Unveiling the secrets of snakes: Analysis of environmental, socioeconomic, and spatial factors associated with snakebite risk in Paraná, Southern Brazil.

The state of Paraná is home to three out of the five medically significant snake genera in Brazil and lacks of snakebite epidemiology studies. This study aimed to ascertain the spatial, environmental, and socioeconomic factors associated with snakebite risk by analyzing notification data of cases in the state of Paraná. Notification and socioeconomic data were gathered from the online platforms of the National System of Notifiable Diseases (SINAN) and the Brazilian Institute of Geography and Statistics (IBGE). Land cover and land use maps were obtained from the Mapbiomas platform in raster format and subsequently converted into vectors using QGis software. The proportions of land use and land cover in square kilometers (km2) were then calculated. All acquired data were tabulated using Microsoft Excel 365 software. For spatial analysis, GeoDa software version 1.20 was utilized to calculate the Global and Local Moran indices, assessing spatial correlations. Between 2007 and 2021, 12,877 notifications were recorded, with an average incidence of 8.22/100,000 inhabitants in the state, 8166 (63.41%) caused by Bothrops, 1534 (11.91%) caused by Crotalus, 56 (0.43%) caused by Micrurus. 1703 (13.22%) caused by non-venomous snake species, and the remaining cases did not have the identified causative species. The incidents caused by Bothrops and Crotalus showed different distribution patterns. Spatial analysis revealed that key factors contributing to snakebite risk included the presence of native forests, mangroves, apicuns, and monospecific planted forests. The population group at the highest risk comprised rural residents and workers. Furthermore, the absence of basic sanitation and proper garbage collection and disposal exhibited positive correlations with snakebites. Conversely, intensive farming practices with substantial mechanization and pastures demonstrated negative spatial correlations. This study has enabled the identification of the primary factors associated with snakebite risk, facilitating more targeted efforts to prevent snakebite accidents among vulnerable populations.

Snakebites in Northeastern Brazil: accessing clinical-epidemiological profile as a strategy to deal with Neglected Tropical Diseases.

BACKGROUND: Brazil ranks first in the number of snakebites in South America. A detailed analysis of these cases is required to improve the public health planning. In this study, we retrospectively examined the clinical and epidemiological profiles of snakebites in Maranhão between January 2009 and December 2019. METHODS: Data were obtained from the compulsory notification forms provided by the Health Department of Maranhão. RESULTS: A total of 17,658 cases were recorded during the study period. Most of the bites were from snakes belonging to the genus Bothrops. Medical care was mostly within three hours after the bite. Most cases were classified as mild and most victims recovered; however, 139 deaths were recorded. Most bites occurred among people aged 20-39 years, mainly among rural workers. The most frequent local clinical manifestations were pain, edema, and ecchymosis. The most common systemic clinical manifestations include neuroparalysis, vagal syndrome, and myolysis. Most snakebites occurred between January and March. The municipalities with the highest number of notifications were Buriticupu (936 cases), Arame (705 cases), and Grajaú (627 cases). CONCLUSIONS: The clinical profile of snakebites in Maranhão is similar to that observed in other states of Northeast Brazil. However, we found that some systemic manifestations are not compatible with the etiology of snakebites, which leads us to believe that the problem could be the lack of knowledge of the health professionals at the site of envenomation, who may not be ready for attendance, and an important lack of health centers with snake antivenom to treat snakebites.

Barriers and opportunities for improving management of snakebites: Perspectives of healthcare workers in Northern Uganda.

