Written Answers Nos. 889-909
889. Deputy Claire Kerrane asked the Minister for Health if those aged between 60-69 years of age will be offered an alternative vaccine to a vaccine (details supplied) in cases in which they have a significant history of blood clots themselves or in their family to ensure older persons are not worried in relation to the vaccine and to ensure high compliance within the age group; and if he will make a statement on the matter. [21302/21]
Amharc ar fhreagra918. Deputy Seán Canney asked the Minister for Health the options open to persons aged 60 to 69 years of age who do not want to receive a vaccine (details supplied) but are anxious to be vaccinated; when they can expect to receive a vaccine; and if he will make a statement on the matter. [21399/21]
Amharc ar fhreagra1098. Deputy Seán Haughey asked the Minister for Health if those aged over 60 years of age have a choice in relation to the vaccine which will be administered to them particularly persons that have been prone to blood clots previously; if he is satisfied with the safety of a vaccine (details supplied) for this age cohort; and if he will make a statement on the matter. [22313/21]
Amharc ar fhreagraWhile a person can, of course, refuse any offer of vaccination on religious, conscientious or other grounds, provision of one or other authorised COVID-19 vaccine(s) during the immunisation programme will be based on clinical expert guidance, including from the National Immunisation Advisory Committee, to ensure the optimal stewardship of scarce resources and equitable access to safe and effective vaccine(s) for a given population.
As this is a service matter, I have asked the Health Service Executive to respond to the deputy directly, as soon as possible.
890. Deputy Bríd Smith asked the Minister for Health the position in relation to the sale and use of vaping and e cigarettes by children and young adults; the regulations in relation to same; if he plans to amend or bring forward proposals to deal with teens and young adults using vaping e cigarettes; and if he will make a statement on the matter. [21304/21]
Amharc ar fhreagra891. Deputy Bríd Smith asked the Minister for Health if his attention has been drawn to the risks of young teens becoming addicted to nicotine as a result of the use of vaping and e cigarettes; if statistics or studies have been commissioned by his Department on the issue; if so, if they will be made available; his plans to deal with increased use of vaping products by children and young adults; and if he will make a statement on the matter. [21305/21]
Amharc ar fhreagraI propose to take Questions Nos. 890 and 891 together.
The most recent data on vaping among young people in Ireland is from the European Schools Project on Alcohol and other Drugs (ESPAD) 2019 Ireland report. The survey was completed by almost 2,000 Irish students aged 15 and 16 years and found that 39% of students surveyed reported having ever used an e-cigarette; of these 16% reported using one in the last 30 days. Separately, the Health Behaviour in School Age Children Study (HBSC) 2018 found that 22% of 12-17 year olds reported having tried e-cigarettes. Both the ESPAD and HBSC surveys received funding from my Department and are publicly available.
In October 2020 the Health Research Board delivered the findings of an evidence review on e-cigarettes. The review found that use of e-cigarettes is associated with an increased likelihood of smoking in adolescents. It also found that while electronic cigarettes may represent a reduction in harm relative to smoking, they are not harmless. The Health Research Board review was commissioned by my department and is available on their website.
The General Scheme of the Public Health (Tobacco and Nicotine Inhaling Products) Bill provides for a prohibition on the sale of e-cigarettes to, or by, persons under the age of 18. The Bill will also introduce a licensing system for the retail sale of nicotine inhaling products. The General Scheme of the Bill is with the Office of Parliamentary Counsel for drafting and has also been referred to the Oireachtas Committee on Health for Pre-Legislative Scrutiny.
892. Deputy Róisín Shortall asked the Minister for Health if contact tracing calls are recorded; if so, the reasoning for same; and if he will make a statement on the matter. [21307/21]
Amharc ar fhreagraAs this is a service matter, I have asked the Health Service Executive to respond to the deputy directly, as soon as possible.
893. Deputy Róisín Shortall asked the Minister for Health if passengers arriving into Ireland by ferry are required to complete the passenger locator form; the steps he has taken to ensure that all persons entering Ireland by ferry and who have been in a designated state within the past 14 days are subject to mandatory hotel quarantine; and if he will make a statement on the matter. [21308/21]
Amharc ar fhreagraPersons arriving into Ireland from overseas are required to present both a COVID-19 Passenger Locator Form or PLF e-receipt and evidence of a negative/non-detected RT-PCR pre-departure test taken within 72 hours of arrival.
