 Mae gyda ni yw'r cwestiynau o blynedd. Yn y cwestiynau. Ym y peth yn ynchangos i fynd i'r gyfer y cyfan. Y peth yma yng nghymru sy'n ymddangos i'r cwestiynau o ffaxiwn. Tyn ni'n gwybod i'r gwaith. Rydyn ni'n gwybod i'r cwestiynau i'r cyfan? Rydyn ni'n gwybod i'r cyfan. trailer, am gywethe? Dyma. Dyma. Mae'n cholwscu ar y cyfnod, Sut mae'r bobl yn ysgrifennu. Mae'n ysgrifennu, mae ti'n byb ar holl gael agu ar gyffredinol. Mae'r bobl yn y cilydd. Ni'n gwybod hefyd, byddwn yn gwahanol yna hwn ar gweddol 24 tango ddiagnodau, cwestiwch, siaradau mewn adminain Mae'r ffordd yni, mae'n cyfeirio fod ynddo i'n gwahanol na fyddain. Dyma'r gyfo'n amri anyway. Next. The question was just to the modeler. Sorry, Fabio. Did you include estimates of vaccine coverage in the model? No, because it was very unclear what previous vaccine coverage of those populations were when they were still in Myanmar. So it was mainly assumption-based, talking to people what they would think it could be. Okay. Now we're going to collect discussion questions. Lots of hands up at the back. Two hands in the back row and one here by the pillar. Would you like to start while the others collect them out of the bag? So the question is for Bashir. Happy birthday. Can you hear me? Okay. So thanks for the study because it's been long due and very needed. I'm wondering before the study happened there were a lot of proposals. Matt and I were in a meeting last year and there were already a lot of proposals to do distribution of SMC for people to just take at home. Have you reported these results back to the Niger Ministry of Health and to other organisations doing SMC? And what has been the response? Is this actually going to affect the implementation plans for many of those organisations? Okay. While you're thinking about that, two questions at the back. This is a question for Bakir Assal. Can you please tell us who you are and your affiliation? Yes. My name is Ivan and I am from MSF OCB. My question is I saw that you did a match case control study and you decided to match by age and village of origin. This choice to match by village of origin was done because of different prevalence in these areas or because the difference in understanding the SMC. Thank you. The other question in the background. Yes. Hello. You've got the microphone. My name is Ghassan. I'm from MSF Middle East unit. My question regarding the malaria profile access. Do you think having alternative medication preparation like oral suspension or syrup could provide better compliance and continuity of profile access for children? I think it's hard to believe that a toddler or a four months baby can easily take a pill. Thank you. Any other questions waiting? Yes, by the pillar. Thanks. I'm Tom from MSF Southern Africa. Just again, a bit similar question Bakir. I was a bit unclear what the operational question around why you did not do dots in both in all groups for the first dose given it's a long acting drug. It's fairly usual to give the first dose of SP when somebody is seen with pregnant women. Was there an operational reason? Was it somehow going to be less feasible to give the first dose by dot with the children? Why was that in question? Person in the middle and then the person by the pillar. Roger Dick. Roger Dick men's unit. My question is about the diphtheria outbreak presentation. I understand that that's a real time analysis. But are you able to share information about the case fatality rates with regards to the respective subgroups in terms of severity and age groups? Thanks. OK. And the final question for now by the pillar. Yes. I'm Isabel. I'm an entrepreneur and the founder of Immersive Rehab. And my question is about, I guess to Matt, about the randomized clinical trials that you are doing. How do they, could you make a comparison between trials done in the Western world and how you approach them where you are working? And yes, kind of the health economic model around that as well. OK. We'll answer those now and see how we get on for time. You've got a question. In terms of the case fatality rates for diphtheria, overall the case fatality rate for the outbreak was less than 1%. We haven't fully broken that down yet, but it was quite low and lower than certainly expected in terms of diphtheria. One of the questions that has come out was actually was the case definition too sensitive and were all of the cases that were reported as suspected indeed diphtheria. Because lab capacity at the time for confirmatory testing was extremely low. So we were seeing more than 100 cases a day, but the maximum amount of cases that could be tested per day were 15. So we don't really have a definitive answer in terms of the breakdown. OK. Also on the line, who's next? So for the question about whether we reported the result of our findings, yes, we reported the result to the Ministry of Health. So some partners are taking care of it now, so they consider our recommendation and SMC is being implemented with other partners. So as for the question to why did we choose non-dots, actually is much simpler. And we assume that after some years of SMC, caregivers have already the experience to do the SMC. So it's going to be cost effective, actually, because there is no need to have an agent to describe. So actually that's one of the reasons. So for the question about other malaria prophylaxis, I will ask. I didn't hear that question. Yes. One thing I did want to clear up was the question about who's targeted for SMC. SMC by definition is for under fives. It's for preschool children alone. They have expanded it to five to nine-year-olds in Senegal, and there they're using school-based strategies, but SMC is specifically for preschool-aged children in the south. To answer the question about the matching is we didn't have reliable incidence data from these areas and prevalence data from the villages, so we just chose to match by village to preclude any potential problems. And then I had a question about trials in the developed world. Menachoccal meningitis in the developed world outbreaks are of a very different scale and a very different style. They're often in college dorms or military barracks where they have a big outbreak is tens of cases. In the Sahel Menachoccal meningitis outbreaks, I mean the historical example is in Kono in 1996 when there were 150,000 cases with a 10% case fatality or 15% case fatality in Kono. It's a different beast altogether. It's very much linked to the seasonality. As soon as it rains, epidemics are over. It's a different beast. It's the same disease, but it's a completely different dynamic, so I don't think there's a real comparison to doing that sort of a trial in the developed world. Even of the studies that have been done on prophylaxis in the developed world, there are very, very few. I think there's four that were included in the meta-analysis for the most recent WHO recommendations, and they're all based on a very, very small number of cases. So it's really not at all the same thing. Thank you. We've got time for a couple more questions if there are any. Yes? And another one by the pillar, behind the pillar. Are