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Increased risk for hepatitis C associated with solvent use among Canadian Aboriginal injection drug users Shaw, Souradet Y; Deering, Kathleen N; Jolly, Ann M; Wylie, John L Jul 19, 2010

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Shaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Open AccessR E S E A R C HResearchIncreased risk for hepatitis C associated with solvent use among Canadian Aboriginal injection drug usersSouradet Y Shaw*1,2, Kathleen N Deering3, Ann M Jolly4,5 and John L Wylie2,6,7AbstractBackground: Solvent abuse is a particularly serious issue affecting Aboriginal people. Here we examine the association between solvent use and socio-demographic variables, drug-related risk factors, and pathogen prevalence in Aboriginal injection drug users (IDU) in Manitoba, Canada.Methods: Data originated from a cross-sectional survey of IDU from December 2003 to September 2004. Associations between solvent use and variables of interest were assessed by multiple logistic regression.Results: A total of 266 Aboriginal IDU were included in the analysis of which 44 self-reported recent solvent use. Hepatitis C infection was 81% in solvent-users, compared to 55% in those reporting no solvent use. In multivariable models, solvent-users were younger and more likely to be infected with hepatitis C (AOR: 3.5; 95%CI: 1.3,14.7), to have shared needles in the last six months (AOR: 2.6; 95%CI:1.0,6.8), and to have injected talwin & Ritalin (AOR: 10.0; 95%CI: 3.8,26.3).Interpretation: High hepatitis C prevalence, even after controlling for risky injection practices, suggests that solvent users may form closed networks of higher risk even amongst an already high-risk IDU population. Understanding the social-epidemiological context of initiation and maintenance of solvent use is necessary to address the inherent inequalities encountered by this subpopulation of substance users, and may inform prevention strategies for other marginalized populations.BackgroundIn developed countries, sexually transmitted infections(STI) and bloodborne pathogens (BBP) disproportion-ately affect marginalized populations. In the UnitedStates, Australia, and Canada the combined impact ofpoverty, lack of access, and historical and systemicoppression have resulted in overrepresentation of indige-nous populations in national HIV/AIDS and STI statis-tics, especially amongst females and youth[1-6]. WithinCanada, injection drug users (IDU) account for a signifi-cant proportion of prevalent HIV and other BBP (such ashepatitis C [HCV]) infections, and are an especiallyimportant risk group sustaining endemicity of thesepathogens within Aboriginal populations[4,7-9]. How-ever, despite progress in, and substantial efforts towardsboth understanding, and addressing BBP epidemics inCanadian Aboriginal populations[7], the transmission ofsome BBP, such as HIV and HCV, appear to be growingunabated[10-12]. This paradox has motivated researchersto examine heterogeneity in marginalized subpopula-tions, with the intention of finding and describing sub-populations that may be at particularly high risk of BBPtransmission, as well as the environmental contextswithin which they are embedded[13-16].To this end, solvent abuse has been shown to be a par-ticularly serious and destructive issue affecting Aborigi-nal populations in Canada, and elsewhere[17-25]. InNorth America, the lifetime use of solvents has beenreported to be as high as 44% in some high-riskgroups[26], with some studies finding the prevalence oflifetime use at 17% by the eighth grade[27]. Solvent use isa term broadly applied to the self-administered inhalation* Correspondence: umshaw@cc.umanitoba.ca1© 2010 Shaw et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.of a variety of volatile, psychoactive substances that are Centre for Global Public Health, University of Manitoba, R070 Med Rehab Bldg 771 McDermot Avenue, Winnipeg, Manitoba R3E 0T6, CanadaFull list of author information is available at the end of the articleShaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Page 2 of 8found in many common products, including gasoline andadhesive glue[24,28]. Solvent users have elevated rates ofnegative health outcomes including mental illness[29,30],damage to the central nervous system, heart