bb492438aee1822c8d567a6770280385 pmc_34067391.pdf f4155bc40e575008a76629a04cd35f789ad3cd1e pmc_34067391.pdf 22156aa6ef68ca4e3813c5eb1d59fa6f0d918c8b4c0267acf2f571bb08f5460e pmc_34067391.pdf Title: Impact of a Nosocomial COVID-19 Outbreak on a Non-COVID-19 Nephrology Ward during the First Waveof the Pandemic in Spain Subject: Introduction: The aim of this study was to analyze a nosocomial coronavirus disease 2019 (COVID-19) outbreak that occurred on a polyvalent non-COVID-19 ward at a tertiary care university hospital in Spain during the first wave of the pandemic and to describe the containment measures taken. The outbreak affected healthcare workers (HCWs) and kidney disease patients including transplant patients and those requiring maintenance hemodialysis. Methods: The outbreak investigation and report were conducted in accordance with the Orion statement guidelines. Results: In this study, 15 cases of COVID-19 affecting 10 patients and 5 HCWs were identified on a ward with 31 beds and 43 HCWs. The patients had tested negative for severe acute respiratory syndrome coronavirus 2 infection on admission. One of the HCWs was identified as the probable index case. Five patients died (mortality rate, 50%). They were all elderly and had significant comorbidities. The infection control measures taken included the transfer of infected patients to COVID-19 isolation wards, implementation of universal preventive measures, weekly PCR testing of patients and HCWs linked to the ward, training of HCWs on infection control and prevention measures, and enhancement of cleaning and disinfection. The outbreak was contained in 2 weeks, and no new cases occurred. Conclusion: Nosocomial COVID-19 outbreaks can have high attack rates involving both patients and HCWs and carry a high risk of patient mortality. Hospitals need to implement effective infection prevention and control strategies to prevent nosocomial COVID-19 spread. Keywords: nosocomial outbreak; COVID-19; infection control Author: María Milagro Montero, Carlota Hidalgo López, Inmaculada López Montesinos, Luisa Sorli, Cristina Barrufet Gonzalez, Judith Villar-García, Roberto Güerri-Fernández, Milagros Herranz, Marta Crespo, María Dolores Arenas Jiménez, Julio Pascual, Cristina González Juanes and Juan P. Horcajada Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Sat May 22 12:05:54 2021 CEST ModDate: Sat May 22 12:05:54 2021 CEST Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 9 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 1228930 bytes Optimized: no PDF version: 1.5 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- IFVPBL+URWPalladioL-Ital Type 1 Custom yes yes no 102 0 LNOXXL+URWPalladioL-Bold Type 1 Custom yes yes no 103 0 JYPLJJ+VnURWPalladioL-Bold Type 1 Custom yes yes no 104 0 AJKEBD+URWPalladioL-Roma Type 1 Custom yes yes no 105 0 OHKNFJ+VnURWPalladioL Type 1 Custom yes yes no 108 0 YYFPCJ+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 114 0 MCBCCI+SourceSansRoman-Regular Type 1C Custom yes yes no 131 0 MCBCCM+SourceSansRoman.613wght Type 1C Custom yes yes no 132 0 MCBCCO+SourceSansRoman-Bold Type 1C Custom yes yes no 133 0 JLZORU+EURM10 Type 1 Builtin yes yes no 176 0 URYLRZ+URWPalladioL-BoldItal Type 1 Custom yes yes no 188 0 PDTLUH+CMSY10 Type 1 Builtin yes yes no 189 0 BPNNGJ+TimesNewRoman,Bold CID TrueType Identity-H yes yes yes 194 0 BPNOMK+PalatinoLinotype TrueType WinAnsi yes yes no 195 0 BPNNHK+TimesNewRoman CID TrueType Identity-H yes yes yes 196 0 BPNNIL+TimesNewRoman,Italic TrueType WinAnsi yes yes no 197 0 BPNOLG+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 198 0 BPNOMI+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 