 Right. Thank you. It's really a great pleasure to be here talking to you guys this afternoon. I'm going to take you through a little bit of an analysis that we did of the water and sanitation programs in response to a recent hepatitis E outbreak in Amptiman Chad. And we'll get into some of the specifics in the title there. Before I go deeper into that analysis though, I want to educate you just a little bit about hepatitis E and about some of the Watsan programming, what we call WASH programming in MSF. Hep E virus is an acute viral infection of the liver, which causes jaundice or yellowing of the eyes and skin. It can also cause quite a few other significant symptoms, and especially in pregnant women, can have a very high mortality up to 20, 30%. In the midst of an outbreak, we define a case of jaundice, a new case of jaundice as an acute jaundice syndrome. Initially, this is checked with a laboratory study, but then we start to just use the case definition. The transmission is fecal-oral, and I'll discuss that a little bit more in a few slides. And MSF's experience with Hep E is increasing. Most recent outbreak before this one was in Maban, South Sudan, and we have quite a few other similar outbreak responses in the past. So this outbreak was in Amptiman Chad. It's in the southeast corner of Chad there, as you can see. And it's a town of roughly 50,000 people. MSF has a project there already, and we first started noticing cases in September of 2016 in pregnant women. Since that time, by 2017, by April, there have been over 1,100 cases of acute jaundice syndrome added to the line list. And we actually have a poster outside if you want to take a look at that. There's a few more details there, including details like the incidence map that you see there of the city. Briefly, though, this is the outbreak, the epidemic outbreak curve that we plotted for this outbreak, ranging from September to April. And each of those columns represents a two-week time period. You can see that in roughly January and February, where we were having the most cases, almost 150 per week. So quite a few cases overall. And we, a little bit, there we go. So what do we do in response to this outbreak? We moved quite aggressively for several objectives. One was to treat and care for patients. And we did this through an outreach network, active case finding, and clinical case management when necessary in the hospital or as an outpatient using the MSF Hepatitis E protocol. But then what we'll talk about a little bit more today was interrupting the spread of infection through hygiene programming and safe water programming. This involved hygiene promotion, hygiene kit distribution to 10,000 households in the city, as well as water treatment using a bucket and water, city water network chlorination programming. The diagram that you see here is what's called the F diagram. And this is a classic representation of how fecal oral diseases are transmitted from one person to the next person. And importantly, it gives you an opportunity to intervene. The areas in red are where we intervened in this project on safe water and on hygiene. We didn't really do anything around sanitation for this project. And then lastly, I just want to give a couple of words about what chlorine and hepatitis E. So we use chlorine in this program, in this project, in order to kill and prevent recontamination of the water. Initially, at the point of distribution, we have what's called FRC or free residual chlorine at a target of 0.5 milligrams per liter. And this deactivates the virus. We had regular monitoring that was showing that we were typically meeting that goal. The next point though is at the point of use at home when people are using and drinking the water several hours later. And there we go for an FRC of 0.2 milligrams per liter up to 24 hours later. And this prevents recontamination. So just a couple pictures to set some context. This was the distribution of our hygiene kits, some soap and buckets there. This was a mapping exercise that we did. We had water chlorination programming in all 75 water points in the city. These were private wells that people would go to with gerry cans. And then there were two water towers in the city. And so we were also doing inline chlorination at these water towers. This is a couple pictures of the wells. And we had staff typically putting concentrated chlorine solution into those gerry cans in order to do this chlorination. Okay. So a little bit of background there now moving on to this analysis. This analysis was conducted in order to understand the coverage of these interventions. So we were looking at hygiene promotion messaging. We were looking at how well we were doing in terms of hygiene kit distribution. And then importantly, we were looking at how well our water chlorination efforts were working in people's homes at the point of use. That's that second FRC target of 0.2 milligrams per liter. To do this, we did a random sample of 395 homes from the total in the town. Our respondents were women 18 years or old, over 18 years, self identifying as responsible for water supply in the household and consenting. They completed a survey. But then in addition to that, we did water FRC testing with pool testers in the people's homes with water that was in their storage containers in their homes. These were typically large clay pots that they would transfer water into when they got home. This was conducted over a two week period in December of 2016 by several of our national staff in local language. We had quite a few results. We did a several page survey and I won't present them all today, but some pertinent things that I think are interesting. One, we had quite a high response or participation rate of 392 households. And one of the questions that we asked was what are the sources of the water that you receive? So we found that 69% of people reported getting water from these 75 private wells around the city. And then a 36% reported that they had direct pipe water from the city water supply into their home. We also asked some questions regarding the coverage of hygiene promotion messages in the city. In particular, we were interested in how people were hearing about this type of messaging. We were quite active in the city and so you can see there that 90% of people had a household, had an MSF employee visiting their household. And this led to promotion of hygiene as well as we had staff at the water points. And so 45% had contact that way. There were several other methods there that you can see. We looked at the hygiene kits. Almost all respondents reported that they had received a hygiene kit in the distribution and these items were directly visualized in the homes by our surveyors. The column there