Flu Vaccination During Early Pregnancy Linked to Nearly Eightfold Risk of Miscarriage
- September 26, 2017 • 84,550 views
- Disponible en Español
Story at-a-glance
- In recent years, pregnant women have been told to get an increasing number of vaccinations, even though there’s a shocking lack of studies to confirm the safety for mother and child
- In 2009, reports of miscarriage following receipt of the pandemic H1N1 swine flu vaccine (pH1N1) started emerging. Now, a study has found that women who had received a pH1N1-containing flu vaccine two years in a row were more likely to suffer miscarriage within the following 28 days
- Most miscarriages occurred during the first trimester, but several also took place in the second trimester. Median fetal term at the time of miscarriage was seven weeks
- In all, pregnant women receiving concurrent pH1N1-containing flu vaccines had a nearly eightfold higher risk of miscarriage
- On August 28, 2017, the AAP recommended that newborns who weigh at least 2,000 grams (4.4 pounds) should receive their first dose of hepatitis B vaccine within 24 hours of birth
By Dr. Mercola
Most pregnant women know to abstain from alcohol, tobacco and other obvious toxins to protect the child growing in their womb, but what about vaccines? In recent years, pregnant women have been told to get an increasing number of vaccinations, even though there’s a shocking lack of studies to confirm the safety for mother and child.
As noted by Barbara Loe Fisher, president of the National Vaccine Information Center (NVIC) in her 2013 article, “Vaccination During Pregnancy: Is it Safe?”:1
As far as the scientific evidence is concerned, it’s still unknown whether the influenza vaccine can cause fetal harm or affect your reproductive capacity,14 which is why the vaccine manufacturer product inserts state that the influenza vaccine should only be given to a pregnant woman if it’s “clearly needed.”
Pregnant women are essentially expected to stick to recommendations out of sheer faith, since vaccine recommendations are not based on weighty scientific evidence. In fact, health statistics suggest there’s something very wrong going on in the U.S., seeing how we have one of the highest maternal and infant mortality rates in the world.
As of last year, global rates for maternal mortality had fallen by half — except in the U.S., where the number of women who die from pregnancy-related complications has significantly increased.15 Infant mortality rates are also far higher in the U.S. than in any of the other 27 wealthy countries surveilled by the Centers for Disease Control and Prevention (CDC).16
Could this be related to the fact that American babies and pregnant women receive the greatest number of vaccines? While there’s no research clearly proving this, there’s also no evidence to refute the hypothesis that excessive vaccinations may be part of the problem.
Now, a paper18, 19,20 published in the journal Vaccine is yet again raising questions about whether it is safe to give pregnant women flu vaccine. They found that women who had received a pH1N1-containing flu vaccine two years in a row were more likely to suffer miscarriage within the following 28 days.
While most of the miscarriages occurred during the first trimester, several also took place in the second trimester. The median fetal term at the time of miscarriage was seven weeks. In all, 485 pregnant women aged 18 to 44 who had a miscarriage during the flu seasons of 2010/2011 and 2011/2012 were compared to 485 pregnant women who carried to term.
Of the 485 women who miscarried, 17 had been vaccinated twice in a row — once in the 28 days prior to vaccination and once in the previous year. For comparison, of the 485 women who had normal pregnancies, only four had been vaccinated two years in a row. While the study could not establish direct causation, the researchers call for more research to assess the link. Commenting on the study, which was funded by the Centers for Disease Control and Prevention (CDC), Amanda Cohn, CDC adviser for vaccines stated:
Remember the former head of the CDC, Julie Gerberding, left the CDC in 2009 to later become president of Merck Vaccines, a position she held until December 2014, when she became Merck’s executive vice president of strategic communications, global public policy and population health.
Notably, this edit was done without disclosing the edit made, which is standard practice. I would not be at all surprised if the study actually gets retracted in coming weeks for some perceived shortcoming or flaw, even though it’s virtually impossible to find a published study that isn’t impervious to such critique. As noted by J.B. Handley, co-founder of Generation Rescue:23
While you can certainly take the time to pore through the medical literature, available on PubMed for example, all you really have to do to confirm or refute this particular statement is to look at a flu vaccine package insert, which will tell you that safety and effectiveness have NOT been established in pregnant women. This means there are no studies showing pregnant women will benefit from flu vaccination. Nor are there any studies to support the claim that getting vaccinated during pregnancy is in fact safe.