Persons who are planning to travel to Ireland should familiarise themselves with the requirements for their arrival, including whether or not they are arriving from or have transited through a designated state in the previous 14 days. Persons who arrive from designated states are required to undergo quarantine in a designated facility, which they must pre-book and pre-pay for before arrival, in addition to other requirements such as competing a PLF and holding a negative RT-PCR test result. This information, as well as additional information regarding exemptions to the requirement to quarantine in a designated facility, are available on https://www.gov.ie/en/publication/a6975-mandatory-hotel-quarantine/ and all official communication in this regard directs persons to review this information before arrival.
Persons who are travelling who are required to undergo quarantine in a designated facility should identify themselves to their carrier before boarding their flight or sailing and all carriers arriving in Ireland have been instructed to not allow boarding for any such persons who do not have the correct and complete documentation.
In the case that a person arrives from a designated country who has not complied with the above restrictions, they are identified on arrival and are required to undergo quarantine as normal.
Where a person arrives from a non-designated country but has failed to provide either a valid RT-PCR test or there is an issue with a claimed exemption, they are also directed to attend a designated facility. Persons without a valid RT-PCR may be released pending the result of a test taken on arrival. Persons who believe they are exempt may appeal their obligation to quarantine, however this can only occur once quarantine has begun.
If a passenger has been identified as required to undergo Quarantine in a Designated Facility, they are directed to a designated immigration channel away from other passengers and then undergo normal immigration procedures and customs controls.
Passengers are then accompanied to meet the Defence Forces State Liaison Officer and provided with dedicated transport to their assigned quarantine facility. They are accompanied on this journey by a member of the security team and the vehicle is escorted by members of the SLO team.
Infection Prevention and Control protocols are maintained throughout this process to ensure that passengers arrive at their facility both safely and comfortably to begin their quarantine.
894. Deputy Matt Carthy asked the Minister for Health when he plans to revise the restrictions for church services; if he plans to permit services with limited attendance; and if he will make a statement on the matter. [21313/21]
Amharc ar fhreagraI recognise the negative impact the restrictions on religious services have had on people given the importance and significance of such services. However, Level 5 restrictive measures currently remain in place. Any measures introduced at any level of the Plan are aimed at limiting the spread and damage of COVID-19 and are necessary to protect our key priorities of supporting and maintaining health and social care services, keeping education and childcare services open and protecting the most vulnerable members of our communities.
The Government announced a phased easing of restrictions over April in recognition of the significant impact that the extended period of Level 5 restrictions is having on people. The focus of this easing of measures is on enabling more outdoor activities in order to improve the health and wellbeing of society. Furthermore, from 26 April, maximum attendance at funerals increased to 25.
The situation will be subject to ongoing review taking account of the evolving epidemiological situation, the impact of the reopening of priority services, and available evidence in relation to vaccine deployment, uptake and effectiveness. The NPHET and the Government will consider the position and this week a reopening plan for the further easing of measures over the coming months will be announced.
Significant progress has been made on suppressing the virus due to the huge effort of our citizens. By working together, we have saved lives and limited the impact of the disease on society in Ireland. We all must continue to do everything possible to avoid the virus spreading.
895. Deputy Michael McNamara asked the Minister for Health when the restrictions will be eased at Limerick Maternity Hospital given that the Rotunda Hospital, Dublin has lifted the restrictions on partners; and if he will make a statement on the matter. [21318/21]
Amharc ar fhreagraAs this is a service matter, I have asked the Health Service Executive to respond to the Deputy directly, as soon as possible.
896. Deputy Cathal Crowe asked the Minister for Health if a directive will be issued to all hospital groups nationwide to allow birthing partners attend maternity appointments of all kinds with a pregnant woman given the current level of vaccination against Covid-19. [21320/21]
Amharc ar fhreagraAs this is a service matter, I have asked the Health Service Executive to respond to the Deputy directly, as soon as possible.
897. Deputy Seán Canney asked the Minister for Health the reason patients with significantly reduced lung capacity are not receiving early vaccinations given the dangers that Covid-19 poses to their health; and if he will make a statement on the matter. [21325/21]
Amharc ar fhreagraThe COVID-19 Vaccine Allocation Strategy sets out a provisional list of groups for vaccination. The Strategy was developed by the National Immunisation Advisory Committee (NIAC) and my Department, endorsed by the National Public Health Emergency Team (NPHET), and approved by Government on 8 December 2020.
