Vaccine Concerns in the Developing World

Are people in developing countries really desperate for vaccines? Do they really walk for hours to get their children vaccinated. Maybe they do. But clearly, not everyone in the developing world is a believer. In fact, as you’re about to read, some are vaccinated at gunpoint…

Philippines

In 2015, more than 80% of people in the Philippines strongly agreed with the statement that vaccines are safe. A more recent poll in 2018, found that only 20% of people in the Philippines agreed with the statement. In 2015, 82% of people were confident in the effectiveness of vaccines, but in 2018, only 22% felt that vaccines are effective [1]

What happened in the Philippines between 2015 and 2018, that so badly shook people’s faith in vaccines?

It seems the main driver was a disastrous dengue vaccine trial for Dengvaxia, which was given to more than 800,000 school-children (although numbers from different media outlets vary – from 720,000 up to 830,000), from early 2016 through to early 2018 [2].

The program was then suspended, but not before more than 3000 children were hospitalized [3] – some for dengue fever. As of September 2018, at least 150 deaths had been reported among children who received the vaccine, but authorities declared that many of those were due to pneumonia, leukemia, asthma, central nervous system infections, and therefore ‘occurred naturally’ [4].

More than 190,000 of those vaccinations were given without parental consent [5].

The public confidence in vaccines was so severely shaken by the disaster, that routine vaccination rates in children fell to 50%-60% in 2018. Seventy-seven percent of schoolgirls had received the first shot of HPV vaccine, but only 8% of schoolgirls got the second shot.

A supplemental vaccine drive, to raise measles vaccination rates, saw health workers going from door to door, and many mothers hid their babies. As little as 36% of babies in metro Manila region received the vaccine. The Department of Health Undersecretary remarked that “health workers would spend up to 30 minutes trying to convince parents to have their children vaccinated” [6].

Health secretary Francisco Duque III declared “If needed, they (health workers) must woo the parents to allow the DOH to administer vaccines on their kids” [7].

Thailand

In some provinces in Southern Thailand, vaccination rates are below 50%, as Muslim believers refuse vaccinations. Islamic leaders addressed the issue, by saying that “though some vaccines contain ingredients derived from pigs, which are forbidden for Muslims, it was more important for a good Muslim to remain in good physical health at all times”.

“Therefore, until alternative vaccines that do not contain haram ingredients are invented, Muslims may use vaccines without having to worry that they are violating the Islamic doctrine” [8].

The messages of support from religious leaders are displayed on health authority websites, in an effort to quell concerns, and promote vaccination. Despite vaccination teams visiting schools and homes, some parents signed letters declaring they would not receive vaccines – now, or in the future [9].

India

In an effort to persuade reluctant villagers to have their children vaccinated for polio, the Indian government and UNICEF also use religious leaders to increase vaccine uptake. Islamic leaders give speeches before Friday prayer services, using quotes from the Koran, to encourage their people to accept vaccines. Newspaper columns are prepared and signed off by religious leaders. They also conduct radio question-and-answer sessions to reassure hesitant parents [10].

Vaccine hesitancy in remote areas is hardly surprising. As one religious leader put it: “For decades, the government machinery has not reached out to them; there are no proper roads, no drainage systems, no employment opportunities, no basic facilities – and suddenly a team of health officials arrive there to say we care for your children and therefore we want to vaccinate them [10].

Uganda

In 2016, the Ugandan government announced a new law that would punish non-compliant parents with six months jail time. Anybody found making “public misleading statements about vaccinations could face two years in prison or a fine, under the same law”. A Ugandan baby must have an ‘immunization card’ in order to have their birth registered, and obtain a birth certificate. That immunization card must be shown in order to enrol at school [11].

One religious group in Uganda, known as Njiri Nkalu, are vehemently opposed to vaccines, believing in divine protection, rather than man-made vaccines. In 2016, health workers, along with armed police, forcefully entered their homes and vaccinated some 200 children. Many of the parents and children tried to flee into nearby sugarcane fields, but were rounded up and vaccinated for polio. One member was heard to say: “We don’t see why you bring all these guns to harass us. Our children are protected by God and we don’t need polio vaccines” [12].

At least ten members of the group were detained by police, but later released without charge [13].