If something has not been established, the issue is still wide-open for debate. To claim anything else is simply to spout opinions. Handley provides the following screen shot, showing the fine print from a 2016 package insert for Sanofi Pasteur’s Fluzone Quadrivalent vaccine, which is routinely given to pregnant women.
They just don’t know it, and articles like Sun’s perpetuate the false idea that “a multitude” of studies have already established safety and effectiveness of flu vaccination during pregnancy.
For example, a study25 published in Human & Experimental Toxicology in 2012, based on reports from the Vaccine Adverse Events Reporting System (VAERS) database during three consecutive flu seasons, starting with the 2008/2009 season, found “an ascertainment-corrected rate of 590 fetal-loss reports per million pregnant women vaccinated (or 1 per 1,695).”
Canadian researchers have also found that people who receive consecutive flu seasonal vaccinations start to experience declined flu protection. As reported by CBC News in January 2015:26
Research has shown that stimulating a woman’s immune system during midterm and later-term pregnancy significantly increases the risk that her baby will develop autism27 during childhood, and/or schizophrenia during the teenage years or early adulthood.28 It may also increase the risk of seizures in the baby, and later, as an adult.29 In fact, a number of neurodevelopmental and behavioral problems can occur in babies born to women immunologically stimulated during pregnancy.30,31,32
Despite such evidence, ACOG issued a notice September 13, the same day the featured study was published, saying it’s perfectly safe to receive the flu vaccine during pregnancy, no matter what the study in the Vaccine journal suggests. According to ACOGs press release:33
The rules are looser, apparently, for everyone else. All in all, this is one giant experiment on pregnant women and infants — which Sanofi Pasteur even admits in its patient information sheet — and it is being driven by pharma greed and institutional power, infected with denialism.
The CDC’s Advisory Committee on Immunization Practices started recommending this in October 2016, and the AAP is now following suit. I cannot think of a more unnecessary and unjustifiable vaccine than hepatitis B to an infant weighing only 4 pounds. Hepatitis B is transmitted from IV drug abuse, sexual activity with an infected partner, a blood transfusion using contaminated blood, or from a hepatitis B-positive mother.
This recommendation is medically unjustifiable, absolutely irrational and has no basis in science. The singular threat of this disease during infancy is if a child is born to an infected mother. Since that’s the case, why not screen all pregnant women for the disease and only give the vaccine to those infants whose mothers actually test positive for hepatitis B?
That kind of revised rational policy would be a lot less expensive, and far safer for the majority of babies born in the United States. The AAP admits that “the birth dose of hep B vaccine is a critical safety net for infants born to infected mothers when the mother’s results are not obtained, are misinterpreted, are falsely negative, are transcribed or reported inaccurately, or are not communicated to the infant care team.”
In other words, because medical records are in such disarray, and future compliance to questionable vaccines simply can’t be predicted, let’s just vaccinate all the babies instead of trying to figure out if the mother might be hep B positive. That kind of attitude really does not instill confidence in basic medical record keeping — especially if the mother is indeed tested during pregnancy.
If false negatives are truly of such great concern, just test her twice, say, at her first obstetrics checkup and then again just before giving birth. Two false negatives are unlikely, and if they cannot keep track of test results obtained in the last nine months, then something else really needs addressing.
Unsurprisingly, the hepatitis B vaccine35 has also been scientifically linked to 69 different diseases and adverse consequences, including death. A 2001 study,36 which assessed adverse events associated with the hepatitis B vaccine in children under the age of 6, concluded the “hepatitis B vaccine is positively associated with adverse health outcomes in the general population of U.S. children.”
The benefit of only measuring humoral immunity (antibodies) as a means of measuring vaccine effectiveness is that it can be easily determined by drawing blood samples. If specific vaccine-induced antibodies are present, the person is presumed to be immune to that infection and protected.
The whole point of vaccines is to stimulate antibody production without a cell mediated reaction preceding it. The theory goes back to the early days when it was believed that the humoral (antibody) arm of the immune system was the most important part of stimulating immunity.
However, research reveals that individuals who, due to a genetic abnormality are unable to generate antibody production, actually recover from infectious illness just as well as those able to make normal antibodies.37 They also usually have protection in the future upon re-exposure.
