 I would like now to start the panel discussion. I think we will ponder over your last question, but I knew there were some questions from the back following Daphne's presentation, and maybe I can invite those first if you're right with that. So there's a question from the online listeners, and we will proceed with that and then follow on with your questions at the back. Thank you. I actually have four questions. Four questions. Two of them are short ones for Anne, and then two are for the panel, if that's all right. So my first question for Anne is from medicine, who is asking, is HPV vaccination too controversial in countries where sexual promiscuity is a board and preventative measures disdain? So the idea with HPV vaccination is you should give it before you have a sexual intercourse. So the target is young women like 11 years old, and that's the difficulty with the EPI that you need to get them after the normal EPI programme. But there's also some effect of giving it after your sexual debut, because you might be infected with one HPV type, but not all of them, and they're covering several different HPV types. Yes, and maybe to add to that, I don't think that in the world of HPV vaccination, and there are many promoting this at the moment, there is a condition on being vaccinated that you must stick only with one sexual partner following your vaccination. Couldn't be difficult to monitor as well. Sorry, my second answer is from Dr Sanko, who is asking, what did you do for the 4% of women with an outcome of cervical cancer once confirmed, and are there services in place to provide further management? So in the country we have, there is a further service but it's quite expensive, so you can get a hysterectomy, you can get everything but it costs several hundreds of dollars. So most patients can't afford that, and we did a small follow-up on the, not on the patients with confirmed cancer, but the one with clinical suspicion of cancer, and one had died, one was waiting for a hysterectomy, and the rest had not done anything else. So that's a problem among our cohort, which is a very poor cohort. I think there is a great need for better availability of cancer treatment across many developing countries, including radiotherapy and palliative care. Thank you. So my third question for the panel is from Dr Sikides, from the Lancet, who's asking, commenting as well, what I've heard so far this morning makes me wonder, are we being too cautious about assessing treatments in children and pregnant women? I think that is a bit of a general question, so the question is, are we being too cautious about assessing treatments in children and pregnant women? About assessing treatment. I think this was in relation with the oral cholera vaccine, I think so. I think so. So are we being too cautious when it comes to young children regarding consent and pregnancy and pregnant women? Would you care to maybe give a comment or not? I think, yeah, there is something where we could be very cautious when there is a pregnant woman and babies in the game. For example, in cholera vaccine, where there is no real reason why we should exclude them from the vaccination, but there is no very important safety data that really ensure everybody that there will know whatever occurs be it is not so sure to vaccinate them, then we won't do it. And I think we as MSF, maybe we could have like a back step to see what is really the benefit and the risk on vaccinating those pregnant women. And in the case of cholera, oral cholera vaccine, this is clear that we should include them without an adept. I think this would be quite a big debate that lots of people will have points of view on. It's not fair to ask you to answer the question. We'll bear it in mind. Can we have the last online question? This is another big one as well. From Trish Schuertel in Australia, who's asking, how do research has become involved in projects if we're increasingly concerned with accountability? Does evaluation need central coordination? That's also a very broad question. So the first part is should. How do we become involved in research if we're increasingly concerned with accountability? I guess the big question is, does evaluation need central coordination? I think this is about research ethics and good research conduct. I think this came from the last presentation. I'm going to ask each of the four presenters to say something in response to that. Bear in mind that's not a definitive response because this is obviously a very important, far-ranging question. Would we like to start with Timothy, maybe? I think field research is critically important, asking questions in the clinical setting. It's part of, I think, MSF's mandate. As for us, we didn't need an ethical review because we only did analysis of our routinely collected data, but I think it's always important to comment on if you do it and if you don't do it and for what reason. I imagine, as we talked a lot about innovation, and in MSF we tend to try to innovate in medical point of view, then we have the duty to make some ethical research attached to this innovation to monitor and evaluate our actions. I think that was somehow the point that we wanted to show with this study as well, that we thought of having, because we like standardisation, because it makes things graspable and easy, and that we wanted to show with this study is that if we try to standardise too much, then it leaves gaps. For that reason, it's of