 Last up we have Amanda Tiffany, Amanda's an epidemiologist she was back and forth from West Africa so many times in the last year I gave up worrying for her and started worrying about her mother but anyway Amanda, over to you. So I'm really happy to be here today to present the the follow-up of survivors of Ebola virus disease in Freetown because as someone who's walked around for the last year with a notebook full of names of sick people and people who subsequently died I'm really happy that we're finally taking the opportunity to really look at the survivors and kind of what they're experiencing after discharge. So hoping that previous presenters would have already covered background on EVD and that you would all be familiar with it. I've included this slide simply to remind us that to date there have been over 25,000 cases and 10,500 deaths from this EVD epidemic that began in little Gekidu in Guinea and this has affected six African countries two of which currently have ongoing transmission. So according to WHO the first confirmed EVD cases in Sierra Leone occurred in the district of Kailaun during the week of May 19th 2014. So in Western area where Freetown the capital of Sierra Leone is located the first reported cases were in mid June 2014. So as you can see in these epidemic curves be prepared by John's group the peak of the epidemic occurred in Sierra Leone on the left in Western area on the right in December 2014. So overall there have been over 12,000 confirmed cases in Sierra Leone and 3,800 deaths approximately 30% of these have happened in Western area so however in the good news there have been over 3,500 survivors. So in response to this peak in cases in Freetown MSF Switzerland opened the Prince of Wales Ebola Management Center or EMC as I will refer to it which was a hundred bed unit in Freetown on December 10th 2014. So there were many many activities associated with the center in addition to psychological support which was provided to patients and their families during hospitalization. Additional activities included health promotion both in the community and in the center community and household disinfections and support to quarantined households in Western area. So finally this EVD survivor program that I'm about to speak about is started on February 3rd 2015. So the objective of the program is to provide care and treatment for the clinical and psychological sequelae experienced by EVD survivors after discharge and to document their evolution. Now to be eligible for follow-up a survivor needs to be discharged from any MSF EMC in Sierra Leone or be a survivor from another EMC who is also a family member of an MSF survivor. It's a little bit complicated but for survivors from non-MSF facilities we need to be able to confirm their status as a survivor because unfortunately there are many fake survivor certificates floating around. So in order to verify their status we have to get in touch with the center from which they were discharged and get all of the information that way. And so then finally in order to be to participate in the project we have to be able to contact them so we can schedule their follow-up and that they present for follow-up. So activities during follow-up visits include cycle social support, a meeting with a psychologist, health promotion activities including group discussions and clinical consultations during which a full physical examination and vision screening is carried out. So support is also provided for family planning and referrals for specialized care such as the eye clinic, the HIV clinic or the cardiologist are also carried out. So all of these visits for specialized care are also paid for by MSF. Now once enrolled in this program weekly follow-up visits are scheduled for all of the survivors. So for survivors who were discharged from the EMC after the follow-up program began we tried to have their first follow-up visit be either the day they were discharged or immediately the day after. And so for survivors who were discharged prior to beginning this follow-up program their first visit was scheduled as soon as we could contact them and arrange for them to follow up, be followed up. Okay so for some preliminary results so this project is still ongoing so we've seen probably we've had almost a thousand visits from survivors but consequently the data will present our preliminary and for today we'll concern only the first follow-up visit for survivors discharged from the MSF Switzerland Prince of Wales EMC in free-town. So all clinical results will be stratified by CT value as explained by previous presenters and in this I've used less than 20 and 20 and above like in ESA's presentation. So I've included all survivors even those for whom CT values were not available so the column titled total is all survivors even those machine CT values and in the CT value columns it's only those survivors for whom CT values were available. So things will not necessarily add up across rows. So here we go so 43.9% of those survivors are female with a median age of 22.5 years. At their first visit their median body mass index was 20 which is approximately normal for adults, median CT add admission to the EMC was 21.2 and 24.5 days was the median time between a survivor's discharge and their first follow-up visit. So at the first follow-up visit the median number of physical complaints expressed by survivors was three and overall 23.2% of all survivors released had their first follow-up visit within six days after discharge from the EMC and so none of these indicators aside for CT add admission were significantly different between the two groups at the first visit. Now the six most commonly cited complaints at first visit were headache, joint pain, vision inocular problems, excessive fatigue, loss of appetite and muscle pain. A large proportion of the headaches were reported by survivors who also reported eye problems and additional complaints