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Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1228-1237
Knowledge, attitudes, and practices toward onchocerciasis among local population in Bioko Island, Equatorial Guinea

1 Fundacion Jimenez Diaz University Hospital; National Centre for Tropical Medicine, Institute of Health Carlos III, Madrid, Spain
2 National Centre for Tropical Medicine, Institute of Health Carlos III; Network Biomedical Research on Tropical Diseases (RICET in Spanish), Institute of Health Carlos III, Madrid, Spain
3 National Centre for Tropical Medicine, Institute of Health Carlos III, Madrid, Spain
4 Institute of Health Carlos III, National Program for Control of Onchocerciasis and other Filariasis, Ministry of Health, Malabo, Equatorial Guinea
5 Network Biomedical Research on Tropical Diseases (RICET in Spanish), Institute of Health Carlos III; National Centre for Microbiology, Institute of Health Carlos III, Madrid, Spain
6 Department of Epidemiology and Public Health, Rey Juan Carlos University, Madrid, Spain
7 National Centre for Tropical Medicine, Institute of Health Carlos III; National Centre for Microbiology, Institute of Health Carlos III, Madrid, Spain

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Date of Web Publication6-Nov-2017


Introduction: Since 1998, the African program for onchocerciasis control has been working with ultimate goal of reducing the public health impact associated with onchocerciasis in Equatorial Guinea. Although dedicated community engagement is crucial for the success of this program, there is no information on the levels of community's knowledge, attitude, and practice (KAP) toward onchocerciasis in this country. Methods: A cross-sectional study was carried out in Bioko Island from mid-January to mid-February 2014. Sampling was carried out by multistage cluster survey. Sociodemographic characteristics, KAP, and stigma-related questions were collected through a pretested questionnaire. A bivariate analysis was performed and results were adjusted by sex and age using logistic regression. Results: A total of 140 housekeepers or head of households agreed to participate. Around 54% of the interviewees had heard about the disease, of which more than one-third identified the disease as filariasis (28/68, 41.2%). Overall, 19.3% respondents highlighted the bite of a blackfly as the main mode of transmission. From those who had a familiar affected by onchocerciasis in the past, 21 out of 32 (65.6%) pointed ivermectin as the preferred treatment and 43.8% pointed out the health center as the first choice place to seek for treatment. About 67.1% of individuals believed that having onchocerciasis would not cause any contact avoidance with other members in the community. Conclusions: People's practices toward onchocerciasis tend to be better than disease knowledge in Bioko Island. Increasing awareness through community-based campaigns and educational activities is encouraged in the current onchocerciasis preelimination stage at Bioko Island.

Keywords: Attitudes and practices, equatorial guinea, knowledge, onchocerciasis, stigma

How to cite this article:
Alonso LM, Ortiz ZH, Garcia B, Nguema R, Nguema J, Ncogo P, Gárate T, González-Escalada A, Benito A, Azcarraga PA. Knowledge, attitudes, and practices toward onchocerciasis among local population in Bioko Island, Equatorial Guinea. Ann Trop Med Public Health 2017;10:1228-37

How to cite this URL:
Alonso LM, Ortiz ZH, Garcia B, Nguema R, Nguema J, Ncogo P, Gárate T, González-Escalada A, Benito A, Azcarraga PA. Knowledge, attitudes, and practices toward onchocerciasis among local population in Bioko Island, Equatorial Guinea. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Jul 10];10:1228-37. Available from:

   Introduction Top

Onchocerciasis or “river blindness” is a chronic parasitic disease caused by the filarial nematode Onchocerca volvulus. It is transmitted by blood-sucking Simulium blackflies. The greatest morbidity of onchocerciasis is due to cutaneous and ophthalmologic complications.[1] Onchocerciasis may not directly cause death, but it carries great social and economic consequences.[2] It is the fourth most common cause of blindness in the world, and onchocercal skin disease (OSD) is a leading cause of morbidity in endemic areas, both resulting in psychosocial consequences and isolation. Globally, the disease is responsible for the loss of more than one million disability-adjusted life years (DALYs).[3],[4]