The officers also forcefully entered the homes of Tabliq Muslims who had refused vaccines for their children. The District Commissioner, who accompanied the officers, said “Although the operation was a success, there are those who were tipped off and disappeared into the bushes with their children. We shall come back to get them” [12].

Nigeria

In 2003, three states in Northern Nigeria boycotted the oral polio vaccine, due to the alleged discovery of contaminants, including trace amounts of estrogen. The boycott lasted for 15 months [14].

Today, many in the African nation still remain deeply suspicious about the true motive of aggressive vaccination programs. One group is the infamous Boko Haram (which translates to ‘Western education is forbidden’), who came to the world’s attention in 2014, when it was reported they had kidnapped 276 school-girls.

It is too dangerous for vaccinators to go into Boko Haram-held territory during national immunization days, but they do manage to get those who are leaving, or fleeing the area…” At the bus stations, and the state and national border crossings, the lunchbox-toting teams (the polio vaccines are packed into lunchboxes) are there. Peering into cars, lifting the cloaks of women perched on motorbikes to find the babies strapped to their fronts and backs. Squeezing in the little vials of vaccine.

“If they say no, then we tell them they can go back,” said superintendent of immigration, Charles Tashllani, imposing order on Nigeria’s border with Niger in Katsina. Here, late in the evening, the Polio Emergency Operations committee reviews the campaign’s first day, which has seen 3,661 teams immunise 28,882 underfives. The detail is such that eight missing marker pens are on the agenda, as is the sacking of two town announcers who did not inform people about the programme” [15].

But it’s not just extremists who have their doubts. Media reports over the years, reveal that hundreds of parents have been threatened with jail time and prosecution [16].

Pakistan

In 2015, more than 500 parents were arrested by police in Pakistan, for not allowing their children to have the polio vaccine. They could be released on bail, only if they signed an affidavit that they would allow their children to get the vaccine.

A UNICEF team leader in Pakistan explained that “First the workers (try to) convince them, then their supervisors, then senior members of the community”. If all that coercion and intimidation fails, and the parents still resist, then the police are called to arrest them” [17].

Earlier this year, a health worker was murdered, trying to persuade a man to let his children have the oral polio vaccine [18]. This comes amidst reports of an angry mob of parents setting fire to a hospital, after school-children were vaccinated, and 75 students later fell sick. Doctors denied the illness was due to vaccines, and suggested they probably felt sick due to their parent’s anxiety about vaccines [19].

China

In January, 2019, hundreds of parents in Jinhu, China, marched in the streets, demanding an explanation for the expired vaccines given to their children. More than 100 children had suffered fevers, skin rashes, and vomiting – some for months on end – since receiving the vaccines.

“Local authorities eventually found that an entire batch of vaccines was used instead of being destroyed”. Parents claimed the same kinds of reactions had been occurring for at least 10 years, and believe expired and faulty vaccines had been used for years.

Riot police from neighbouring counties were brought in to quench the protests, and authorities banned both regular and social media from reporting on ‘inflammatory’ news about vaccines [20].

It is just one, on a growing list, of vaccine scandals and controversies in China, with many parents declaring they have lost faith in China-made vaccines [21].

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References:

[1] Larson HJ, Hartigan-Go K, de Figueiredo A, Vaccine confidence plummets in the Philippines following dengue vaccine scare: why it matters to pandemic preparedness, Human Vaccines & Immunotherapeutics, 2018.

[2] Newey S, Trust in vaccines plummet following dengue scandal in Philippines, The Telegraph, 12th October 2018, https://www.telegraph.co.uk/news/0/trust-vaccines-plummet-following-dengue-scandal-philippines/. Accessed March 2019.

[3] DOH: Over 3000 students hospitalized after dengue shot, Rappler, 13th April 2018, https://www.rappler.com/nation/200187-doh-students-hospitalized-dengvaxia. Accessed March 2019.

[4] Tomacruz S, 19 out of 154 kids died of dengue despite Dengvaxia shot, Rappler, 26th September 2018, https://www.rappler.com/nation/212904-doh-report-number-children-dead-dengue-dengvaxia-shot-september-2018. Accessed March 2019.

[5] ABS-CBN News, Failon Ngayon: Dengvaxia, Available on youtube, https://www.youtube.com/watch?v=AQObs3vk3l0 (see at 5:39), Accessed March 2019.

