schools is becoming the evolving standard. Efforts should be made to ensure this access in all schools, and also to educate likely first responders in CPR and AED use. More education and legislature are needed to ensure that all schools in the state, as well as the country, have readily available access to AEDs in the unfortunate, but not unlikely event of SCA.


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(2.) Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med. 1993; 22: 1652-1658

(3.) The American Heart Association in collaboration with the International Liaison Committee on Resuscitation Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 4: the automated external defibrillator: key link in the chain of survival, Circulation 2000. 102:160-176.

(4.) National Conference of State Legislatures. Updated November 2010. Accessed December 2010.

(5.) Rothmier JD, Drezner J, Harmon JG. Automated external defibrillators in Washington State high schools. Br J Sports Med. 2007;41:301-5.

(6.) Monroe A, Rosenbaum DA, Davis S. Emergency planning for sudden cardiac events in North Carolina high schools. N C Med J. 2009 May-Jun;70(3):198-204.

(7.) Maron BJ. Sudden death in young athletes. N Engl J Med. 2003;349: 1064-1075.

(8.) Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009; 119: 1085-1092

(9.) Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Non traumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995; 27: 641-647.

(10.) Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Eur Heart J 2005;26:516-24.

(11.) Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. J Am Med Assoc 1996;276:199-204.

(12.) Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med. 1993;22:16521658.

(13.) Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med. 2002; 347: 1242-1247.

(14.) Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswamy K, Barbera SJ, Hamdan MH, McKenas DK. Use of automated external defibrillators by a U.S. airline. N Engl J Med. 2000; 343: 12101216.

(15.) Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000; 343: 1206-1209.

(16.) Hazinski MF, Markenson D, Neish S, Gerardi M, Hootman J, Nichol G, Taras H, Hickey R, OConnor R, Potts J, van der Jagt E, Berger S, Schexnayder S, Garson A Jr, Doherty A, Smith S. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004; 109: 278-291.

(17.) Stults KR, Brown DD, Schug VL, et al. Prehospital defibrillation performed by emergency medical technicians in rural communities. N Engl J Med. 1984; 310: 219-223.

(18.) Lombardi G, Gallagher J, Gennis P. Outcome of out-of-hospital cardiac arrest in New York City: the pre-hospital arrest survival evaluation study. JAMA. 1994; 271: 678-683.

(19.) Olympia R, Wan E, Avner J. The Preparedness of Schools to Respond to Emergencies in Children: A National Survey of School Nurses. Pediatrics. 2005; 116: e738-e745.

(20.) Jones E, Vijan S, Fendrick AM, Deshpande S, Cram P. Automated external defibrillator deployment in high schools and senior centers. Prehosp Emerg Care 2005. 9382-385.

(21.) England H, Hoffman C, Hodgman T, Singh S, Homoud M, Weinstock J, Link M, Estes NA. Effectiveness of automated external defibrillators in high schools in greater Boston. Am J Cardiol. 2005; 95:1484-1486.

(22.) Stone v Frontier Airlines, Inc, 256 F Supp 2d 28 (D Mass 2002).

(23.) Somes v United Airlines, Inc, 33 F Supp 2d 78 (D Mass 1999).

(24.) Fruh v Wellbridge Health and Fitness, 02-10689 PBS (US Dist Ct Mass).

(25.) Ingram v Busch Entertainment Corporation dba Busch Gardens Tampa Bay, 95-5183 (Fla 1996).

Christopher W. Mercer, MD

Pediatric Resident, WVUSOM, Morgantown

Larry A. Rhodes, MD

Professor of Pediatrics, Division of Pediatric Cardiology

Department of Pediatrics, WVUSOM, WVU Children's

Hospital, Morgantown

John R. Phillips, MD

Associate Professor of Pediatrics, Division of Pediatric

Cardiology, Department of Pediatrics, WVUSOM, WVU

Children's Hospital, Morgantown
Table 1. WV School-based AED Survey Data

                                              HIGH         MIDDLE
                                             SCHOOLS      SCHOOLS

                                            #     %      #      %

Schools with AEDs                          65    76%     71    62%
Schools without AEDs                       21    24%     44    38%
Schools with emergency response plan       81    94%    107    93%

Schools with AEDs, how many?