199 0 CPPOCC+TimesNewRoman,Bold CID TrueType Identity-H yes yes yes 241 0 CPPPGE+PalatinoLinotype TrueType WinAnsi yes yes no 242 0 DAAAMM+Arial CID TrueType Identity-H yes yes yes 243 0 CPPOED+TimesNewRoman CID TrueType Identity-H yes yes yes 244 0 CPPOFE+TimesNewRoman,Italic TrueType WinAnsi yes yes no 245 0 CPPPEB+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 246 0 CPPPFC+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 247 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2023-10-21 02:37:58 CEST RepresentationInformation: pmc_34067391.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2023-03-31 12:14:01 CEST Size: 1228930 Format: PDF Version: 1.5 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 0 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: ViewerPreferences: HideToolbar: false HideMenubar: false HideWindowUI: false FitWindow: true CenterWindow: false DisplayDocTitle: false NonFullScreenPageMode: UseNone Direction: L2R ViewArea: CropBox ViewClip: CropBox PrintArea: CropBox PageClip: CropBox PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: ぉのぴひはつふっぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸲ Item: Title: きちぴづひどちぬびぜ〴ぜ〰ちのつぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮ㄩ‾㸊⡜㌷㙜㌷㝜〰ぉのびぴどぴふぴどはのちぬぜ〴ぜ〰こづぴぴどのでぜ〴ぜ〰ちのつぜ〴ぜ〰こぴふつべぜ〴ぜ〰ぐづひどはつぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㈩‾㸊⡜㌷㙜㌷㝜〰こぴふつべぜ〴ぜ〰くぢなづっぴどぶづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴ぜ〰ちのつぜ〴ぜ〰いちぴちぜ〴ぜ〰こはふひっづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ぃぬどのどっちぬぜ〴ぜ〰ぃぬちびびどてどっちぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃくざぉい〭〱〹ぜ〴ぜ〰ちのつぜ〴ぜ〰いづてどのどぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃちびづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Children: Item: Title: ぉのびぴどぴふぴどはのちぬぜ〴ぜ〰こづぴぴどのでぜ〴ぜ〰ちのつぜ〴ぜ〰こぴふつべぜ〴ぜ〰ぐづひどはつぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㈩‾㸊⡜㌷㙜㌷㝜〰こぴふつべぜ〴ぜ〰くぢなづっぴどぶづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴ぜ〰ちのつぜ〴ぜ〰いちぴちぜ〴ぜ〰こはふひっづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ぃぬどのどっちぬぜ〴ぜ〰ぃぬちびびどてどっちぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃくざぉい〭〱〹ぜ〴ぜ〰ちのつぜ〴ぜ〰いづてどのどぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃちびづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: こぴふつべぜ〴ぜ〰くぢなづっぴどぶづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㌩‾㸊⡜㌷㙜㌷㝜〰ざちひどちぢぬづびぜ〴ぜ〰ちのつぜ〴ぜ〰いちぴちぜ〴ぜ〰こはふひっづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ぃぬどのどっちぬぜ〴ぜ〰ぃぬちびびどてどっちぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃくざぉい〭〱〹ぜ〴ぜ〰ちのつぜ〴ぜ〰いづてどのどぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃちびづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: ざちひどちぢぬづびぜ〴ぜ〰ちのつぜ〴ぜ〰いちぴちぜ〴ぜ〰こはふひっづびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㐩‾㸊⡜㌷㙜㌷㝜〰ぃぬどのどっちぬぜ〴ぜ〰ぃぬちびびどてどっちぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃくざぉい〭〱〹ぜ〴ぜ〰ちのつぜ〴ぜ〰いづてどのどぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃちびづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: ぃぬどのどっちぬぜ〴ぜ〰ぃぬちびびどてどっちぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃくざぉい〭〱〹ぜ〴ぜ〰ちのつぜ〴ぜ〰いづてどのどぴどはのぜ〴ぜ〰はてぜ〴ぜ〰ぃちびづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㔩‾㸊⡜㌷㙜㌷㝜〰ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: ぉのぴづひぶづのぴどはのぜ〴ぜ〰きづぴとはつびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㈮㘩‾㸊⡜㌷㙜㌷㝜〰こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: こぴちぴどびぴどっちぬぜ〴ぜ〰ぁのちぬべびどびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸳ Item: Title: げづびふぬぴびぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮ㄩ‾㸊⡜㌷㙜㌷㝜〰ぅばどつづねどはぬはでどっちぬぜ〴ぜ〰ぃふひぶづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮㈩‾㸊⡜㌷㙜㌷㝜〰ぃちびづぜ〴ぜ〰いづぴづっぴどはのぜ〴ぜ〰ちのつぜ〴ぜ〰ぅばどつづねどはぬはでどっちぬぜ〴ぜ〰ぉのぶづびぴどでちぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮㌩‾㸊⡜㌷㙜㌷㝜〰くふぴぢひづちにぜ〴ぜ〰きちのちでづねづのぴぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Children: Item: Title: ぅばどつづねどはぬはでどっちぬぜ〴ぜ〰ぃふひぶづぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮㈩‾㸊⡜㌷㙜㌷㝜〰ぃちびづぜ〴ぜ〰いづぴづっぴどはのぜ〴ぜ〰ちのつぜ〴ぜ〰ぅばどつづねどはぬはでどっちぬぜ〴ぜ〰ぉのぶづびぴどでちぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮㌩‾㸊⡜㌷㙜㌷㝜〰くふぴぢひづちにぜ〴ぜ〰きちのちでづねづのぴぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Item: Title: ぃちびづぜ〴ぜ〰いづぴづっぴどはのぜ〴ぜ〰ちのつぜ〴ぜ〰ぅばどつづねどはぬはでどっちぬぜ〴ぜ〰ぉのぶづびぴどでちぴどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳畢獥捴楯渮㌮㌩‾㸊⡜㌷㙜㌷㝜〰くふぴぢひづちにぜ〴ぜ〰きちのちでづねづのぴぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Item: Title: くふぴぢひづちにぜ〴ぜ〰きちのちでづねづのぴぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Item: Title: いどびっふびびどはのぜ〴〩਼㰠⽓ 䝯呯 䐠⡳散瑩潮⸴ Item: Title: げづてづひづのっづび Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: JLZORU+EURM10 FontSubset: true FirstChar: 31 LastChar: 31 FontDescriptor: FontName: JLZORU+EURM10 Flags: Symbolic FontBBox: -32, -243, 1060, 720 FontFile: true Font: BaseFont: IFVPBL+URWPalladioL-Ital FontSubset: true FirstChar: 2 LastChar: 121 FontDescriptor: FontName: IFVPBL+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: LNOXXL+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 252 FontDescriptor: FontName: LNOXXL+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: JYPLJJ+VnURWPalladioL-Bold FontSubset: true FirstChar: 161 LastChar: 226 FontDescriptor: FontName: JYPLJJ+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: AJKEBD+URWPalladioL-Roma FontSubset: true FirstChar: 2 LastChar: 252 FontDescriptor: FontName: AJKEBD+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: OHKNFJ+VnURWPalladioL FontSubset: true FirstChar: 129 LastChar: 226 FontDescriptor: FontName: OHKNFJ+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: URYLRZ+URWPalladioL-BoldItal FontSubset: true FirstChar: 110 LastChar: 110 FontDescriptor: FontName: URYLRZ+URWPalladioL-BoldItal Flags: Symbolic FontBBox: -170, -300, 1073, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: PDTLUH+CMSY10 FontSubset: true FirstChar: 21 LastChar: 21 FontDescriptor: FontName: PDTLUH+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 35, 759, 167, 795 Annotation: Subtype: Link Rect: 515, 759, 560, 795 Annotation: Subtype: Link Rect: 156, 641, 167, 654 Annotation: Subtype: Link Rect: 432, 641, 443, 654 Annotation: Subtype: Link Rect: 35, 482, 87, 501 Annotation: Subtype: Link Rect: 61, 346, 154, 355 Annotation: Subtype: Link Rect: 35, 336, 96, 343 Annotation: Subtype: Link Rect: 35, 162, 97, 184 Annotation: Subtype: Link Rect: 153, 89, 154, 98 Annotation: Subtype: Link Rect: 35, 77, 147, 86 Annotation: Subtype: Link Rect: 418, 118, 425, 127 ActionDest: 323 Annotation: Subtype: Link Rect: 480, 93, 487, 102 ActionDest: 323 Annotation: Subtype: Link Rect: 470, 67, 477, 76 ActionDest: 323 Annotation: Subtype: Link Rect: 120, 17, 281, 28 Annotation: Subtype: Link Rect: 398, 17, 558, 28 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 296, 699, 303, 708 ActionDest: 323 Annotation: Subtype: Link Rect: 296, 686, 303, 695 ActionDest: 323 Annotation: Subtype: Link Rect: 217, 649, 224, 658 ActionDest: 323 Annotation: Subtype: Link Rect: 227, 649, 234, 658 ActionDest: 323 Annotation: Subtype: Link Rect: 327, 636, 334, 645 ActionDest: 323 Annotation: Subtype: Link Rect: 529, 611, 541, 620 ActionDest: 323 Annotation: Subtype: Link Rect: 544, 611, 556, 620 ActionDest: 323 Annotation: Subtype: Link Rect: 529, 598, 541, 608 ActionDest: 323 Annotation: Subtype: Link Rect: 544, 598, 556, 608 ActionDest: 323 Annotation: Subtype: Link Rect: 295, 574, 302, 582 ActionDest: 323 Annotation: Subtype: Link Rect: 302, 573, 314, 582 ActionDest: 323 Annotation: Subtype: Link Rect: 451, 