[6] Tomacruz S, Parents still scared of govt’s free vaccines a year after Dengvaxia scare, Rappler, 27th September 2018, https://www.rappler.com/nation/212927-child-vaccination-rate-philippines-as-of-september-2018#cxrecs_s. Accessed March 2019]

[7] Cepeda M, Duque to health workers: ‘Woo’ parents to avail of vaccination programs, Rappler, 21st Febrary 2018, https://www.rappler.com/nation/196551-duque-health-workers-woo-parents-vaccination. Accessed March 2019.

[8] Rujivanarom P, ‘Vaccine Denial’ Behind Measles Deaths in the South, The Nation, Thailand Portal, http://www.nationmultimedia.com/detail/national/30356655. Accessed February, 2019.

[9] Vejpongsa J. Muslim concern about vaccine fuels Thai measles outbreak, AP News, 6th November, 2018.

[10] Pisharoty S. Interview: Muslim clerics to address misconceptions on ongoing measles-rubella vaccine drive, The Wire, 24th April, 2017.

[11] Global Press News Service, Anti-vaccine parents in Uganda face jail time under new law, The Seattle Globalist, 23rd August 2016.

[12] Yolisizira Y. 10 arrested over polio immunization, The Monitor, 3rd June 2016. As of 29th June, this article is still available online, at: https://www.monitor.co.ug/News/National/10-arrested-polio-immunisation/-/688334/3186268/-/view/printVersion/-/11q2sgd/-/%2523.

[13] Uganda 2016 International Religious Freedom Report, https://www.state.gov/documents/organization/268952.pdf Accessed March, 2019. (Note: This document has since been moved or removed from the State Department website, despite both the 2015 and 2017 reports still being available…)

[14] ABC News. Vaccine Boycott Grows in Northern Nigeria, 24th February, 2004.

[15] McVeigh T. Nigeria battles to beat polio and Boko Haram, The Guardian, 7th May 2017.

[16] Hundreds of Nigerian parents refuse polio vaccines, The Star, 2nd August 2011, https://www.thestar.com/news/world/2011/08/02/hundreds_of_nigerian_parents_refuse_polio_vaccines.html. Accessed March 2019.

[17] Saifi S, Botelho G. Over 500 Pakistani parents arrested for children’s failure to get polio vaccine, CNN, 4th March 2015.

[18] Farmer B. Polio worker gunned down in Pakistan trying to persuade family to vaccinate children, The Telegraph, 9th April 2019.

[19] Farooq Khan O. People set hospital afire in Peshawar, Times of India, 23rd April 2019.

[20] Police and parents clash in Jiangsu after 145 children get sick from expired vaccines, Asia News, 11th January 2019, http://www.asianews.it/news-en/Police-and-parents-clash-in-Jiangsu-after-145-children-get-sick-from-expired-vaccines-45954.html. Accessed March 2019.

[21] Leng S, Huang K. As new vaccine scandal grips China, parents say they have lost faith in the system, South China Morning Post, 22nd July, 2018.

A Brief History of the ‘Antivax’ Movement

It is often assumed that the ‘anti-vax’ movement began with Andrew Wakefield, and ‘that autism study’, or former Playboy model Jenny McCarthy’s claims that her son’s autism was caused by vaccination.

But did these two events really cause tens of thousands of parents to begin questioning vaccines and getting embroiled in bitter skirmishes on social media? Personally, I had never heard of Andrew Wakefield, or Jenny McCarthy, when I first began to delve into the vaccine subject, in early 2010.

Opposition to vaccination is not a new phenomenon – for as long as there have been vaccines, there has been fierce opposition. Originally focused in England, that opposition really gained momentum when the Compulsory Vaccination Act was passed in Victorian England, in 1853.

The main pockets of opposition to compulsory vaccination were among the working class, and the clergy, who believed it was ‘un-Christian’ to inject people with animal products [1].

The original Vaccination Act in 1840 had provided free vaccination for the poor, to be administered by the Poor Law guardians. This law, however, was a failure, as the “lower and uneducated classes” did not take up the offer of free vaccination [1].

The Compulsory Vaccination Act of 1853 went a lot further – it ordered all babies up to 3 months old be vaccinated ( to be administered by Poor Law Guardians), and in 1867, this was extended up to 14 years of age, and penalties for non-compliance were introduced.

