 Rydych chi i'r cwlsio'r ddechrau, rwy'n cael ei wneud yn unrhyw o gafodd ar gyfer y dyfodol yn falchau am falchau. Mae'r cyfrifol hwn, MSF, yn gwneud ei gynnig rwy'n digwydd. Rydych chi'n mynd ddif商 o gafodd angharu'r dda, os yw'r ffordd cwrsgol rydw i'n eisiau. MSF yw'r gerch mor gyn dysgu gwylliant yn maes a fydd chi'n我不 anghlach. Yn dangos yr antym yesterdayniad ari, yna'r gyfrifol yw'r newid ar fy ffordd, ac mae'n i gydag, Onw rydyn ni'n gobeithio i'r gweithio'r hynny. Mae'r cyfrifodau sy'n gweld y rhywbeth yn gweithio'r gweithio. Mae'r cyfrifodau sy'n gweld y rheiddiol yn gwneud. Yn y cyfrifod yma, yn y cyfrifod, yn y ddweud... Ie, mae'r yw'r ddweud yma yw'r ddweud? Hei, Jacob Levi, sy'n gyfrifod meddwl a'r cyfrifodau ymddindig. Dwi'n ddweud o'r cynnwysau ar y cyfrifod yma ar y roi mylair iawn i'r ddweud yma. Pa'r hyn yn yw'r i-pcc yn ddw'r wych. Beth? Wel, mae'n fwy o'r gweinwysg yng Nghymru a'r ddweud ar y Llyfrgell mewn gwahanol, ac mae'r bobl yn ymgylchedd yn ymgylchedd. Mae'r ddechrau yn gwahanol yn iawn. Mae'r cyfnod i Gwngor yn gwyngor, mae'n ni'n gwyngor gwyngor gwyngor gwyngor, mae mae'r ddweud yn gwyngor gwyngor gwyngor gwyngor ac mae'n gwyngor gwyngor gwyngor gwyngor gwyngor gwyngor. Felly, mae'r gweithio'n cwngo, mae'n gweithio'n gweithio'n gweithio'n gwirionedd gwahanol, ac mae'n gweithio'n gweithio'n gweithio. Felly, mae'r gweithio'n gweithio'n gweithio am hwn, maen nhw'n gweithio'n cwngo. Mae'n ddweud o'r cwestiynau newydd. Felly, mae'n ddweud o dr Melang�n yn Barboy, oedd yna ymddyliau, mae'n ddweud ond y gyfnodau medlawni arweigffydd would be in distributing drugs versus the MDA approach. Why don't we start off? I think probably you can get two answers at that one. Why didn't you start off? Yeah, sure. I don't know if it's the question how much the adherence plays the role in this mass-track distribution. I don't know if this is the question. That's right, don't worry. There's another question as well, please, from MSF UK, so it's for the panel. Mae gwaith ymddyngos fel MSMC ydw i'r cyfnodd yn cyfleidau, ond ydw hwnnw wedi cyflwytoedd eu moddol MSF, bod Prayol Gweinfaeth siaradau i'r parom sydd yn cyfleidau? Yn pwy ffrifegwyr y Llywodraethau ei fydd yn i'n effeithio? Roedd ydw yn cyfleidau cyflwytoedd? Yn gyfnodd MSMC yng Nghymru, yna'r ffordd na'r ffordd wedi'r ymnodd gan y pwrddath i'r ddau. Yn gyrgyntaf, yna'n olygu'r ddae. ac mae'n rhaglaid i gael i'r cyflwyno'r brifoedd o'r rhaglaid yma. Mae'n dechrau i'r cyflwyno ac yn gael i'r cyflwyno i'r Cymraeg yn y canlyniadau ac mae'n cyflwyno i'r cyflwyno i'r cyflwyno. Mae'n gwrth gwrdd yma, MSEF yn eich cyflwyno i'r Cymraeg yn canlyniadau ac mae'n dweud i'r cullig o'r fanfyrdd yma. Mae'n dweud i'r cyflwyno i'r gweithiau a'r gweithiau yn y cwrs. Mae'n ddweud i'r gweithio'r cwrs. Hello, Frederick Seely from Malaria World Journal. So, very interesting talk especially at the end about malaria in the Congo, and especially the description of the very high resistance rate against insecticides and the poor effectivity of the bed nets. So my question would be, do you think that more active factor controls such as active insect trapping or liversidal activity, if that would be feasible to supplement the provision of bed nets? Yes, I think it's very useful to do more factor studies in this kind of locations because now we only know what happened on one time point, but it's very interesting to know what will happen in time because we already see that resistance is developing, so we really have to take care of what kind of insecticides we use in the houses for sprays, but also on the bed nets, so it's really useful to do more factor studies. Lately down here, and if you want to ask a question, if you put your hand up now, I then know how many questions I want to raffle through by the end. Hi, Emily from St Mary's Hospital. It's also a question from, thank you for a great talk. The patients where you detected recrudescence by sending the blood spots to Holland for PCR, were you able to genotype those strains and did you find wild type or resistant strains? So far what we've done where we are at the moment is that we did the PCR and now we're going to sequence them, so we're at the stage of sequencing them. Thank you. Gentleman, just in front of the pillar of that. Hi, I'm Yosun Amir, I'm from the board of MSF Holland. My question is also for Marit and thank you for an excellent presentation about a very fascinating trend that we see. Can you be a bit more specific about what your theory is about what is... You mentioned some factors, right, environmental, et cetera, but do you have a more specific theory of what might be the case? To be really disappointing, no. I think we're all a bit lost. I think there are several factors in play. One is that at a certain point when you get a rise in cases, such a large population is infected, that you get a really rapid increase, which is hardly stoppable. So if you go down, also you get a very... So if 1% of the population is infected, the chance that a mosquito actually bites that one person is really quite low, so the whole transmission chain goes down. I think we've reached a point in Kongu where it's just gone completely wild. These were our first four guesses, and apart from the vector study, it hasn't yielded a lot. So we were thinking, oh, there might be a superbug out there, but we didn't find superbugs. So, yeah, we have to continue the research. Gentleman down here at the front. One of the... Charles from MSF UK. One of the reasons I think that drives malaria is both the behavior of the mosquito and also of human behavior. I wonder if one of the studies looked into the human behavior, especially how long the people