 So good evening. This is the last presentation. So I just want to start with two disclaimers One is that I know nothing about snakes and South Sudan and I've never been to South Sudan My only knowledge of snake bites was the last week where I was briefed through Skype with a team that did this fantastic study and I read some literature. The second disclaimer is that I would like to to share with you that when as a member of the scientific committee we decided to accept this presentation For for several reasons. One is that this is actually neglected. We realize that is a neglected condition Second this study as you will see is very well done as well methodologically well done and third the start their findings are striking and For it coincides with a global Adventum crisis that is happening this this time So I can only share with you some excitement of discovering a new field and I hope that I will do justice to the people who did the study So our colleagues are in this little town in the north of South Sudan called Agok And they run a hospital of almost 200 beds and they do almost everything from emergencies to maternity maternal health And they have a lot of snake bites snake victims and one of these Victims is this little cute fella who was bitten by a snake here on his face so the the the team they are decided to to study this the the snake bites in there in their area and They actually realize that this is a worldwide neglected neglected the condition with quite significant burden, but also quite underestimated I mean if you see the the numbers of bites 5.5 million 1 million and venoms and the deaths vary between 94 to 150,000 just to give you a little bit of data about India that I discovered recently The estimates were something between 1,500 deaths due to snake bites to 50,000 and there was a survey done Which called 1 million deaths in the one part looked also at snake bite deaths and they found approximately 46,000 So actually it was closer to the higher estimate So back to Sudan our colleagues there they had in a month of May 2014 90 cases or three three snake bites a day and they had three deaths in the 2014 so This I think kind of triggered this study and this is what I said about a methodologically well done study I'm surprised as epidemiologists that they use three sources of data So one was the hospital registers some teams will just stop there will not go further Even we know that the hospital data usually don't give a lot of information. They did one survey Using a kind of a snowballing thing. They found some high Figures 409 bites. They thought that maybe something was wrong with their survey. So they did another one With randomly selected more well done So actually have three sources of information and what is surprising is that what made them and this is a picture from the Survey in the field. So what actually they thought that it was too high What was the survey number one with an incidence of one six eight eight per one hundred thousand bytes? 1688 bytes per 100,000 population per year actually it was another estimate because the second survey was were more well Done so much higher at three five nine six per 100,000. This is extremely high numbers 100,000 per year Extremely high numbers of snake bites and the quite high case fatality ratio the first survey 4.4 and the second survey 2.3 percent and They looked also the distribution to demographics of the snake bite victims and you can see here that they looked at the gender and Age groups. There is a bit of discrepancy between the three sources of data The hospital data shows more female more males more male victims while the community surveys So more female victims. I think this is a interesting finding. Maybe the team wants to explore more There was no much difference between the age distribution. I Will skip this because this table because it's actually identical to this one and this shows pictures of sniff the seven species of snakes to be honest. I know I only know The cobra because it looks like the cartoons of the snake charmers also in India But I have to tell you that there is a for the ones who find this fascinating and actually it's quite useful Not just fascinating. There is a database and there is an Indian database Which I think and I am sure that there are some other south asian the Indian one is WWW Indian snakes dot org is even easy to remember and I ask you to Will ask you to consult it. It's interesting. So describing the epidemic in time and place Location of snake bites at 37% in the house. I think this is very interesting Activity while most of the people were out in the bush 20% of the people who were bitten when while they were sleeping I think this is quite scary biting sites mostly the legs but as you saw from the previous picture any part of the body can be bitten this little fellow was bitten on his face and Timing of the bites evening and late night up to midnight apparent in the snakes are Looking at seasonality Look at seasonality if you see the three these are the three graphs from the three different sources of data Similar pattern small differences. I don't think I want to go through this But again this what is shows here is that you have a season in India and in Southeast Asia is the monsoon season I guess this is also the rainy season in Sudan where most of the snakes are at their nastiest when they go out and stay and Looking at the clinical characteristics of the people who get in venom first of all 65% almost of the people who were beaten