The 2014 Drug Trend Report. Chest. Cost and management of asthma exacerbations in Spanish hospitals (COAX study in hospital services). 1235 South Clark Street Suite 305, Arlington, VA 22202 Medicine for asthma is most commonly taken through an inhaler, which gets the medicine straight into your lungs where it is needed. The assessment of asthma burden is a challenge. Asthma Inhalers Ask our pharmacist about common questions about inhalers, medicines, and treatments to help relieve asthma symptoms and prevent asthma attacks Default sorting Sort by popularity Sort by average rating Sort by latest Sort by price: low to high Sort by price: high to low Missed school and work days decreased between the 2 periods (9.2 days in 1996-1998 vs 6.4 days in 2004-2006). Winer RA, Qin X, Harrington T, Moorman J, Zahran H. Asthma incidence among children and adults: findings from the behavioral risk factor surveillance system asthma call-back survey—United States, 2006–2008. National Health Interview Survey (NHIS) 2012. Terms and Conditions, Asthma inhalers can stunt the growth of children, scientists have said. DOI: http://dx.doi.org/10.1016/j.jaci.2010.10.020. In the literature, lifetime asthma, diagnosed asthma and current asthma were defined in 8, 12 and 29 different ways, respectively. However, in individuals with <5 years old and >65 years old, the number of hospitalizations has been increasing in the last two decades, especially in areas/regions with low socioeconomic development [18–20]. J Allergy Clin Immunol. 2000;67:65–70. Even in medium-or high-income countries are difficulties to implement national asthma plans. In fact, the best combination of questions to define asthma in epidemiological studies is not known. The authors concluded that epidemiological asthma definitions can lead to highly variable estimates of asthma prevalence and a standardized operational definition is needed [6]. CAS  AJMC. In elderly asthmatics with several comorbidities, exacerbation of asthma symptoms is frequent, leading to increased medication need, increased outpatient hospital visits and hospital admissions, and contributing to an increase of asthma costs to the patient and society. Martínez-Moragón E, Serra-Batllés J, De Diego A, Palop M, Casan P, Rubio-Terrés C, Concepción Pellicer on behalf of the Asthma Cost Study Group. View product . Average life expectancy of asthmatics is lower than that of the general population. In fact, the highest prevalence of severe asthma symptoms among children with wheeze in the past 12 months is found in LMICs [11]. Confused about what a spacer is or how to use it? Am J Manag Care. Severe asthma, despite being less prevalent than other asthma severity classes (Fig. This equals about. This has caused asthma to drop to the seventh most costly illness. 2011. Trends in European life expectancy: a salutary view. Most asthma medicines are inhaled through the mouth using an inhaler or puffer. 2004;23:723–9. GINA) and at national/regional levels, were created trying to delineate better diagnosis and treatment strategies, emphasizing that achieving clinical control and reducing future risk should be the primary targets of asthma management; moreover, they propose approaches that promote a more adequate use of healthcare resources and should present as cost-effective strategies. Lee YH, Yoon SJ, Kim EJ, Kim YA, Seo HY, Oh IH. There are some generic barriers to achieve a better health, which include poverty, poor education, lack of sanitation and poor infrastructure; and some environmental barriers that include tobacco smoking, pollution and poor nutrition. The economic burden of asthma is an important measure of its effect on society. However, this may be an underestimation as asthma underdiagnosis is well-known [1]. The population-based studies have greater generalizability, whereas the clinical-based studies have greater diagnostic certainty and, frequently, data on disease severity that is particularly relevant to asthma costs. Globally, asthma costs were increasing, closely correlated with comorbidities, age and asthma severity [22]. 2007;29:233–9. 2003;111:263–8. of Health, Civil Society and the donor community to act on their SDG commitments and to scale up cost-effective interventions to reduce the burden of NCDs, including asthma, globally. Accordini S, Corsico AG, Braggion M, Gerbase MW, Gislason D, Gulsvik A, Heinrich J, Janson C, Jarvis D, Jõgi R, Pin I, Schoefer Y, Bugiani M, Cazzoletti L, Cerveri I, Marcon A, de Marco R. The cost of persistent asthma in Europe: an international population-based study in adults. Asthma’s Impact on the Nation: Data from the CDC National Asthma Control Program. Regarding asthma-related hospitalizations, children and adolescents have a prevalence that is at least twice that of adults. Controller medications may also be called preventers. Jan:127(1):145-152. Haahtela T, Tuomisto LE, Pietinalho A, Klaukka T, Erhola M, Kaila M, Nieminen MM, Kontula E, Laitinen LA. Article  What are the asthma controller (preventer) medications and how do they work? This post hoc analysis assessed the efficacy and safety of budesonide/formoterol (BUD/FORM) maintenance and reliever therapy (MART) for treatment of persistent asthma in adolescent (age 12–17 years) subgroups within six randomised, double-blind trials. 