 So, anyone who would like to start off with any questions to us? Yes, sir. My question is for Rupa, Daniela Ryan from the Manson Unit. Rupa, is there two questions really? One, what was the penicillin sensitivity in keftroxen for the strep pneumoniae? And the second thing is that is the sensitivity testing an automated testing machine or is it actually just done by disk diffusion with plates on a desktop? So, disk diffusion? Is it one of the things we put in a culture and then you get a readout of sensitivities or is it a much more manual system? It's manual, so it's a disk diffusion. And for... So 100% sensitivity to seftriaxone and I didn't include it here because it wasn't part of our routine analysis. We're still working on it for penicillin MICs. So, more to come. And to differentiate bloodstream and CSF. I think you've actually got something online, have we? Yeah, we have one question from online, from a nursing colleague, Steven Flanagan for Josie Gilday, to say what practical steps should MSF take in order to increase the quality of nursing care in their projects? Okay, well I think steps are actually already being taken, so now every MSF section actually has an individual nursing advisor. And I think one of the struggles really with the practical steps to take is that they're quite a lot of them. But first it would be that nurses really in the field should just be nurses. Now I loved being in the field and being the pharmacist and in charge of the kitchen and the nutritional kitchen and I thought, wow, this is a great challenge. Woohoo! And you know, I'm not just nursing. But then it made me realise that I was starting to neglect my nursing role and I don't know if you would have noticed but on that theoretical framework I developed I missed out meeting the needs, the basic needs of the patients because I'm so used to having the caretakers and that really shocked me and so I think that's a really practical thing we need to look at what is the role of a nurse and what isn't. Because so many times we end up running the pharmacy and other things like that. I think one of the other important things as a nurse that I'm talking is you're very much in the field helping people to help themselves. So as a nurse if you are going in there but you're not just doing the individual nursing care of the patient, you're training the caretaker to do the work. So it's helping them to help themselves so important. Yeah. Hi, this is another message for Josie as a NHS nurse at the DTN. I just wanted to ask if an overly systematic approach do you think potentially takes away from a holistic nursing care expert? Yeah, I think it's really difficult to find that balance but what I really think we need to look at is currently there are limitations to our organisation and systematic structures and in this case in the study I found that nurses were really task orientated and really only around the administration of medication but what had happened was they were also mini-pharmacists so they were counting the drugs in the morning they were then making an order for them to go into the pharmacy to collect them and actually so this system had narrowed their view of nursing care and prevented them really from having that holistic view. So it's definitely difficult to find that balance but I think it's something in MSF we need to explore more and I think the starting point is really let's base our care around meeting the needs of the patient and work out from there to create our systems. Thank you very much. Lady in red at the back. I hope the microphone works as time. Hope it works now. Marta again infected this is Doctor this question is for Charles thank you very much for your talk I was wondering which potential predictors dropped of your model. Did you look at splint size or malnutrition? Thank you. Yes indeed we looked at other predictors and the splint size was dropped malnutrition was dropped weakness was dropped and I think that was it age young age as well but nevertheless I also should say that most of the predictors we had in this call are some of the predictors we commonly collect in settings where we work. Hi I'm just a medical microbiologist in the NHS. Question for Rupa thank you very much for your presentation very nice. Just a couple of questions I wanted to ask you. It's very interesting you were mentioning that such a high rate of SPL positive and not actually you haven't found any MRSA positive bacteria. Is he common finding as well in adults or it's just something that you have noticed in kids or you might find some bacteria. And the other thing is that you were saying that you were trying to review the first line choice for antibiotics moving from cataracts and I mean have you thought about something with regards to the sensitivity most of the strains of enterobacteriasis were fully sensitive to the case but you're thinking about revising your choice. Thanks. Thank you. So in response to the first question about rates of MRSA and ESBL is it a common finding? I guess this speaks to a bigger issue about documentation of rates of antibiotic resistance. So the short answer is I don't know. I think nobody knows because there is such a poor city of good quality data particularly I mean I think this is problem across much of resource poor settings but certainly in places where MSF works I mean there is some data coming out of West Africa Ghana reporting that 70% of their Klebsiella isolates were ESBL producing. I didn't look it up for Staph aureus I didn't look it up for Staph aureus I