and lungs[28,31,32], as well as mortality[32,33]. Contributing to itsperniciousness, solvents are primarily legal and easilyobtainable[18,34]. As well, multiple factors have beenidentified as being associated with solvent use, includingage, sex, ethnicity, education level, co-existing alcohol orother substance use disorders, and child and physicalabuse[35-39]. In youth, solvent use has been linked tobroader societal issues such as higher school drop-outrates[40], delinquency (including criminal activity)[36,39]and family conflict[39,41]. Salient to this study, an associ-ation between chronic solvent use in adolescence andinjection drug use among the most marginalized of popu-lations has been demonstrated[20,42-44].On the treatment side, a particular defining feature ofchronic solvent use is that it is typically associated withthe most marginalized populations, with, for examplehigher levels of anti-social behaviour, trauma-exposureand psychiatric morbidities[19,24,45]. In response to theburgeoning need for Aboriginal-specific programs, Can-ada has over a dozen solvent abuse treatment centresspread across the country[46]. These centres operateunder a continuum of interventions, including preven-tion, early intervention, residential treatment and envi-ronmental deterrence. Furthermore, evidence suggestsIDU with a solvent use background have a "specificcourse of addiction"[39], often with much more detri-mental outcomes, and a particular intransigency to treat-ment[39,47]. This "deviant group within a deviant group"has been recognized since the late 1970s[47], but is stillpoorly understood, relative to other IDU groups.Despite the link observed between solvent use and IDU,and the disproportionate burden of both solvent abuseand STI/BBP infection in Aboriginal populations, there islittle published research on solvent use among AboriginalIDU. We therefore undertook this study to examine theassociation between solvent use and socio-demographicand drug-related risk factors in Aboriginal IDUs in Mani-toba, Canada. We were also interested in examining therelationship between solvent use and injection of othertypes of illicit substances, as well as being infected with aBBP (i.e., HIV and HCV).MethodsStudy setting and survey instrumentThe study setting and survey instrument have beendescribed previously[48-50]. This was a cross-sectionalsurvey of IDU in Winnipeg, Manitoba, Canada (pop.mants) and word-of-mouth. Eligibility criteria includedself-reported use of illicit injection drugs in the 6-monthperiod prior to interview and having an age of 15 years ormore. Potential participants made telephone contact withthe study nurse, who administered all surveys in-person.Interviews took place in a private setting of the partici-pant's choosing. An honorarium was provided to all studyparticipants providing written or oral consent. The ques-tionnaire was divided into three sections. The first sec-tion consisted of questions based on the respondent'sown characteristics, the second elicited information onthe respondent's egocentric network (i.e., the people withwhom the respondent had regular contact with), whilethe third section asked questions on the respondent'sIDU risk network. The first section was of primary inter-est for this study. The study design was approved by theHealth Research Ethics Board of the University of Mani-toba and the Winnipeg Regional Health AuthorityResearch Review Committee.MeasuresThe outcome measure in this study was a binary variabledescribing solvent use, which was derived from a positiveanswer for "Gasoline/Solvents" to the survey item "In thelast 6 months, which of the following drugs have you usedwithout injecting?" The study sample of IDUs was subset-ted to only individuals who self-identified as Aboriginal,and included those who identified as 'First Nations' or'Metis'. Variables were grouped into four categories:socio-demographic, injection-related behaviours, otherdrug use and BBP status. Socio-demographic variablesincluded: age, which was categorized as 15-29, 30-39, and40 years or more; education, which was coded as'dropped out less than grade 12' or 'grade 12 or higher';and place of birth, which was coded as 'born inside Mani-toba' or 'born elsewhere'. Injection-related behavioursincluded: locales where drugs were injected (in the last 