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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 292-297

Effects of the face mask on the skin during the COVID-19 pandemic in Saudi Arabia


1 Department of Dermatology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia
2 Medical Students, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia

Date of Submission29-Mar-2022
Date of Acceptance29-Jul-2022
Date of Web Publication15-Sep-2022

Correspondence Address:
Dr. Salim Ali Algaadi
Department of Dermatology, College of Medicine, Majmaah University, Al-Majmaah 11952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_64_22

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  Abstract 


Introduction: The use of face mask in these COVID-19 times has increased manifolds. This has led to various skin problems due to the adverse reaction caused by the mask. This study aimed to observe the skin effects of the face mask during the COVID-19 pandemic among individuals in Saudi Arabia. Materials and Methods: Cross-sectional study in different regions of Saudi Arabia with data collection was done using a self-administered online questionnaire in the adults above 18 years of age of both sexes. Results: The study involved 516 participants who were mostly young population with male predominance. In general, 37% of face skin reactions related to mask use, whereas 63% of participants did not notice any skin reaction from face mask wearing. Most of them wear surgical masks (85.5%), of which 36.7% of them reported adverse skin reactions (ASRs) related to surgical masks. Furthermore, using the mask for >4 h is approximately double the risk of skin changes, and a significant association has been found between the duration of mask use and ASRs. Finally, no significant association was observed between prolonged face mask use and aggravation of pre-existing skin diseases by face masks. Conclusion: The overall prevalence of skin reactions associated with face masks was 37%. The most frequent skin reaction was acne and itching symptoms, followed by acne alone. Regarding mask type, both surgical and cloth masks were associated with a significantly high incidence of ASRs, which was statistically significant.

Keywords: COVID-19, effects, face mask, pandemic, skin


How to cite this article:
Algaadi SA, A Almulhim YA, Y Alobaysi YM, Alosaimi AM, S Alshehri MS. Effects of the face mask on the skin during the COVID-19 pandemic in Saudi Arabia. Adv Hum Biol 2022;12:292-7

How to cite this URL:
Algaadi SA, A Almulhim YA, Y Alobaysi YM, Alosaimi AM, S Alshehri MS. Effects of the face mask on the skin during the COVID-19 pandemic in Saudi Arabia. Adv Hum Biol [serial online] 2022 [cited 2022 Oct 7];12:292-7. Available from: https://www.aihbonline.com/text.asp?2022/12/3/292/356116




  Introduction Top


The COVID-19 epidemic has wreaked havoc on worldwide populations, putting economic and medical strains on governments all over the globe. According to the World Health Organization (WHO), the causal agent is a new coronavirus.[1] The sickness spreads quickly from person to person; according to the WHO, it took the virus 12 weeks to reach the first 100,000 cases and just 12 days to reach the second 100,000 cases globally.[2] Social distance, hand cleanliness and the use of face masks were among the techniques used to minimise the spread of the unusual virus. Face masks and personal protection equipment (PPE), such as Goggles, face shields and N95 respirators, have been found to induce dermatological illnesses or worsen pre-existing dermatoses in the general public, despite their usefulness in limiting transmission.[3]

Mask usage is no longer limited to health-care employees; in several countries, notably Saudi Arabia, all citizens are required to wear a face mask whenever they leave their homes as part of preventative efforts. Mask usage has been linked to negative skin responses, particularly when used for > 4 h/day.[3] When compared to individuals who use a mask for a shorter period, those who wear a mask for 4–8 h or more have a higher chance of experiencing unfavourable skin responses.[4] Those who replace their masks regularly have a reduced risk than those who do not change their masks for a long time.[5]

In the general population, the prevalence of adverse skin responses associated with mask wear during COVID-19 is about 62.3%.[3] Several adverse skin responses have been documented as a result of long-term usage of face masks and PPE, including hyperhydration, epidermal barrier collapse and contact reactions. In a various research, facial acne has been identified as the most prevalent skin manifestation.[5],[6],[7] Acne flare-ups are linked to an increase in humidity and warmth in the region covered by masks, which causes epidermal keratinocyte hypertrophy and acute duct blockage.[8],[9],[10]