on the far right represents direct visualization of soap at water point, hand washing points in people's homes. So that's optimistic. And then I'll just jump here to the other side. We were asking some questions about other uses of soap. And so quite a few people were using their soap for washing clothes or other activities besides just hand washing. And then finally just a couple slides here on the results of our chlorine testing. So 97% of people had accepted chlorination at the point of collection. So that's quite an optimistic finding. People were quite willing to take on this change in their water. We did have 43% of households achieve a safe FRC level. So that's that target of 0.2 milligrams per liter at the time that we did this testing. There were several factors that were associated with this, several subgroups that had a median greater than 0.2. In particular, households that had time less than six hours since the last refill, we were asking people when they last refilled their water. Empty storage containers. A lot of people were mixing new water with old water. And so of course that dilutes the water and makes the residual chlorine in the water less effective at preventing recontamination. And then finally the group that had received their water from private wells was more likely to have a higher safer level than from the piped or river water. In a subgroup that had put their water into an empty storage container up to 18 hours after collection, we had 71% having a safe level. So that's a quite, that's the group to target in other words. We did, the prior side was subgroup analysis. This slide looked at Poisson regression analysis just to look at a little bit more robust analysis of this data. And you see the same factors come out here with time since last refill, in this case less than 18 hours and water level before refill being empty as important factors here. So some lessons from this analysis of our programming. Well, we found that health and hygiene messaging was effectively delivered and that people were able to recall this messaging quite well. We gained a deeper understanding of the local water sources and transport storage mechanisms through this project. One example there is that we learned through some of this analysis the local practice of transferring water and then dumping it out into local storage containers at home. And then in particular, we found that time since chlorination and mixing water significantly affect the FRC levels in drinking water at the point of use. There are of course several limitations as in any study. Responder bias is always a problem. FRC measurement methods was something that we paid attention to in terms of the pool testers that were used. These are commonly used in the field for testing chlorination levels. However, they're not the most precise instruments. And then just jumping to the last one there, importantly, this study did not evaluate the effect of these interventions on the transmission of the virus or the progression of the outbreak. There's plenty of comments to be made about that and happy to discuss that. But we were really looking at the coverage of these interventions in the community. So a couple of recommendations from this. Well, we think that there should be further studies looking at these kind of things. It's a pretty common recommendation after you do a research. We found that, you know, water chlorination and hygiene promotion programs are feasible in open or in non-camp urban settings. And so with the appropriate resources, these can be implemented. We really like to understand and have a better understanding of the improved. We'd like to have a better understanding of the monitoring of FRC and the relationship between household level point of use chlorination and the levels that are put at the point of distribution. And so that's something that should be addressed in future. Messaging really should be focusing on clean empty storage containers and limiting the time since water was collected. And then finally, if you remember back to that F diagram, we see that an approach emphasizing provision of safe water and promotion of hand hygiene may be protective against recontamination of drinking water, especially in a setting where more complex sanitation programming is not feasible. So I just want to acknowledge all the people that were involved and there are many more than I could even list here. This is a picture of some of our survey team. And then turn it over for questions. So thank you very much. Thank you very much again. Excellent talk and staying in time. We have two minutes for questions and Estrella, I think you need a microphone. Thank you for the presentation. I have a question on your last point because I'm medic. So a couple of years ago or last year Ruby presented the Maban outbreak of HEPI. And if I remember correctly, it showed that there was little impact of the Watson interventions. Now you're presenting an evaluation of the Watson intervention without an evaluation of the of the impact. So what's the point if we keep and I'm not not what the study is well done. But what's the point in doing this surveys if we're not assessing what the impact on on the hepatitis E it's probably having an impact on diarrhea overall and which is great. But if we're not assessing what the impact on hepatitis E is then should we keep doing these and outbreak context to hopefully reduce hepatitis E even though we don't know if it actually does reduce hepatitis E. Great question and the most challenging one. Was was the large effort that we went to to respond to this outbreak in terms of chlorination program in terms of all of this stuff worth doing. I think yes. But then the next question is should why didn't we really look at that much closer. Well I came to feasibility it came to identifying for example a source of the infection that we saw cases everywhere in this city and assumed it was the water but never were really able to pin down exactly you know one whale or one water point where it was coming from. Epi is very challenging to study in general because of the six week long period latency period or incubation period and so any intervention you do you do now doesn't even show an effect for one to two months and so finding a causative correlation or I should say you may find a correlation but even going this next step and finding some kind of causative link between these interventions and and change in the epidemic curve is challenging. We did see as you saw earlier in the slides at the epidemic curve starting to come back down and and then now eventually is is almost completely back at baseline and so we can draw the conclusion that probably our efforts worked but I can't give you that data right now.