2004;114:40–7. A person with asthma that does not have insurance visits the emergency room more than a person that has health insurance. 2002 ;12: 1036 - 1041 . Asthma often generates temporary incapacity for work and a significant percentage of premature permanent disability retirements, although mortality rate is low. Economic Cost of Treating the Patient With Asthma in Spain: The Asma Cost Study. These unfavorable scenarios lead to a situation in which dozens of millions of human beings suffering from asthma, from all age groups, cannot afford the right to breathe well [51, 53]. 2005;83:548–54. 5 - Government and pharmaceutical industry relationship regarding medication, mainly the use of generic drugs to asthma treatment. Expenditures with asthma among USA individuals (aged 5–56 years) were compared using the 1996 to 1998 and the 2004 to 2006 Medical Expenditure Panel Surveys [32]. Objective Overuse of short-acting bronchodilators is internationally recognised as a marker of poor asthma control, high healthcare use and increased risk of asthma death. PubMed Central  PubMed Central  Nevertheless, in Europe and Korea it is the outpatient medication and human resources that are responsible for most of the direct costs [10, 28, 34, 35]. 2003;91:251–7. 2006;61:663–70. Nonadherence to inhaled medication leads to poor asthma control and increased healthcare utilisation. Lai CK, De Guia TS, Kim YY, Kuo SH, Mukhopadhyay A, Soriano JB, Trung PL, Zhong NS, Zainudin N, Zainudin BM, Asthma Insights and Reality in Asia-Pacific Steering Committee. Carlos Nunes. 2014.  http://www.cdc.gov/asthma/impacts_nation/asthmafactsheet.pdf, [4] Wang LY, Zhong Y, Wheeler L. Direct and indirect costs of asthma in school-age children. Cost of Asthma on Society. Upon the first epidemiological publications on asthma, it was noted that asthma prevalence was higher in social classes with a high or very high annual income and that asthma severity was higher among the most disadvantaged. Accessed 22 Oct 2014. World Health Organization. The most common co-morbidities related to asthma are rhinitis/rhinosinusitis, gastroesophageal reflux disease, sleep apnea, psychiatric diseases and cardiac diseases. There are lots of different inhalers and it is very important that you know how to use yours properly. Although asthma is generally accepted as a costly illness, the total costs to society (direct, indirect and intangible asthma costs) are difficult to estimate, mainly due to different disease definitions and characterizations but also to the use of different methodologies to assess the asthma socio-economic impact in different societies. He's one of 1,400 UK residents who die this way, each year. Stock S, Redaelli M, Luengen M, Wendland G, Civello D, Lauterbach KW. CRDs affect more than 1 billion people worldwide, and asthma is a large contributor, affecting children, adults and the elderly, often throughout their entire lives. March 2015. http://lab.express-scripts.com/drug-trend-report/, Asthma and Allergy Foundation of America Finally, intangible costs are those related with unquantifiable losses, such as the decrease in quality of life, increases in pain or suffering, limitation of physical activities and job changes. CAS  Antonicelli L, Bucca C, Neri M, De Benedetto F, Sabbatani P, Bonifazi F, Eichler HG, Zhang Q, Yin DD. Price based on 100mcg/50mcg, 1 diskus inhaler (generic if available). 2014;68:557–67. The prevalence of other co-morbidities is lower, and it is estimated that together they do not exceed 20 to 30% in children and young adults. A GoodRx analysis of cash prices for asthma inhalers shows that prices climbed about 35% from 2013 to 2018, from an average price of around $280 in 2013 to more than $380.. In children 5 to 17, asthma is one of the top reasons they miss school. Ismaila AS, Sayani AP, Marin M, Su Z. In the period from 2000 to 2009 it was found, in the same surveys, that although medical costs for patients with asthma increased or remained stable across all age groups over the 10-year period, outcomes did not improve; this stresses the need to reflect about the relation between