548, 463, 557 ActionDest: 323 Annotation: Subtype: Link Rect: 464, 548, 476, 557 ActionDest: 323 Annotation: Subtype: Link Rect: 288, 473, 300, 482 ActionDest: 323 Annotation: Subtype: Link Rect: 300, 473, 312, 482 ActionDest: 323 Annotation: Subtype: Link Rect: 515, 372, 527, 381 ActionDest: 323 Annotation: Subtype: Link Rect: 543, 83, 555, 92 ActionDest: 323 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 532, 87, 539, 99 ActionDest: 184 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 397, 424, 404, 436 ActionDest: 184 Annotation: Subtype: Link Rect: 455, 424, 462, 436 ActionDest: 234 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 356, 90, 363, 102 ActionDest: 184 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 350, 352, 362, 361 ActionDest: 323 Annotation: Subtype: Link Rect: 448, 339, 460, 348 ActionDest: 323 Annotation: Subtype: Link Rect: 544, 277, 555, 286 ActionDest: 339 Annotation: Subtype: Link Rect: 544, 189, 556, 198 ActionDest: 339 Annotation: Subtype: Link Rect: 417, 88, 429, 97 ActionDest: 339 Annotation: Subtype: Link Rect: 426, 63, 438, 72 ActionDest: 339 Page: Sequence: 7 Annotations: Annotation: Subtype: Link Rect: 425, 697, 437, 706 ActionDest: 323 Annotation: Subtype: Link Rect: 270, 647, 282, 656 ActionDest: 339 Annotation: Subtype: Link Rect: 399, 622, 411, 631 ActionDest: 339 Annotation: Subtype: Link Rect: 462, 509, 474, 518 ActionDest: 339 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 104, 696, 141, 706 Annotation: Subtype: Link Rect: 148, 696, 184, 706 Annotation: Subtype: Link Rect: 419, 683, 560, 694 Annotation: Subtype: Link Rect: 56, 672, 228, 683 Annotation: Subtype: Link Rect: 306, 660, 560, 671 Annotation: Subtype: Link Rect: 56, 649, 85, 660 Annotation: Subtype: Link Rect: 294, 626, 331, 637 Annotation: Subtype: Link Rect: 104, 592, 141, 602 Annotation: Subtype: Link Rect: 148, 592, 184, 602 Annotation: Subtype: Link Rect: 519, 568, 557, 579 Annotation: Subtype: Link Rect: 59, 558, 95, 568 Annotation: Subtype: Link Rect: 261, 522, 298, 533 Annotation: Subtype: Link Rect: 494, 499, 532, 510 Annotation: Subtype: Link Rect: 205, 465, 242, 476 Annotation: Subtype: Link Rect: 127, 443, 164, 453 Annotation: Subtype: Link Rect: 334, 419, 372, 430 Annotation: Subtype: Link Rect: 289, 397, 327, 407 Annotation: Subtype: Link Rect: 311, 373, 348, 384 Annotation: Subtype: Link Rect: 59, 339, 97, 349 Annotation: Subtype: Link Rect: 103, 339, 139, 349 Annotation: Subtype: Link Rect: 182, 304, 219, 315 Annotation: Subtype: Link Rect: 226, 304, 262, 315 Annotation: Subtype: Link Rect: 255, 269, 292, 280 Annotation: Subtype: Link Rect: 299, 269, 335, 280 Annotation: Subtype: Link Rect: 121, 246, 458, 257 Annotation: Subtype: Link Rect: 422, 223, 459, 234 Annotation: Subtype: Link Rect: 519, 200, 557, 211 Annotation: Subtype: Link Rect: 59, 189, 95, 200 Annotation: Subtype: Link Rect: 509, 166, 546, 177 Annotation: Subtype: Link Rect: 307, 131, 345, 142 Annotation: Subtype: Link Rect: 488, 108, 525, 119 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 91, 721, 560, 732 Annotation: Subtype: Link Rect: 56, 709, 135, 720 Annotation: Subtype: Link Rect: 122, 676, 160, 686 Annotation: Subtype: Link Rect: 272, 640, 310, 651 Annotation: Subtype: Link Rect: 316, 640, 352, 651 Annotation: Subtype: Link Rect: 193, 606, 230, 617 Annotation: Subtype: Link Rect: 336, 583, 374, 594 Annotation: Subtype: Link Rect: 380, 583, 416, 594 Annotation: Subtype: Link Rect: 308, 560, 346, 571 Annotation: Subtype: Link Rect: 352, 560, 388, 571 Checksum: 7f7572e2 Type: CRC32 Checksum: bb492438aee1822c8d567a6770280385 Type: MD5 Checksum: f4155bc40e575008a76629a04cd35f789ad3cd1e Type: SHA-1