Snakebite and its impact in rural communities: The need for a One Health approach

Who are the most affected by Bothrops snakebite envenoming in Brazil? A Clinical-epidemiological profile study among the regions of the country

Snakebite envenoming represents an important Neglected Tropical Disease (NTD) that mainly affects tropical and subtropical developing countries according to the World Health Organization (WHO). As a priority issue in the tropics, it is estimated that accidental encounter between snakes and humans is the leading cause of morbidity and mortality among all NTDs in the world. In Brazil, an extremely diverse country with continental dimensions, snakebite envenoming is the second leading cause of reported human envenoming. Treating the disease has been an unprecedented challenge for Brazilian Health Systems for decades. Despite access to Antivenom therapy and distributing it free of charge across the country, Brazil faces numerous issues regarding the notification process and accurate treatment targeting for at-risk populations. Thus, this study aimed to identify the temporal epidemiological dynamics of accidents caused by Bothrops snakes in Brazil, the country's major group of venomous snakes, based on secondary information from the online database provided by The Brazilian Notifiable Diseases Information System (SINAN). For this purpose, reported Bothrops snakebites between 2012 and 2021 were counted, then the data were analyzed. We looked at the frequency, occurrence, mortality rates, case fatality rate (CFR), age and gender distribution, and the time lapse between the incident and the initiation of Antivenom therapy. The data were also organized considering regional variations of the country. Throughout the studied period, a total of 202,604 cases of envenoming caused by Bothrops spp. were notified, resulting in 766 fatalities. These accidents were found to occur in variable proportions across different regions in Brazil, with notable concentrations observed in the North, Northeast, and Southeast regions. The epidemiological profile of patients varied greatly between the regions, revealing that snake envenoming is much more a social, economic, and ecological problem than a medical one. In conclusion, our study provides an overview of the clinical and epidemiological profile of envenoming by Bothrops snakes in Brazil. Notably, this is the first study to present such information in a country as vast and diverse as Brazil, encompassing a comparative analysis of its regions using SINAN data, that proves to be a very useful national tool to improve the control and management of envenoming.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report

Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.

Broadening the research landscape in the field of snakebite envenoming: Towards a holistic perspective

Snakebite envenoming (SBE) is a neglected tropical disease that kills and maims hundreds of thousands of people yearly, particularly in impoverished rural settings of the Global South. Understanding the complexity of SBE and tackling this disease demands a transdisciplinary, One Health approach. There is a long-standing research tradition on SBE in toxinology and human medicine. In contrast, other disciplines, such as veterinary medicine or social sciences, still need to be better developed in this field, especially in countries with a high incidence of SBE. Broadening the disciplinary landscape, connecting various research approaches, methods, and data across disciplines and sectors, and engaging with communities affected by SBE in implementing evidence-based solutions are needed. This review summarizes areas that require strengthening to better understand the complexity of SBE and to generate a robust body of knowledge to be translated into effective public health interventions.

Multifaceted community health education programs as powerful tools to mitigate snakebite-induced deaths, disabilities, and socioeconomic burden

Snakebite envenoming (SBE) predominantly affects rural impoverished communities that have limited access to immediate healthcare. These communities often hold numerous myths/misbeliefs about snakes and SBE. Moreover, healthcare professionals who practice in rural regions often work in unstable situations with limited medical infrastructure and therefore, lack sufficient knowledge/experience and confidence in the clinical management of SBE. Due to the lack of reliable statistics on the true burden of SBE, developing health policies for this condition by relevant authorities may be difficult. Hence, it is critical to improve awareness about SBE among rural communities, healthcare professionals and health authorities using robust multifaceted community health education approaches. Here, we describe the design, development, implementation, and impact of distinctive community health education approaches that we used in India and Brazil. A wide range of educational tools including information leaflets, posters, pocket guides, learning materials for healthcare professionals and short/long video documentaries were developed in local languages and used to engage with target communities through direct assemblies as well as mass/traditional and social media. Notably, we used diverse methods to determine the impact of our programs in improving awareness, treatment-seeking behaviour, and clinical practice. The people-centred approaches that we used were inclusive and highly impactful in instigating fundamental changes in the management of SBE among rural communities. The resources and approaches presented in this article can be easily adapted for wider use in other countries in order to collectively reduce SBE-induced deaths, disabilities and socioeconomic ramifications.