asthma costs and outcomes [46]. Nunes, C., Pereira, A.M. & Morais-Almeida, M. Asthma costs and social impact. Economic burden of asthma: a systematic review. A recent estimate of total annual asthma costs in the USA, stated that they were growing fast and steadily, from $USD 12 billion in 1994 to $USD 56 billion in 2011 [23]. Asthma and Allergy Foundation of America 1235 South Clark Street Suite 305, Arlington, VA 22202 Phone: 1-800-7-ASTHMA (1-800-727-8462) Phone: 1-800-7-ASTHMA (1-800-727-8462) We need to do something about this issue. It is also a very effective way because inhaling the medicine takes it straight into your lungs. Trends in asthma-related direct medical costs from 2002 to 2007 in British Columbia, Canada: a population based-cohort study. Int Arch Allergy Immunol. Eur Respir J. 2012;18:499–504. Gergen PJ. From 2001 to 2011, the number of people with asthma grew by 28 percent. The public health implications of asthma. Insurance co-pays are typically less. One decade ago, few were the countries with a national asthma program focused on disease control, as it was the case in the USA, and in Europe in countries like Finland, France or Portugal. Insurance coverage and barriers to care for people with asthma. 2011;127:145–52. In recent decades, both asthma prevalence and incidence have been increasing worldwide, not only due to the genetic background, but mainly because of the effect of a wide number of environmental and lifestyle risk factors. Similar results were found in several other surveys, namely in European asthmatic adults [14]. These people were also the most likely to not keep receiving treatment. If you know you'll be dancing something extra-aerobic, take a puff from the inhaler 30 minutes prior. The asthma costs are very variables from country to country, however we can estimate that a mean cost per patient per year, including all asthmatics (intermittent, mild, moderate and severe asthma) in Europe is $USD 1,900, which seems lower than USA, estimated mean $USD 3,100. Clin Geriatr Med. Children with asthma were more likely to have full year health insurance than adults. The total cost of asthma in UK has been estimated to be about $5 billion. The authors included 68 studies and found that hospitalization and medications were the most important drivers of direct costs; work and school loss accounted for the greatest percentage of indirect costs. It is important that you use your asthma inhaler correctly to get the full benefit of the medication you are taking. Turk J Pediatr. 1 of 2 Hannah Hayes, 13, uses an asthma inhaler at her family's vacation home in Truckee, Calif., last month. Trends in cost and outcomes among adult and pediatric patients with asthma: 2000-2009. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Arch Pediatr Adolesc Med. WHO factsheet 206: bronchial asthma. The financial burden of asthma: a nationwide comprehensive survey conducted in the republic of Korea. Available at http://www.ginasthma.org. Most people with asthma, however, don't use the correct technique. We can divide them into 2 strategies: one related to “reliance on market mechanisms in service provision” and another in “mostly public provision and public insurance”. The interaction with patient payment and/or reimbursement makes a significant difference on the total direct cost supported by asthma patients and their families [40]. 2006;130(1 Suppl):4–12. Article  So, worldwide, it is estimated that nowadays more than 300 million people have asthma [1]. A metered-dose inhaler (MDI) is a device that delivers a specific amount of medication to the lungs, in the form of a short burst of aerosolized medicine that is usually self-administered by the patient via inhalation.It is the most commonly used delivery system for treating asthma, chronic obstructive pulmonary disease (COPD) and other respiratory diseases. Mukherjee M, Gupta R, Farr A, Heaven M, Stoddart A, Nwaru BI, Fitzsimmons D, Chamberlain G, Bandyopadhyay A, Fischbacher C, Dibben C, Shields M, Phillips C, Strachan D, Davies G, McKinstry B, Sheikh A, Burden and True Cost of Asthma in the UK Research Team. Privacy In 2007, the cost of asthma grew to $56 billion. Worldwide, asthma accounts for about 1% of all DALYs lost, which simultaneously reflects high prevalence and severity [51]. 