 So moving swiftly on to another disease in pregnancy, cholera and pregnancy and vaccination, and our presentation comes from Lise, who is currently working with the WHO over to you. Good morning everybody. So we will now talk about pregnancy outcome after mass vaccination campaign with the Norale Coral vaccine. I will bring to you the results of our retrospective cohorts today. We conducted in Guinea, jointly with Epicentre, MSF OCG and the Ministry of Health of Guinea. Since 2010, the WHO has recommended the use of oral cholera vaccine as an additional strategy for cholera control and has precalified to kill wholesale oral cholera vaccines. Pregnant women are at high risk of complication and the risk of fatal deaths has been reported as 2 to 36 percent during cholera episodes. But due to lack of safety data, pregnant women have been excluded from most cholera vaccination campaigns. In 2012, rective campaigns have been conducted in Guinea with the oral cholera vaccines in Bofa and Foricaria perfectures. All the people aged one year and over were targeted, regardless of the pregnancy status. In our study, we aimed at determining whether there was a difference in pregnancy outcomes between vaccinated and unvaccinated pregnant women. The retrospective study took place from November 11 to December 4, 2013. The sample size was calculated to detect a 1.5 increase in the risk of pregnancy loss among vaccinated women. 1,200 vaccinated and 360 unvaccinated women were to be interviewed. All the households of Bofa and Kobah Superfecture were visited to interview all the women who might have been pregnant in 2012. Women were included in the study if there were residents of Kobah and Bofa Superfecture were aged 16 to 50 years old, pregnant in 2012 and provided an informed consent. Exclusion criteria were non-residents in Bofa prefecture at the time of the vaccination campaign, absence after two surveyors' visits and non-vaccination status and refusal to participate. Standardized questionnaire was used to collect data through face-to-face interview in local languages. Mothers and children were referred to a pediatrician if the questionnaire elicited any concerns about potential illnesses or malformations. The pediatrician was in charge of determining if there were malformation but also of patient management. The main outcome was the pregnancy loss defined as any loss of a project of conception after the woman recognized she is pregnant. Secondarily, we distinguish miscarriage and stillbirth according to the time of the loss. These outcomes were orally reported by the mother and verified on official documentation when possible. Malformation were defined as physical defects reportedly identified on the living baby by the pediatrician after a clinical examination. Primary exposure was the intake of the oral coronavaccination call during the pregnancy. A fetus was considered as exposed if the mother was pregnant during the campaign, if she received at least one dose of the oral coronavaccine and if she received a dose between the date of conception and the date of birth or loss. The main and secondary analysis were based on women pregnant during the vaccination campaign. We calculated the incidence of pregnancy loss and the incidence of malformation among fetuses exposed to the vaccine and among fetuses not exposed to the vaccine. Then we compared those incidents by calculating an adjusted risk ratio and its 95% confidence intervals through binomial regression. In the secondary analysis, we do the same procedure but distinguishing between miscarriage and stillbirth. Finally, our bias indicator analysis was based on women pregnant in 2012 but after the vaccination campaign so that the exposure was the intake of the vaccine by the mother but none of those fetuses were exposed to the vaccine that were conceived after the intake. The study protocol was approved by the National Ethics Committee of the Republic of Guinea and by MSF ethics review board. So over 10,000 households were visited and over 15,000 women aged 16 to 50 years old were asked about their pregnancy status. Believe me, my service hates me a lot. Over 3,000 women were reported a pregnancy in 2012. Overall, 1,543 women were included in the main and secondary analysis with 1,312 fetuses considered as exposed and 272 considered as nonexposed. In terms of baseline characteristics, the women vaccinated during their pregnancy were not different from the women not vaccinated aside from Owing and Noven and Television. On the other hand, in the bias indicator analysis, 951 pregnancies were included. This table summarizes our main findings. So in the main analysis, remember we compared the incidence of pregnancy loss among the fetus exposed to the vaccine and among the fetus non-exposed to the vaccine. Even if we can see that the incidence of pregnancy loss appears to be a little bit higher among fetus exposed to the vaccine, there were no significant difference in the incidence of pregnancy loss between the exposed and the non-exposed fetuses after taking into account other confunders like subprofectory, household side, antenatal care, multiple pregnancy, number of live babies, number of stillbirth, and choleraepes in 2012. Concerning malformation, there were a very low number of negative events with only 10 children diagnosed with malformation by the pediatrician and there were no significant difference among the two groups of fetuses. In our secondary analysis, we split