With extended mask usage, chronic cumulative irritant contact dermatitis and, in rare cases, allergic contact dermatitis may develop as a consequence of the confined and heated environment behind the mask, which increases skin permeability and sensitivity to physical and chemical irritants.[11] According to Choi et al., the most prevalent skin illness associated with mask usage is new-onset contact dermatitis (33.94%), followed by new-onset acne (16.97%).[12]

Other skin problems have been linked to mask usage, including itching, pigmentation and the Koebner phenomenon (KP).[4],[13] The KP is the emergence of new skin lesions on previously undamaged skin as a result of trauma, as initially documented by Heinrich Koebner in 1876.[14] It is linked to a variety of disorders, the most frequent of which are psoriasis, vitiligo and lichen planus.


  Materials and Methods Top


The purpose of this observational cross-sectional study was to determine the prevalence of adverse skin responses among people over the age of 18 who were residing in various regions of Saudi Arabia (both Saudi and non-Saudi), including both males and females. The data were collected from 516 participants using Google Forms (online method) from September to November 2021. The level of precision formula was used to calculate the minimum required sample size; after placing the values (P = 0.5, q = 0.5, z = 1.962 and d = 0.052), the sample size came out to be 384. A self-administrated questionnaire was used for data collection. The first part of the questionnaire contained information related to demographics. The second part focused on questions related to face mask use, type and duration, adverse skin reactions (ASRs) with prolonged use of face mask, history of skin disease and whether wearing face mask aggravates the existing skin diseases or not. The content validity of the questionnaire was assessed by two experts in the field, and changes were made before administering it to the participants. The research was approved by the Majmaah University's Research Ethics Committee vide reference no MUREC-October. 21/COM-2021/8-1. The data were analysed using IBM SPSS 28 IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. (Armonk, NY: IBM Corp). Frequencies and percentages are reported for categorical variables. Pearson's Chi-square and Fisher's exact tests were applied to observe associations between qualitative study variables. A value of P < 0.05 was considered statistically significant.


  Results Top


The highest number of participants were observed from the age group of 18–30 years (355 [68.8%]) followed by the age group of 41–50 years (87 [16.9%]), whereas the lowest number of participants fall in the age of 60 years and above (10 [1.9%]). The study demonstrated that the majority of the participant were male (276 [53.5%]). It was seen that majority of individuals hold Bachelor's degrees (406 [78.7%]), whereas the least participants were identified from Elementary education (2 [0.4%]) and PhD degrees (4 [0.8%]). Furthermore, it was detected that the majority of the participants were from the central region (325 [63%]), and the lowest participants were from the northern region (20 [3.9%]) and southern region (24 [4.7%]). It revealed that the majority of the participants were non-health health-care workers (477 [92.4%]), and the minority of the participants were the health-care workers (39 [7.6%]) [Table 1].
Table 1: Demographic data

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From the total number of 516 participants, there were 113 (47.1%) female participants and 76 (27.5%) male participants who had noticed ASRs due to prolonged use of face masks. A significant association was observed between sex and ASRs due to prolong use of face masks (P = 0.000).

According to the age groups, 135 participants from the age group of 18 to 30 years were severely affected due to prolonged use of masks, which was followed by the age group of 41–50 years, where 33 participants had noticed ASRs, and the least age group were affected were >60 years of age where one participant was reported. No significant association has been found between age and ASRs due to prolong use of face masks (P = 0.113).