On the 23rd of February, I announced an update to Ireland’s COVID-19 Vaccine Allocation Strategy. In comprising the initial Vaccine Allocation Strategy, the NIAC listed several conditions associated with increased risk of severe disease and death. In the intervening period, national and international evidence has become available which has enabled a more detailed analysis of underlying conditions that may increase the risk of developing severe disease or death. The NIAC has now been able to more comprehensively identify those medical conditions and to distinguish between those which place a person at very high or high risk of severe disease if they contract the virus. Medical conditions and the magnitude of the risk they pose will continue to be monitored and periodically reviewed.
On the 30th of March, the Government approved a further update to the COVID-19 Vaccination Allocation Strategy. Based on clinical, scientific and ethical frameworks produced by the National Immunisation Advisory Committee and my Department, following the vaccination of those most at risk, future groups will be vaccinated by age, in cohorts of 10 years (i.e., 64-55; 54-45, etc.).
The move to an age-based model better supports the programme objectives by:
- protecting those at highest risk of severe disease first, which benefits everyone most;
- facilitating planning and execution of the programme across the entire country;
- improving transparency and fairness.
Further details are available here:
https://www.gov.ie/en/press-release/93f8f-minister-donnelly-announces-update-to-irelands-vaccination-prioritisation-list/
People with chronic severe respiratory disease (for example, severe cystic fibrosis, severe COPD, severe pulmonary fibrosis) will be vaccinated in Group 4. Vaccination of this group began in March.
People with other chronic respiratory disease (for example, stable cystic fibrosis, severe asthma (continuous or repeated use of systemic corticosteroids), moderate COPD) will be vaccinated in Group 5 or Group 7, depending on their age.
898. Deputy Jim O'Callaghan asked the Minister for Health if it is planned to vary the requirement for persons travelling to Ireland from the United Kingdom to quarantine in view of the low incidence of Covid-19 that exists in the United Kingdom; and if he will make a statement on the matter. [21338/21]
Amharc ar fhreagraThe Health Act 1947, as amended, provides that all persons arriving in Ireland from a designated state, or having travelled through a designated state in the previous 14 days, are required to undergo mandatory quarantine in a designated facility unless they are an exempted traveller under the Act. All applicable travellers must reserve and pay for a place in mandatory hotel quarantine.
The designation of states will be subject to ongoing review in line with the provisions of Section 38B of the Health Act 1947, which was inserted by the Health (Amendment) Act 2021. A full list of designated states can be accessed on gov.ie/quarantine.
Mandatory hotel quarantine is also necessary in circumstances where passengers coming from non-designated states, do not provide evidence that they have a negative or ‘not detected’ result from a COVID-19 Reverse Transcription Polymerase Chain Reaction (RT-PCR) test carried out no more than 72 hours before arrival into Ireland.
The Government continues to evaluate wider policy on international travel as informed by the epidemiological situation and public health advice. In this context, regulations have been introduced to allow fully vaccinated persons arriving from designated states to be exempt from Mandatory Hotel Quarantine.
However, this only applies to persons who are ‘fully vaccinated’ with an EMA-approved vaccine and there will be a requirement to quarantine at home following arrival into the State. Passengers who are fully vaccinated are also required to provide a negative pre-departure RT-PCR test taken in the 72 hours pre-departure and to complete a period of self-quarantine at home or wherever specified in their passenger locator form.
The following table sets out the definition of ‘fully vaccinated’;
|
Type of Vaccine |
You are regarded as fully vaccinated after |
|
Pfizer-BioNtech |
7 days after 2nd dose |
|
Moderna |
14 days after 2nd dose |
|
Oxford-AstraZeneca |
15 days after 2nd dose |
|
Johnson & Johnson/Janssen |
14 days after single dose |
Neither I as Minister for Health nor my Department have a role in decisions relating to whether individual persons must enter mandatory quarantine or whether individual persons are exempted travellers. All such decisions are to be determined in accordance with the provisions of the Act.