stay outside before they go to bed, but also when you mentioned about the river, something echoed to me. I've ever worked near a lake and actually people use mosquito nets for other activities rather than using them. Shall I answer? Yeah. So, yes, the human behavior is certainly the next step, what I indicated. We need to see how long people stay outside. There are other factors that have... Just that there is more electricity actually keeps people outside for longer and things like that, so we need to look into that for sure. The second question, help me. Fishing nets, yes. What can I say? Yes and no. I think with the study that Ruby did for the knowledge and attitude, there are lots of people once they associate the mosquito with malaria that are willing to sleep under a bed net. I think we need to have more innovative approaches to the bed nets, for example. The really clever ones now where there is a small light inside the mosquito net which makes you want to sit and read inside a mosquito net. So the clever ways to evolve those are you can print now, you can have really like arsenal, I don't know what, on your bed net. So that's really good things. But yes and no, so yes you see them everywhere, but I also think when you ask people, and this is more random anecdotal evidence, if you ask them, and they also protect their crops with it, but they're old ones because we keep redistributing them. So I think the good part from the cap survey is that you see that if people are knowledgeable, that they're really quite happy to sleep under them. And actually one of the really nice studies, part of the study was that we could see that if people had been explained by MSF, I have to get my notes now, but they were like five times more likely to hang them correctly and not to wash them and not to hang them in the sun too often. So good explanation really helps with good bed net distribution. The ones that you see are not all the ones they should sleep under, I'm not sure. You'd like to come in and I'm going to comment also on that one. Maybe one thing, because there was a question on adherence, I was not sure what it was, but I would like to jump onto the merit set on qualitative things. And actually when we evaluated adherence through the quantitative survey, we got the figure like over 99% which really doesn't seem very realistic. But when we did a qualitative evaluation and observation at home, we realized that there is a lot of problems of taking the tablets at home. So it's also we need to be very careful which method we use to evaluate on different subjects. My comment would be if it is true that there is an increase in an area as a result of a reduction in mosquito susceptibility, that is a very important finding. However, following on from Charles's, I do wonder whether there could be some issue about health seeking behaviour. Which could have also given rise to apparent reproduction. Gentleman at the back, lady at the front, both ask and then that's the final two questions and I'll ask any member of the panel to answer those two. Thank you, Tom Churchill at Imperial College. Just to go beyond that, what you just suggested, is do you have any idea if the population is stable? Because could you just not be seeing an increase in incidence because of an increased number of people? Not discounting the fact that you clearly have issues with the sexual resistance. Lady here at the front. Barglay route MSF UK. John, you made the point very well that malaria control was a critical part of the Ebola response. I wondered if you had any thoughts on what the role of malaria control is as we start to think about the post-Ebola response. So what should MSF be doing in Sierra Leone and Iberia going forward? Sure, that's a very good question. And I think MSF did those mass distributions as an emergency measure. And Ebola care, or sorry, malaria healthcare is an essential component as is a lot of things like maternal healthcare and things that I think the assumption was that the healthcare systems would get up and running faster than they did. And so just my conversations with colleagues in the field was that, you know, that was a lesson learned is to get, is to address other healthcare needs, not just malaria, but certainly prenatal care and safe deliveries and addressing other healthcare needs because that really suffered during the Ebola outbreak and that was really inexcusable. Can I take the first one? Yes, to come back to your question. So we have no indications that there is a comparable rise in population. There has certainly been some shifts in population, especially in North Kivu, but not so much in South Kivu and Katanga. The other, there were far more ways that we could see that there was an increase. One of them is, for example, that every woman who comes to antenatal care, regardless of her symptoms, will be tested for malaria every time she comes. And there we can see a steady increase in positivity rates over the past years, showing that the random population has more, there is more malaria or at least more parasite carriage in the random population. Thank you. Thank you to all of our speakers for some excellent talks and very interesting discussions. Thank you. Thank you very much. We've got half an hour for the break. I just wanted to remind the speakers and the chair for the next session to come down to the front. And I just wanted to pick up because there was a couple of people who picked up on a couple of the questions, and it might be something for discussion. How do we measure the impact of our preventative measures as MSF or other organisations? A very challenging question for research. Thank you very much.