This demonstrates the importance of the Th1 arm of immunity, and suggests humoral immunity may only play a secondary role in natural resistance against targeted “vaccine-preventable” diseases. This, and the fact that vaccines fail to confer lifelong immunity, suggests that having a cell mediated response is necessary. What’s more, research suggests that when Th2 is excessively stimulated through vaccination, your immune function may be compromised long term, leaving you more vulnerable to cancer.
Autoimmune diseases involve excessive antibody production while cancer involves cell mediated immune failure. This is why therapies that stimulate the cell mediated or innate immune system, such as Coley's toxins, can be helpful against cancer. What this suggests is that our modern vaccine policy, which is a full-scale assault on the cell mediated immune system, is a contributing factor to many of the chronic diseases we see.
There are also dozens of studies demonstrating that contracting certain childhood diseases actually protects you against various types of cancer later in life — everything from melanoma to leukemia. There's even evidence suggesting childhood diseases help protect against future heart disease.
These and hundreds of other studies can be found in Neil Z. Miller’s book, “Miller’s Review of Critical Vaccine Studies: 400 Important Scientific Papers Summarized for Parents and Researchers.” If you’re on the fence when it comes to vaccination, this is a book not to be missed.
Most pregnant women know to abstain from alcohol, tobacco and other obvious toxins to protect the child growing in their womb, but what about vaccines? In recent years, pregnant women have been told to get an increasing number of vaccinations, even though there’s a shocking lack of studies to confirm the safety for mother and child.
As noted by Barbara Loe Fisher, president of the National Vaccine Information Center (NVIC) in her 2013 article, “Vaccination During Pregnancy: Is it Safe?”:1
“Although since the 1970s public health officials have recommended influenza vaccinations for pregnant women in the second or third trimester,2 relatively few obstetricians promoted the vaccine until the past decade when, in 2006, the Centers for Disease Control (CDC) strengthened recommendations that all pregnant women, healthy or not, should get a flu shot in any trimester.3
[C]urrent vaccine recommendations4,5,6 are endorsed by the American Congress of Obstetricians and Gynecologists (ACOG)7,8 the American Academy of Pediatrics (AAP) and other medical trade associations.9,10
With these recommendations, the time-honored rule of avoiding any potential toxic exposure that might interfere with the normal development of the fetus has been suspended and replaced with an assumption that vaccination during pregnancy is safe.”
Vaccinations During Pregnancy Have No Basis in Science
Fisher goes on to list no less than 10 vaccine facts pertaining to the lack of evidence of safety in pregnant women. For starters, drug companies did not test the safety and effectiveness of giving influenza vaccine to pregnant women before the vaccines were licensed in the U.S.,11,12 and data on inflammatory and other biological responses to vaccination during pregnancy that could affect pregnancy and birth outcomes is still lacking.13As far as the scientific evidence is concerned, it’s still unknown whether the influenza vaccine can cause fetal harm or affect your reproductive capacity,14 which is why the vaccine manufacturer product inserts state that the influenza vaccine should only be given to a pregnant woman if it’s “clearly needed.”
Pregnant women are essentially expected to stick to recommendations out of sheer faith, since vaccine recommendations are not based on weighty scientific evidence. In fact, health statistics suggest there’s something very wrong going on in the U.S., seeing how we have one of the highest maternal and infant mortality rates in the world.
As of last year, global rates for maternal mortality had fallen by half — except in the U.S., where the number of women who die from pregnancy-related complications has significantly increased.15 Infant mortality rates are also far higher in the U.S. than in any of the other 27 wealthy countries surveilled by the Centers for Disease Control and Prevention (CDC).16
Could this be related to the fact that American babies and pregnant women receive the greatest number of vaccines? While there’s no research clearly proving this, there’s also no evidence to refute the hypothesis that excessive vaccinations may be part of the problem.
Flu Vaccine May Be Associated With Increased Risk of Miscarriage
In 2009, reports of miscarriage following administration of the H1N1 swine flu vaccine started emerging.17 Dozens of women claimed they lost their babies just hours or days after getting the vaccine, which had not been tested on pregnant women or, if it was, the evidence was never published. Not surprisingly, these instances were passed off as coincidental. After all, miscarriages do happen, and for any number of different reasons.Now, a paper18, 19,20 published in the journal Vaccine is yet again raising questions about whether it is safe to give pregnant women flu vaccine. They found that women who had received a pH1N1-containing flu vaccine two years in a row were more likely to suffer miscarriage within the following 28 days.