Onchocerciasis is endemic in thirty-seven countries, most of which are located in Sub-Saharan Africa, bearing the 99% of the disease burden.[5] Up-to-date, two global strategies to fight against onchocerciasis in Africa have been developed and launched by the World Health Organization and other partners: the Onchocerciasis Control Program (OCP) in 1974 and the African Program for Onchocerciasis Control (APOC) in 1995.[6] Both initiatives have conferred enormous public health benefits: over 90 million people are annually treated, protecting 115 million of people at risk, and preventing over 40,000 cases of blindness every year.[2] As a result of this success, now the focus has shifted to transition from APOC to a bigger attention toward elimination of neglected tropical diseases in Africa.[6]

Onchocerciasis is an endemic disease in both mainland and insular Equatorial Guinea (EG) although the highest prevalence has traditionally been found in Bioko Island.[7] The disease in the island is forest type with predominance of cutaneous disease. The main vector belongs to the subcomplex Simulium squamosum, which is closely related to Simulium yahense.[8] The onchocerciasis control activities in Bioko Island started in 1989[9] and was followed by APOC in 1998. A study developed in 2006 revealed a decrease in prevalence from 74.5% to 38.4% in rural areas and a reduction in community microfilarial load from 28.29 microfilariae/snip to 2.32 microfilariae/snip, after 8 years of vertical ivermectin distribution.[10] According to the most recent data from the Ministry of Health (MoH), in 2013, onchocerciasis prevalence in Bioko Island was estimated in 0%–3% (personal communication).

OCP had been remarkable successful in many African countries including EG, and some of them are moving fast toward elimination.[7] Involvement of individuals and communities is a key component of onchocerciasis control activities, especially in preelimination stages. Nevertheless, it has been described that once effective control program activities are in place, community perception of risk, and hence participation in community-directed treatment with ivermectin (CDTI) activities may diminish.[11] To attain community participation and design socially/locally acceptable control strategies, health program planners and implementers must be familiar with people's local knowledge and attitude toward onchocerciasis,[12] which have a strong influence on compliance.[13]

Although a lot of attention has been paid to the clinical aspects, there is little information on the knowledge and perception of local populations toward onchocerciasis in EG.[14] In the current preelimination context in Bioko Island, assessing factors which may affect adherence to the program has great importance as well as to generate information on the awareness, challenges, and obstacles faced during ivermectin distribution and other control activities. Therefore, we aim to describe people's knowledge, attitudes, and practices (KAP) toward onchocerciasis in Bioko Island after more than 16 years of control activities.

   Methods Top

Study design and sample size

A “cross-sectional study” under the format of KAP survey was carried out within the framework of a wider research project entitled, “strengthening the National Program for Control of Onchocerciasis and other filariasis in EG.” This project aimed at improving and updating the current epidemiological data on these infectious diseases in this country.

Study area

This study was carried out in Bioko Island, EG, from mid-January to mid-February 2014. The island of Bioko is a part of the Republic of EG, which also includes the mainland and the island of Annobon. It is located in the Bay of Guinea in Central Africa, about 40 km southwest of the Cameroon coast. The surface area of Bioko Island is of approximately 2,017 km 2 and is about 72 km in length. Four different districts can be found in the island. According to the 2011 census, the population was 260,000, most of the inhabitants living in the northern part of the island.[14] The interior of the island is covered with dense forests on the steep slopes of volcanoes and calderas. The highest peak reaches 3,011 m above sea level. The island has a humid tropical environment.

Sample size and sampling technique

Sample size was calculated according to previous estimates of onchocerciasis prevalence in the area, based on MF skin snip assessments (0%–3% in 2013 epidemiological evaluation). The sample size was computed using Epi-Info version 3.4.1 free software considering the following parameters: 95% confidence interval (CI), 80% power, and 3% standard error. A multistage sampling technique was carried out. First, twenty subdistricts were randomly selected from the whole Bioko Island to reach the necessary sample size. Secondary, sampling units were randomly selected houses in each of the selected subdistricts. The main housekeepers in every household were identified for the interview. In the absence of the housekeeper, the head of the household answered the questionnaire. Only those who had lived in Bioko Island for at least 5 years before the survey were included in the study. Exclusion criteria included immigrants from other countries and not usual habitation in the household. Each interview was made by house-to-house visit.