According to the occupation, it appears that students were the most affected participants (111 participants, 38.7%), followed by non-health-care workers, which were estimated to be 51 participants (38.3%) who were noticed to have ASRs due to prolonged use of face masks. No significant association has been found between occupation and ASRs due to prolong use of face masks (P = 0.943) [Table 2].
Table 2: Association between sex, age and occupation with adverse skin reactions (adverse drug reactions)

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When the association between type of face mask and ASRs were studied, the majority of participants wore a surgical mask 85.5% (n = 441), of which only 36.7% of them reported ASRs related to surgical masks (n = 162). 13% of participants wore a cloth mask and the majority of them reported no ASRs (64.2%, n = 34). The minority of participants report wearing of surgical mask covered by a piece of cloth (0.8%, n = 4) and N95 mask respirators (0.8%, n = 4), in which 75% of individuals wear a surgical mask covered by a piece of cloth reported no ASRs, whereas 50% of those who wear N95 mask reported ASRs. No statistically significant association was observed between the type of face mask and the prevalence of ASRs (P = 0.942) [Table 3].
Table 3: Relationship between type of face mask and the association of adverse skin reactions

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The majority of the participants wore a mask for <4 h (n = 245), and 24.9% faced skin changes underneath. For participants wearing a mask for 4–8 h (n = 217), a significant number of individuals have ASRs (44.2%). Only a few participants use a mask for >8 h (n = 39), where a significant number of them have ASRs (43.6%). It has been observed that using a mask for >4 h is approximately double the risk of skin changes. A significant association has been found between the duration of mask use and ASRs according to P value (P = 0.000) [Table 4].
Table 4: Relationship between duration of mask use and adverse skin reactions

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Regarding the relationship between frequency of mask change and ASRs, the majority of the participants use one mask for 1 day (n = 214), and a significant number of them have shown ASRs (43.5%). For those individuals using 3 masks/day (n = 28), it was observed that 35.7% of them have ASRs. Regarding those who use one mask for >3 days (n = 102), only 25.5% of them have ASRs. A P = 0.008 certainly indicated that there is a significant association between the frequency of mask change and ASRs [Table 5].
Table 5: Relationship between frequency of mask change and adverse skin reactions

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Acne and itching symptoms were the most prevalent reported symptoms (42.4%, n = 87), followed by acne (26.8%, n = 55) and itching symptom (13.2%, n = 27) among the participants. Few participants suffered from ASRs such as rashes on the face (1.5%, n = 3), rashes behind the ears (4.9%, n = 10) and skin pigmentation (2%, n = 4). Only 4.4% (n = 9) of participants reported demonstrating other symptoms such as headache and difficulty in breathing due to prolonged use of face masks [Table 6].
Table 6: Prevalence of mask-related adverse skin reactions

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The prevalence of participants having skin diseases and their association with prolonged use of face masks has been studied comprehensively. The majority of participants have no skin diseases (65.1%, n = 336), whereas 39.4% of participants report skin diseases (n = 180). Amongst total skin cases (100%, n = 180), the majority of participants faced acne problems (n = 48 among 114 cases, 42.1%) as an aggravated condition after wearing a face mask. Following it, eczema remained the second most common problem after acne, with 29.2%, n = 7 out of 24 cases facing it. Few minor reports have been observed where melasma was reported in three participants (23.1% of cases) out of 13 participants, psoriasis in a single case, and rosacea amongst two individuals. Some participants presented >1 skin disease (n = 18), whereas seven agreed on the aggravation condition after wearing a face mask. It was observed that most of them suffered from acne and melasma (a total of 138 cases). However, it was reported that their condition was not aggravated by face masks (~65%, n = 83). From this study, no significant association was observed between prolonged face mask use and aggravation of pre-existing skin diseases by face masks (P = 0.177) [Table 7].
Table 7: History of skin disease and aggravation of previous skin condition with face mask use

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  Discussion Top


The goal of this study was to find out which skin responses are certainly linked with long-term usage of a face mask. The total prevalence of face mask-related skin responses was 37% (n = 189) in the current research, which was low when compared to the prevalence of 54.5% (n = 454) in a study conducted in Thailand.[5]