BACKGROUND: Snakebites are a neglected public health problem that pose a significant burden on affected individuals and communities in many sub-Saharan African countries, including Uganda. However, the barriers and facilitators to snakebite management within healthcare settings are not as well understood and well-documented. The aim of this study was to explore the experiences and perspectives of healthcare workers involved in handling snakebite incidents at individual and health system levels in Arua and Gulu districts in Northern Uganda. We sought to understand how healthcare workers manage snakebite cases, what challenges they encounter, and what opportunities they perceive for improvement. METHODS: We conducted a qualitative study using in-depth interviews with 18 healthcare workers from different cadres, seniority levels, and facility types. We used iterative thematic analysis to explore the management procedures, challenges, and opportunities for snakebite management. Using thematic analysis, we identified the overarching themes and subthemes related to snakebite management and associated barriers and opportunities. RESULTS: The main barriers to snakebite management identified by healthcare workers were inadequate knowledge and skills; limited availability of antivenom; lack of protocols for snakebite management; delayed treatment-seeking for patients; and poor referral systems. The main opportunities for improvement were regular in-service training; increasing public education and awareness about snakebite prevention and management; and increased funding and research. CONCLUSION: This study highlights the need for interventions to address the identified barriers while leveraging the existing opportunities to enhance snakebite management in Uganda. Specifically, we recommend the provision of regular training and support to healthcare workers, developing clinical guidelines, and improving the availability of antivenoms.

Structural capacity and continuum of snakebite care in the primary health care system in India: a cross-sectional assessment.

BACKGROUND: In 2019, the World Health Organization, set a target to halve the burden of snakebite, by 2030, and identified 'health systems strengthening' as a key pillar of action. In India, the country with most snakebite deaths, the Union Government identified (in September 2022) training of health workers as a priority action area. In this policy context, we provide empirical evidence by analysing the most recent nationwide survey data (District Level Household and Facility Survey - 4), to assess structural capacity and continuum of snakebite care in primary health care system in India. METHODOLOGY: We evaluated structural capacity for snakebite care under six domains: medicines, equipment, infrastructure, human resources, governance and finance, and health management information systems (HMIS). We categorised states (aspirant, performer, front-runner, achiever) based on the proportion of primary health centres (PHC) and community health centres (CHC), attaining highest possible domain score. We assessed continuum of snakebite care, district-wise, under five domains (connectivity to PHC, structural capacity of PHC, referral from PHC to higher facility, structural capacity of CHC, referral from CHC to higher facility) as adequate or not. RESULTS: No state excelled ( front-runner or achiever) in all six domains of structural capacity in PHCs or CHCs. The broader domains (physical infrastructure, human resources for health, HMIS) were weaker compared to snakebite care medicines in most states/UTs, at both PHC and CHC levels. CHCs faced greater concerns regarding human resources and equipment availability than PHCs in many states. Among PHCs, physical infrastructure and HMIS were aspirational in all 29 assessed states, while medicines, equipment, human resources, and governance and finance were aspirational in 8 (27.6%), 2 (6.9%), 17 (58.6%), and 12 (41.4%) states respectively. For CHCs, physical infrastructure was aspirational in all 30 assessed states/UTs, whereas HMIS, medicines, equipment, human resources, and governance and finance were aspirational in 29 (96.7%), 11 (36.7%), 27 (90%), 26 (86.7%), and 3 (10%) states respectively. No district had adequate continuum of snakebite care in all domains. Except for transport availability from CHC to higher facilities (48% of districts adequate) and transport availability from PHC to higher facilities (11% of districts adequate), fewer than 2% of districts were adequate in all other domains. CONCLUSION: Comprehensive strengthening of primary health care, across all domains, and throughout the continuum of care, instead of a piece-meal approach towards health systems strengthening, is necessitated to reduce snakebite burden in India, and possibly other high-burden nations with weak health systems. Health facility surveys are necessitated for this purpose.

How and why snakebite became a global health priority: a policy analysis.