Data collection

A structured questionnaire was pretested through intervention on pilot communities which were not included in the study to check cultural acceptability and validity. When needed, the participants were interviewed in their local languages by trained local data collectors (health extension workers). The questionnaire was designed to cover basic sociodemographic information, risk factors for onchocerciasis, and variables to address knowledge, attitudes, and practices (KAP variables). Sociodemographic data included age, sex, occupation, civil status, family size, and educational status of respondents. To address knowledge aspects, questions regarding clinical manifestations, organs affected, cause, and transmission of the disease were considered. Information on help-seeking behaviors, prevention practices and stigmatizing attitudes were also collected. Questions were both closed and open-ended.

After the interview, some open questions were included and recorded into predefined categories by trained personnel.

Statistical analysis

The collected data were double entered into a data entry file using EpiData software, V.3.1. The data were then transferred to SPSS version 18.0 (SPSS Inc., Chicago, Illinois, USA) and analyzed according to the study objectives. Frequencies and percentages were used to summarize data and to explore the differences by sociodemographic variables. These differences were assessed by Student's t-test and Chi-square tests for continuous and categorical variables, respectively. Some KAP variables were redefined and recategorized to proceed with this analysis. Educational level, which was found to be significantly associated to most KAP variables, was used to perform bivariate analysis. Age and sex, considered socially relevant, were included as adjustment variables in the multivariate analysis. Logistic regression models were obtained using a manual backward stepwise procedure. P values <0.05 were considered statistically significant.

Ethics statement

The study was approved by the Ethical Advisory boards of the Health Institute Carlos III in Spain and the MoH in EG (CEI PI 21_2014). The study complied with current national and international regulations and standards for biomedical research in human subjects. The village and neighborhood representatives were informed of the day of the visit and the scope of the study by an official letter from the Equatoguinean MoH. Written informed consent was obtained from all participants before study inclusion. Anonymity was assured. A written statement was also included on the introductory part of the questionnaires in which further information concerning the purpose of the study and the confidentiality of the research information was given. The written consent was obtained from parents or guardians in those individuals younger than 18 years old. Data were analyzed in anonymous form.

   Results Top

A total of 142 households were visited, of which 140 agreed to participate in the study. 92/140 (65.7%) of the respondents were female, with a mean age of 47.5 years old (range: 21–85 years old). The 59.3% of interviewed people were household's head. 93/140 (66.9%) of subjects were married and 40/140 (42.2%) worked in agriculture (33% were employed and 23.9% answered to have their own business). Regarding the educational level, 6 persons (4.3%) were illiterate, 76 (54.3%) had received secondary education, and 15 (10.7%) had a university degree. Most individuals (135/140, the 96.4%) were able to write and read. No significant differences by sex were observed [Table 1].
Table 1: Sociodemographic characteristics of the study population, Bioko Island, Equatorial Guinea, January 2014

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Knowledge on onchocerciasis

Among the respondents, 75/139 (54%) had heard about onchocerciasis and 71/140 (50.7%) were aware of its main clinical manifestations. From those who had heard about the disease, 28/60 (41.2%) identified the disease as “filaria,” 15/68 (22.1%) as an itching disease, and 8/68 (11.8%) as a fly-transmitted disease. Regarding symptoms, 32/70 (45.7%) considered itching as the main clinical manifestation, followed by body scratching (37.1%) and swellings (7.1%) [Table 2].
Table 2: Onchocerciasis knowledge and practices in Bioko Island, Equatorial Guinea, January 2014

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Around 24% (29/121) of the study population knew that the disease affected the skin, and 19/121 (15.7%) appointed eyes and skin as the principal organs affected by onchocerciasis. The 19.3% of the respondents (27/140) answered that the disease was transmitted by insect bite, and 96/140 (68.6%) did not know or did not answer this question. Among those who were aware of the transmission mechanism, 42.9% said that the breeding sites were located close to the rivers.