Comparable research was conducted in Korea, with a prevalence of 58.09% (n = 176) of face mask-related skin problems, which was higher than our study. There was no significant relationship between the kind of face mask and the related adverse skin responses (P = 0.942). The surgical mask was the most common form (85.4%, n = 441), and the majority of those who used it had no skin responses (63.3%, n = 279). In both surgical and textile masks, the incidence of adverse skin responses was almost the same (36.7% and 35.8%, respectively).[15]

Our findings contrast with those of Thai research, which revealed that the frequency of adverse skin responses in surgical masks was greater than that in cotton masks and that this difference was statistically significant with acne flare-ups. In terms of the relationship between the duration of mask use and the appearance of ASRs underneath, we discovered that those who wear a mask for <4 h have a lower risk of developing ASRs, with only 24.9% of them developing ASRs, compared to those who wear a mask for 4–8 h and those who wear a mask for >8 h, both of whom have a higher risk of developing ASRs underneath, with around 44% of them developing ASRs.[4]

When our findings were compared with the observations of Chaiyabutr et al., it was perceived that they have a higher prevalence of ASRs overall, but a similar finding regarding the effect of longer mask use on developing ASRs, it was found that 53.9% of those who wear a mask for <4 h develop ASRs, 70.5% of those who wear a mask for 4–8 h develop ASRs, and 77.7% of those who wear a mask for >8 h develop ASRs.[4] The findings of another study by Techasatian et al. were consistent with our findings, indicating that those who wear a face mask for <4 h (48.9%) have a lower risk of ASRs than those who wear it for 4–8 h (52.9%) and those who wear it for >8 h (64.4%), respectively.[5] Itching was more prevalent in individuals who used the face mask for longer periods.[15] Based on our own study and the findings of these previous studies, it may be inferred that the longer a mask is worn, the greater the chance of developing ASRs.

When comparing the frequency of face mask changes to the development of ASRs, it was observed that individuals using a single face mask/day have a greater chance of developing ASRs than those changing the face mask 2–3 times/day and those using a single mask for 2–3 days or more. As a result, it was observed that often changing the mask is connected with a decreased risk of ASRs, which may be explained by the existence of excellent hygiene, which lowers the risk of ASRs. There is no apparent reason for the decreased incidence of ASRs in individuals who wear a single face mask for numerous days, although other variables such as length of usage and kind of face mask may play a role. This is in line with another research, which indicated that people who wear a single mask had a 1.5 times greater risk of ASRs than those who change masks regularly.[5]

Another research explains why using a single mask for numerous days has a reduced risk of ASRs than using a single mask every day; curiously, the study found no link between mask reuse and ASRs, but that reusing after cleaning reduces the risk. Thus, although the frequency of face mask changes is not substantially linked with ASRs under the surface, it is preferable to replace the mask for improved cleanliness and a reduced risk of infection.[4] The most common symptoms were acne with itching symptom (42.4%, n = 87), acne alone (26.8%, n = 55), and itching symptom alone (13.2%, n = 27). According to similar research conducted in Korea, acne was the most common skin lesion (68.98%, n = 124/180), followed by rashes (26.67%, n = 48/180).[16] A systematic evaluation revealed comparable findings, with itching being the most common skin response.[17]

There was no statistically significant relationship between continuous face mask usage and the worsening of pre-existing skin disorders by face masks (P = 0.177) in those with pre-existing skin disease. The majority of participants who reported skin problems had acne, with 57.9% (n = 66) of them reporting that face masks did not exacerbate their condition, while 42.1% (n = 48) reported that face mask aggravated their condition. Similar findings were obtained in research by Ying et al., where they revealed that 31.9% of the participants had pre-existing skin illness (n = 129), and 44.2% of them had aggravation after using a face mask for an extended period.[18] Eczema is the second-most common skin condition (n = 24), with the majority of people reporting that face masks do not worsen their symptoms (70.8%, n = 17).