The Amazonian Tropical Bites Research Initiative, a hope for resolving zoonotic neglected tropical diseases in the One Health era

BACKGROUND

Neglected tropical diseases (NTDs) disproportionately affect populations living in resource-limited settings. In the Amazon basin, substantial numbers of NTDs are zoonotic, transmitted by vertebrate (dogs, bats, snakes) and invertebrate species (sand flies and triatomine insects). However, no dedicated consortia exist to find commonalities in the risk factors for or mitigations against bite-associated NTDs such as rabies, snake envenoming, Chagas disease and leishmaniasis in the region. The rapid expansion of COVID-19 has further reduced resources for NTDs, exacerbated health inequality and reiterated the need to raise awareness of NTDs related to bites.

METHODS

The nine countries that make up the Amazon basin have been considered (Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Surinam and Venezuela) in the formation of a new network.

RESULTS

The Amazonian Tropical Bites Research Initiative (ATBRI) has been created, with the aim of creating transdisciplinary solutions to the problem of animal bites leading to disease in Amazonian communities. The ATBRI seeks to unify the currently disjointed approach to the control of bite-related neglected zoonoses across Latin America.

CONCLUSIONS

The coordination of different sectors and inclusion of all stakeholders will advance this field and generate evidence for policy-making, promoting governance and linkage across a One Health arena.

A mechanistic model of snakebite as a zoonosis: Envenoming incidence is driven by snake ecology, socioeconomics and its impacts on snakes

Snakebite is the only WHO-listed, not infectious neglected tropical disease (NTD), although its eco-epidemiology is similar to that of zoonotic infections: envenoming occurs after a vertebrate host contacts a human. Accordingly, snakebite risk represents the interaction between snake and human factors, but their quantification has been limited by data availability. Models of infectious disease transmission are instrumental for the mitigation of NTDs and zoonoses. Here, we represented snake-human interactions with disease transmission models to approximate geospatial estimates of snakebite incidence in Sri Lanka, a global hotspot. Snakebites and envenomings are described by the product of snake and human abundance, mirroring directly transmitted zoonoses. We found that human-snake contact rates vary according to land cover (surrogate of occupation and socioeconomic status), the impacts of humans and climate on snake abundance, and by snake species. Our findings show that modelling snakebite as zoonosis provides a mechanistic eco-epidemiological basis to understand snakebites, and the possible implications of global environmental and demographic change for the burden of snakebite.

Snakebite victim profiles and treatment-seeking behaviors in two regions of Kenya: results from a health demographic surveillance system

INTRODUCTION

Snakebites are a major cause of permanent injury and death among poor, rural populations in developing countries, including those in East Africa. This research characterizes snakebite incidence, risk factors, and subsequent health-seeking behaviors in two regions of Kenya using a mixed methods approach.

METHODS

As a part of regular activities of a health demographic surveillance system, household-level survey on snakebite incidence was conducted in two areas of Kenya: Kwale along the Kenyan Coast and Mbita on Lake Victoria. If someone in the home was reported to have been bitten in the 5 years previous to the visit, a survey instrument was administered. The survey gathered contextual information on the bite, treatment-seeking behavior and clinical manifestations. To obtain deeper, contextual information, respondents were also asked to narrate the bite incident, subsequent behavior and outcomes.

RESULTS

8775 and 9206 households were surveyed in Kwale and Mbita, respectively. Out of these, 453 (5.17%) and 92 (1.00%) households reported that at least one person had been bitten by a snake in the past 5 years. Deaths from snakebites were rare (4.04%), but patterns of treatment seeking varied. Treatment at formal care facilities were sought for 50.8% and at traditional healers for 53.3%. 18.4% sought treatment from both sources. Victims who delayed receiving treatment from a formal facility were more likely to have consulted a traditional healer (OR 8.8995% CI [3.83, 20.64]). Delays in treatment seeking were associated with significantly increased odds of having a severe outcome, including death, paralysis or loss of consciousness (OR 3.47 95% CI [1.56; 7.70]).

