 I would like to share the experience of Metsan Saint-Francier in the investigation of a large epidemic of dystonic reaction in Central Africa. In December 2014, patients with suspected meningitis were reported by the Ituri Health District in the Northeast Democratic Republic of Congo that shared a border with Uganda and South Sudan. A few weeks later, Metsan Saint-Francier was approached by the Ministry of Health to support investigation and response to the outbreak. E is a picture of Nono, a village of 6,000 people in the rural area known as the epicenter of the outbreak. Cases were mainly observed from three health zones with a total population of half a million. This presentation describes the outbreak investigation. This experience was detective medical work, and I will try to present it to you if you were there at each step of the investigation. List of patient demographic characteristics, clinical features, and outcome were described. Cerebral spinal fluid was analyzed in and out of DRC for evidence of meningitis using pastorex, culture, PCR, and RT-PCR. Some other relevant laboratory tests were performed, which I will mention later. This investigation met the criteria of the MSF Ethics Review Board for exemption from Ethics Review. As the initial suspicion was meningitis, we used this as a case definition. As the outbreak involved, we refined our case definition, which I will discuss later. Over eight months, there were 930 patient admissions, 62 percent were children under 15 years old. Some of the clinical signs presented by a sample of the patient are described in this table. In February 2015, the clinical features suggested that the outbreak was probably not caused by meningitis. What were the special features not matching with meningitis? First of all, the patients were described as having few signs of meningitis, including fever. Some patients were described as having general condition without loss of consciousness. Some patients presented spasm of the neck or tauticalis. Some were described with protrusion or retraction of the tongue, hypersalivation. There were some clustering of cases within households. Some relapses were also described. The age-spread trauma was from one month to over 70 years old, and the crisis lasted from a few minutes to several hours and responded well to diazepam. Most patients presented two or three episodes on the first day with recovery in two or three days. Very few patients with cerebrospinal fluid evidence for niserem and meningitis or other gem, and finally, there were very low mortality and absence of severe CKL. Some videos of patients were reviewed by pediatric neurologists. I would like to show you a 20-second video of patients treated in MSF facility for which oral consent to record was obtained. The pediatric neurologist suggested partial truncal dystonic reaction. This insight changed our strategy of intervention from an outbreak of suspected meningitis to an outbreak of unknown origin resulting in acute dystonic reaction. As health workers had difficulty in correctly assessing meningal signs such as neck stiffness, the case definition of meningitis was certainly misused by confusing neck stiffness from meningitis with muscle spasms of the neck from extra pyramidal syndrome. As we started to suspect dystonic reaction, we improved the collection of data regarding this dystonic sign in order to refine the case definition. We also decided to collect some urine samples from patients presenting dystonic reaction and a history of all the medication given to the patient. We sent all of them abroad for screening analysis. Among 930 patients with dystonia or suspected meningitis, 11 death occurred in the MHL facilities. Poor information is available on this patient and the cause of death. This is a die of meningitis, of semen malaria, or to an intoxication linked with the dystonic reaction we just don't know. All other patients admitted survived with no severe sequelae recorded. There are a lot of detail in this graph. Let me explain to you. It's basically an epidemic curve with the light blue representing the total number of patient admission for acute dystonic reaction from December 2014 till August 2015. You can see the MSF contribution in dark blue from end January 2015, the red arrow where we start. The number admission of patients under five years old and the number of relapses. Till the point of the yellow arrow, we thought the cause of the heartbreak was meningitis and then we started to suspect dystonic reaction as already mentioned. The blue arrow is a very important step in the investigation and represents a detection of haloperidol in the first urine analyzed. In the nine urine samples taken from patients with dystonic reaction, haloperidol was detected in all samples. The finding of haloperidols in the urine makes sense and match perfectly with the clinical description of the patient with dystonic reaction. At that stage of the investigation, we discovered the cause of the dystonic reaction but not yet the source. Where does haloperidol come from? Haloperidol is an antipsychotic drug used in the treatment of schizophrenia, mania and delirium. Extra pyramidal side effects seen in the video, such as dystonia reaction, muscle spasm, rigidity, opistotonous are among the most frequent adverse reaction in therapeutic use of haloperidol which occur in about 30% of patients taking this drug. Some of these patients remembered having taken some drugs but it was difficult to assess this very well. We knew some took chloroanferinicol, dexametazone, dizepam and parastamol tablets. Now the green light, the green arrow, represents the first detection of haloperidol in tablets sold as dizepam, which Valium is one of the famous brands. The sociological analysis of 39 medicine samples revealed the presence of haloperidol in all nine yellow tablets imprinted with the letter AGOG and sold labelled as dizepam. No dizepam or other toxic substance were detected in these nine AGOG tablets and the other 30 medicine samples, so the not AGOG, didn't contain haloperidol but all contained the appropriate active pharmaceutical ingredient according to the labelling. Not the decrease of the case admission from May, I will come back later to that point. We found haloperidol AGOG in five different packaging.