huge importance to go into detail and look into your data and see how for, at soon for, operational perspective that you can adapt your strategies and your management so you can provide better care, you can do better. So, yes, I think. Thank you very much. I would now like to open to the floor again. There are two burning questions up about the lady in the white top microphone first. Could we give the lady with the white top a microphone? Thank you. Could I start off with a comment on one of the earlier questions? Could you say where you're from and your name maybe? Oh, sorry. Jane Cooper, I'm a student at the LSE at the moment. I think there are a few things more controversial than labelling other people's sexual behaviour as promiscuous. I think that links into all the other topics we're discussing because if we haven't thought through our attitudes to sex, then we are at risk of neglecting topics which have an impact on women's health. So I think it's important that we do talk about sex, but let's try not to be judgmental, please. Then if I could turn to some questions on the presentations. Could you take one question at a time? What is your first question, please? My first question is in relation to the last presentation on context specific or standardized package. Do you think there would be merit in soliciting feedback or undertaking qualitative research to solicit the views of clinic attendees, communities and local councillors? Thank you. Okay, thank you for that question because I think it draws up something very important that this is all qualitative analysis and we need to do more qualitative one, sorry, and it must be very important to look into one part of the satisfaction of the care that the survivors received, but also to understand better their barriers to come. Why did they come in late? Why is there a refusal of different treatments? We understand sometimes that it's a lot about how you present it as well. Like in another project we try to offer contraceptives as well and then the care providers were like, but we can't offer contraceptives to women who just have been raped. How do you come on to that? And we say, yes, if you look at it from a broader perspective it might be needed, so I think it's absolutely a component that needs to be added that will enrich the studies that we are having now. Thank you. I'm going to move to the gentleman behind you. I will remember you have more questions. Go ahead. Hi, I'm Gabriel Fitzpatrick, my name MSF Ireland. I only have one question. And it's regarding the last speaker. We know there's circumstantial evidence that sexual violence and rape is a big issue in institutions such as prisons and psychiatric institutions in countries where MSF works. So my question is for those centres that were in your study, were any of those patients coming from those institutionalised settings where you know you've marginalised people or were any of those centres doing any outreach work into say prisons or psychiatric centres? As far as I know on the different profiles of the survivors included in this and on the settings that we were working, no and definitely not as a focus of these settings. We know as well that for instance in schools a lot might happen so when you see a lot of child survivors it's also something to question and to investigate further in. But in older projects that are running for the moment for instance working with migrants there we know that a lot of the survivors coming from there at the moment where the violence happened was while being for instance in prison or our search institutions as you mentioned. But not from the study settings that I was presenting here or not in an important number. This gentleman at the back go ahead. Would you pass him the microphone please? Thank you. Hi I sit along Medical Director for ACA. My question is also towards Daphne and sexual violence. It's a broader question and it's actually an operational question. I think across our portfolios it's fair to say that we have introduced sexual violence intervention in a number of our countries but yet a lot of our patient numbers come from very few countries namely DRC. So one of the challenges that we face is actually how do you prioritise sexual violence activities within quite an integrated programme that is looking at numerous health needs. And then my second point is the lessons learned from places like DRC. How do you then put adapt that to contexts like South Sudan where actually we just do not see the numbers of sexual violence survivors that we know that exist? Okay thank you for that. Can I just ask if there's anyone else who has a question pertaining to this at this moment so we bundle them and then move to another topic maybe. Yes would you care to ask your question and Daphne would you then answer? I'm Charles Soncoe from MSF UK. My question is about there was a difference, a clear difference between the two settings in terms of the victims of violence. My question is are there possible reasons for the differences in pub coverage because in DRC it was 100% but in Monrovie it was around 80%. So trying to respond to these three questions. One was on how to prioritise or to look into which context to implement or to integrate these packages of care. Well actually as a general recommendation from our working group on reproductive health and sexual violence we'd like to say please be ready in any project in MSF to give at least a minimum package of care to