Doctors were encouraged to report non-vaccinators to the authorities, by “financial inducements for compliance and penalties for failure”. While the 1853 Act had introduced one-off fines or imprisonment, the 1867 Act increased this, to continuous and cumulative penalties, so that parent’s found guilty of default could be fined continuously, with increasing prison sentences, until their child reached 14 years of age [2].

(As an interesting side-note here, the vaccination laws were not the only incursions of the state during this time, at the expense of personal liberty, and private bodily autonomy. The Contagious Diseases Acts of 1864, 1866, and 1869, required that any woman suspected of prostitution was to be medically inspected for venereal disease. If deemed to be infectious, she was confined in hospital for treatment, with or without her consent. The Notification of Infectious Diseases Acts in 1889 and 1899 required that all contagious diseases – except tuberculosis, which is rather odd, since it was a major killer at the time – be reported to the local medical officer, who could then forcibly remove the patient to hospital, whether they consented or not [1].

Meanwhile, the vaccination laws were tightened yet again in 1871 (ironically, the same year that a large smallpox epidemic raged across Europe and England – a testament to how ‘effective’ the compulsory laws had been?), making it compulsory for all local authorities to hire Vaccination Officers [2].

In response to these increasingly draconian measures, the Anti-Vaccination League was formed in England, and a number of anti-vaccine journals sprang up, which “included the Anti-Vaccinator (founded 1869), the National Anti-Compulsory Vaccination Reporter (1874), and the Vaccination Inquirer (1879)”.

A number of other writings and pamphlets were distributed widely – for example, 200,000 copies of an open letter titled ‘Current Fallacies About Vaccination’, written by Leicester Member of Parliament, P Taylor, were distributed in 1883 [2].

The vaccination process was painful and inconvenient, for both parents and children alike. The vaccinator used a lancet (a surgical knife with sharp, double-edged blade) to cut lines into the flesh in a scored pattern. This was usually done in several different places on the arm. Vaccine lymph was then smeared into the cuts. Infants then had to be brought back eight days later, to have the lymph (pus!) harvested from their blisters, which was then used on waiting infants [1].

Following the strict 1871 amendments to the law, parents could even be fined 20 shillings for refusing to allow the pus to be collected from their children’s blisters, to be used for public vaccination [1].

By this point, severe and sometimes fatal reactions to the vaccine were being reported, and doubts began to grow about how effective the vaccine really was [3].

The town of Leicester was a particular hot-bed of anti-vaccine activity, with many marches and rallies, demanding repeal of the law, and advocating other measures of containment, such as isolation of the infected. Up to 100,000 people attended these rallies [4].

The unrest and opposition continued for two decades, and an estimated 6000 prosecutions were carried out, in the town of Leicester alone [3].

The following excerpts from the Leicester Mercury bears witness to the deep convictions held by those who refused to submit to the mandatory measures:

‘George Banford had a child born in 1868. It was vaccinated and after the operation the child was covered with sores, and it was some considerable time before it was able to leave the house. Again Mr. Banford complied with the law in 1870. This child was vaccinated by Dr. Sloane in the belief that by going to him they would get pure matter. In that case erysipelas set in, and the child was on a bed of sickness for some time. In the third case the child was born in 1872, and soon after vaccination erysipelas set in and it took such a bad course that at the expiration of 14 days the child died“.

Mr Banford was fined 10 shillings, with the option of seven days imprisonment, for refusing to subject his fourth child to the vaccine [5].

And again…‘By about 7.30 a goodly number of anti-vaccinators were present, and an escort was formed, preceded by a banner, to accompany a young mother and two men, all of whom had resolved to give themselves up to the police and undergo imprisonment in preference to having their children vaccinated. The utmost sympathy was expressed for the poor woman, who bore up bravely, and although seeming to feel her position expressed her determination to go to prison again and again rather than give her child over to the “tender mercies” of a public vaccinator. The three were attended by a numerous crowd and in Gallowtreegate three hearty cheers were given for them, which were renewed with increased vigour as they entered the doors of the police cells [6]”.

Eventually, there were so many refusers in the town of Leicester, that some local magistrates and politicians declared their support for parental rights, and encouraged their peers to do the same [3].