Onchocerciasis was considered an important health problem by 83.6% (117/140), and 65/140 (46.4%) answered that they knew how to treat the disease. After adjusting by sex and age, we found that men knew better than females how the disease was transmitted (adjusted odds ratio [aOR]: 3.31; CI 95%:1.38–7.94). Moreover, educational level was found to be associated with several knowledge variables, such us knowledge about symptoms and knowledge about which body parts are affected [Table 3].
Table 3: Differences in onchocerciasis knowledge, practices, and attitudes by study level among interviewees in Bioko Island, Equatorial Guinea, January 2014

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Practices related to onchocerciasis

The 22.1% of the interviewees (32/140) had a family member with a history of onchocerciasis. From this group, 65.6% said that the affected family member used a drug (ivermectin) as first treatment option, while the 6.3% (2/32) answered that they went for traditional medicine. The 43.8% (14/32) answered that the sick person preferred to go to a health center to seek the necessary treatment while 12/32 (37.5%) chose to attend the hospital. The main reasons for catching these health facilities were the expectation to find health professionals with better knowledge on the disease (10/28, 35.5%), to receive a better treatment 3/28 (25%), followed by proximity (6/28, 21.4%).

Overall, 38/140 interviewees (27.1%) expressed to have used preventive measures to avoid the disease. Within this group, 30/39 (76.9%) identified the intake of ivermectin as the most common strategy to prevent onchocerciasis and 3/39 (7.7%) appointed avoiding bites as their first-line preventive method [Table 2].

After adjustment by sex and age, those with higher educational level referred more frequently attending to a hospital when a family member was affected by the disease than those with lower education (aOR: 0.07, CI95%: 0.01–0.92) [Table 3].

Attitudes and psychosocial perspective

Attitudes toward the disease were assessed by asking the participants how they would treat the disease in case his/her relatives were affected by onchocerciasis. Overall, 105/140 (75%) of respondents reported that they would use a drug (ivermectin) in that case, and 80/135 (59.3%) would prefer going to a hospital to get an adequate care. The 49.3% (66/134) recognized that the main motivation for attending a hospital would be to find health professionals with better knowledge on the disease. Our results show that 66 out of 139 respondents (47.5%) considered that the disease would affect job attendance of the sick person, while 48/139 (34.5%) think that individuals with the disease should keep on with their normal professional activity. From the psychosocial perspective, the 115/139 (82.7%) of individuals would be worried if a relative was diagnosed of onchocerciasis. The most common feelings in this case would be concern (58/140, 41.4%) and sadness (39/140, 27.9%) [Table 4].
Table 4: Main results of onchocerciasis attitudes in Bioko Island, Equatorial Guinea, January 2014

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No differences in attitudes/beliefs by sex and age were found. Those with higher education level were more likely to refer that if a family member was affected by the disease, he/she would make use of medicines/drugs as treatment (aOR: 6.02, CI95%:2.44–14.81)[Table 3].


Stigma questionnaire section revealed that 25/140 (67.1%) of individuals believed that having onchocerciasis would not cause contact avoidance with other members in the community. Moreover, 94/140 (67%) thought that the disease should not affect the options of marriage in affected individuals.

Bivariate analysis showed that those with higher educational level were more likely to refer that if a relative had the disease, he/she should avoid contact with the community, and this association stayed significant after adjustment (aOR: 6.43, CI95%:1.70–24.31). Furthermore, respondents with higher educational level considered that onchocerciasis would affect marriage prospects in affected relatives more frequently than those with a lower educational level (aOR: 4.84, 95%CI: 1.23–19.12).

   Discussion Top

Our study provides an overview of the knowledge, attitudes and practices (KAP) towards onchocerciasis in Bioko Island after more than 16 years of control activities. Overall, we found there is some knowledge on general aspects related to onchocerciasis was identified among the respondents. Several deficiencies were found on knowledge about the mode of disease transmission. Ivermectin and health services were the preferred options for treatment, as expected in areas with long history of onchocerciasis control activities.[15] Those with higher educational level tended to show better knowledge and perform better practices than those with lower education. Although stigmatizing attitudes were not remarkable in the overall population, those with higher education presented higher levels of stigma.