According to research conducted in Korean hospitals, (82.42%, n = 272/330) of the participants had pre-existing skin illnesses, and (57.35%, n = 156/272) of patients with pre-existing skin dermatoses suffered deterioration of their pre-existing skin dermatoses (including acne, atopic dermatitis, contact dermatitis, seborrhoeic dermatosis and rosacea). Acne was the illness that masks exacerbated the most (46.67%, n = 56/120). To limit sebum production, precautions such as using an oil control moisturiser with Lycocalcon A as one of the components and applying a dressing before using the mask are suggested.[3],[19] Preventing sebum duct blockage and acne development by wearing correctly fitting masks and applying non-comedogenic moisturisers to the skin below before donning PPE to lubricate the skin and decrease friction.[20] Surgical masks should be replaced every 4 h, and N95 masks should be changed every 3 days, respectively. Patients with oily skin should clean their faces with a wet towel containing moisturising substances frequently.[21]

The American Academy of Dermatology also advises against trying new skincare products that irritate the skin or increasing the usage of strong products such as retinoids, chemical peels and washes.[22] It is also a good idea to take regular pauses from wearing the mask to reduce the amount of time you are exposed to it.[8],[23]


  Conclusion Top


The overall prevalence of skin reactions associated with a face mask was 37%. The most frequent skin reaction was acne and itching symptoms, followed by acne alone. Regarding mask type, both surgical and cloth masks were associated with a low incidence of ASRs, which was statistically insignificant. Regarding the duration of using a face mask, wearing a face mask for >4 h/day, and using one mask for a whole 1 day were significantly associated with increased incidence of face mask-induced skin reactions. The most prevalent pre-existing skin disease was acne, followed by eczema. A significant number of people with acne report acne flaring associated with prolonged use of face masks. However, it was statistically insignificant. The face mask is an effective measure to prevent the spread of an infection that is increasingly adopted these days by many health organisations around the world to limit the spread of the novel COVID-19 virus. However, the prevalence of skin reactions associated with face masks was low in the present study. However to minimise the adverse reactions, we recommend using a face mask for <4 h/day and using 2 or 3 masks for 1 day, no difference between surgical and cloth masks in eliciting skin reactions. In the present study, only four participants reported using the N95 mask, which was an insufficient sample to report a finding and make a recommendation regarding that type of mask, so another higher-level study is recommended to make more specific recommendations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.  Back to cited text no. 1
    
2.
World Health Organization. Coronavirus Disease 2019 (COVID-19). Situation Report – 59. World Health Organization; 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200319-sitrep-59-covid-19.pdf?sfvrsn=c3dcdef9_2. [Last accessed on 2020 Mar 21].  Back to cited text no. 2
    
3.
Darlenski R, Tsankov N. COVID-19 pandemic and the skin: What should dermatologists know? Clin Dermatol 2020;38:785-7.  Back to cited text no. 3
    
4.
Chaiyabutr C, Sukakul T, Pruksaeakanan C, Thumrongtharadol J, Boonchai W. Adverse skin reactions following different types of mask usage during the COVID-19 pandemic. J Eur Acad Dermatol Venereol 2021;35:e176-8.  Back to cited text no. 4
    
5.
Techasatian L, Lebsing S, Uppala R, Thaowandee W, Chaiyarit J, Supakunpinyo C, et al. The effects of the face mask on the skin underneath: A prospective survey during the COVID-19 pandemic. J Prim Care Community Health 2020;11:215013272096616.  Back to cited text no. 5
    
6.
Foo CC, Goon AT, Leow YH, Goh CL. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome – A descriptive study in Singapore. Contact Dermatitis 2006;55:291-4.  Back to cited text no. 6
    
7.
Elisheva R. Adverse effects of prolonged mask use among healthcare professionals during COVID-19. Journal of Infectious Diseases and Epidemiology, 2020;6. doi:10.23937/2474-3658/1510130.  Back to cited text no. 7
    