CONCLUSION

Snakebite incidence and outcomes vary by region in Kenya, and treatment-seeking behaviors are complex. Work needs to be done to better characterize the spatial distribution of snakebite incidence in Kenya and efforts need to be made to ensure that victims have sufficient access to effective treatments to prevent death and serious injury.

Snakebite Management and One Health in Asia Using an Integrated Historical, Social, And Ecological Framework

Snakebite envenomation continues to contribute to high fatality and morbidity rates across Asia. Yet snake bite is one of many outcomes due to human-snake conflicts, which themselves are only one type of human-snake relationship among the diversity of such interactions. We propose that human-snake relationships need to be explored from a perspective integrative of history, ecology, and culture in order to adequately and holistically address snake bite. In order to contextualize this concept within a language already understood in conservation research, we characterize and develop four interconnected themes defining human-snake relationships as a social ecological system. By breaking down the multifaceted nature of human-snake relationships under a social ecological systems framework, we explore its applicability in contributing to a unified strategy, drawing from both social and natural sciences for ending the snakebite crisis.

A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study

BACKGROUND

Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India.

METHODS

We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots.

FINDINGS

The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes.

CONCLUSIONS

The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.

Estimating and predicting snakebite risk in the Terai region of Nepal through a high-resolution geospatial and One Health approach

Most efforts to understand snakebite burden in Nepal have been localized to relatively small areas and focused on humans through epidemiological studies. We present the outcomes of a geospatial analysis of the factors influencing snakebite risk in humans and animals, based on both a national-scale multi-cluster random survey and, environmental, climatic, and socio-economic gridded data for the Terai region of Nepal. The resulting Integrated Nested Laplace Approximation models highlight the importance of poverty as a fundamental risk-increasing factor, augmenting the snakebite odds in humans by 63.9 times. For animals, the minimum temperature of the coldest month was the most influential covariate, increasing the snakebite odds 23.4 times. Several risk hotspots were identified along the Terai, helping to visualize at multiple administrative levels the estimated population numbers exposed to different probability risk thresholds in 1 year. These analyses and findings could be replicable in other countries and for other diseases.

Promoting co-existence between humans and venomous snakes through increasing the herpetological knowledge base

Snakebite incidence at least partly depends on the biology of the snakes involved. However, studies of snake biology have been largely neglected in favour of anthropic factors, with the exception of taxonomy, which has been recognised for some decades to affect the design of antivenoms. Despite this, within-species venom variation and the unpredictability of the correlation with antivenom cross-reactivity has continued to be problematic. Meanwhile, other aspects of snake biology, including behaviour, spatial ecology and activity patterns, distribution, and population demography, which can contribute to snakebite mitigation and prevention, remain underfunded and understudied. Here, we review the literature relevant to these aspects of snakebite and illustrate how demographic, spatial, and behavioural studies can improve our understanding of why snakebites occur and provide evidence for prevention strategies. We identify the large gaps that remain to be filled and urge that, in the future, data and relevant metadata be shared openly via public data repositories so that studies can be properly replicated and data used in future meta-analyses.

Prospects and Challenges of Developing Plant-Derived Snake Antivenin Natural Products: A Focus on West Africa

Snakebite envenomation (SBE) is an important public health issue that is now receiving renewed attention following its reclassification as a Neglected Tropical Disease (NTD). Most incidences occur in rural areas of resource-limited countries, as such, timely and appropriate medical care for SBE is often inaccessible. The administration of anti-snake venom serum (ASV) is the only effective definitive treatment of SBE, but treatment failure to available ASVs is not uncommon. Emerging evidence highlights the potential of small-molecule compounds as inhibitors against toxins of snake venom. This presents an encouraging prospect to develop an alternative therapeutic option for the treatment SBE, that may be amenable for use at the point of care in resource-constraint settings. In view of the pivotal role of natural products in modern drug discovery programmes, there is considerable interest in ethno-pharmacological mining of medicinal plants and plant-derived medicinal compounds toward developing novel snake venom-neutralising therapeutics. In this review, we compile a collection of medicinal plants used in the treatment of SBE in West Africa and highlight their promise as potential botanical drugs or as sources of novel small-molecule compounds for the treatment of SBE. The challenges that must be surmounted to bring this to fruition including the need for (sub) regional collaboration have been discussed.