In the current pre-elimination context in Bioko Island, assessing factors which may affect sustainability of the onchocerciasis control program has great importance. Information on the KAP level towards onchocerciasis in the community will support the regional and national health authorities to design appropriate strategy to improve outcomes, and potentially achieve elimination.

Knowledge on onchocerciasis

In general, our study reveals that there is some knowledge on several aspects related to onchocerciasis in Bioko Island. Less than half the population had heard about the disease and was aware of the main clinical manifestations. Moreover, more than one third identified the disease as “Filaria”. Previous KAP studies in different African countries already pointed out the existence of some knowledge on different aspects related to onchocerciasis in affected communities, especially those related to clinical manifestations, although a huge variability among countries exist.[12],[16],[17],[18]

Regarding clinical knowledge on onchocerciasis, around half the population knew about the disease and identified itching as the most important symptom. Less than one third pointed eye and skin as the main organs affected. These poor results contrast with the high therapeutic coverages in Bioko Island.[10] A study carried out in Nigeria (2004) found that the majority of the study population recognized onchocerciasis manifestations, even though less than half of the respondents (48.2%) knew about this disease. In this study, communities with higher disease prevalence had better knowledge than those with lower prevalence.[17] Nigeria has a longer history of onchocerciasis control activities than EG, which may explain the better knowledge that they found compared to our results.[18] Other potential factors influencing these differences could be the lack of adequate community-based information and educational campaigns on onchocerciasis in Equatorial Guinea, in comparison with this country.[10]

In our study, knowledge on onchocerciasis transmission was quite poor. Among those who identified the flies as the main mode of transmission, less than half pointed rivers as potential breeding sites. Misconceptions regarding onchocerciasis transmission had been previously described in other endemic countries such as Ethiopia [16] and Nigeria.[18],[19] In these studies, sexual intercourse, witchcraft, food and air were also considered as potential modes of transmission. In 2005 aerial larviciding campaign was successful in eliminating S. yahense from Bioko Island, with no evidence of vector reappearance in the following three years.[7] The current absence of the vector may affect the population knowledge on disease transmission. In any case, information on this regard among the population is desirable, It has been suggested that infection by onchocerciasis tend to occur more frequently among respondents who lack of adequate knowledge of the disease.[20] The positive impact of community-based educational interventions on the knowledge towards onchocerciasis and adherence to control activities has been well described in the literature.[21],[22],[23] This becomes especially crucial in those areas in pre-elimination phases.

No remarkable differences by sex and age were found in most knowledge variables, with the exception of knowledge on disease transmission, better in males than in female respondents. On the contrary, educational level was significantly associated to most knowledge questions, suggesting that the level of education may be a proxy variable for better access to adequate health information and education. This observation was also described in Imo State, Nigeria, where only health workers attributed onchocerciasis to the bites of vectors.[17]

Practices related to onchocerciasis

From those respondents with a relative who had onchocerciasis in the past, around two thirds pointed out ivermectin as the first line treatment. Furthermore, most individuals expressed a preference to attend a health centre or hospital to seek the necessary treatment. Traditional medicine was identified as the first option for onchocerciasis treatment only by a 2/32 interviewees. In a survey carried in Ethiopia, the majority of the interviewed people knew that the disease was treated with modern medicine (98.1%), and identified ivermectin as the drug used to treat this disease (88.4%).[12] In contrast, other studies indicate that traditional healers still represent a strong cultural force in some African countries such as Nigeria, with a significant clout to treat different infectious disorders, including onchocerciasis.[17],[18] Nevertheless, the Nigerian study was carried out in rural areas beyond the reach of government health services, which may affect population practices on this regard.

Other factors that might influence onchocerciasis related practices include the trust level on health systems, the drug availability and financial constraints, as suggested by the multi-country survey developed by the Pan-African Study Group on OSD in 1995.[24] In our study, most participants said that the main reasons for choosing public health facilities, among others options, were to find health professionals with better knowledge on the disease and to receive a better treatment. This could be reflecting a higher trust in health services in EG.

With regards to preventive practices, it is striking that almost two thirds of interviewed subjects referred that they did not use any method for preventing the disease.