BACKGROUND: Snakebite was added to the WHO neglected tropical disease (NTD) list in 2017, followed by a World Health Assembly resolution in 2018, and an explicit global target being set to reduce the burden in 2019. We aimed to understand how and why snakebite became a global health priority. METHODS: We conducted a policy case study, using in-depth interviews, and documents (peer-reviewed and grey literature) as data sources. We drew on Shiffman et al's framework on global health network to guide the analysis. RESULTS: We conducted 20 interviews and examined 91 documents. The prioritisation of snakebite occurred in four phases: pre-crescendo, crescendo, de-crescendo and re-crescendo. The core snakebite network consisted of academics, which expanded during the re-crescendo phase to include civil society organisations and state actors. The involvement of diverse stakeholders led to better understanding of WHO processes. The use of intersecting and layered issue framing, framing solutions around snake antivenoms, in a background of cross-cultural fascination and fear of snakes enabled prioritisation in the re-crescendo phase. Ebbs and flows in legitimacy of the network and reluctant acceptance of snakebite within the NTD community are challenges. CONCLUSION: Our analyses imply a fragile placement of snakebite in the global agenda. We identify two challenges, which needs to be overcome. The study highlights the need to review the WHO criteria for classifying diseases as NTD. We propose that future prioritisation analysis should consider identifying temporal patterns, as well as integrating legitimacy dimensions, as in our study.

Healthcare practitioners' knowledge of snakebite management and associated factors in high-burden, low-resource settings in Uganda.

BACKGROUND: Snakebites cause significant morbidity and mortality in Uganda. Effective management of snakebites requires knowledge of the appropriate first aid measures, as well as knowledge of the appropriate antivenom to use, but little is known about familiarity with effective snakebite management techniques and associated factors among healthcare practitioners (HCPs) in Uganda. METHODS: In May 2022, we collected data on sociodemographic characteristics, knowledge of snakebite first aid, envenomation signs, diagnosis and antivenom administration among 311 HCPs from two snakebite high-incidence districts in Uganda using a semi-structured questionnaire. RESULTS: Of the 311 HCPs, 64.3% had ever treated snakebite cases, 87.1% were confident to provide supportive treatment, but only 9.6% had ever been trained on snakebite management. Overall, 22.8% of HCPs had high knowledge of snakebite management. Higher education (at least degree vs certificate; PR=2.21 95% CI 1.508 to 4.56), older age (30-45 vs <30 y; PR=1.97, 95% CI 1.22 to 3.21) and previous training (PR=1.82, 95% CI 1.08 to 3.05) were associated with high knowledge of snakebite diagnosis and management. CONCLUSIONS: Overall, knowledge of snakebite management was limited. Training, level of education and age of the HCP all had an impact on knowledge. Deliberate efforts are required to increase HCPs' knowledge of snakebite case care in high-burden regions to manage incident cases.

Clinical aspects of snakebite envenoming and its treatment in low-resource settings.

There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.

Upper Extremity Crotalid Envenomation: A Review of Incidence and Recent Trends in Management of Snakebites.

PURPOSE: The goal of this study was to evaluate the recent trends in the management of upper extremity Crotalid envenomation in the state of Georgia, United States. METHODS: A retrospective review of the Georgia Poison Center database looking at the reported snakebites to the upper extremity between 2015 and 2020 was performed. Patient demographics, timing and location of injury, severity of envenomation, treatment, including use of antivenin and surgical intervention, and reported complications related to the use of antivenin was extracted. RESULTS: A retrospective review of snakebites between 2015 and 2020 showed 2408 snakebite cases with a mean patient age of 37.4 years. Males incurred 62.8% of all bites. The highest incidence was in summer 52.5%, and between the hours of 5 PM to midnight 57.2%. Overall, 1010 (41.9%) of all bites were categorized as venomous snakebites (55.6% copperhead, 20% rattlesnake, 2.4% cottonmouth, and 22% miscellaneous [including 3 Elapid envenomations] or unidentified. The total number of venomous bites to the upper extremity was 575 (56.9%) and 567 patients received antivenin. Envenomation severity was mild in 29%, moderate in 45%, severe in 10%, and undetermined in 16% of cases. Crotalidae polyvalent immune Fab (Ovine) was the main antivenin used, with overall mean initial therapy dose of 6.2 vials and 59% of patients receiving maintenance therapy. Three patients (0.5%) had a severe anaphylactic reaction to antivenin requiring cessation of therapy. Seven patients had acute compartment syndrome of the upper extremity requiring fasciotomy (3 copperhead, 2 rattlesnake, and 2 unidentified). There was no reported mortality during this period. CONCLUSIONS: Hand surgeons should be familiar with the management of upper extremity Crotalid envenomation. Antivenin remains the main treatment for symptomatic patients. Crotalid snakebites rarely require operative intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Assessment of snakebite management practices at Meserani Juu in Monduli District, Northern Tanzania.