Snakebites in Rural Areas of Brazil by Race: Indigenous the Most Exposed Group

Animal stings are environmental hazards that threaten millions annually and cause a significant socioeconomic impact. Snakebite envenoming affects 2.7 million people globally every year, mostly the poorest and rural communities, with approximately 27,000 annual cases in Brazil. This study’s objective is to identify the most exposed racial group for snakebites in rural areas of Brazil and analyze possible differences in the outcome of an accident. A retrospective epidemiological study was conducted using a database of rural snakebite cases from Brazil’s Ministry of Health (2017). Descriptive analysis and a regression model were performed to examine the association of bad outcomes after a snakebite with several covariables. While mixed-race individuals presented the highest number of cases (61.79%), indigenous and white populations were the racial groups with the highest and lowest exposure rates (194.3 and 34.1 per 100,000 population, respectively). The fatality rate was 3.5 times higher in the indigenous population compared to the white population. In the multivariable model, the number of hours between the accident and health care received and the case classification suggested an association with a bad outcome. Snakebite is prominent in Brazil, particularly among indigenous groups. Antivenom is available in the Brazilian Health System; however, efforts need to be made for decentralization.

Integrating lay knowledge and practice into snakebite prevention and care in central Africa, a hotspot for envenomation

The WHO has identified the goal of halving deaths and disability from snakebite envenomation (SBE) by 2030 through a four-pillar program that promotes accessible and affordable treatments, strengthens health systems, promotes community and multi-level engagement, and mobilizes partnerships, coordination and resources to advocate for global action. This initiative could accelerate multi-disciplinary research and action in central Africa, a “hotspot” for SBE, but it offers little specific guidance about anthropological research to be conducted. This commentary develops that research agenda. It surveys anthropological, ethnohistorical investigations in the central African forest to elaborate the socio-cultural and historical significance and practices around snakes and snakebites. It draws from south and southeast Asian and Latin American literatures to illustrate anthropological contributions to SBE research. It then outlines a Central African research agenda employing ethnobiological investigation of snake ecologies, participatory evaluations of humans-snake contacts, and interviews and participant-observation of local prevention and treatment practices and knowledge. This research will co-develop policies and practices with forest communities and leaders and regional and national authorities to reduce the burden of SBE.

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Central African forests are a hotspot for snakebite envenomation.

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SBE research in central Africa has not mobilized anthropological literatures or methodologies.

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Policies to reduce SBE burden in central Africa should build on participatory research.

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Policies to reduce SBE burden should be co-developed with local and national stakeholders.

A scoping review of current practices on community engagement in rural East Africa: Recommendations for snakebite envenoming

Community empowerment and engagement is one of the four strategic aims highlighted in the WHO strategy to prevent and control snakebite envenoming. Inappropriate health-seeking behaviours contribute to adverse outcomes, and community engagement is key in driving behavioural change. WHO has highlighted East Africa as a geographical area of concern for snakebite envenoming. The overall aim of the project is to develop a community engagement toolkit for snakebite envenoming and other NTDs. The objective of this scoping review was to identify current practices in recent community engagement in rural East Africa; the applicability of these results to snakebite envenoming are discussed. PubMed, Web of Science, PsycINFO and Google Scholar were searched from 1 January 2017 to 3 September 2020. Search terms were used to identify publications which related to rural communities and health or disease, for both humans and animals. After reviewing the full papers for all geographical areas, 112 publications were included, 30 of which were conducted in East Africa. Papers included nine different countries and covered a broad range of health topics; notably, water, sanitation and hygiene, nutrition, and maternal and child health. Only one publication considered animal health. The most common form of engagement was in the context of a group meeting, lecture, presentation, discussion or question and answer session (63.3%). A variety of locations within the community were used to engage with people, the most common being an individual's household (23.3%). Communication factors was the key influencer for engagement, both positively and negatively. Key barriers to engagement include local languages and health beliefs, literacy levels, mobile phone ownership and the level of mobile Internet coverage, burden of agricultural work and weather conditions. This study provides an extensive overview of recent public health community engagement in East Africa, which will serve as a useful resource for any group seeking to plan an intervention in remote and rural areas in East Africa. Furthermore, it serves as a guide to help tailor community engagement to snakebite envenoming.

