 It's my great pleasure to welcome Chris Whitty to chair the next session. He is the Chief Scientific Advisor at the UK Department for International Development and a professor at the London School. So, thank you very much, Chris. So I'll crack straight in because I think what people want is to listen to the talks and to the questions and answers afterwards. Except just to say that Jeremy and I went to the same neurology training session. So, if you want your friends to go into international health encouragement to do neurology. The first, so we can have three really important talks here. Malaria is at a crossroads. There have been enormous improvements over the last five years and building on quite a lot of improvements over the last 15 years. But we now got some new tools and also some very significant new challenges. And the three talks we got today address three of those. So it's a really great pleasure to be chairing this. I've always enjoyed this meeting very much. Welcome in particular to the people who are watching online. I'd like to ask Elena Koskolova to come up. Elena is a clinician and epidemiologist. She's worked with MSF since 1999 and did her masters at the school. And she's going to be talking about C's normal area, chemo prevention, chemo prophylaxis. Thank you for this opportunity to present some results of our work on C's normal area, chemo prevention in Niger. But I would like to confess in the beginning that it's really an important pressure to present after such a great speech. And especially for a non-English speaker. So I would like to address also to all the non-English speaker because I think it's really difficult for us. So briefly the seasonal malaria prevention is a strategy that aims to prevent malaria episodes. And it's recommended to be implemented in the places where malaria transmission is highly seasonal with the most of the cases concentrated within a very short period of time. And the SMC consists of administrating intermittently a full anti-malarial treatment which is actually given for three days to children between three and 59 months at monthly interval for a maximum of four treatment rounds per year. It's also the studies really demonstrated an important impact of SMC that can reduce more than 75% of malaria episodes both simple and severe. So why MSF did decide to implement SMC in Niger? First, because malaria is the most important cause of morbidity and mortality in Niger. Secondly, because the malaria transmission is highly seasonal in Niger but most importantly it is because Niger is really facing this double peak of acute severe malnutrition in an area that is happening at the same time and is resulting in an important increase of morbidity and mortality every year which is creating tremendous pressure on hospitalization services. So since 2013 actually all four MSF sections present in Niger started to implement SMC in its project areas targeting more than 400,000 children in 2014. Sulphadox and Pyramid Amin and Amodiakin is using a cobblester form which really makes easier the distribution compared to using loose tablets and it's organized through the campaigns either through the fixed distribution sites or through the using the door-to-door teams. In Niger it was decided to organize four distribution rounds between July and October and the first doses is given at the site and the two other doses are given by mothers at home. Our experience from two years is very positive. So actually the population adhered very well to the strategy. It's very well accepted, the coverage is very high and it will show that adherence to three days strategy is very good. However, we realize that demonstrating an impact using programative data is quite challenging. So what we decided to do actually as I mentioned the impact of SMC was well documented so we didn't want to invest in heavy research demonstrating an impact of SMC in Niger but at the same time we have to say that actually giving this awfully tasting tablets to the children especially to the small one is extremely challenging and somehow we want to monitor the effectiveness of the SMC. So we decided actually to estimate the effectiveness of SMC in Magaria district globally and per each SMC round and then also actually to evaluate how this effectiveness changed depending on time that elapsed since the last SMC distribution. So we decided to be very simple and we selected four Sentinel sites which were actually health structures that MSF was supported and we set up during the SMC period an individual data collection on all fever cases in children under five years old. Then we also conducted population based cross-sectional coverage survey after the end of the SMC and then actually we decided to use a very simple method that it's used to estimate the vaccine effectiveness. The method is used as screening method or rapid estimation method and in this method we consider the proportion of cases that has been vaccinated and proportion of population that has been vaccinated. When applied this to the SMC effectiveness actually we consider the proportion of malaria cases that received the last SMC and this is taken from the individual data collection in the Sentinel sites and then actually the proportion of population that received SMC which is actually taken from the coverage surveys. So we then followed up the malaria episodes that were defined as fever and positive rapid diagnostic test. What is important to mention here is that we used the test that it's based on detection on histidine rich protein 2 antigen. During the analysis period that went from the first day after the first distribution till the 20-end day after the fourth distribution we had in total more than 4,500 fever cases and in this more than 3,000 tested positive with ADT for malaria which is 66% and importantly you have to see an important increase of positive ADTs going from 23% up to the 84% for the four distribution round. So then how we applied the equation for the SMC effectiveness. So we first calculated the proportion of malaria cases that received the last SMC which was globally 79% and varied between 41% and 87% and then from the survey we took the coverage of SMC which was actually very high and varied between 85% and 94%. Then using the equation we globally estimated the SMC effectiveness being 63% but you can see actually how the SMC effectiveness decreased from the first to the fourth round from 94% to the 16%. And you can see this also graphically so very high effectiveness after the first round but very low effectiveness after the fourth round. Then we also stratified the analysis on the time elapsed since the last SMC distribution and you see that actually the trend is the same so it's decreasing effectiveness from the first to the fourth round but with quite important difference for the first 21 days since the last distribution and for the last seven days before the next distribution with practically no effectiveness during the third and fourth round. So what we can conclude with this. We think that the method, the simple method we use it's proved really practical to evaluate SMC effectiveness. Then also actually we suggest that SMC is effective because the global 63% we think it's a good result of SMC effectiveness but this protective effect seems to wane through the distribution rounds. We think actually that there might be several distribution to these results that we observed. So the first one might be the increase in exposure to malaria over time but very importantly we think that it's really the use of the HRP2 test that might remind positive weeks after the parasite clearance and we don't have data on resistance to SP and IAQ so we cannot exclude that this is contributing as well even though we think that actually this is not very probable. Concerning the limitations, of course there is a problem of representativeness of the four Sentinel sites. The biggest constraint is really the use of HRP2 test giving the false positive results especially during the highest malaria transmission season. Then also we only had the global SMC estimates which might not correspond to the coverage in the Sentinel sites and also we didn't account on the potential differences between children that received and did not receive SMC and then it's a simple monitoring so accuracy of the data in simple monitoring need to be always questioned. On the recommendation side we think that as we see that SMC effectiveness decreased during the last seven days of each cycle the narrowing of the interval could be beneficial at this especially during the malaria peak so in this context would be probably the narrowing the interval between the third and the fourth SMC distribution. Then we also think that use of other type of tests so the PLDH test will definitely improve the interpretation of the results so it's something that we are going to use hopefully this year on the Sentinel sites and then of course we need more data from all Sentinel sites for more years and also the better coverage estimates to improve the generalizability of our results and at the end we think that this simple method of monitoring SMC could become a part of monitoring evaluation package of SMC activities. So I would like to thank all the MSF staff working on SMC Minister of Health for the contribution but really, really most importantly all the mothers that brought and did great effort to bring the children to the SMC and thank all of you for listening. That was an excellent talk. You're escaping before you're allowed. I'm going to allow one question. We started a little bit late as long as it's short and to the point. There's a gentleman up at the top there. Hello, I'm Tom from Imperial College. What was your seasonality profile of episodes in Nigeria before you introduced SMC? So could just not your variability and effectiveness be differences in seasonality? I'm not sure if I understood the question but the seasonality, it's like most of the cases is concentrated within four months. The problem of this year was that the season started a little bit late which means actually the SMC started sooner. So it would be more effective probably if the distribution started two, three weeks later. Thank you very much indeed.