survivors of sexual violence. So that's the general recommendation but we know that there are competing priorities and that's for this reason we also tried to make it more simple. We know it's not a simple topic but that the minimum that we should be ready is that once someone comes to our services that we can give them the correct treatments and a minimum of emotional support. So we tried to make it less heavy and then at the same time it is very interesting to look at operational portfolios where vertical programmes can be set up because we do know that when also enough attention is put onto the topic that we do see the victims coming to our services. So perhaps that gives a little bit of a response to that first one. And then when looking into context as South Sudan but there are many other contexts where it is challenging to bring up the topic and also from there we learned a couple of lessons and one is actually that we need to start talking about it and we cannot expect actually that the survivors start talking about it and come to our service and knock on our door and say why don't you provide the service. So it's actually something up to us care providers to say let's open the discussion and it starts just with your medical teams and with all the other teams you have in your projects and with focus group discussions and so on to open the topic and then you will see more frequently than not that it's not always such a hot topic to talk about and once you can start talking about it it can be much easier as well to start implementing it and to offer this kind of care. So I would really like to invite everyone on the field to start to taking the first step and not to wait for the first step to come from the survivors as it's very difficult. And then there was the question on the coverage of PEP initiation in Monrovia perhaps to be on her side I don't know why it was lower. I'm not sure if that could be drawn out of the of the analysis that we were able to do. We had the rough data or not the rough data we had patient individual databases where we can see what is the coverage but I'm not sorry for that one I don't know in Liberia why it was lower than in DRC. Thank you very much Daphne for that marathon run. I know there are quite a few questions around the cholera vaccination among pregnant women and I'd like to open the floor a little bit for people who have still remaining questions around that. Does that include you sir in the yellow shirt please go ahead. Thank you. My name is Hugo Smeist from MZF Holland and also from the University Medical Centre in Utrecht. I have a question for Lisa. A nice study about side effects and effect signs but I wasn't quite clear about your design. You were looking at women who were pregnant but how did you know that they were pregnant and isn't it possible that you missed a large group of pregnant women especially the women in the first trimester of the pregnancy and what could you say about what effect would this have on the results. Thank you. Thank you for your question. Yeah actually that's why one of the limitation of retrospective cohort is that you come after the battle. So basically we entered in all the households and we ask if one of the women in the household has been pregnant whether the children is alive or not has been pregnant in 2012 and if the response was yes the answer was yes then we have for the booklet of the children if there were any visits in an antenatal care. But yes one of the two response of your question the first is that in our definition of a pregnancy loss is a loss after the woman recognises she's pregnant and that the first one because most of the of the miscarriage occurred and the woman didn't know she was pregnant and she didn't notice she's losing a fetus so we couldn't at all include these kind of laws and it would be very difficult to do that even in a prospective study because you would have to test every woman in in in age of of being pregnant to see if maybe she's pregnant so this is a tough part. But then we all say it was very declarative and actually more than 80% of the woman had a booklet for the children but if the children was alive then for the woman who lost the fetus it was not the case because the the fetus was never born so this is why prospective study would be really useful because then when you vaccinate a woman who is pregnant you can follow her and one of the question was do we miss more losses for women that were vaccinated because they were afraid of saying yes I was vaccinated and I lost the baby or do we miss more losses for unvaccinated that were ashamed of not getting the vaccine and then losing the baby that's a question we have and that's all the tricky part of her respective cohort. Thanks Liz thank you very much for that answer it's very complicated to do these studies and I think your point was also that if you're talking about congenital abnormalities if they exist they are most likely to be lost very early on in the pregnancy so that is an important study but important limitations there are two questions here about a colour vaccination which we will take and then move on we are running out of time so can we have short questions and short answers go ahead sir you were first I think sorry Nick yeah thank you um my name is Paul Bournshire I'm from BBC media action um so my question really is that um in the colour vaccination survey did you collect any data on maternal mortality did you ask perhaps using