6months), and this list included their own house, a familymembers' or friends' residences, an empty house, a shel-ter/hostel, hotel, shooting gallery and on the street; shar-ing needles (ever and in the last 6 months); sharing otherinjection equipment; injecting someone as a service;injecting someone as a favour; and ease of obtaining nee-dles. The time frame for the last four questions was 6months.Participants were asked which drugs they injected mostfrequently and finally, in terms of BBP infection, HIV andHCV status was assessed using venous blood samples,tested at Cadham Provincial Laboratory (Winnipeg, MB).Specimens were screened for HCV and HIV with AxSYMHCV (Abbott, Mississauga, ON) and AxSYM HIV1/2 gO675,000) conducted from December 2003 to September2004. Recruitment was advertised at local communityhealth centres, meeting places (as identified by key infor-(Abbott, Mississagua, ON), respectively. Presumptivepositives were confirmed for HCV with Chiron HCV 3.0RIBA (Ortho-Clinical Diagnostics, Markham, ON). Pre-Shaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Page 3 of 8sumptive HIV positive specimens were confirmed bywestern blot (BioRad, Montreal, QC).Statistical methodsAssociations between solvent use and variables of interestwere assessed using χ2 tests. Variables that were signifi-cant at the p < .20 level were included in multivariablelogistic regression analysis. A parsimonious model wasdesired, so therefore, with the exception of sex (whichwas forced into the model to adjust for its effects), a back-wards stepwise regression procedure was used to elimi-nate variables that were not significant at the p < .05 level.Odds ratios (OR) and their 95% confidence intervals (95%CI) are reported for univariate and multivariable analy-ses. Multicollinearity of the final model was assessedusing VIF and tolerance statistics. Stata version 9 wasused in performing all analyses[51].ResultsA total of 272 IDU identified as Aboriginal. An additional6 that identified as transgendered were excluded from theanalyses due to small numbers, leaving a total sample sizeof 266. Overall, 44 (16.5%) of the study sample reportedsolvent use in the last 6 months. Table 1 displays a com-parison of characteristics of solvent and non solvent-using IDU. Broadly speaking, the two groups differed sig-nificantly, at least at the p < .05 level, by age, injectionlocations, injection risk behaviours, type of drugsinjected and BBP status (Table 1).Socio-demographic, injection-related and BBP status characteristicsSpecifically, solvent-using IDU tended to be younger inage (p < .001) with an average age of 31.6 years (SD: 7.5),compared to non-solvent-using IDU, who averaged 36.3years of age (SD: 9.1). Solvent users were more likely tohave reported injecting in a family house (OR: 2.71;95%CI: 1.32,5.79), empty house (OR: 2.67; 95%CI:1.16,6.14), hotel (OR: 2.34; 95%CI: 1.20,4.57), shootinggallery (OR: 2.76; 95%CI: 1.35,5.66) and on the street(OR: 2.05; 95%CI: 1.05,4.02). Solvent users were morelikely to have reported sharing needles in the last 6months (OR: 3.74; 95%CI: 1.78,7.85). In terms of the mostfrequent drugs injected, solvent users were more likely toreport Talwin & Ritalin injection (OR: 11.69; 95%CI:4.73,28.87), while less likely to report cocaine (OR: 0.42;95%CI: 0.22,0.81) and crack (OR: 0.26; 95%CI: 0.09,0.77)injection. No solvent users reported heroin, amphet-amines or methadone as their most frequently injecteddrug. Finally, solvent users were more likely to be HCVpositive (OR: 3.33; 95%CI: 1.46,7.58). Solvent users wereMultivariable analysisAfter backwards elimination, the following variablesremained in the final logistic regression model (Table 2):HCV status (p = .016), sharing needles in the last 6months (p = .048), Talwin & Ritalin injection (p < .001)and age (p < .001), adjusted for sex. All variablesremained significant if sex was removed from the model.DiscussionThis study examined the association between solvent usein Aboriginal IDU and socio-demographic factors, drug-related risk factors, use of other illicit substances and BBPinfection. We found that after adjusting for other vari-ables including sex, solvent use was significantly associ-ated with Talwin & Ritalin injection, HCV status and agein this population.Some important limitations of the study should