BACKGROUND: Snakebite envenoming represents a tragically neglected tropical disease mostly affecting poor people living in remote areas of developing countries, primarily in sub-Saharan Africa. Anti-snake venom (ASV) is the only approved specific treatment for systemic envenoming from snakebite, but it remains largely unavailable in many parts of developing countries. There is paucity of data on snakebite management practice in Tanzania. This study aimed at assessing the community management practices of snakebite and availability of anti-snake venom in the public health facilities in Monduli District, Northern Tanzania. METHODS: A cross sectional study was carried out between May and June, 2018 involving 67 victims, 147 other household members, and 35 public health facilities. A structured questionnaire, respondent interview, and health facility report/document review were considered during data collection. Clean data were analyzed using SPSS version 20. RESULTS: Sixty-seven snakebite victims and 147 other household members were interviewed during a household survey. All snakebite cases reported to having visited a health facility after snakebite with the majority 55/67 (82.1%) reporting the use, prior attendance to medical care, of some form of local treatment such as tourniquets 13 (19.4%), local incision 11 (16.4%), and snakestone 7 (10.4%). None of the public health facilities in Monduli District attended a snakebite case and had never stocked anti-snake venom products. In this area, 45 snakebite cases were reported to be managed at Meserani snake park clinic where anti-snake venom products were available and provided for free in the period between January 2017 and December 2017. CONCLUSION: Majority of the snakebite cases at Meserani Juu relied on local methods for the management of snake bites of which most are of unknown efficacy and safety. Furthermore, none of the primary public health facilities in Monduli District stocked antivenom despite being a habitat for different kinds of venomous snakes. The government and local non-government organizations should collaborate so as to improve the anti-snake venom availability and the provision of snakebite preventive and management awareness programs, especially to the rural communities.

Estimating economic and disease burden of snakebite in ASEAN countries using a decision analytic model.

BACKGROUND: Understanding the burden of snakebite is crucial for developing evidence-informed strategies to pursue the goal set by the World Health Organization to halve morbidity and mortality of snakebite by 2030. However, there was no such information in the Association of Southeast Asian Nations (ASEAN) countries. METHODOLOGY: A decision analytic model was developed to estimate annual burden of snakebite in seven countries, including Malaysia, Thailand, Indonesia, Philippines, Vietnam, Lao PDR, and Myanmar. Country-specific input parameters were sought from published literature, country's Ministry of Health, local data, and expert opinion. Economic burden was estimated from the societal perspective. Costs were expressed in 2019 US Dollars (USD). Disease burden was estimated as disability-adjusted life years (DALYs). Probabilistic sensitivity analysis was performed to estimate a 95% credible interval (CrI). PRINCIPAL FINDINGS: We estimated that annually there were 242,648 snakebite victims (95%CrI 209,810-291,023) of which 15,909 (95%CrI 7,592-33,949) were dead and 954 (95%CrI 383-1,797) were amputated. We estimated that 161,835 snakebite victims (69% of victims who were indicated for antivenom treatment) were not treated with antivenom. Annual disease burden of snakebite was estimated at 391,979 DALYs (95%CrI 187,261-836,559 DALYs) with total costs of 2.5 billion USD (95%CrI 1.2-5.4 billion USD) that were equivalent to 0.09% (95%CrI 0.04-0.20%) of the region's gross domestic product. >95% of the estimated burdens were attributed to premature deaths. CONCLUSION/SIGNIFICANCE: The estimated high burden of snakebite in ASEAN was demonstrated despite the availability of domestically produced antivenoms. Most burdens were attributed to premature deaths from snakebite envenoming which suggested that the remarkably high burden of snakebite could be averted. We emphasized the importance of funding research to perform a comprehensive data collection on epidemiological and economic burden of snakebite to eventually reveal the true burden of snakebite in ASEAN and inform development of strategies to tackle the problem of snakebite.