In a survey carried in Enugu State, Nigeria,[25] only 10.1% of the interviewed recognized the intake of ivermectin to prevent the disease, in spite of being aware of the disease. Bearing in mind the therapeutic coverages with ivermectin given by the Equatoguinean MoH for Bioko Island (around 80%),[26] our results may suggest a lack of a deep understanding of differences between treatment and prevention, and thus the implications of both practices. Preventive care adherence can be also influenced by the fact that onchocerciasis is considered almost an eliminated disease, with the consequent decrease in the risk perception. Previous research in Nigeria suggested that the compliance with ivermectin treatment may not be effective if communities perceive onchocerciasis as a low-priority health problem.[27] In our study most interviewed considered onchocerciasis as an important health problem (83.6%), thus it does not seem to be the reason for such as low drug intake. On the other hand, priority given to other infectious disease with a higher impact on mortality, such us HIV or malaria,[28] might also be influencing our results on this respect. Further research is needed to clarify this issue.

Attitudes and psychosocial perspective

Stigma and its psychological consequences associated to onchocerciasis disease have been well documented in the literature.[24],[29],[30] The Pan-African Study Group on Onchocercal Skin Disease (1995) found that approximately one-third of those affected by OSD reported low self-esteem and difficulties in attaining marriage.[24] Following this study, other authors also described the association between onchocerciasis and social isolation, shame and low self-esteem.[31] We found scant stigmatizing attitudes among our study population, which reinforce the idea of the positive impact of control activities on stigma associated to onchocerciasis. This has been previously described by Tchounkeu YF et al. in Africa, following 10 years of implementation of onchocerciasis control activities. They found that people who had lived in communities where CDTI had been implemented less than 5 years tended to stigmatise OSD patients more than those people who had lived in communities with longer history of onchocerciasis control.[32]

However, some stigmatizing aspects may still exist, especially in those interviewees with higher educational levels. This is contrary to what could has been expected, considering that individuals with higher educational level are also supposed to have better access to health education and, hence, less stigmatizing attitudes. Description of higher levels of stigma associated to specific socio-demographic variables, such us gender or age, have been previously reported,[30],[32] but the association of onchocerciasis stigma and educational level has not been documented in the literature. Further research is needed to better understand these findings.


The present study was conducted in twenty sub-districts in Bioko Island, thus, the findings may not be generalizable to a larger population. The reader is also alerted to limitations inherent to the nature of this study, namely its descriptive nature and the use of only a quantitative methodology (KAP survey) for assessment of beliefs and practices in the population. KAP questionnaires are easy to use and collect data from individuals more reliably. But some related information may be missed because of the format of the questionnaire or the limited options. Moreover, an information bias could be identified in the study as some selected individuals were asked if some family member suffered onchocerciasis in past, without having any diagnosis confirmation. Additionally, the cross-sectional nature of this data does not allow us to examine causality in the described associations between variables. Further qualitative and quantitative research, if possible with larger samples, are encouraged to understand the consequences of the disease in the community, as well as the difficulties in adherence to control programs.

   Conclusions Top

During the last years, huge advances have been achieved on onchocerciasis control in Equatorial Guinea and the country is moving fast towards elimination. Ensuring a high level of adherence to CDTI program through involvement of individuals and communities is essential to achieve this goal in pre-elimination stages.

Overall, our analysis reveals that people's practices towards onchocerciasis tend to be better than disease knowledge in Bioko Island. In spite of this, onchocerciasis prevalence rates have been remarkably decreasing in the last years in Bioko Island and the importance of these factors in the study area still needs to be assessed.[33]

We strongly recommend increasing awareness on onchocerciasis in the population through community-based campaigns. Appropriate communication and health education strategies should increase the awareness regarding the importance of proper prevention techniques, as well as early diagnosis and treatment to bring a constructive outcome in the near future. The health educational messages should also affirm the belief that repeated treatment with ivermectin prevents onchocerciasis.[34]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Laura Moya Alonso
Jimenez Diaz Foundation, Avda Reyes Catolicos 2, 28040, Madrid
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_726_16

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  [Table 1], [Table 2], [Table 3], [Table 4]


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