While most of the miscarriages occurred during the first trimester, several also took place in the second trimester. The median fetal term at the time of miscarriage was seven weeks. In all, 485 pregnant women aged 18 to 44 who had a miscarriage during the flu seasons of 2010/2011 and 2011/2012 were compared to 485 pregnant women who carried to term.
Of the 485 women who miscarried, 17 had been vaccinated twice in a row — once in the 28 days prior to vaccination and once in the previous year. For comparison, of the 485 women who had normal pregnancies, only four had been vaccinated two years in a row. While the study could not establish direct causation, the researchers call for more research to assess the link. Commenting on the study, which was funded by the Centers for Disease Control and Prevention (CDC), Amanda Cohn, CDC adviser for vaccines stated:
"I think it's really important for women to understand that this is a possible link, and it is a possible link that needs to be studied and needs to be looked at over more [flu] seasons. We need to understand if it's the flu vaccine, or is this a group of women [who received flu vaccines] who were also more likely to have miscarriages.”At present, the CDC is not making any changes to its recommendation for pregnant women, which states they should get vaccinated against influenza no matter which trimester they’re in.21 This is reprehensible public health policy at its worst. Sacrifice the health of women and their unborn children so corporations can profit.
Remember the former head of the CDC, Julie Gerberding, left the CDC in 2009 to later become president of Merck Vaccines, a position she held until December 2014, when she became Merck’s executive vice president of strategic communications, global public policy and population health.
Washington Post Tries to Minimize Impact of Its Report
Not surprisingly, vaccine industry shills are up in arms about the findings, and already, there are signs suggesting industry pressure is being applied to stifle the news. The original story published by The Washington Post, written by Lena Sun, was headlined “Researchers Find Hint of a Link Between Flu Vaccine and Miscarriage.” That headline was quickly changed to “What to Know About a Study of Flu Vaccine and Miscarriage.”22Notably, this edit was done without disclosing the edit made, which is standard practice. I would not be at all surprised if the study actually gets retracted in coming weeks for some perceived shortcoming or flaw, even though it’s virtually impossible to find a published study that isn’t impervious to such critique. As noted by J.B. Handley, co-founder of Generation Rescue:23
“The mainstream media is doing their best to minimize a devastating study showing a high correlation (7.7-fold) between flu vaccines and miscarriages. A review of the scientific literature shows a body of evidence that supports the new study’s conclusions.”Commenting specifically on The Washington Post’s obvious tiptoeing around the issue, he writes:
“[W]hile I’ve seen a number of different ways for reporters to try and minimize the implications of damaging studies, Ms. Sun’s headline may just take the cake: ‘Researchers find hint of a link between flu vaccine and miscarriage’ … “hint” is not a statistical term nor does “hint” in any way provide a specific assessment of risk.
“Hint” is more like a word that you hope might keep people from reading your article … [T]he actual conclusions by the study authors were deeply troubling … [A]n odds ratio is ‘a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.’
In plain English, an odds ratio greater than 1 would tend to imply that two things are in fact linked (like tobacco use and lung cancer). What was the odds ratio for spontaneous abortion for women who had received an H1N1 shot in 2010–2011 and then a flu vaccine in 2011–12?
The study says 7.7 … that’s not a “hint,” that’s a giant disturbing alarm (which is why the damage control is being rolled out en masse today). Women who had received the two flu shots in successive seasons were almost 8x more likely to have a spontaneous abortion than those who had not …”
Safety of Flu Vaccine Has Not Been Established in Pregnant Women
Sun’s article deserves further critique, which Handley also addresses, and that is her statement that the CDC’s advice to vaccinate pregnant women is “based on a multitude of previous studies.” This simply isn’t true, and you can verify this for yourself (which is what Sun should have done).While you can certainly take the time to pore through the medical literature, available on PubMed for example, all you really have to do to confirm or refute this particular statement is to look at a flu vaccine package insert, which will tell you that safety and effectiveness have NOT been established in pregnant women. This means there are no studies showing pregnant women will benefit from flu vaccination. Nor are there any studies to support the claim that getting vaccinated during pregnancy is in fact safe.