Prevalence and therapeutic management of snakebite cases in the health facilities of the Bouenza department from 2009 to 2021, Republic of Congo.

Introduction: few studies exist of snake bites in the Republic of Congo. This study reports epidemiological and management data on snake bites in the Bouenza department of the Republic of Congo. Methods: this is a retrospective and descriptive study based on questionnaire and analysis of files of snakebite victims over a period of 13 years (2009-2021). We collected data on incidence, age, gender, site of the bite, the season of the bite, deaths and treatment. Results: we identified 81 cases of bites recorded in 14 healthcare facilities: 54.32% of cases (44/81) at Nkayi Base Hospital; 11.11% (9/81) at Madingou Base Hospital; 1-5% (1-4/81) at each of the remaining facilities. Eight deaths were recorded in four health facilities. The sex ratio of snakebite victims was 1 (41 males: 40 females). The age most affected was 25-55 years (54.32% or 44/81). The lower limb was the bite site most reported at 13.98% (but in 84% or 68/81 cases the site was not recorded). More bites occurred during the rainy season (80.25%; 65/81). All victims received only symptomatic treatment based on antibiotics, anti-inflammatories and analgesics, as anti-venom serums are unavailable. The recorded incidence of snake bites in Bouenza was 18.62 per 100,000 of population. Conclusion: our study offers a preliminary report from a little-studied region. The incidence of snakebites recorded in Bouenza is lower than expected compared with studies from other African countries, and with earlier (20 years ago) studies from Congo. This may reflect incomplete record-keeping in under-resourced healthcare facilities.

ICMR task force project- survey of the incidence, mortality, morbidity and socio-economic burden of snakebite in India: A study protocol.

BACKGROUND: Snakebite is possibly the most neglected of the NTDs (Neglected Tropical Diseases). Half of the global deaths due to venomous snakebites, estimated at 100,000 per year, occur in India. The only representative data on snakebite available from India is the mortality data from the RGI-MDS study (Registrar General of India- 1 Million Death Study) and another study on mortality from the state of Bihar. Incidence data on snakebite is available for 2 districts of the state of West Bengal only. Hospital-based data on snakebite admissions and use of ASV are gross underestimates as most snakebite victims in rural India depend more on alternate treatment methods which do not get represented in National registries. The proposed study is a multi-centric study to determine the incidence, morbidity, mortality and economic burden of snakebites in India covering all 5 geographical zones of the country. PROTOCOL: A community level surveillance for snakebite covering 31 districts in 13 states of India in order to obtain annual incidence of snakebites from the community. Frontline health workers will be trained to gather information on new cases of snakebite over the study period of 1-year, from "wards "(smallest administrative subunit of a village or town) that they represent in the study districts. Dedicated field officers would collect data on snakebites, victim characteristics, outcomes, utilization of health facilities on a questionnaire sheet designed for this purpose. The study duration is for 18 months from April 2022 to October 2023. DISCUSSION: The study would be the first of its kind in India looking prospectively at the incidence of snakebite covering 13 states in 5 zones of India and a population of 84 million. Our study covers 6.12% of the total population of the country as compared to the incidence study conducted in Sri Lanka which covered 1% of the total population.

Clinico-epidemiology and management of hump-nosed pit viper (Hypnale spp.) bites in dogs.