you just stretching or are you asking a question? Is that Pilates or a question? It's Pilates, and one up here. I think if we can take three for the moment. So let's do the first one down here in front. Thanks. My question is to Matt. Actually two questions. One is you mentioned that WHO needed more evidence. Can you just tell us what that evidence that was needed is? And the other question is, as you know this, the issue of resistance in communities when you do mass vaccination or at least vaccination at community level is still an issue for discussion or ongoing discussion, as you say. Two questions is enough. Would you tell us who you are? It was the beginning of a question, Edithas. Oh, right. Sorry. Hurry up. Okay, a great question. Did you think the method that you used is good enough or you should actually find another way of demonstrating resistance development? Thank you. By the pillar, behind the pillar. Estrella-Lasry MSF. So it's for the diphtheria outbreak. While we were responding to the outbreak in Bandladesh, we were also responding to an outbreak in Yemen, was the same modelling proposed to be used for the outbreak in Yemen or was it only used for Bandladesh? Okay, thank you. And there was one down here. Who's got the microphone? Hi, thanks. Thanks to everybody for your presentations. Beth Stringer MSF. It may fall on from that question about diphtheria. So you had it, the outbreak in various countries you mentioned already. I wonder how many of those MSF was responding in and also just read actually that diphtheria has been with us since the fifth century and we've been managing over the centuries to control it somehow, but obviously in India there has been concern about control for some time. But are you reflecting beyond coverage of vaccination on why you have it popping up at the moment? Okay. Is there one more, yes? Last one? Yeah, just a quick one. So, for Matt and Bishare as well, it looked like in the village level treatment you ended up treating 76% of the population. So, that's probably not feasible at a large scale. Are there certain, well maybe, okay. Talk to that. No, I'll finish your question. I guess I was just wondering if there are certain settings where you can imagine it making sense, maybe lower prevalence settings where you would not be treating 76% of the population. Yes, so you were asking about Yemen if we could have done that or if we did the modelling there. No, we didn't. And I just want to say that those models are very specific of the place still because there's a lot of information in there that is actually not just numbers. There's a lot of other information in there and we maybe could have done one, but it would maybe have been a completely different model depending on the situation. So, no, we didn't do anything for Yemen. And so then for the other sort of two-part question of Beth, of the five outbreaks that were happening globally, MSF was involved with Bangladesh and Yemen. And in terms of reflecting on why we see this cropping up, I think it's really important to understand how the vaccine works because the vaccine is not against the actual bacteria. It's against the toxin that the bacteria can produce. So, the bacteria still works out in various populations and as you see declining in health systems and populations not being continuously vaccinated for those preventable diseases, then over time you will also see that popping up again. To Cipro, in terms of the evidence that's needed, so I think historically, so one of the reasons we look at attack rates is that it allows us to compare epidemics. The attack rate in the control arm was 451 per 100,000. That's a medium-sized outbreak on historical standards. And it happened at the end of the season. This was a short outbreak over four weeks. I think there's some questions about duration of protection. I would like to see... I was a policymaker. I would like to know if this was a big outbreak that started in February and was going to last for three more months before the rain came, would you still have the same results? And I'd also be curious to know about what happens in cities where transmission patterns might be different than in the rural area where this trial was done. And I think there's also concerns about antibiotic resistance, which is a nice segue into the next question about is this the right thing to do? Is this the right methods to have used this question? As a background, Episcenalto has actually been working in that area for over a decade, and we have historical data about rates of antibiotic resistance in that population from even like 10 years ago. We were looking at about 30% of kids admitted to hospital, had super-resistant bugs growing, carriage of super-resistant bugs. So we were very, very surprised by these results, to say the least. We had been known that this was going to be the results. When we planned the trial, maybe we would have thought about something different, but the problem is that it's actually difficult to imagine what you would do. If your concern is resistant invasive disease due to an enterobacter, I mean, are you going to monitor? You just wouldn't ever have the power to say, oh, well, this month I had two resistant salmonella cases in my hospital versus three after the super-resistant, after the super-distribution. So it would be really, really tough to actually design a study that would detect a difference if there was one. So I think that we're sort of left, and especially now that we have those results, we're sort of left with this method that is admittedly unsatisfying, but it's also doable in the field. We can take stool samples at home, we can inoculate them in the Cary Blair, we can take them back to our lab and plate them up, and that's sort of much more doable than doing a massive, community-wide, invasive disease surveillance program. And then lastly, and I won't be sure to say this too, the 76% coverage, I'm not sure that that's... I'm not sure of doing this trial, it was really tough. We had a lot of ideas about how it was going to go in the beginning, and we thought that doing the distributions would be really tough. That was the easiest part. You can treat 1,000 people in a half a day, two nurses, a plastic table and a nurses' aid, and that part was honestly easy. Of course it is easy. So doing the trial again makes me a little bit scared because it's actually, the study is tough, but to do the strategy, it was... Just open your mouth, you know. Okay, thank you. Speakers, are you all done? No more questions to answer? I just want to say thank you again to the speakers for a super afternoon. You can see what I meant when I said this would be the exciting bit. And it really remains for me to say it just shows how doing your best and making a sensible contingency decision, how to go forward, can save lives, families, local communities and businesses. It can avert a bigger disaster and you can learn something from your results to pass on to the next people who have to deal with something. So thank you very much. I've really enjoyed your presentations and it's time for me to hand over to the MC now.