If something has not been established, the issue is still wide-open for debate. To claim anything else is simply to spout opinions. Handley provides the following screen shot, showing the fine print from a 2016 package insert for Sanofi Pasteur’s Fluzone Quadrivalent vaccine, which is routinely given to pregnant women.
Source: Medium, “Devastating Flu Vaccine-Miscarriage Study Sparks Ridiculous Spin,” September 13, 2017
The company’s patient information sheet24
for this vaccine also points out that “Sanofi Pasteur Inc. is
collecting information on pregnancy outcomes and the health of newborns
following vaccination with Fluzone Quadrivalent during pregnancy.” In
other words, pregnant women everywhere are participating in an
uncontrolled experiment in progress. They just don’t know it, and articles like Sun’s perpetuate the false idea that “a multitude” of studies have already established safety and effectiveness of flu vaccination during pregnancy.
Successive Flu Vaccinations Depress Immune Function
We’ve actually known that successive flu vaccinations take a toll on immune function, raising your risk of more severe infections as time goes on — including the possibility of miscarriage if you’re pregnant.For example, a study25 published in Human & Experimental Toxicology in 2012, based on reports from the Vaccine Adverse Events Reporting System (VAERS) database during three consecutive flu seasons, starting with the 2008/2009 season, found “an ascertainment-corrected rate of 590 fetal-loss reports per million pregnant women vaccinated (or 1 per 1,695).”
Canadian researchers have also found that people who receive consecutive flu seasonal vaccinations start to experience declined flu protection. As reported by CBC News in January 2015:26
“During the 2009 H1N1 pandemic, researchers at the B.C. Centre for Disease Control originally thought seasonal flu shots from 2008 might offer extra protection against the new pandemic strain. They were puzzled to find instead, seasonal flu vaccination almost doubled the risk of infection with pandemic flu.
Dr. Danuta Skowronski and her colleagues went on to do five more studies during the summer that showed the same effect in people and in ferrets, which are considered the best animal model of flu.”
Vaccinating Pregnant Women Is Unwise
It has always been a principle of medicine that one should not vaccinate pregnant women, except in extreme cases, because the risk to the baby developing in the womb is too high. It’s only in recent years that this policy is being blatantly violated.Research has shown that stimulating a woman’s immune system during midterm and later-term pregnancy significantly increases the risk that her baby will develop autism27 during childhood, and/or schizophrenia during the teenage years or early adulthood.28 It may also increase the risk of seizures in the baby, and later, as an adult.29 In fact, a number of neurodevelopmental and behavioral problems can occur in babies born to women immunologically stimulated during pregnancy.30,31,32
Despite such evidence, ACOG issued a notice September 13, the same day the featured study was published, saying it’s perfectly safe to receive the flu vaccine during pregnancy, no matter what the study in the Vaccine journal suggests. According to ACOGs press release:33
“The safety of vaccines used during pregnancy is of critical concern to ob-gyns. ACOG carefully tracks pregnancy-related vaccine safety information through its involvement in the National Vaccine Advisory Committee (NVAC) through the U.S. Department of Health & Human Services (HHS) and the Advisory Committee on Immunizations Practices (ACIP) through the Centers for Disease Control and Prevention (CDC).
For many years, ACOG and the CDC have recommended that every pregnant woman receive a flu shot in any trimester. Multiple published studies, as well as clinical experience, have all supported the belief that the flu vaccine is safe and effective during pregnancy.”As you can see, even ACOG claims there are “multiple published studies” in existence showing flu vaccination is safe during pregnancy, despite the fact that vaccine makers actually negate such claims in their package inserts — and vaccine manufacturers are prevented, by federal law, from outright lying in their package insert.
The rules are looser, apparently, for everyone else. All in all, this is one giant experiment on pregnant women and infants — which Sanofi Pasteur even admits in its patient information sheet — and it is being driven by pharma greed and institutional power, infected with denialism.
Why Vaccinate Newborns With Unjustifiable Vaccine?