the pregnancy loss in miscarriage and stillbirth and again, there were no significant association between neither stillbirth nor miscarriage with the exposure to the vaccine. Finally, the results of our bias indicator analysis were very similar to the results of our main and secondary analysis with no significant association with the exposure to the vaccine. This is the first estimate of the risk of negative outcomes of pregnancy after the intake of the oral cholera vaccine chancel during a reactive vaccination campaign. The exposure to the oral cholera vaccine was not significantly associated with the risk of pregnancy loss and malformation in our retrospective cohort. This is coherent with the findings of a study conducted in Zanzibar in 2009 on the effects of inadvertent intake of decoral on pregnancy outcome. On the other hand, at the same time, the risk of pregnancy loss in our cohort was three times higher among women who declared a cholera episode in 2012. There are some limitations in our study. First, the number of negative events was low and the vaccine coverage was higher than expected, reducing the power of our analysis. Second, we might have suffered from information bias typical of retrospective studies. Concerning the outcome, few pregnancy laws could be refined on official documentation and it could have affected our point estimate, being difficult to know in which direction. Second, concerning the exposure, less than 25% of the women could show their vaccination card and the incidence of silver was higher among the women who could show the card than among the women who reported already to be vaccinated. So it could have diluted a little bit the risk of still birth among exposed fetuses. But to further investigate the presence of information bias, we conducted the bias indicator analysis and no significant difference was found between vaccinated and unvaccinated women and the results of these bias indicator analysis was very similar to the main and secondary analysis. In conclusion, in our large retrospective cohort, no association was found between fetal exposure to the oral cholera vaccine chancel and the risk of pregnancy loss and matformation. Despite the weaknesses of a retrospective design, we can conclude that if a risk exists, it is very low. Additional prospective studies are warranted to add some evidence base on the use of oral cholera vaccine during pregnancy. But pregnant women are particularly vulnerable during cholera episodes and should be included in cholera vaccination campaigns when the risk of cholera is high, such as during outbreaks. I would like to thank the people of Guinea for their participation and their kindness. The Ministry of Health of Guinea and all the district health and medical officers involved for their support. All the MSFACG team that was very enthusiastic and supportive and my excellent study team in Bofa that were really wonderful. Thank you. Thank you very much for trying to simplify what was a very complicated and very large study for us and the floor is open for discussion. Yes, go ahead please. Thanks. This is Zoe Mullen from Lancet Global Health. You kicked off by saying that most pregnant women are excluded from most campaigns. I just wondered what was the rationale for including the pregnant women in this particular one? We had some debates because before this campaign they were mainly excluded. But then the vaccination is not contraindicated in the pregnant women. The insert of the two vaccines only stated that there were no safety studies to be able to include in the pregnant women and they just stated that we should make some benefit risk evaluation before vaccinating the woman. And then there is no reason why this killed well-sale vaccine could be harmful for the fetus. It is killed, it is oral, and it doesn't enter into the system and it doesn't trigger any systemic reaction like fever. There is no rationale why it could be harmful for the fetuses. On the other hand we knew that it was very harmful for the fetus if they get cholera and it was an outbreak. So we decided to include them but to monitor if it was a good choice on that. Okay, we have time I think for one more short question and would you keep your other one till later. So the lady, sorry, I have to give preference to the online team. Please keep your questions for the panel. So I have a question from Andre Westman who asks should pregnant women be included in the preemptive vaccination campaigns given the current evidence? Actually at the beginning we would have preferred to make a recommendation we should include the pregnant woman whatever in preemptive or reactive vaccination. What we could say is that for sure if a risk exists while vaccinating if there is very low and really lower than if the woman get the cholera during her pregnancy so during an outbreak sure we don't we there is no problem. Then during a preemptive vaccination campaigns maybe we could wait for more prospective studies because we had some information bias in our studies so we are not so confident in some points. So maybe we could wait for more prospective studies to be more sure about that and just try to insist on other strategies to control the cholera rather than the vaccination in preemptive campaigns. Thank you very much again and we will defer the rest of the questions I'm sure there will be time for more discussion about this important topic in a while. So a final applause for you and may I welcome