2011;32:35–40. Asthma control is often suboptimal in adolescents, but few studies have evaluated asthma treatments in this population. Article  A multicentre population-based study. Int J Tuberc Lung Dis. Both premature deaths and permanent disabilities are costly, especially for those countries where these situations are more common [2, 5]. Jan 2005. In general, in the 28 countries from the European Community, it was estimated that there are more than 30 million of asthmatics (mean asthma prevalence of 7%), that account for a total expense of more than €20 billion in the European population aged from 15 to 64 years [33]. Asthma Inhalers: What You Need to Know. The relation between direct and indirect asthma costs is variable and depends on country and type of study. [1] United States Environmental Protection Agency. http://www.cdc.gov/asthma/asthma_stats/insurance_coverage.htm, [7] Carrier E and Cunningham P. Medical Cost Burdens Among Nonelderly Adults with Asthma. BMC Pulm Med. Objective: The CRITical Inhaler mistaKes and Asthma controL study investigated the association between specific inhaler errors and asthma outcomes. Rev Port Imunol. Data, Statistics, and Surveillance. The total cost of asthma includes both direct costs, like medicines and hospital stays, and indirect costs, like missed work days and productivity. Aumann I, Prenzler A, Welte T, Gillissen A. With most the world population living in urban areas, the environmental conditions as the lifestyle changes have certainly influenced the asthma prevalence rate increase [2, 5]. 2012;2:15. In addition, it can cause early permanent disability and premature death. The disease burden and health priorities differ from one country or region to another, but asthma, as other noncommunicable chronic respiratory diseases, must be in the agenda of each national authority [1, 53]. Clin Transl Allergy. One study showed that patients getting treatment pay more out-of-pocket costs. Methods: This analysis used data from the iHARP asthma review service-a multicenter cross-sectional study of adults with asthma. A study showed that 16 percent of people with asthma reported high health costs, spending more than 10 percent of their income for out-of-pocket expenses. Epidemiology and costs of asthma in Germany - a systematic literature review. Costs of asthma according to the degree of severity. The studies of the economic effect of asthma have been principally of 2 kinds: those using population-based sampling frames or administrative databases to provide cost estimates for entire regions or nations, and those using clinical-based sampling frames [21]. domestic or professional preventive measures, assistance in home care, transportation to medical visits…). CAS  In low income countries, asthma guidelines are strikingly hard to implement, and more research is needed to evaluate whether therapeutic trials conducted in high income countries, and resultant recommendations, are equally applicable to low income regions. Asthma is a complex chronic disease that presents acute exacerbation periods with dyspnea and bronchospasm which are usually reversible by bronchodilators [1]. This is an increase of 6 percent. Even in medium- or high-income countries, asthma burden is not seen as a health public problem and it is often poorly known. 2005;25:47–53. In poor households, relatively small costs related with health promotion and disease control can be disastrous and assumed as catastrophic expenditures. A comparison of albuterol administrated by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma. Alibaba.com offers 1,598 asthma inhaler products. If you have asthma, your doctor may prescribe a long-acting inhaler to use regularly for overall asthma control and/or a short-acting (rescue) inhaler to use as needed for asthma … However, only in 2009 was published the first systematic review of the literature regarding the economic burden of asthma. In elderly, however, co-morbidities are more frequent (>50%). By using this website, you agree to our However, when interpreting these comparisons, we should consider that even within the most developed countries in the world, life expectancy at birth in men differs among European Union state members [52]. 2009;45:481–6. Accessed 15 Dec 2014. Kim CY, Park HW, Ko SK, Chang SI, Moon HB, Kim YY, Cho SH. Prev Chronic Disease. 2007;49:179–88. Resource costs for asthma-related care among pediatric patients in managed care. Arch Bronconeumol. 