can and there was a second part of that question comparing adults to kids so we only focus on the pediatric in this project so I have no information whatsoever about adults in the population and with regards to seph triaxone as a first line yeah I think we are not yet in a position to change seph triaxone out of our first line I think where there is a role in considering a second antibiotic as you say like potentially gentamicin or amicacin just a broadened spectrum I would try to reserve that though for those patients that have identified bloodstream infections with a gram negative or Klebsiella and or E. coli in particular thank you very much ladies black and white thanks very much we will continue in with the UK department of health and I just wanted to follow up on the antibiotic resistance issue at the bigger picture level where you are just going firstly to ask is there a place where you can log that data at that kind of global or national level maybe with WHO or some kind of database and secondly just to note that in the UK department for health there is a planning stage going up capacity specifically around antibacterial resistance so AMR but only for the kind of bacteria you are talking about so it would be great actually to follow up later and to make sure that we can join that up into the planning phases thanks so in response to the first question I think there are several initiatives to try to improve surveillance of antibiotic resistance globally the WHO led glass initiative is meant to be a world wide surveillance system and in theory that is great in reality there are still many deficits most of sub-Saharan Africa remains a gaping hole in terms of microbiology data likewise the Middle East so I think there is increasing enthusiasm and desire to have these structures be more robust and actually do the job of surveillance so hopefully that will and MSF is actively participating in those discussions hopefully that will become more robust with time the other caveat that I would add is that surveillance data is really difficult to use to inform guidelines for sepsis so that's a slightly annoying nuance but I'd be happy with better surveillance data and yes building life capacity I mean for me you can't talk about antibiotic resistance without having access to microbiology I mean we can wait and we are waiting for adapted rapid tests for the field but in the meantime we're building labs and we are trying to partner with external laboratories that can ensure some quality so that's been our approach in OCP my question is to Marwa I think that the focus on male sexual violence is quite welcome but I just wanted to ask whether you looked at knowing also that with MSF projects we recognised that even for female sexual violence we are not actually doing well enough did you look at whether what you were concluding on is it a relative situation as in it's as bad in males as it is in women based on what potential is happening out there and kind of the second part to that is if you make adjustments as in your recommendation is there a risk that then the women women's access is reduced so this is a study it's still new it's still ongoing so we are still adjusting for a lot of factors but right now we are really considering the main factor which is the access of male victim to care according to the setup so as I have explained earlier that some of the setups only offer MCH access from the field that those are areas of active conflict so we are expecting a higher percentage of males presenting to our services compared to females and this was actually not a true scenario because we only found like 3% out of the whole victims that we are receiving and again still we are adjusting for a lot of factors while the study is still ongoing but yeah it's still we are not capturing and the reporting is affecting both gender males and females Javed from MSF Charles I am really excited by your presentation can I extract with Kieran's permission promise for you to come back next year and give us an update on implementing that tool and what you find and secondly Marwa the question was half sort of covered actually a little bit by this last question can you give us an idea of sort of the general setting is the setting where you think we might be able to it was the easier point of entry for male victims of sexual violence do you get an idea of or do you have an idea of what question we can ask for you know as a clinician in those settings having been there in these projects is there an opener that we can just use you know we are famously taught with suicide it doesn't you know ask are you feeling suicidal it doesn't bring up those ideas in the person you should feel safe that you can ask that is there such a question that we can extract you know to help this person volunteer that they've suffered that abuse okay so I haven't been in all the context but I can speak from some of them so and I can relate to one of the patient's story that he accessed one of the services for a totally different reason and it was actually one of our mental health services and we didn't know that he is an SV victim and he was not improving and he refused to like talk to a lot of the people providing care and when like I remember after maybe four to five consultations of mental health consultation he finally declared that he was an SV victim and that was the primary reason behind his mental illness so I know that it's a very there is no like ideal question to ask the patient to encourage him while he was an SV even though