899. Deputy Michael Healy-Rae asked the Minister for Health the status of a hospital appointment for a person (details supplied); and if he will make a statement on the matter. [21339/21]
Amharc ar fhreagraIt is recognised that waiting times for scheduled appointments and procedures have been impacted in the last year as a direct result of the COVID-19 pandemic.
Elective hospital care was curtailed for the first quarter of 2021, in line with the rapid increase in Covid -19 hospital admissions, with only critical time dependent elective procedures undertaken.
On 23 March the HSE published the “Safe Return to Health Services Plan”. This plan outlines a three phased approach for the proposed restoration of services across Community Services, Acute Hospital Operations, Cancer Services and Screening Services. It sets target times for their safe return and details the conditions and challenges that will have to be met. Every phase of the plan has been informed by clinical guidance and putting patient and staff safety first. Decisions in relation to the type and volume of activity will be made at site level based on local COVID-19 numbers, available capacity and guidance from national clinical leads.
The schedule outlined in the plan for resumption of services will be regularly monitored by the HSE and updated as appropriate, dependant on public health advice and healthcare capacity.
Patient safety remains at the centre of all hospital activity and elective care scheduling. To ensure services are provided in a safe, clinically aligned and prioritised way, hospitals are following HSE clinical guidelines and protocols.
Under the Health Act 2004, the Health Service Executive (HSE) is required to manage and deliver, or arrange to be delivered on its behalf, health and personal social services. Section 6 of the HSE Governance Act 2013 bars the Minister for Health from directing the HSE to provide a treatment or a personal service to any individual or to confer eligibility on any individual.
The National Waiting List Management Policy is a standardised approach used by the HSE to manage scheduled care treatment for in-patient, day case and planned procedures. It sets out the processes that hospitals are to implement to manage waiting lists and was developed in 2014 to ensure that all administrative, managerial and clinical staff follow an agreed national minimum standard for the management and administration of waiting lists for scheduled care.
In relation to the particular query raised, as this is a service matter, I have asked the Health Service Executive to respond to the Deputy directly, as soon as possible.
900. Deputy Thomas Gould asked the Minister for Health when minimum unit pricing will be implemented as prescribed in the Public Health Alcohol Act 2018. [21340/21]
Amharc ar fhreagraThe introduction of minimum unit pricing of alcohol products is currently subject to a Government Decision which envisaged that it would be introduced in Northern Ireland and in the Republic simultaneously.
Northern Ireland Health Minister Robin Swann recently set out that he and his Department do not have capacity to implement minimum unit pricing in Northern Ireland during his mandate. On that basis I intend to explore alternative approaches to the introduction here of this very important public health measure.
901. Deputy Thomas Gould asked the Minister for Health if the Health Research Board drugs and alcohol behavioural study will be published. [21341/21]
Amharc ar fhreagraThe National Drug and Alcohol Survey is a general population survey of households to measure the extent and pattern of drug use among a representative sample of those aged 15 and over in Ireland. The survey is conducted by the Health Research Board.
The completion of the fieldwork for the 2018/2019 survey by a third-party organisation was delayed due to difficulties in recruiting experienced interviewers. The fieldwork was eventually completed in March 2020. It is understood that an analysis of the survey data is now being completed and a that final report will be submitted for approval to the board of the Health Research Board in Q2 2021. Publication of the report will follow soon afterwards.
I look forward to the publication of the report on the National Drug and Alcohol Survey by the Health Research Board. By understanding recent trends in drug and alcohol use, this will allow use to better plan the development of drug and alcohol services. It will also inform the mid-term review of the national drugs strategy and the strategic action plan for 2021-2015.
902. Deputy Thomas Gould asked the Minister for Health the status of the mid-term review of the National Drugs Strategy. [21342/21]
Amharc ar fhreagraThe national drug strategy, Reducing Harm, Supporting Recovery, sets out government policy on drug and alcohol use for the period 2017 to 2025. The strategy provides an integrated public health approach to drug and alcohol use, focused on reducing the harms for individuals, families and communities and promoting rehabilitation and recovery. The strategy is a dynamic strategy and contains 50 actions which are to be delivered over the period 2017-2020.
The Department has commenced a mid-term review of the actions in the strategy, in consultation with stakeholders. The review provides an opportunity to reflect on progress in implementing the strategy from 2017 to 2020, progress achieved to-date under the action plan, any new issues that have arisen including the impact of Covid-19 and to consider the development of new actions to address emerging needs and challenges.