What is the impact of snakebite envenoming on domestic animals? A nation-wide community-based study in Nepal and Cameroon

Snakebite envenoming is a life-threatening disease in humans and animals and a major public health issue in rural communities of South-East Asia and sub-Saharan Africa. Yet the impact of snakebite on domestic animals has been poorly studied. This study aimed to describe the context, clinical features, treatment, and outcomes of snakebite envenoming in domestic animals in Nepal and Cameroon. Primary data on snakebite in animals were recorded from a community-based nation-wide survey on human and animal snakebite in Nepal and Cameroon (Snake-byte project). Mobile teams collected data on snakebite in humans and animals in 13,879 and 10,798 households in Nepal and Cameroon respectively from December 2018 to June 2019. This study included 405 snakebite cases (73 in Nepal and 332 in Cameroon) in multiple types of animals. An interview with a structured questionnaire collected specific information about the animal victims. Snake bites in animals took place predominantly inside and around the house or farm in Nepal (92%) and Cameroon (71%). Other frequent locations in Cameroon were field or pasture (12%). A large diversity of clinical features was reported in all types of envenomed animals. They showed either a few clinical signs (e.g., local swelling, bleeding) or a combination of multiple clinical signs. Only 9% of animal victims, mainly cattle and buffaloes and less frequently goats, sheep, and dogs, received treatment, predominantly with traditional medicine. The overall mortality of snakebite was 85% in Nepal and 87% in Cameroon. Results from this nationwide study show an important impact of snakebite on animal health in Nepal and Cameroon. There is a need for cost-effective prevention control strategies and affordable snakebite therapies in the veterinary field to save animal lives and farmer livelihood in the poorest countries of the world. The WHO global strategy to prevent and control snakebite envenoming supports a One Health approach, which may help develop integrated solutions to the snakebite problem taking into account human and animal health.

Mental health conditions after snakebite: a scoping review

Introduction

Snakebite is a neglected tropical disease. Snakebite causes at least 120 000 death each year and it is estimated that there are three times as many amputations. Snakebite survivors are known to suffer from long-term physical and psychological sequelae, but not much is known on the mental health manifestations postsnakebite.

Methods

We conducted a scoping review and searched five major electronic databases (Ovid MEDLINE(R), Global Health, APA PsycINFO, EMBASE classic+EMBASE, Cochrane Central Register of Controlled Trials), contacted experts and conducted reference screening to identify primary studies on mental health manifestations after snakebite envenomation. Two reviewers independently conducted titles and abstract screening as well as full-text evaluation for final inclusion decision. Disagreements were resolved by consensus. We extracted data as per a standardised form and conducted narrative synthesis.

Results

We retrieved 334 studies and finally included 11 studies that met our eligibility criteria. Of the 11 studies reported, post-traumatic stress disorder (PTSD) was the most commonly studied mental health condition after snakebite, with five studies reporting it. Estimate of the burden of PTSD after snakebite was available from a modelling study. The other mental health conditions reported were focused around depression, psychosocial impairment of survivors after a snakebite envenomation, hysteria, delusional disorders and acute stress disorders.

Conclusion

There is a need for more research on understanding the neglected aspect of psychological morbidity of snakebite envenomation, particularly in countries with high burden. From the limited evidence available, depression and PTSD are major mental health manifestations in snakebite survivors.