One                                        38    58%     54    76%
Two                                        15    23%     15    21%
Three or more                              12    18%      2     3%

Length of time AED in school

< 1 year                                    8    12%     11    15%
1 - 2 years                                15    23%     22    31%
2 - 5 years                                26    40%     28    39%
> 5 years                                  12    18%      7    10%

How was device obtained?

Grants/donation/county provided            47    72%     43    61%
Used school funds                          19    29%     26    37%

Why was device obtained?

Donation                                   25    38%     14    20%
Nurse Recommended                          20    31%     24    34%
Staff/Faculty Recommended                  17    26%     15    21%
Doctor Recommended                          4     6%      2     3%
Parental Recommendation                     3     5%      3     4%
Previous Incident at School or              5     8%      1    1 %
  another school

Is device registered with local EMS?

Yes                                        37    57%     36    51%
No                                          4     6%      6     8%
Unsure                                     18    28%     24    34%

Who is trained to use AED?

Schools that have school nurses trained    58    89%     65    92%
Schools that have teachers trained         49    75%     54    76%
Schools that have administrators trained   45    69%     52    73%
Schools that have coaches trained          44    68%     41    58%

Schools without AEDs, what are barriers?

Cost                                       15    71%     37    84%
Lack of trained personnel                  10    48%     18    41%
Unfamiliar with AED                         5    24%     10    23%
Liability issues                            4    19%      9    20%
School Board Policy                         0     0%      1     2%

                                             SCHOOLS       TOTALS

                                            #     %      #      %

Schools with AEDs                          16    67%    152    68%
Schools without AEDs                        8    33%     73    32%
Schools with emergency response plan       18    75%    206    92%

Schools with AEDs, how many?

One                                        12    75%    104    68%
Two                                         3    19%     33    22%
Three or more                               1     6%     15    10%

Length of time AED in school

< 1 year                                    1     6%     20    13%
1 - 2 years                                 2    12%     39    26%
2 - 5 years                                10    63%     64    42%
> 5 years                                   3    19%     22    14%

How was device obtained?

Grants/donation/county provided            15    94%    105    69%
Used school funds                           3    19%     48    32%

Why was device obtained?

Donation                                   13    81%     52    34%
Nurse Recommended                           2    12%     46    30%
Staff/Faculty Recommended                   4    25%     36    24%
Doctor Recommended                          1     6%      7     5%
Parental Recommendation                     2    12%      8     5%
Previous Incident at School or              1     6%      7    5 %
  another school

Is device registered with local EMS?

Yes                                        10    62%     83    55%
No                                          1     6%     11     7%
Unsure                                      4    25%     46    30%

Who is trained to use AED?

Schools that have school nurses trained     6    37%    129    85%
Schools that have teachers trained         15    94%    118    78%
Schools that have administrators trained   15    94%    112    74%
Schools that have coaches trained          11    69%     96    63%

Schools without AEDs, what are barriers?

Cost                                        8    100%    60    82%
Lack of trained personnel                   5    62%     33    45%
Unfamiliar with AED                         1    12%     16    22%
Liability issues                            1    12%     14    19%
School Board Policy                         0     0%      1     1%

Table 2. Details of deaths occurring in WV schools.

                                Students         Adults
Age                           12 - 18 years   40 - 60 years   Total

Death detail                        7              15          22
  Trauma                            1               1           2
  Sudden collapse                   4               8          12
  Congenital heart disease          2               1           3
  Seizure history                   1               0           1
  Electrocution                     0               2           2
  Unwitnessed                       0               4           4
  Rest                              2
  Active/gym class                  4
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