The National Oversight Committee gives leadership and direction to support the strategy. The committee has membership from statutory, voluntary and community sector and is chaired by me as Minister for State. The committee has received regular updates on the mid-term review and a draft report will be presented to a special meeting of the committee in May for its consideration.
The review when finalised will be brought to Government for approval. Publication of the review and supporting documents will follow soon thereafter.
I am committed to working with all stakeholders to ensure that the national drugs strategy is relevant and appropriate to address the societal challenges arising from the use of drugs, especially for children and young people and for those at greatest risk of harm.
903. Deputy Thomas Gould asked the Minister for Health the engagements undertaken by the Minister for State with responsibility for the National Drugs Strategy in relation to rehabilitation and detox residential treatment waiting times. [21343/21]
Amharc ar fhreagraThe National Drugs Strategy ‘Reducing Harm Supporting Recovery’ sets out the Government’s strategy to address the harm caused by substance misuse in Ireland up to 2025. The Department of Health provides over €150 million to drug and alcohol services every year to support the strategy.
The Health Research Board reports annually on the number of cases treated for problem drug and alcohol use. In 2019, there were 10,666 cases treated for problem drug use and 7,546 cases treated for problem alcohol use. This data includes 1,571 inpatient drug treatment cases, where the client attending the service stays overnight, e.g., in-patient detoxification, therapeutic communities, respite, and step down, and 2,806 inpatient alcohol treatment cases.
It is important when looking at waiting lists for drug and alcohol services to be aware of the impact COVID-19 had on society and particularly on drug and alcohol service provision. Several factors have impacted on waiting lists for drug and alcohol detoxification over the course of the pandemic. These include (a) a reduction in capacity to comply with public health guidance, (b) restrictions on new entries, (c) closures due to outbreaks and (d) difficulties carrying out face to face assessments and validating waiting lists as many of the interactions are telephone only.
Unfortunately, the necessary Covid-19 safeguards have resulted in increases in waiting times for residential addiction treatment across the country ranging from an average of 2-6 weeks in some services to an average of 6-9 months in other services. The HSE cannot change the capacity issues that have arisen due to the introduction of social distancing measures to deal with the Covid-19 pandemic.
Notwithstanding the limitations of Covid-19, the Department of Health provided an additional €2 million for residential drug and alcohol treatment services in 2021. This funding will provide an additional 100 stabilisation treatment episodes as part of the North East Inner City initiative, a further 150 episodes nationally in tier 4 residential treatment services and 100 treatment episodes in a residential step-up treatment facility for CHOs 3, 4 and 5. In addition, over €1.3 million is being provided for the establishment of a 20 bed residential therapeutic community for expectant women and women with children in the mid-west region, which will cater for 125 episodes per annum.
In summary this €3.3m in additional funding will provide an additional 475 treatment episodes this year.
Several important initiatives have been introduced to restore and continue access to drug and alcohol services during Covid-19. The Department of Health has issued guidance for the operation of drug and alcohol support groups and treatment programmes during COVID-19, including in level 5.
In addition, the Department has developed a 'Framework for the ‘Restoration and Continuation of Drug and Alcohol services', in a planned and appropriate manner in line with public health advice. To support the Framework, the Department provided once-off funding of €480,000 in November 2020 for the restoration of drug and alcohol services including the adaptation of services, premises, online meetings, and personal protective equipment. In addition, the HSE has also provided guidance for the safe delivery of residential treatment services.
I am fully committed to the provision of drug and alcohol treatment services. I acknowledge the challenges faced by service providers during Covid-19 and will continue to support service providers to fully resume services.
904. Deputy Danny Healy-Rae asked the Minister for Health if he will provide clarification regarding mandatory hotel quarantine for children (details supplied); and if he will make a statement on the matter. [21356/21]
Amharc ar fhreagraIn accordance with the Health Act 1947 (Exempted Traveller) (COVID-19) (Amendment) (No. 3) Regulations 2021, persons who are fully vaccinated, as well as any dependents who accompany them, are now exempt from the requirement to undergo quarantine in a designated facility. All such persons and dependents are however still required to adhere to all other current travel and public health advice, including the need to quarantine at home or at the address specified on their passenger locator from, following their arrival.