2004;3:209–23. In a cohort study of children and adolescents, followed during 20 years, it was found that patients with moderate and severe asthma had an average of 7.4 consultations per year, 3.4-fold higher than the general population needs in term of medical visits per year. Consequently, it can be said that asthma, worldwide, is “globalized and affect all countries as a public health problem”. There are striking global variations in the prevalence of asthma symptoms in children, with an up to 13-fold difference between countries [1, 5]. There are underserved individuals living in large urban centers of high-income countries with limited access to health care. Google Scholar. In Europe, for instance, there are several types of health public facility organization. In the United States of America (USA), per the National Health Interview Survey (NHIS)-2012, about 40 million people suffered from lifetime asthma (13% of the USA population) and 26 million people (8%) suffered from current asthma [4]. Available at: www.who.int/mediacentre. © 2021 BioMed Central Ltd unless otherwise stated. Within the direct costs, in some regions, like USA and several countries from Central/South America and Southeast Asia, the expenses with hospital inpatient care represent the major component [1, 22, 25]. November 2014. http://www.ajmc.com/journals/issue/2014/2014-vol20-n11/medical-cost-burdens-among-nonelderly-adults-with-asthma/P-1, [8] Consumer Reports. Evaluating Inhaled Steroids Used to Treat: Asthma. Available at: www.who.int/mediacentre/factsheets/fs206/en. J Allergy Clin Immunol. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. In 2002, the total cost of asthma in the United States was $53 billion. Asthma Research and Practice Chest. Estimating the incidence, prevalence and true cost of asthma in the UK: secondary analysis of national stand-alone and linked databases in England, Northern Ireland, Scotland and Wales - a study protocol. ? National Center for Environmental Health. Another study reporting data from Europe in a real-world evaluation of the economic cost of persistent asthma among adults per the degree of disease control (462 patients aged 30–54 years from 11 European countries, examined in clinical settings in the European Community Respiratory Health Survey II, 1999 to 2002), found that the mean total cost per patient was €1,583 and, in this study, this was largely driven by indirect costs (62.5%). Copyright © 1995-2021. asthma res and pract 3, 1 (2017). Recent data from the general population showed that in children up to 5 years old, the overall asthma incidence rate was 23/1,000 children per year; this incidence rate decreased among youth aged 12–17 years old to 4,4/1,000/year. Mortality death rate and DALY rate per 100.000 inhabitants, age- standardized. Borderias Clau L, Zabaleta Murguionda M, Riesco Miranda JA, Pellicer Ciscar C, Hernandez Hernandez JR, Carrillo Diaz T, Lumbreras GG. Since 2009, the cost of inhaled asthma medicines have increase by an average of 50 percent. Accessed 25 Oct 2014. http://www.who.int/mediacentre/factsheets/fs206/en/. Severe asthma has an estimated prevalence of up to 8% within asthmatics. In Fig. Americans suffering from asthma are much more likely to have health insurance than those that do not have asthma. CN, AMP and MMA equally contributed to writing the manuscript. J Allergy Clin Immunol. These numbers show that the current cost of asthma on our society is important. 2014;51:769–78. This contributes significantly to indirect costs and reflects on DALYs, as a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death. Most patients with persistent asthma need daily medication, have yearly differences in total medication cost among European countries. 2012;7:e50949. Those suffering from asthma tend to have trouble paying for health care. Burney P, Jarvis D, Perez-Padilla R. The global burden of chronic respiratory disease in adults. National Health and Nutrition Examination Survey 2005–2006. Also, atopic sensitization and comorbidities are present in a large percentage of asthmatics. Nunes C, Ladeira S. Asthma, from childhood to adulthood, longitudinal prospective study of a cohort of asthmatics during a period of 20 year. PubMed  Nov 2013. https://www.consumerreports.org/health/resources/pdf/best-buy-drugs/InhaledSteroidsFINAL.pdf, [9] The Express Scripts Lab. 1998;12:1322–6. From 2001 to 2011, the number of people with asthma grew by 28 percent. Global Asthma Report 2014 available at http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014N°978-0-473-29126-6. Chronic cough or phlegm and having a high BMI significantly increased the individual total cost [14]. Inhalers are the main treatment for asthma, a respiratory condition marked by spasms in the main passageway (bronchi) of the lungs, causing difficulty in breathing.. An asthma inhaler is a handheld device that delivers medication straight into the lungs, delivering the medication faster and with fewer side effects compared to oral or intravenous drugs. 