by snakes had the invenoming syndrome and the three most common syndromes are The cytotoxic one which is like swelling and up to the crosses of the of the area of the affected area You have a mototoxic syndrome where you have clotting disorders That's like the blood clotting disorders and neurotoxic syndrome And there are some other symptoms symptoms like cardiotoxic and etc But I think these are the three most common and according to the literature This is not only in Sudan or in India or in Southeast Asia. It happens worldwide in this particular study They found that 55% of the patients had cytotoxic 26 hymo toxic and 4% almost neurotoxic syndrome These are some pictures just to show that how it looks when you have some of these syndromes and also this little bottle Yeah, it's just a simple test to see clotting and it doesn't require sophisticated Machinery or or devices just a bottle and some time waiting to see So our team there has this Syndromic approach and they have this nice algorithm. I don't know if it's really visible and late Just there but actually what it it shows it shows that based on the history of snake bite You look at different syndromes what I described before cytotoxic and neurotoxic and motoxic and then you based on that you can see what are the snakes and What are the snakes most likely and if you add this algorithm is actually this is the adivinum Algorithm where based on the snakes or based on the syndrome you can Administer the the appropriate one to be honest for me that I don't know so much snakes I say why we don't have a polyvalent adivinum that we can give with no brain is why we need algorithms we just have to have a bottle and Just give it to everybody who has a syndrome whatever is the syndrome whatever is the snake bite, etc I guess these are also our colleagues from Sudan are more affected than me asking this silly question then looking at risk factors for death I think they If you see the This analysis shows that age Was children and adolescents 0 to 0 to 15 were the most affected Syndrome this the progressive cytotoxic symptom has the odds to to die from after a snake bite was almost 31 and If you haven't I think this is important if you haven't been given an adivinum your odds of death were 25 I think this is quite high. It shows the confidence and there was a quite wide But it's because the number of deaths. It's it's quite small in this analysis Difference between access to adivinums in this particular setting that you see that in the health facility It was 27% that people that got the adivinum well in MSF hospital. It was 81 And also if you see the last line there, I think it's interesting to mention about the communities that traditional practices still were Were used and 68 67% of things what about this thing that it's kind of traditionally many cultures and communities Cut and suck incision and suction 46 were using a black stone to treat the snake bites and tourniquets a Very nice mapping. I think this could help also to identify some interventions If there are some you just plot the People who the the snake bites the locations of snake bites in a GPS system this I don't think you can see the Green are the snake bites and the red Points there are the snake bites deaths so This is this was the first snake bites snake bite survey in South Sudan I think it was this the team has to be commanded for this great job that they done there They have some limitations Maybe snakes were misclassified and maybe they have since they asked the people recall bias is always a problem with This kind of surveys However, they found quite high in incidence compared to African literature and a very high community case fatality ratio in the community To two three two point three to four point four percent You notice the large variety at least seven pictures. They are large varieties of snakes Species which actually highlights what I said why we don't have a polyvalent advenom instead of having several little bottles and trying to find which one is to use Highly seasonal monsoon period and the high odds of death if you have not given if you are not given the advenom and This is the conclusion That this study reports may be the highest and documented incidence of snake bites a very high mortality Among patients who don't get treatment They use the quite nice study methodology using three to source the sources of data and They addressed a quite neglected tropical disease issue in a neglected area So the team there and I think most of us will call will echo their call ask for positioning of the advenoms to the places that are needed is like finding the hotspots where the snake bites happen and Make sure that the divinium is there not in state capitals or in the six country capitals or hospitals hospitals and Make sure that you train the communities and the staff how to how to handle the snake bites and Just to finish with this advenom. I said to it was a glow is there is a global crisis right now I think I was briefed that just this month next month The last bats produced by companies is about to expire. There is no new production. There are several Companies who produce advenom including some Indian manufacturers, however, there is no match about please the data or their efficacy and and safety and I hope that I did at least I didn't serve knowledge But I hope it served the enthusiasm Excitement that this was a very good study and I'm very happy that I was given the opportunity to present it on their behalf Thank you very much