bestated at the outset. First and foremost, ours was a cross-sectional study, and a causal linkage between solvent useand injection drug use cannot be inferred from the data.Although both likely share determinants, our data areinsufficient to establish causality. Aboriginal individualsin Canada face a combination of socially and structurallydetermined vulnerabilities, including high rates ofentrenched poverty, unemployment, homelessness andsexual and physical abuse[2,52,53]. Many of these factorsstem from a history of colonization, oppression, systemicracism and discrimination in Canadian society and haveresulted in Aboriginal Canadians having unequal accessto a variety of resources [2,54]. Thus, the perniciousnessof both solvent and injection drug use within Aboriginalpopulations is more likely a result of these determinants.Second, solvent use was measured broadly. The measureused was not precise enough to discriminate betweenchronic and casual use. Similarly, different types of sol-vents were not captured in this study. Third, since a sam-pling frame was not possible to construct for thismarginalized and hidden population, the sample was notrandomly generated and may not be representative ofAboriginal IDUs in other settings, or in Winnipeg.Fourth, social desirability bias, or high non-response rateis always an issue with self-reported data; however, it islikely that this would have served to underestimate asso-ciations toward the null. Finally, the sample size was rela-tively small and thus may have not had power to detectsignificant findings.Previous studies in Winnipeg have reported Talwin &Ritalin injection as being strongly associated with bothAboriginal ethnicity[50,55] and high HCV preva-lence[49]. That HCV infection is three times more likelyin the population of solvent-using Aboriginal IDU, aftermore likely to be HIV positive than their non-solventusing counterparts (17.5% versus 8.3%), but this was notstatistically significant at the p < .05 level (p = .076).controlling for Talwin & Ritalin injection and risky injec-tion practices, strongly suggests the existence of pocketsof higher risk even amongst an already high-risk subpop-Shaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Page 4 of 8Table 1: Characteristics of 266 Aboriginal IDU by solvent-use status, Winnipeg ManitobaSolvent use status; no. (%)Users (n = 44) Non-users (n = 222) Odds Ratio (95% CIs) PSocio-DemographicAge15-29 21(47.7) 51(22.4) Ref <.00130-39 17(38.6) 86(37.7) 0.48 (0.23,0.99)40+ 6(13.6) 91(39.9) 0.16 (0.07,0.42)Mean (SD) 31.6(7.5) 36.3(9.1)Female 25(56.8) 117(52.7) 1.18 (0.62,2.27) .617Born outside province 5(11.4) 37(16.7) 0.64 (0.24,1.73) .362At least grade 12 38(86.4) 169(76.1) 2.35 (0.90,6.15) .135Injection LocationsOwn House 27(61.4) 121(54.5) 1.33 (0.68,2.57) .403Family House 14(31.8) 32(14.4) 2.71 (1.32,5.79) .005Friend's House 37(84.1) 158(71.2) 2.14 (0.91,5.05) .077Empty House 10(22.7) 22(9.9) 2.67 (1.16,6.14) .017Shelter/Hostel 0(0.0) 6(2.3) n/a .277Hotel 28(63.6) 95(42.8) 2.34 (1.20,4.57) .011Shooting Gallery 15(34.1) 35(15.8) 2.76 (1.35,5.66) .004Street 18(40.9) 56(25.2) 2.05 (1.05,4.02) .034Injection Risk BehavioursShare needles (Ever) 25(56.8) 104(46.9) 1.49 (0.78,2.87) .227Share needles (6 months) 15(34.1) 27(12.2) 3.74 (1.78,7.85) <.001Share injection equipment 13(29.6) 72(32.4) 0.87 (0.43,1.77) .708Inject someone as service 9(20.5) 62(28.2) 0.66 (0.29,1.44) .291Inject someone as favour 19(43.2) 97(44.1) 0.96 (0.50,1.85) .912Ease of obtaining needles 34(77.3) 188(84.7) 0.61 (0.28,1.36) .227Drugs InjectedCocaine 21(47.7) 152(68.5) 0.42 (0.22,0.81) .008Talwin & Ritalin 38(86.4) 78(35.1) 11.69 (4.73,28.87) <.001Morphine 7(15.9) 63(28.4) 0.48 (0.20,1.12) .086Heroin 0(0.0) 18(8.1) n/a --Amphetamines 0(0.0) 4(1.8) n/a --Methadone 0(0.0) 9(4.1) n/a --Crack 4(9.1) 61(27.5) 0.26 (0.09,0.77) .010Crystal Methamphetamine 1(2.3) 9(4.1) 0.55 (0.07,4.46) .570Dilaudid 3(6.8) 23(10.4) 0.63 (0.18,2.21) .470Oxycontin 1(2.3) 6(2.7) 0.84 (0.10,7.13) .871BBP StatusHIV (n = 233) 7(17.5) 16(8.3) 2.34 (0.90,6.15) .082Hepatitis C (n = 238) 33(80.5) 109(55.3) 3.33 (1.46,7.58) .004Shaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Page 5 of 8ulation[39,47]. It was also demonstrated that these quali-tatively distinct 'higher-risk' groups can be distinguishedwhen both injectable