 I'd like to invite John Pringle, he's John here, great. John Pringle's a polymath, he's a nurse, an epidemiologist, has a doctorate in public health and in bioethics, and he's just come back from Sierra Leone where he was managing Ebola, John. Yes, thank you, I didn't really manage Ebola, but the cases did go down after I got there, but I had hope. Anyway, thank you very much. It's a privilege to be here and to be presenting on behalf of my research team. So the title of my talk is anti-malaria mass drug administration in the Ebola epidemic in Sierra Leone and Liberia. Malaria and Ebola thrive together. In the Ebola outbreak in West Africa, malaria is hyperendemic and left to flourish. A sustained Ebola transmission disrupts health systems. It's important to know that malaria fevers mimic Ebola and people that have malaria fevers are apt to overrun Ebola management centers, not just overwhelming the centers themselves, but putting themselves at risk for nosocomial Ebola infection. Therefore, it's no surprise that back in November of 2014, the WHO recommended Mass Drug Administration, or MDA, with Artemisinin-based combination therapies in areas that are heavily affected by the Ebola outbreak, and where malaria transmission is high and access to malaria treatment is very low. Now, it's one thing to make a recommendation, and it's another thing entirely to implement it. And to MSF's credit, we stepped up and we did two distribution rounds in Freetown and Monrovia. We did two mass drug administrations of three-day courses of Artesanate Amodiaquin as both treatment and chemo prevention for malaria in Freetown and Monrovia, and we did it in collaboration with the corresponding ministries of health. This was an unprecedented undertaking. In Monrovia, we distributed in four administrative zones to a population of over half a million. Distributions were done differently in each site. In Monrovia, it was a fixed-site family kit distribution that was later assessed through a phone-cohert study. In Freetown, we distributed in the greater Freetown area to a population of 1.8 million people, and we did it with a house-to-house distribution, huge undertaking involving about 5,000 distributors, and it was assessed by a serial two-stage cluster surveys. Of course, before we did the distributions, we had to mount social mobilization. We had to let people know that this was coming, why it was coming, and how important it was. We had town criers. In Freetown, we had 700 town criers. We distributed leaflets and banners. We had radio jingles, radio and TV panels. We had SMS messages by mobile phone. We did social media campaigns, and we held advocacy meetings with politicians, community leaders, and villagers. The distributions are arguably a success. In Monrovia, we found that more than 95% of the sampled households that received vouchers, in fact, attended both distribution rounds. Taking at least one dose was 53% in the first round and a bit lower, 22% in the second round. Of those taking doses, 16.5% of people reported an adverse event, typically mild, and I'll have a slide on adverse events later. In Freetown, we did distributions in December and January. We did distribution coverage surveys that found, in the first distribution, 88% of people received medications. And in the second round, we broke it down by adults and children, but it was 92% in the second round, which was huge coverage. In fact, it was 85%. So we surpassed our goal. Taking correctly in the first round was 75%. And by taking correctly, we mean by taking all the pills over the three days without any mistakes. So it was a pretty high threshold, and we were pleased by that. In the second round, it was 64% of adults and 86% of children. Adverse events reported were quite high, 66% in the first round, 54% for adults, and 39% for children in the second round. And we attribute this to the fact that we're having door-to-door conversations, so people are more apt to discuss any possible side effects. But importantly, over 90% of those surveys said that they liked the idea of the mass distribution and would accept medication in future distributions. So what were the adverse events we were seeing? Well, they were typically quite limited and mild. So as an example, in Freetown, in the second round, we assessed both adults and children. The most common side effects was weakness, feeling sleepy or dizzy, having headache, and then more rare were loss of appetite, vomiting, and diarrhea. So as I've said, this was a huge undertaking. We feel it was a big success, huge challenges. The countries in which we worked, we had MSF operational centers had not already had a presence, so we were setting up there from scratch, huge commitments in term of time, logistics, and human resources, and all of this was unfolding in the time of an Ebola outbreak. So this was the largest mass drug administration of anti-milarials in Africa done in the time of an Ebola outbreak. We were using out-of-date maps at the beginning, although our GIS officers got as excellent maps as time went on. We were using old census data and finding that, in fact, the populations have doubled in some of the areas. We had challenges in mobilizing communities, building trust and support, and we faced challenges in how to evaluate our coverage and our impact, and how to properly assess and monitor for adverse events in collaboration with the Ministry of Health. So in conclusion, the scale and the scope of the MDAs were unprecedented. In Monrovi and Freetown, they differed quite a bit in context, the point in the outbreak that we did the distribution and the methodology that we assessed it. We found that MDAs can be feasible, accepted and welcomed, that malaria control is a crucial part of Ebola response, and I'm gonna just cite now a recent study was published in the Lancet that modeled the effect of the Ebola outbreak on malaria. It estimated that the indirect effect of the Ebola epidemic on malaria morbidity and mortality is probably of similar size as the public health burden directly caused by the Ebola virus disease. The authors' findings suggest that measures to prevent malaria infection, such as the emergency mass drug administration of ACTs, were urgently needed, while health systems were given time to recover. So I think what we conclude is that malaria control is in fact a crucial part of the Ebola response and that non-Ebola health needs must be addressed. So I'd just like to thank the residents of Monrovi in Freetown, MSF France, MSF Spain and Episantra, our Ministry of Health partners, and you in Scientific Day. So thank you very much. Another excellent talk. We have a few minutes for questions provided they're shortened to the point. Jeremy. It sounds very right, and I don't doubt it, but how do you know you achieved what you said you think you have achieved? How do we know we achieved what we were setting out to do? We were looking to get 85% coverage, for example, in Freetown. We feel we've surpassed that based on our own cluster surveys. We got great buy-in by communities. No, I meant the impact on morbidity and mortality or whatever else one was measuring, not whether you achieve your goals, but the impact on health. Yeah, and that's a good question, and that was one of the challenges. How do we measure the impact? My understanding is that the WHO is currently doing an evaluation to measure the impact. We have some indication that malaria fevers went down from, I can't remember the exact figures, but something from like 3% to 0.1%. It's hard to measure, though, because fevers are so stigmatized in a time of Ebola to ask people about fevers. They tend to underreport. That's our feeling. But other than that, we will see what the WHO has to say. Adi, just behind the pillar. Hi, this is Thria Lazarie from MSF. If I can add to that, thank you, John, for the presentation, but if I can add to that, we did a cohort study in Monrovia where we assessed reported fever prior to the first round and after the second round, and we saw quite a significant decrease in malaria as John said, from 3.1 to 0.8%. There's more data being collected. Unfortunately, because of Ebola, malaria was not being confirmed at the time, so RITs were not being done. So there is some information that we just have to assume from what the population was reporting. What we cannot get information on so far is on the impact of the second objective, the reduction of attendance of people with fever to Ebola treatment centers, which is unfortunate, but we will probably not be able to find out to get that information. Thank you, Mr. Al. Thank you very much indeed. I'll take one last question, lady behind the second pillar. Hello, thank you. My name is Mayama Conte from Freetown. Hello, Freetown. My question is, you said that WHO is doing the evaluation, thinking that it was MSF that did the mass drug administration. Why should you leave it to WHO to take the credit? Thank you for your question. So just to reaffirm that we, MSF, we did our own evaluation. We did two serial cluster surveys but we work with our partners, we work with the Ministry of Health and so my understanding is that was the WHO will be doing an assessment, but I don't have the details of those negotiations, but I take your point. Thank you very much. Great, thank you very much again for another excellent talk. Okay, thank you. Thank you.