Human envenoming from the bite of the abundant hump-nosed pit viper (Hypnale spp.) (HNPV) is a frequent occurrence with victims experiencing unpleasant and sometimes life-threatening consequences. Further, clinico-pathology, treatment and management measures in HNPV envenomed dogs are under recognized. Prospective investigations were performed to assess the clinico-pathology and management options for HNPV envenomed dogs brought to the University of Peradeniya's Veterinary Teaching Hospital from January, 2012 to March 2018. We recorded the local and systemic manifestations, hematological and urinary abnormalities of 78 dogs in which HNPV bite had been witnessed by the owner. Mild swelling, extensive swelling, hemorrhagic blistering and hemorrhagic bullae at the site of bite were observed in 59%, 31%, 6% and 4% of the dogs, respectively. Some dogs were subjected to surgical excision of necrotized tissue including limb amputation. We observed the following systemic clinical effects in envenomed dogs: neurotoxicity (13%), acute kidney injury (AKI) (14%) and coagulopathy (16%). All dogs showed leukocytosis with mean white blood cell count of 25.25 × 103/µL. Mild anemia and thrombocytopenia were detected in 29% of the dogs. There was a significant correlation between extent of local tissue injuries with length of hospitalization (LH). The mean time of coagulopathy observed was 21.3 h (IQR: 8-48 h). In coagulopathic dogs, there was a strong correlation between LH and extent of local tissue injury (rs = 0.7751, P < 0.0001); LH and whole blood clotting time(CT) (rs = 1.0, P < 0.0001); PT and aPTT (rs = 0.4712, P < 0.001). LH was significantly correlated with the development of AKI (p = 0.0013). Lack of specific antivenom (AVS) for HNPV envenoming provided an opportunity to study the remaining treatment options. Therefore, the study allowed the identification of local and systemic effects, hematological abnormalities, possible supportive treatments and drawbacks of management measures for envenomed dogs.

Assessment of the effect of snakebite on health and socioeconomic factors using a One Health perspective in the Terai region of Nepal: a cross-sectional study.

BACKGROUND: Snakebite envenoming has a substantial health and socioeconomic effect in rural communities. However, there are insufficient epidemiological and animal data, which prevents accurate assessment on the effects of snakebite. We aimed to assess the health and socioeconomic effect of snakebite using a One Health perspective. METHODS: In this cross-sectional survey-based study, we assessed the health and socioeconomic effects of snakebite data using a multicluster survey that was previously done as part of the SNAKE-BYTE project in the Terai region, Nepal. Health effect was measured in terms of disability-adjusted life years (DALYs). Livelihood losses encompassed out-of-pocket health-care expenditures, losses of productivity due to days off work, and the losses due to mortality and treatment costs in domestic animals. Mortality losses in domestic animals were also estimated as animal loss equivalents, and overall human and animal health effect expressed using modified DALYs for zoonotic disease (zDALYs). FINDINGS: We estimate an annual snakebite burden of 200 799 DALYs (95% CI 103 137-357 805), mostly due to mortality in children and women. Snakebite is estimated to lead to US$2·8 million in yearly livelihood losses associated with human and animal cases. Overall, we estimate a yearly human and animal health burden of 202 595 zDALYs (104 300-360 284). INTERPRETATION: These findings present robust evidence on the extent of snakebite's health and socioeconomic effect and emphasise the need for a One Health perspective. The results also stress how improved data collection at the community level is crucial for improved assessments of its effect. FUNDING: Swiss National Science Foundation.

Geographical accessibility to the supply of antiophidic sera in Brazil: Timely access possibilities.