and non-injectable drug use is con-sidered.The relatively low prevalence of both HIV and HCVamong IDU in our geographic setting has motivatedresearchers to ask what role, if any, public healthresponses in Winnipeg may have contributed to lowerprevalence[56]. Both HIV and HCV prevalence in thesubset of solvent-using IDU are relatively higher thanother IDU in our sample; and at 18% and 81% respec-tively, are in closer alignment with the prevalenceobserved in other jurisdictions[57,58]. This dichotomy inprevalence reinforces the exceptionally high risk faced bysolvent-using IDU, and their real or potential ability to bemissed by what otherwise may be an effective publichealth response. This higher-risk group is particularly rel-evant given the recent attention paid to especially highrates of HIV in Aboriginal populations in central Can-ada[11,12], and serve to illustrate that BBP epidemics inCanada are not homogeneous.Solvent use is an issue where there are no easily-identi-fiable solutions[23,24]. Solvent users are at the bottom ofa drug-using hierarchy, in terms of perception by othersubstance users and practitioners, and by the sheer vol-ume of their social and personal challenges[29,39,42,47].Thus, given the already difficult lifestyle and behaviouralissues related to injection drug use[58,59], a combinationof solvent use and injection drug use within Aboriginalpopulations may present considerable, and specific chal-lenges for treatment[39,47]. For example, although thereis well-established literature on the effectiveness of harm-reduction efforts such as needle-exchange programs incurtailing the spread of BBPs[60,61], the constituents ofan equivalent and appropriate harm reduction strategyfor solvent users have not been well articulated in the lit-erature [24], although practical advice may include usingsolvents in groups, and using clean rags or sponges. Aswell, outreach efforts to these populations may be undulyhigher risk of HIV seroconversion[10], perhaps an espe-cially chaotic lifestyle is contributing to the higher HCVprevalence in our solvent-using subpopulation.Understanding outlier populationsAs Kuller has suggested that understanding epidemics in"outlier" populations may have substantial benefits inunpacking transmission dynamics in more mainstreampopulations[62], a deeper examination of this, and similarsubpopulations is warranted. Thus, we submit thatunderstanding the exogenous factors that contribute tosolvent use in IDU may result in better understanding ofmarginalized subpopulations in general, particularly withrespect to understanding the trajectory of use[63]. Forexample, it has been recognized that solvent use is typi-cally a group activity[23,24,26]. The natural consequenceis the tendency to form closed networks[64], in this casecomprised of fellow solvent-using IDU. This may be par-ticularly true in our study population of Aboriginal IDUs,since individuals have been shown to form more cohesivestructures according to ethnicity[65]. At the same time,the near ubiquity and accessibility of sources of solventsand inhalants is clearly a key contributor to theirabuse[66]. Recent programs that seek to address solventuse in adolescent Aboriginal Canadians through improv-ing individual-level coping strategies recognize that with-out multi-level support structures (e.g. family,community, environment) in place, individual recovery islikely to fail[25]. Other researchers have found that strongpeer group sanctions against solvent use, in concert withmessages concerning the dangers of solvent use were pro-tective against lifetime and current use of solvents[23].Thus, finding ways to identify and engage with solventusers and their peers may have application with otherhidden and marginalized populations. Along this line,some authors have suggested that solvent use may be amarker for an inherently more challenging type of sub-stance user[19,45]. Thus, it may be useful to understandto what extent the actual choice of solvent use is a proxyTable 2: Adjusted Odds Ratios, Multivariable Logistic Regression of Predictors of Solvent Use, Aboriginal IDU, Winnipeg ManitobaOdds Ratio (95% CIs) Standard Error pHepatitis C 3.52 (1.27,14.68) 1.85 .016Share needles (last 6 months) 2.61 (1.01,6.78) 1.27 .048Talwin & Ritalin injection 9.97 (3.77,26.34) 4.94 <.001Age (per year increase) 0.91 (0.86,0.96) 0.02 <.001Female 0.80 (0.35,1.81) 0.33 .587hampered by the considerable stigma attached to chronicsolvent use. Similar to recent Canadian research demon-strating that IDU who also smoked crack cocaine were atfor characteristics that distinguish the most marginalizedof subpopulations. Understanding the populations thatbecome chronic abusers of easy-to-obtain substancesShaw et al. Harm Reduction Journal 2010, 7:16http://www.harmreductionjournal.com/content/7/1/16Page 6 of 8(such as solvents) may help to facilitate a more generalunderstanding of subpopulations that have proven to beintractable to treatment.The fact that solvent use clusters around Talwin & Rit-alin injection suggests two other interesting areas forfuture research. First, other authors have demonstratedthe advantages of understanding IDU from a poly-injec-tion drug use perspective[67]. Here, we have demon-strated the practicality of examining IDU in their use ofboth injection and non-injection drugs. At the treatmentlevel, this perspective highlights the importance of treat-ing two or more qualitatively distinct addictions concur-rently[68,69]. For example, Stenbacka et al. demonstratedthat opiate-injecting IDU undergoing methadone mainte-nance therapy (MMT) were more likely to relapse if theyhad co-occurring alcohol abuse issues[69]. Secondly, theclustering of solvent and Talwin & Ritalin use suggeststhat the use of either is driven, to a certain degree, byopportunism. Although our data cannot provide a defini-tive answer, it would be useful to know under what cir-cumstances IDU resort to inhaling solvents. Assuminginhalation is their 'fallback' method, and philosophicallysimilar to MMT, perhaps a reliable supply of other inject-able or non-injectable drugs would deter this subpopula-tion of IDU from using solvents, and thus prevent someof the more serious neurological and cognitive deficitsassociated with long-term chronic use[70,71].ConclusionIn conclusion, although addressing social or peer groupnorms has long been advocated as part of an effectiveprevention and treatment strategy for IDU, perhapsstructural-level interventions are especially indicated forsolvent-using Aboriginal IDU. At a time when rates ofHIV and other BBPs are escalating in Canadian Aborigi-nal populations, studies like this one can help inform tar-geted strategies, as well as motivate harm reductionresearch in very marginalized populations. The strongsocially-constructed vulnerabilities of Aboriginal popula-tions, the illegality of injection drug use, the obduracy ofsolvent use to traditional regulation and control, and theextreme marginalization of solvent users may be interact-ing to create a 'perfect storm' for those IDU alreadyinfected, and those at high risk for infection to slipthrough the cracks in public health systems.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsSS was responsible for conceptualization of the study, analysis, interpretationof data and writing of the manuscript. KD made substantial contributions todata analysis and interpretation and revised the manuscript critically, andAcknowledgementsFunding for this study was provided by the Canadian Institutes of Health Research. The authors acknowledge contributions from Margaret Fast, Gayatri Jayaraman, Katherine Dinner and Maxine Zasitko.Author Details1Centre for Global Public Health, University of Manitoba, R070 Med Rehab Bldg 771 McDermot Avenue, Winnipeg, Manitoba R3E 0T6, Canada, 2Department of Community Health Sciences, University of Manitoba S113 - 750 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W3, Canada, 3School of Population and Public Health, University of British Columbia 2206 East Mall, Vancouver, British Columbia V6T 1Z3, Canada, 4Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada 100 Eglantine Driveway-Tunney's Pasture, Ottawa, Ontario K1A 0K9, Canada, 5Department of Epidemiology and Community Medicine, University of Ottawa Room 3104-451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada, 6Department of Medical Microbiology, University of Manitoba 745 Bannatyne Avenue, Winnipeg, Manitoba R3E 0J9, Canada and 7Cadham Provincial Laboratory, Manitoba Health 750 William Avenue, Winnipeg, Manitoba R3C 3Y1, CanadaReferences1. 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