The law was finally relaxed in 1898. New laws were passed, allowing for conscientious objection of vaccination [7]. By the end of that same year, more than 200,000 certificates of conscientious objection had been issued, most among the working class, and many were women. [1]

Meanwhile in the United States, smallpox outbreaks in the late 1800’s led to vaccine campaigns, and subsequent opposition in the formation of The Anti-Vaccination Society of America in 1879, followed by the New England Anti Compulsory Vaccination League in 1882, and the Anti Vaccination League of New York City in 1885 [4].

The homeless and the itinerate were blamed for spreading smallpox, and in 1901, the Boston Board of Health ordered ‘virus squads’ to force-vaccinate men staying in cheap boarding rooms [8].

Following a smallpox outbreak in 1902, the Cambridge Board of Health in Massachusetts mandated vaccination for all city residents. This led to possibly the most important, and controversial, judicial decision regarding public health.

One man, Henning Jacobson refused to comply with the mandate, on the grounds that it violated his right to care for his own body as he saw fit. The city filed criminal charges against him, which he fought, and lost, in court. He appealed to the US Supreme Court, who ruled in the State’s favour in 1905, prioritising public health over individual liberty [9].

The ‘anti-vaxxers’ have never gone away in the intervening years, though sometimes they have been more vocal than others, such as in the 1970’s, when there was controversy throughout Europe, North America and Britain, about the safety and potential side effects of the diptheria-tetanus-pertussis vaccine [10].

In 1998, the vaccination argument came to the public attention again, with Andrew Wakefield’s case series published in the Lancet. Although the report was looking at a link between autistic disorders and bowel dysfunction, it mentioned in its conclusion that a number of parents believed their child’s symptoms began after MMR vaccination [11]. The authors felt this potential link deserved more investigation…

The furore and the fall-out are still ongoing. Wakefield was found guilty of failing to get proper ethics approval for the study, and he and a fellow investigator were subsequently ‘struck off’. Wakefield’s fellow investigator later challenged the decision, and won [12]. And while a number of researchers later confirmed the original findings, of bowel dysfunction in autistic children [13-16], Wakefield’s reputation and career have been left in tatters – the subject of mockery and derision.

Anybody who confesses to have doubts about the safety of efficacy of vaccines, as a general rule, get a taste of the same scorn and derision that Andrew Wakefield has received.

Even in the era of smallpox vaccination, the media tended to portray anti-vaxxers in a less-than-flattering light. At that time, the media referred to the debate as a “conflict between intelligence and ignorance, civilization and barbarism [9].

So, are anti-vaxxers really anti-science?

Not according to science.

In 2007, Kim et al analysed vaccination records of 11,680 children from 19 to 35 months of age, to evaluate maternal characteristics that might influence whether the child was fully vaccinated, or not.

They discovered that mothers with tertiary degrees and high incomes were the least likely to fully vaccinate their children, while mothers in poor minority families without high school diplomas were the most likely to fully vaccinate their children [17].

Similarly, a study in 2008 that investigated the attitudes and beliefs of parents who decided to opt out of childhood vaccine mandates, found that they valued scientific knowledge, were adept at collecting and processing information on vaccines…and had little trust in the medical community [18].

In 2017, the Australian Institute of Health and Welfare released their latest figures on vaccination rates. The national average was 93% of children fully vaccinated, yet in Sydney’s upmarket (ie. Highly educated, high income-earning professionals) inner suburbs and northern beaches, as few as 70% of children under 5 were fully vaccinated [19].

The same story was repeated in Melbourne, with the wealthiest – and by association, better educated – suburbs having the lowest vaccination rates. There was an ironic, and rather telling, opening paragraph in The Age, when reporting these figures: “Four of the wealthiest, healthiest suburbs of Melbourne have the worst child vaccination rates in the state [20]

Statistics gathered from Canada tell a similar story – a higher percentage of anti-vaxxers hold university degrees, compared to the national average [21].

It appears that doctors and paediatric specialists are not always in agreement with current vaccine practice either – at least, not when it comes to their own children:  “Ten percent of paediatricians and 21% of paediatric specialists claim they would not follow [CDC] recommendations for future progeny. Despite their education, physicians in this study expressed concern over the safety of vaccines [22]”.