Snakebite accidents are considered category A neglected tropical diseases. Brazil stands out for snakebite accidents, mainly in the Amazon region. The best possible care after snakebite accidents is to obtain antiophidic sera on time. And the maximum ideal time to reach it is about 2 hours after an accident. Based on public health information and using a tool to analyze geographical accessibility, we evaluate the possibility of reaching Brazilian serum-providing health facilities from the relationship between population distribution and commuting time. In this exploratory descriptive study, the geographic accessibility of Brazilian population to health facilities that supply antiophidic serum is evaluated through a methodology that articulates several issues that influence the commuting time to health units (ACCESSMOD): population and facilities' distribution, transportation network and means, relief and land use, which were obtained in Brazilian and international sources. The relative importance of the population without the possibility of reaching a facility in two hours is highlighted for Macro-Regions, States and municipalities. About nine million people live in locations more than two hours away from serum-providing facilities, with relevant variations between regions, states, and municipalities. States like Mato Grosso, Pará and Maranhão had the most important participation of population with reaching time problems to those units. The most significant gaps are found in areas with a dispersed population and sometimes characterized by a high incidence of snakebites, such as in the North of the country, especially in the Northeastern Pará state. Even using a 2010 population distribution information, because of the 2020 Census postponement, the tendencies and characteristics analyzed reveal challenging situations over the country. The growing availability of serum-providing health facilities, the enhanced possibilities of transporting accident victims, and even the availability of sera in other types of establishments are actions that would allow expanding the possibilities of access to serum supply.

Assessment of the availability of snakebite antivenom in health facilities in Ndola District, Zambia: a cross-sectional study.

BACKGROUND: Despite snakebite antivenom being included on the WHO list of essential medicines, many parts of the world, especially Africa, lack effective and safe antivenoms. METHODS: A descriptive, field-based, cross-sectional study was undertaken from August to November 2020 in 40 out of 71 health facilities in Ndola district. Interviews and physical inspection were conducted at each facility. RESULTS: The study revealed that only three (8%) of all the private health facilities had antivenom available at the time of the assessment. Factors significantly associated with antivenom supply included lack of central country supply (90%), lack of demand of the antivenom (55%) and no budget allocation for the antivenom (95%). CONCLUSIONS: Despite the high number of notified snakebites within Ndola district, there remains poor availability of snakebite antivenom within the district.

Snakebites in "Invisible Populations": A cross-sectional survey in riverine populations in the remote western Brazilian Amazon.

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants' demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2-49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4-39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol.

Background: In India, geographical variation, lack of data and underreporting on cases and deaths due to snakebite makes it difficult to estimate socio-economic burden of snakebites. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none so far in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: A cross-sectional community based study for estimating epidemiological and economic burden of snakebite, recruiting victims of snakebite occurring over a nine month period prior to start and over the three month period of the study, across Ernakulam district, Kerala state, India. For the community derived disability weights, 60 adult patients admitted and treated at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The sample size to determine the mortality rate is calculated at 108,458 persons in Ernakulam.The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites. Standard methods for analysis and reporting of mortality, morbidity, years of lives lost, years lived with disability, disability weights, and costs of treatment will be calculated and presented. The study will be started in March 2021 and is expected to be completed by June 2021. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so.The protocol has been developed using guidelines for both cross-sectional studies and  for conducting community derived disability weights. The evidence generated will contribute to knowledge regarding epidemiology, economic burden and community-derived disability weights for snakebites in India and other LMICs.

Assessment of snakebite burdens, clinical features of envenomation, and strategies to improve snakebite management in Vietnam.

The sheer paucity of scientific documentation of herpetofauna in Vietnam and the rudimentary healthcare response to snakebite have stimulated this review. Over six decades of data culled from public data bases and search engines, have been used to assess snakebite burdens, clinical features of envenomation, and strategies for snakebite management in Vietnam. In addition, biochemical and proteomic analyses to decipher venom composition, rapid analytical techniques to be used for clinical diagnosis of snakebite in Vietnam have been discussed in detail. The assessment of efficacy, safety, and quality of commercial antivenom produced in Vietnam and improvement of antivenom production to meet the national requirement has been critically examined. It is apparent that snake bite incidence in Vietnam is exacerbated by mismatch in demand and supply of antivenom therapy, insufficient medical facilities, preference for traditional healers and poor management of clinical records. The impediments arising from geographical and species-specific variation in venom composition can be overcome by the 'Omics approach', and scientific documentation of pathophysiological manifestations post envenomation. The development of next generation of therapeutics, encouraging clinical research, novel approaches and social awareness against snakebite and its treatments have been suggested to significantly reduce the snakebite mortality and morbidity in this region.