but what we can offer is that we can develop more or less sensitive tools and offer more options or more opportunities for a male victim to declare SV while receiving different kinds of care through MSF. This is a question for Marwa as well following up on the question. What were the main reasons for consultation of the men accessing these services? Do you have an idea of that? Okay so it's according to the setup so for like a vertical SV project it's clear from the start he is an SV victim but if we spoke about like a general care facility which is this tuition here he can access for like mental health consultation or any other kind of violence like to say he's a victim of tuition but it's not necessarily an SV and he can declare SV later on. Okay so he can access our service and he said like he's one of the victims of tuition or he's suffering from certain mental health disorders like PTSD or just general anxiety because the general care setup that we classified here in the project is basically clinics that has been set for mental health disorders or any kind of violence not necessarily sexual violence and we offer several opportunities for disclosure while the patient is receiving our care. Hi my name is Nora from MSF Germany I've got a question for Marwa as well so I'm wondering about the entry points. Is there a way to tell if people are the victims of sexual violence regardless of the gender are using tend to use the general care facilities more than the specific SV facilities? Sorry I missed that point. So is there a way to tell whether there are more victims of sexual violence accessing the general care facilities or the SV specific facilities and if so there's a difference between is there then a difference in gender and if so how do you prioritize? Yes so as I've discussed earlier this one is an limitation because unfortunately we don't have the three kinds of setup in a single context or in a single country because like one setup is in one country and the other in the other country and we really are trying to adjust for contextual factors but from what we have seen that like let's say MCH or SV clinics are based in areas with a very high or active conflicts and we know from the ground and from our HP work that people there are experiencing sexual violence so we are expecting like more people to attend our services. Hi my name's Kobeng and I'm from a charity let's go forward and we work on FGM, my questions from Marua and I'm interested to know how this study could be used to develop programmes with male victims of SV and if it's used alongside a programme that engages the community to break down any stigma attached to men who have gone through SV or even females as well. Thank you for this because this is actually under discussion right now because we are trying to implement qualitative components into the study and to reach people in community and to know actually the perception of people living in those communities and actually we are also investigating the integration between SV as an incident and let's say psychological illness so based on the results and we hopefully want to use this on operational level to implement it to improve the access more so far in this study we have like two out of the eight projects only offering these kind of setups that offers a victim to declare SV at several points and it's relatively huge numbers so we are currently undergoing under so many studies to investigate whether like how we could develop the programme more to improve the services and secure for the patients. Last question one last one Katie from MSF I'm struggling to really formulate this question actually so I'll try and keep it as brief as possible I'm curious MSF isn't regularly engaging patients or caretakers or staff in analysing or understanding whether our quality of care of the services that we're providing is good and my question I guess is mostly for Josie did you experience any resistance within the project from the staff about this study that you did and if you did can you talk a little bit about that and secondly do you have any ideas of if you did have some resistance how we move MSF forward in sort of trying to move beyond the test and treat relationship I actually was expecting some resistance with the project but actually I had very little from nurses and caretakers and the nurses especially were very eager to come forward and have their voices heard and so actually a few of them turned up with a list and I was a bit like oh I hadn't quite thought about this happening and actually the patients and the caretakers every morning I would go in and reintroduce myself and explain what I was doing and they were also very eager to explain to them what was important and what was really interesting was they also wanted to explain the importance of the nurses and the nursing care and how important it was to them so I received very little resistance and I think that's possibly maybe to do with the setting and the way people are in Sierra Leone happy to talk to you but I think if I did receive resistance then yes you've lost a very important channel of knowing how to improve your quality care because it was really only through understanding what the nurses and caretakers defined quality medical care as that we were able to see the gaps that were occurring so I'm not quite sure how you would deal with it if there was yeah those problems very short provoked presentations thank you Charles Rupert, Marva and Josie and those stimulation discussions so thank you very much