With the vaccine schedule becoming increasingly crowded, and governments moving towards compulsory vaccination, the anti-vaccination movement is again gathering momentum. Increasing numbers of parents are delaying, declining, or opting for alternative vaccine schedules [23-24].

Around the world, as vaccine scepticism is on the rise, history looks set to repeat, as governments are becoming increasingly more forceful in trying to curb the sentiment. Time will tell how this round will play out…

References:

[1] Durbach, N. They might as well brand us: Working class resistance to compulsory vaccination in Victorian England. The Society for the Social History of Medicine, 2000, 13:45-62.

[2] Porter D, Porter R. The politics of prevention: anti-vaccinationism and public health in nineteenth-century England. Med Hist. 1988;32(3):231-52.

[3] Williamson S. Anti-vaccination leagues: One hundred years ago, Arch Dis Child, 1984, 59: 1195-1196.

[4] Wolfe, R.M., Sharpe, L.K. Anti-vaccinationists past and present. BMJ. 2002d;325:430-432.

[5] Leicester Mercury, 10th March, 1884.

[6] Leicester Mercury, 10th June, 1884.

[7] Wohl A. Endangered Lives: Public Health in Victorian Britain, 1984, Methuen, London, pp. 134-135.

[8] ] Albert, M., Ostheimer, K.G., Breman, J.G. The last smallpox epidemic in Boston and the vaccination controversy. N Engl J Med. 2001;344: 375-379.

[9] Gostin, L. Jacobson vs. Massachusetts at 100 years: Police powers and civil liberties in tensionAJPH. 2005;95:576-581.

[10] Baker, J. The pertussis vaccine controversy in Great Britain, 1974-1986. Vaccine. 2003;21:4003-4011.

[11] Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive development disorder in children, Lancet, 1998, 3519103): 637-641.

[12] Professor John Walker Smith vs General Medical Council [2012] EWHC 503, http://www.eastwoodslaw.co.uk/wp-content/uploads/2013/03/Walker-Smith.pdf. Accessed September, 2017.

[13] Horvath K, Medeiros L, Rabszlyn A, et al. High prevalence of gastrointestinal symptoms in children with autistic spectrum disorder (ASD). J Pediatr Gastroenterol Nutr 2000, 31:S174.

[14] Horvath K and Perman JA. Autistic disorder and gastrointestinal disease, Current Opinion in Pediatrics 2002, 14:583-587

[15] Ashwood P, Anthony A, Torrente F, Wakefield AJ. Spontaneous mucosal lymphocyte cytokine profiles in children with regressive autism and gastrointestinal symptoms: Mucosal immune activation and reduced counter regulatory interleukin-10. Journal of Clinical Immunology. 2004:24:664-673.

[16] Torrente F, Anthony A, Heuschkel RB, et al. Focal-enhanced gastritis in regressive autism with features distinct from Crohn’s and helicobacter pylori gastritis. Am. J Gastroenterol. 2004;4:598-605.

[17] Kim SS, Frimpong JA, et al. Effects of maternal and provider characteristics on up-to-date immunization status of children aged 19-35 months. Am J Public Health, 2007, 97(2): 259-266.

[18] Gullion JS, Henry L, Gullion G. Deciding to opt out of childhood vaccination mandates. Public Health Nurs, 2008, 25(5): 401-408.

[19] Aubusson K, Butt C, Sydney postcode has Australia’s worst vaccination rate for five year old children, Sydney Morning Herald, 8th June, 2017.

[20] Butt C, Spooner R, Melbourne vaccination data: immunisation rates not improving in wealthy inner-city suburbs, The Age, 7th June, 2017.

[21] Chai C, Who are the anti-vaxxers in Canada? New poll profiles resistant group, Global News, 9th March, 2015.

[22] Martin, M. and Badalyan, V, Vaccination practices among physicians and their children. Open Journal of Pediatrics, 2012, 2:228-235.

[23] McCauley MM, Kennedy A, Basket M, Sheedy K. Exploring the choice to refuse or delay vaccines: a national survey of parents of 6- through 23-month olds, Acad Pediatr, 2012, 125): 375-383.

[24] Robison SG, Groom H, Young C. Frequency of alternative immunization schedule use in a metropolitan area, Pediatrics, 2012, 1301): 31-38.