 Good afternoon everybody. I would like to welcome you all to the session and also to the online audience. I am presenting on behalf of my team, so that's me Kanika Kaurala and I would like to acknowledge the effort of the team before I start the presentation because this was a huge study and it is not only my effort, it's also the effort of the whole team and that's why we have these results now. So it's the causes of persistent rebel illness in the eastern part of Nepal. So start with Nepal. So Nepal, it covers an area of around 147,000 square kilometers with a population of approximately 27 million. So that's the map of Nepal and in the center you see a red spot that's Kathmandu, the capital that I am sure most of us know about Kathmandu but you see the two red spots to the eastern side that's where the study was and so you see the two centers separately. It was in a part called Dharan and Thankuta. We chose these two centers because they were in the eastern side and because they had different topography. Dharan is more toward the plains and Thankuta is more towards the hilly side and it will be more evident when you see the results because the presentation of the patients were different and even the diagnosis that we were that was found at the end was different in both the regions. So these are the two hospitals. The one on the top is the one in Thankuta. It's a district hospital and the one below is the institute where I am from, BP Coral Institute of Health Sciences. So the study we did on persistent rebel illnesses which was more than seven days of fever. Fever as we all know presents for many various diseases. It's a syndrome and it can be for cancers, for infectious causes, for connective disorders, so many but we were mainly focused on neglected infectious diseases which were prevalent in the region. This was a part of a EU funded multi-country study called NEDIA which actually stands for neglected infectious disease diagnosis. So we studied the differential diagnosis associated clinical and laboratory predictors in patients with persistent rebel illness. We took patients from more than five, more than an equal to five years old, fewer of more than seven days. The study went on from January 2013 to October 2014 and we did it in two centers. We filled case report forms, took the medical history, physical examination, laboratory investigations at baseline when the patient presented us to us first and even at follow up after one month. The tests that we performed for all the patients who were hemoglobin, white blood cell count, kidney function test, liver function test, blood cultures, urine routine and cultures, malaria rapid diagnostic test and HIV serology. Besides these tests we had other tests which the physician could request for but these were compulsory for all the patients. We also did the chest x-ray, abdominal ultrasound, sputum examination. The testing of samples was done at national reference laboratories and at international reference laboratories. The tests like PCR or ELISA which are not available in the country were done outside. The conditions that we targeted, we call them target conditions because like I mentioned fever can be a presentation for various causes. We were looking for malaria, tuberculosis, leptospirosis, relapsing fever, visceral lisminiasis, HIV, brucellosis, rickettsial disease and enteric fever because these are more prevalent in the area and these are infectious and neglected in the region too. So the formulation of diagnosis, we had case ascertainment done by the experienced physician based on pre-specified case definitions. So now to the results, we had around 578 patients recruited, 447 in BPKIHS and 151 in Dhancutta. So the target conditions, so as you see we, this is for BPKIHS which is in Dharan. We have, because this is endemic to visceral lisminiasis, we have a lot of patients with visceral lisminiasis and then we have tuberculosis, rickettsiosis, scrub typhus, leptospirosis, enteric fever, HIV and relapsing fever. Relapsing fever was, this is the first study to report relapsing fever from Nipal. And then this is the proportion of the cases that we had seen and then other conditions because as I said fever is not only for the infectious diseases. So when the patient came to us, we just recruited them if they had fever. So the other cases causes that were isolated after we found the diagnosis were pneumonia, tonsillitis, respiratory infection, TTI, leukemia, solid tumors, misinfections. You see the last column, that's the undefined. So there were around 48% of cases that were undefined after we ran all the battery of tests nationally, internationally and we still had a lot of undefined cases. So from those 48% that were undefined there were 63% that were suspected to have enteric fever from which 84% had received antibiotics. And then Dhancuta, like I said both the centers are situated in different topographical regions. So you see in Dhancuta we have tuberculosis, scrub typhus, leptospirosis and there is no VL, malaria, brucellosis. Well we had seen VL, many cases of VL in BPKIHS. Same goes here, these are the proportion of the cases that we had seen in Dhancuta and these are the other conditions. So here also we see the last column which is the undefined cases. So we have around 54% of the cases were undefined in Dhancuta also from which 85% were suspected of enteric fever and 91% received antibiotics. So what we plan to do with the results? First we had decided to do the study because there was a study done long back in Nepal in 2004 for fever to find out the prevalence of the various causes of fever but since then there was no other study done. So we thought it's essential that we know what are the prevalent causes of fever and then we wanted to develop a diagnostic guide which we expect, we hope that it helps the healthcare workers in improving the diagnosis for the fever cases. So this is what we developed. You see the first row, the first row is the first step. So if the patient comes to us with fever more than seven days, we do the history taking. So this is something what all physicians do but we have limited the points. So we have just duration of fever, history of VL, pallor, travel history, cough, bloody sputum, abnormal complaints and family history of VL or tuberculosis. So we have listed down the bullet points so that the physician does not forget and these are the very essential points that must be taken. Then we do the examination. So again we have limited the number of points that the physician has to compulsory because we are targeting the primary healthcare levels. So we do not want them to miss out anything. Then we have the lab, the urine, the chest x-ray, the rapid diagnostic tests, ultrasounds and lumbar puncture. Then what you see in the center is a panorama because we think when the patient presents to the physician, the physician never thinks of a disease on itself. The physician thinks of various diseases and how do I treat the patient? So we think that this represents what goes on in the physician's mind. We have put the diseases in boxes and so you see Kalajar or VL, tuberculosis, pneumonia, enteric fever, abdominal infections, urine tract infections, meningitis, leukemia, leptospirosis, sclerosis, sclerosis. So these were the ones that were prevalent in our region in our study and then you see these boxes below the, like I will take the example for tuberculosis and Kalajar. I have put them in red. So you see the boxes below Kalajar. It's, you see a plus and a minus. So that's the positive predictive value. So more likely if the patient has pneumonia, a hemoglobin less than 10 per 10 gram and rapid diagnostic test positive, bone marrow positive for Lishmania and fever more than two weeks, the patient has Kalajar. And when we put it in the negative, so if the rapid diagnostic test is negative, we think that the patient might not have Kalajar. So this is what we plan. And we are still developing this and we hope to put this at the primary healthcare levels and so it'll help for easy diagnosis. These positive and negative, they were, we had the post-test probabilities and from which we got the likelihood ratios and so we developed the positive and negatives. And the conclusion, the common causes of post-test and fever illness differ from the parts of Nepal level, non-endemic for visual Lisminiasis. I stressed on the non-endemic for visual Lisminiasis because the other studies that have been done so far in Nepal are done in areas which are non-endemic for visual Lisminiasis. So it always misses out the visual Lisminiasis, which is pretty prevalent in Nepal. So we wanted to do it in an area which is endemic for visual Lisminiasis. And thank you.