Persons who are fully vaccinated are also required to provide a negative pre-departure RT-PCR test taken in the 72 hours pre-departure and to complete a period of self-quarantine at home or wherever specified in their passenger locator form.
The following table sets out the definition of ‘fully vaccinated’;
|
Type of Vaccine |
You are regarded as fully vaccinated after |
|
Pfizer-BioNtech |
7 days after 2nd dose |
|
Moderna |
14 days after 2nd dose |
|
Oxford-AstraZeneca |
15 days after 2nd dose |
|
Johnson & Johnson/Janssen |
14 days after single dose |
Neither I as Minister for Health nor my Department have a role in decisions relating to whether individual persons must enter mandatory quarantine or whether individual persons are exempted travellers. All such decisions are to be determined in accordance with the provisions of the Act.
More information can be accessed on gov.ie/quarantine.
905. Deputy Emer Higgins asked the Minister for Health if he plans to introduce measures to ensure care for women who initiate legal abortions in Ireland but whose abortion fails beyond the 12-week timeline and must travel abroad to receive an abortion; and if he will make a statement on the matter. [21357/21]
Amharc ar fhreagraSection 12 of the Health (Regulation of Termination of Pregnancy) Act 2018 states that a termination of pregnancy may be carried out by a medical practitioner where, having examined the woman, he or she is of the reasonable opinion formed in good faith that the pregnancy has not exceeded 12 weeks of pregnancy. The medical practitioner must certify this opinion and three days must elapse between certification and the procedure being carried out.
Sections 9 and 10 of the Health (Regulation of Termination of Pregnancy) Act 2018 set out other grounds on which termination of pregnancy is permitted in this country. Section 9 requires that two medical practitioners, having examined the pregnant woman, are of the reasonable opinion formed in good faith that there is a risk to the life, or of serious harm to the health, of the pregnant woman; the foetus has not reached viability; and it is appropriate to carry out the termination of pregnancy in order to avert the risk concerned. One of the two medical practitioners must be an obstetrician; and the other must be an appropriate medical practitioner, and both must certify their opinions in order for the termination to be carried out.
Section 10 deals with emergency situations. It provides that a termination of pregnancy may be carried out by a medical practitioner who, having examined the pregnant woman, is of the reasonable opinion formed in good faith that there is an immediate risk to the life or of serious harm to the health of the pregnant woman, and it is immediately necessary to carry out the termination of pregnancy in order to avert that risk.
It would not be appropriate for me, as Minister for Health, to intervene in medical practice to suggest how medical practitioners treat their patients, or to dictate the practice of obstetrics. Medical practitioners are bound through professional regulatory mechanisms to operate in accordance with best medical practice.
Clinical guidelines for the provision of termination of pregnancy services, within the legal framework set out in the Health (Regulation of Termination of Pregnancy) Act 2018, have been developed by the relevant professional medical bodies.
There is regular ongoing engagement between the Department of Health and the HSE to facilitate the operation of the service and to resolve any operational issues that may arise.
906. Deputy Mark Ward asked the Minister for Health the number of cross border directive mental health referrals that have been sent to Northern Ireland in each of the years 2016 to 2020 and to date in 2021, in tabular form; and if he will make a statement on the matter. [21364/21]
Amharc ar fhreagra907. Deputy Mark Ward asked the Minister for Health the number of mental health referrals to the treatment abroad scheme made in each of the years 2016 to 2020 and to date in 2021, in tabular form; the countries the referrals were to; and if he will make a statement on the matter. [21365/21]
Amharc ar fhreagra908. Deputy Mark Ward asked the Minister for Health the number of cross border directive mental health referrals that have been sent to the UK in each of the years 2016 to 2020 and to date in 2021, in tabular form; and if he will make a statement on the matter. [21366/21]
Amharc ar fhreagraI propose to take Questions Nos. 906 to 908, inclusive, together.
As this is a service matter, I have asked the Health Service Executive to respond directly to the Deputy as soon as possible.
909. Deputy Catherine Connolly asked the Minister for Health further to Parliamentary Question No. 255 of 9 September 2020, the status of the promised alcohol addiction treatment service in Galway city; if a building has been sourced for same; if so, when the treatment service will be up and running; and if he will make a statement on the matter. [21372/21]
Amharc ar fhreagraAs this is a service matter, I have asked the Health Service Executive to respond to the deputy directly.