3. Early death due to asthma is also very important. Asthma-related costs are high and should be systematically monitored using standardized methods; they should consider the natural history of the disease, incidence and prevalence trends, environmental impact, comorbidities, quality of life, ageing of the population, the effect of guidelines implementation and differences in national health systems and income levels. Usually, directs costs contribute to 50 to 80% of the total costs [10, 21, 25–31]. According to the World Health Organization, in 2004, the world total asthma costs probably exceeded those of tuberculosis and HIV/AIDS combined [24]. J Asthma. Management programs focused on treatment regimens which have been shown to reduce hospital admissions represent a cost-effective strategy for the management of asthma. In children aged less than 5 years old and as well as in the mid-childhood ages, 5–14 years old there is a high prevalence worldwide with a significant relevance and even in these age groups is consider as one of the top chronic conditions causing disability-adjusted life years (DALYs). They are the most likely to continue using their medication even if they have trouble paying for it. Asthma expenditures in the United States comparing 2004 to 2006 and 1996 to 1998. Accessed 23 Oct 2014. Accessed 12 Nov 2014. Rank MA, Liesinger JT, Ziegenfuss JY, Branda ME, Lim KG, Yawn BP, Li JT, Shah ND. Asthma is a heterogeneous disease which is characterized by chronic airway inflammation. Thorax. New Zealand asthma patients. This includes the cost of about $1 billion to the public health service. Chest. Fifty people die from the condition every year and according to the Asthma Society of Ireland, 90 per cent of these deaths would have been prevented if patients’ asthma was controlled. : acute respiratory infections, environmental and/or occupational irritants/allergens and tobacco consumption and/or passive exposure, among others). 2014. Gendo K, Sullivan SD, Lozano P, Finkelstein JA, Fuhlbrigge A, Weiss KB. Tiernan Green, from County Armagh, suffered a fatal asthma attack after failing to use his brown inhaler. Asthma. Children with asthma miss 2.48 more days of school each year than children without asthma. Donate Latest research View all. People with asthma have much higher out-of-pocket costs. This frequent need for asthma-related unscheduled medical observations has multiple identified causes, namely reduced compliance or non-compliance to asthma management, severe asthma that is not responsive to the prescribed treatment, economic disadvantage that prevents patients from buying controller medication, insufficient resources in terms of outpatient health professionals and/or equipment and patient exposure to trigger factors (e.g. 2(1). Considering this social impact related asthma costs, under economic point of view that there are significant differences among prices per country, depending of several factors: 3 - Type of health system (Public versus Private), 3.2 - Primary care (developed vs non-developed), 4.1 - Prevention and Promotion in quality of life. Ann Allergy Asthma Immunol. Sullivan PW, Slejko JF, Ghushchyan VH, Sucher B, Globe DR, Lin SL, Globe G. The relationship between asthma, asthma control and economic outcomes in the United States. Young adults with asthma commonly overuse short-acting bronchodilators. Manage cookies/Do not sell my data we use in the preference centre. 2012;49:16–22. About 20 million working-days are lost due to asthma each year [33]. However, the difference is only around 20 to 30% of the cost [36–39]. PubMed  Eur Respir J. The GoodRx Fair Price represents the maximum price that a consumer, with or without insurance, should pay for this drug at a local pharmacy. Considering disease manifestations, patients with asthma can have both short-term treatment for asthma exacerbations and long-term treatment to obtain and maintain asthma control. Sá-Sousa A, Morais-Almeida M, Azevedo LF, Carvalho R, Jacinto T, Todo-Bom A, Loureiro C, Bugalho-Almeida A, Bousquet J, Fonseca JA. 2013;13:70. The global burden of asthma: executive summary of the GINA dissemination committee report. Asthma Facts. As an example, in the UK, an initiative aiming to provide data on previously identified gaps on asthma costs was launched; its ultimate vision is to contribute to obtain valid data that allows policy changes leading to the provision of more cost-effective care [55]. In this review, we will analyze and discuss some items regarding the socio-economic aspects of asthma, such as: Asthma is primarily a chronic inflammatory disease that tends to present as a lifelong condition, with different severity degrees throughout the asthma patient’s life [1, 2]. The global Asthma and Insights and Reality surveys. Asthma is one of the most common chronic diseases in childhood and one of the main causes of hospitalizations [2]. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). Khaltaev N. global burden of asthma grew to $ 56 billion in,. 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