the sisterhood method um to assess whether or not there were differential rates in mortality by vaccination can you do it again did you ask about maternal mortality and did you right use the sisterhood methods which might not be appropriate to be perfectly honest in this setting do you want to give a quick answer it's very quick it's no we just looked at the effect on the feathers so pregnancy loss and malformation that we didn't looked at the maternal mortality and I'm happy to debate the sisterhood method with you in the break Philip De Crow MSF um Lisa um so fantastic study congratulations very important findings I wanted to take this to the policy level because I noticed with your study and also Zanzibar quite wide confidence intervals what have we learnt because you recommended prospective studies next are they going to happen and if not what do we need how much evidence do we need to make a policy recommendation on this in pregnancy that's a very very good question and I would love to say yeah that will occur but maybe then I could give because well I left unfortunately I left episode MN MSF and then maybe I can give forward to people some people that are really involved in MSF to know if they are thinking about vaccinated and and giving a chance to a prospective study to occur okay thank you very much can we have a lunchtime debate about that I think I'm allowed I'm allowed one question for Tim and one for Ann if there is anyone who has a question for either Ann or Tim they may now take the floor is that you in the middle with a scarf around thank you very much and then I'm afraid we will have to end the discussion I'm getting severe warnings from this side of the panel go ahead a question for Tim thanks for the presentation it's really really good outcomes and I was wondering about the treatment outcomes of the pregnant women and also what did you do with the anemia in terms of management thank you I'm Nines MSF Spain the treatment outcomes of the pregnant women were excellent and also a note there was no mortality in the maternity group which was fairly significant to us the anemia is we do targeted therapy in terms of the ferris and foley but what is limited is the ability to transfuse you know it's a donor based society a family donor and this is a real stumbling block in this area it's one of the things that clearly one is one of the immediate recommendations that try to expand into some form of blood bank thank you for that and is there by any chance a question for Ann so if not I do have one go ahead yes Ann I just want to ask kind of your opinion really in terms of really scaling this up particularly when I'm thinking about rural decentralized cervical cancer screening where you've got multiple clinics in terms of human resource I just really really challenge to see how we take this forward and my question is is there a role okay HP vaccination definitely the countries are going for it is there a role at all for each using HPV as the first screening test potentially self-swabbing we've we're rolling out viral aid machines gene expert machines for other things do you think there's a role for MSF to look at HPV as the first screening test and also potentially that will allow us to screen them less frequently therefore a juice workload thank you for the question at new lands clinic the one that I was talking about they do that now it's a study to see how it's working and I've also seen other studies where they say they have more like you can more target down the one section of lesions by combining the HPV test with the screening so I think I haven't seen the outcomes of the study from new lands but I think definitely it's worth following thank you very much brave panel to face this audience thank you especially ninka and all the speakers it's been an excellent session we're running a little bit late because your bad mc was thinking of questions instead of doing his job um a big hello to those in ukraine laos pakistan career vietnam peru and other countries um and the americas who are just joining us can I remind the speakers and the chair for the next session um as well as janine lunin to come to the front for a briefing just before we go to lunch we've got a 45 minute lunch break so to be back here sorry an hour and 15 I tell a lie an hour and 15 I can't add up um for and that's an important reminder because it's not just lunch it's a chance for discussions and it's a chance to look at the posters there is um an online poster competition and you should have voting forms if you want to participate from here if you voted online please don't vote through the paper system again this year we do have a poster prize the prize is a thousand pounds so it's quite significant and that prize is to go to the group to help participate and do further research in in the future um we will be streaming msf scientific day from india our colleagues will start the the leishman isa session at 12 20 so in exactly three minutes if you're not watching please go outside um and don't have your conversations in here so that people can watch and if you want to ask questions um carmen if you can put up your hand one of our volunteers will happily tweet your question so that they get asked in the india room um and also just to remember that you can't bring your lunch back in here so if you do want to watch but you're also hungry make sure that you plan how you're going to get that done I think that's everything enjoy lunch