expressed by survivors do include hair loss which experienced by almost 10% and insomnia as cited by 8.5%. And so as I've just mentioned we are seeing a high prevalence of ocular problems in these EVD survivors. So a total of 54.8% of these survivors have been referred to and attended an eye clinic with whom we formed a partnership in Freetown. The primary diagnosis received during these visits was UVitis while other diagnoses include allergy, cataract and inflamed peridium. So after attending the eye clinic the patient diagnoses are then transmitted to our clinical team so the eye clinic is not at the survivor follow-up. The survivor has to go to the eye clinic and then come back for our follow-up. So of the 45 survivors that were referred to and attended the eye clinic 57.8% were diagnosed with UVitis. So for those who are not familiar UVitis is the inflammation of the UVA which can consists of the middle pigmented vascular structures of the eye and includes the iris, the ciliary body and the coroid. So the most commonly diagnosed categories of UVitis were anterior which is here and pan-Uvitis involving the whole eye. And so other 46.7% of all of the survivors who went to the eye clinic were diagnosed with having something else. I think it's also important to note that with UVitis the prognosis is generally good with individuals who are diagnosed with it but those that receive prompt diagnosis and treatment because if it's left untreated serious complications can arise including cataracts, glaucoma, macular edema and permanent vision loss. So as I already mentioned all survivors are scheduled for a visit with the mental health team during their follow-up. So the data on this slide is a very small amount of the information we have collected which in this case is stratified between time since discharge and first follow-up visit. So at their first follow-up visit 35.5% of all survivors were living in a quarantined household. And when assessing stigma 20% reported being embarrassed or ashamed of having had EVD and 25.4% reported that they felt that others have avoided them because of their EVD infection. And so as far as mental disorders 2.6% reported hallucinations or being irritable or moody. And when using the 20 item self-report questionnaire also known as SRQ 20 to assess emotional distress the median score was five and is slightly higher in those survivors with less time between discharge from the center and their first follow-up visit. And so in conclusion this project is currently ongoing however we have seen that all survivors released from the MSF Switzerland Prince of Wales EMC have that have been able to be reached have come for a follow-up and continue to return. In the survivor cohort we have seen a high prevalence of uveitis particularly anterior and pan uveitis a condition with which with early identification and treatment can prevent long-term consequences. So regarding mental health recently discharged patients appear to have a higher level of emotional distress than those who were released more than three weeks prior to their first visit. I didn't mention this in the probe in earlier on but I think it's important to end on a really good note that over 50% of survivors that have come from the MSF Switzerland EMC have become begun to be discharged from the follow-up program which means that with correct and timely management of the clinical and cycle most of the clinical and psychological problems are improving. And so finally I just like to acknowledge all of the survivors in addition to everyone in Sierra Leone Geneva Paris that and yes that have helped with the project. Thank you. I'm Armand Sprecher MSF Brussels I don't know if it was today or yesterday there was an article published in the New England Journal that confirmed what some of us had suspected for a while is that the interior of the eye is yet another immunologically privileged location where the virus can hang out and I think one of the conclusions of that article is that people performing invasive ocular procedures on Ebola survivors should of course take extreme infection control problems that precautions and I guess I'm assuming that in the eye hospital there nobody's doing invasive procedures but I was just hoping you could confirm that for everyone here because somebody might have read this article and wondered what was going on. No as far as we know there are no invasive procedures being performed in the eye clinic not in our survivors. Other questions go on then. Hi thanks Amanda for the presentation and I just want to ask are you doing any sampling of body fluids in your follow-up and how long is the follow-up for? So the follow-up will continue to at least the end of May so it started in February and go at least until the end of this month but no sampling of body fluids. Can I also ask if you got no intention of I mean you haven't collected any controls at all? No we don't. It was really set up to be a program so this is really programmatic data I mean the ideal would have been to do a big study and have controls and do sampling body fluids and all of these things but unfortunately with the delays that it would have taken we really thought that the most important thing was to start like to start looking at the survivors and trying to help them as much as we can instead of delaying it in the interest of research. All right I think well gone and quick. Hi I'm Maria I'm with the University of Oxford and I was out with MSF in Liberia over Christmas. Is there no clinical follow-up long-term clinical follow-up of survivors for information purposes? What do you mean in terms of body fluids as my colleague said here you know long-term effects over over six months over a year? As far as I know for the moment no. I don't know I know various people have been talking about it but I don't know if anybody's actually done it. It's enrolled at large cohort studies and controls. Okay thank you Amanda.