Novel transdisciplinary methodology for cross-sectional analysis of snakebite epidemiology at national scale

Background

Worldwide, it is estimated that snakes bite 4.5–5.4 million people annually, 2.7 million of which are envenomed, and 81,000–138,000 die. The World Health Organization reported these estimates and recognized the scarcity of large-scale, community-based, epidemiological data. In this context, we developed the “Snake-Byte” project that aims at (i) quantifying and mapping the impact of snakebite on human and animal health, and on livelihoods, (ii) developing predictive models for medical, ecological and economic indicators, and (iii) analyzing geographic accessibility to healthcare. This paper exclusively describes the methodology we developed to collect large-scale primary data on snakebite in humans and animals in two hyper-endemic countries, Cameroon and Nepal.

Methodology/Principal findings

We compared available methods on snakebite epidemiology and on multi-cluster survey development. Then, in line with those findings, we developed an original study methodology based on a multi-cluster random survey, enhanced by geospatial, One Health, and health economics components. Using a minimum hypothesized snakebite national incidence of 100/100,000/year and optimizing design effect, confidence level, and non-response margin, we calculated a sample of 61,000 people per country. This represented 11,700 households in Cameroon and 13,800 in Nepal. The random selection with probability proportional to size generated 250 clusters from all Cameroonian regions and all Nepalese Terai districts. Our household selection methodology combined spatial randomization and selection via high-resolution satellite images. After ethical approval in Switerland (CCER), Nepal (BPKIHS), and Cameroon (CNERSH), and informed written consent, our e-questionnaires included geolocated baseline demographic and socio-economic characteristics, snakebite clinical features and outcomes, healthcare expenditure, animal ownership, animal outcomes, snake identification, and service accessibility.

Conclusions/Significance

This novel transdisciplinary survey methodology was subsequently used to collect countrywide snakebite envenoming data in Nepal and Cameroon. District-level incidence data should help health authorities to channel antivenom and healthcare allocation. This methodology, or parts thereof, could be easily adapted to other countries and to other Neglected Tropical Diseases.

Snakebite envenoming was recently classified as a priority neglected tropical disease by the World Health Organization. Up to five million people are bitten, more than a million envenomed, and around 100,000 victims die, mainly in rural and remote areas of low- and middle-income countries. Snakebite envenoming not only affects victims acutely, but it can also cause long-term disability, disfiguring scars, and heavy economic burden due to treatment costs and inability to work. Previous studies have analyzed snakebite clinical, epidemiological, or socio-economic impacts independently, and little has been done to assess the impact of snakebite in animals and on the livelihoods of the communities that depend upon them.

We present an innovative, holistic, national-scale methodology that includes epidemiology, One Health, economic, and geographic information science approaches into one multi-cluster household survey. We randomly selected 250 sub-district areas from all Cameroonian regions and all Nepali Terai districts, which represented more than 61,000 participants in each country. This methodology could be adapted and implemented in other countries affected by snakebite.

Overview of snakebite in Brazil: Possible drivers and a tool for risk mapping

Snakebite envenoming affects close to 2.7 million people globally every year. In Brazil, snakebites are reported to the Ministry of Health surveillance system and cases receive antivenom free of charge. There is an urgent need to identify higher risk areas for antivenom distribution, and to develop prevention activities. The objective of this study is to provide an overview of the epidemiological situation of snakebite envenoming in Brazil and explore possible drivers; as well as to create a flowchart tool to support decision-makers identify higher risk areas. An ecological-type study was carried out using data by municipality (2013–2017). Study parts: 1) Create a geocoded database and perform a descriptive and cluster analysis; 2) Statistical analysis to measure the association of snakebite and possible environmental and socioeconomic drivers; 3) Develop a flowchart to support decision-makers and the application of this tool in one state (Rio Grande do Sul) as an example. An average of 27,120 snakebite cases per year were reported at the country level. Clusters of municipalities with high numbers of snakebites are mostly found in the Amazon Legal Region. The negative binomial regression model showed association with the snakebite case count: the type of major habitat, tropical or non-tropical; temperature; percentage of urbanization; precipitation; elevation; GDP per capita; a weaker relation with forest loss; and with venomous snake richness. The state where the instrument was applied reported 4,227 snakebites in the period. Most municipalities were considered as medium risk and 56/496 as high risk according to the tool created. Snakebite cases are distributed across the entire country with the highest concentration in the Legal Amazon Region. This creates a complex situation both for better understanding of the association of environmental and socioeconomic factors with snakebites and for the distribution and maintenance of antivenom to remote areas. Research into types of antivenom with a longer shelf life without the need for refrigeration is needed.