8.
Kosasih L. MASKNE: Mask-induced acne flare during coronavirus disease-19. What is it and how to manage it? Open Access Maced J Med Sci 2020;8:411-5.  Back to cited text no. 8
    
9.
Narang I, Sardana K, Bajpai R, Garg VK. Seasonal aggravation of acne in summers and the effect of temperature and humidity in a study in a tropical setting. J Cosmet Dermatol 2019;18:1098-104.  Back to cited text no. 9
    
10.
Sardana K, Sharma RC, Sarkar R. Seasonal variation in acne vulgaris – Myth or reality. J Dermatol 2002;29:484-8.  Back to cited text no. 10
    
11.
Gheisari M, Araghi F, Moravvej H, Tabary M, Dadkhahfar S. Skin reactions to non-glove personal protective equipment: An emerging issue in the COVID-19 pandemic. J Eur Acad Dermatol Venereol 2020;34:e297-8.  Back to cited text no. 11
    
12.
Choi SY, Hong JY, Kim HJ, Lee GY, Cheong SH, Jung HJ, et al. Mask-induced dermatoses during the COVID-19 pandemic: A questionnaire-based study in 12 Korean hospitals. Clin Exp Dermatol 2021;46:1504-10.  Back to cited text no. 12
    
13.
Damiani G, Gironi LC, Kridin K, Pacifico A, Buja A, Bragazzi NL, et al. Mask-induced koebner phenomenon and its clinical phenotypes: A multicenter, real-life study focusing on 873 dermatological consultations during COVID-19 pandemics. Dermatol Ther 2021;34:e14823.  Back to cited text no. 13
    
14.
Sagi L, Trau H. The koebner phenomenon. Clin Dermatol 2011;29:231-6.  Back to cited text no. 14
    
15.
Szepietowski JC, Matusiak Ł, Szepietowska M, Krajewski PK, Białynicki-Birula R. Face Mask-induced Itch: A Self-questionnaire Study of 2,315 Responders During the COVID-19 Pandemic. Acta Derm Venereol 2020;100:00152.  Back to cited text no. 15
    
16.
Park SJ, Han HS, Shin SH, Yoo KH, Li K, Kim BJ, et al. Adverse skin reactions due to use of face masks: A prospective survey during the COVID-19 pandemic in Korea. J Eur Acad Dermatol Venereol 2021;35:e628-30.  Back to cited text no. 16
    
17.
Thatiparthi A, Liu J, Martin A, Wu JJ. Adverse effects of COVID-19 and face masks: A systematic review. J Clin Aesthet Dermatol 2021;14:S39-45.  Back to cited text no. 17
    
18.
Zuo Y, Hua W, Luo Y, Li L. Skin reactions of N95 masks and medial masks among health-care personnel: A self-report questionnaire survey in China. Contact Dermatitis 2020;83:145-7.  Back to cited text no. 18
    
19.
Chularojanamontri L, Tuchinda P, Kulthanan K, Pongparit K. Moisturizers for acne: What are their constituents? J Clin Aesthet Dermatol 2014;7:36-44.  Back to cited text no. 19
    
20.
Masood S, Tabassum S, Naveed S, Jalil P. COVID-19 pandemic & skin care guidelines for health care professionals. Pak J Med Sci 2020;36:S115-7.  Back to cited text no. 20
    
21.
Han C, Shi J, Chen Y, Zhang Z. Increased flare of acne caused by long-time mask wearing during COVID-19 pandemic among general population. Dermatol Ther 2020;33:e13704.  Back to cited text no. 21
    
22.
American Academy of Dermatology Association. Ways to Prevent Face Mask Skin Problems. American Academy of Dermatology Association. Available from: https://www.aad.org/public/everyday-care/skin-care-secrets/face/prevent-face-mask-skin-problems. [Last accessed on 2022 Jan 07].  Back to cited text no. 22
    
23.
Rebmann T, Carrico R, Wang J. Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses. Am J Infect Control 2013;41:1218-23.  Back to cited text no. 23
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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