If vaccinating pregnant women isn’t bad enough, giving newborns, even preemies and low birth weight babies, a completely unnecessary and risky vaccination on the first day of life may be even worse. On August 28, 2017, the AAP recommended that newborns weighing at least 2,000 grams (4.4 pounds) should receive their first dose of hepatitis B vaccine within 24 hours of birth.34The CDC’s Advisory Committee on Immunization Practices started recommending this in October 2016, and the AAP is now following suit. I cannot think of a more unnecessary and unjustifiable vaccine than hepatitis B to an infant weighing only 4 pounds. Hepatitis B is transmitted from IV drug abuse, sexual activity with an infected partner, a blood transfusion using contaminated blood, or from a hepatitis B-positive mother.
This recommendation is medically unjustifiable, absolutely irrational and has no basis in science. The singular threat of this disease during infancy is if a child is born to an infected mother. Since that’s the case, why not screen all pregnant women for the disease and only give the vaccine to those infants whose mothers actually test positive for hepatitis B?
That kind of revised rational policy would be a lot less expensive, and far safer for the majority of babies born in the United States. The AAP admits that “the birth dose of hep B vaccine is a critical safety net for infants born to infected mothers when the mother’s results are not obtained, are misinterpreted, are falsely negative, are transcribed or reported inaccurately, or are not communicated to the infant care team.”
In other words, because medical records are in such disarray, and future compliance to questionable vaccines simply can’t be predicted, let’s just vaccinate all the babies instead of trying to figure out if the mother might be hep B positive. That kind of attitude really does not instill confidence in basic medical record keeping — especially if the mother is indeed tested during pregnancy.
If false negatives are truly of such great concern, just test her twice, say, at her first obstetrics checkup and then again just before giving birth. Two false negatives are unlikely, and if they cannot keep track of test results obtained in the last nine months, then something else really needs addressing.
Unsurprisingly, the hepatitis B vaccine35 has also been scientifically linked to 69 different diseases and adverse consequences, including death. A 2001 study,36 which assessed adverse events associated with the hepatitis B vaccine in children under the age of 6, concluded the “hepatitis B vaccine is positively associated with adverse health outcomes in the general population of U.S. children.”
Your Body Has Two Different Immune Systems
When it comes to vaccination, it’s important to realize there are two parts of the immune system that fight disease in your body. One is the innate immune system that is always ready to work and the other is the adaptive immune system. The adaptive arm consists of Th1 and Th2. Th1 is commonly known as the cell mediated arm, and Th2 known as the humoral or antibody arm. Most vaccines preferentially stimulate the Th2 or humoral part of the immune system that produces antibodies.The benefit of only measuring humoral immunity (antibodies) as a means of measuring vaccine effectiveness is that it can be easily determined by drawing blood samples. If specific vaccine-induced antibodies are present, the person is presumed to be immune to that infection and protected.
The whole point of vaccines is to stimulate antibody production without a cell mediated reaction preceding it. The theory goes back to the early days when it was believed that the humoral (antibody) arm of the immune system was the most important part of stimulating immunity.
However, research reveals that individuals who, due to a genetic abnormality are unable to generate antibody production, actually recover from infectious illness just as well as those able to make normal antibodies.37 They also usually have protection in the future upon re-exposure.
This demonstrates the importance of the Th1 arm of immunity, and suggests humoral immunity may only play a secondary role in natural resistance against targeted “vaccine-preventable” diseases. This, and the fact that vaccines fail to confer lifelong immunity, suggests that having a cell mediated response is necessary. What’s more, research suggests that when Th2 is excessively stimulated through vaccination, your immune function may be compromised long term, leaving you more vulnerable to cancer.
Autoimmune diseases involve excessive antibody production while cancer involves cell mediated immune failure. This is why therapies that stimulate the cell mediated or innate immune system, such as Coley's toxins, can be helpful against cancer. What this suggests is that our modern vaccine policy, which is a full-scale assault on the cell mediated immune system, is a contributing factor to many of the chronic diseases we see.
There are also dozens of studies demonstrating that contracting certain childhood diseases actually protects you against various types of cancer later in life — everything from melanoma to leukemia. There's even evidence suggesting childhood diseases help protect against future heart disease.
These and hundreds of other studies can be found in Neil Z. Miller’s book, “Miller’s Review of Critical Vaccine Studies: 400 Important Scientific Papers Summarized for Parents and Researchers.” If you’re on the fence when it comes to vaccination, this is a book not to be missed.
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