It is estimated that snakebite envenoming affects around 2.7 million people every year worldwide. In Brazil, snakebite is part of the Ministry of Health surveillance system and cases receive antivenom free of charge. With a vast territory and limited production of antivenom, there is need to identify higher risk areas for its distribution and to develop preventative actions. The objective of this study is to provide an overview of the epidemiological situation of snakebite envenoming in Brazil and explore possible environmental and socioeconomic factors related to snakebites. On the basis of this information, a flowchart tool to support decision-makers identify higher risk areas was created and applied in one state as an example. An average of 27,120 snakebite cases per year were reported in Brazil, with the highest number of cases and rates in the Legal Amazon Region. The multivariable statistics analysis showed association of snakebite with environmental factors (type of major habitat, tropical or non-tropical; temperature; precipitation; elevation) and socioeconomic (lower percentage of urbanization; lower GDP per capita); also, a weaker relation with forest loss, and with venomous snake richness. The tool created to support decision-makers was applied in the state of Rio Grande do Sul, with 4,227 reported snakebites during the period. According to this tool, the majority of municipalities in this state were considered as medium risk and 56/496 as high risk. Snakebite cases are distributed across the entire country; however, the highest concentration is in the Legal Amazon Region. This creates a complex situation both for better understanding of the association of environmental and socioeconomic factors with snakebites and for the distribution and maintenance of antivenom to remote areas.

One Health education in Kakuma refugee camp (Kenya): From a MOOC to projects on real world challenges

Today, the world counts millions of refugees but only a fraction of them have access to higher education. Despite the multiple public health problems in refugee camps and the need to build local capacities to prevent and combat them, University level courses in public health are largely unavailable for refugees. This paper describes the development, implementation and evaluation of an innovative two-module blended-learning programme on One Health in Kakuma refugee camp (Kenya). This programme combines: (I) Interdisciplinary and multi-expert MOOC on "Global Health at the Human-Animal-Ecosystem interface"; (II) peer-to-peer learning involving students from University of Geneva Master of science in Global Health and research collaborations around specific and locally-relevant problems; (III) online mentoring and lecturing by experts from the Institute of Global Health of the University of Geneva in Kakuma. A total of 67 refugees applied to Module 1; 15 started the Module 1 in October 2017, of these 14 completed it and 6 passed the exams, finally five students started the Module 2 in October 2018 which they all passed in February 2019. Five student-led collaborative projects were developed focusing on the conception of a community-based monitoring system for prevalent diseases in the camp. With such a pedagogic approach, the programme provides an overview on Global Health challenges at the human-animal-ecosystem interface and the importance of the One Health approach, and introduces students to scientific research through interdisciplinary and international collaborations and innovation. The high number of applicants and positive feedback from students in Kakuma show the interest in One Health education in the camp. This learning experience ultimately aims at building local knowledge and capacity fostering "One Health" champions to reinforce local and national health system. This framework for One Health education could be potentially scaled up to other camps in Africa and the world.

Endocrine and Metabolic Manifestations of Snakebite Envenoming

Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.

SnakeMap: four years of experience with a national small animal snake envenomation registry

SnakeMap is a national cloud-based, veterinary snakebite registry. It was designed to prospectively collect data of the clinical circumstances and temporospatial information on cases of snake envenomation in dogs and cats. We herein introduce the project and summarise the data from the first 4 years of SnakeMap. The registry is a veterinary community-based online database allowing case entry from veterinary hospitals across Australia. Registry data comprise hospital characteristics, patient characteristics, envenoming snake type, treatment and outcome variables, including time and geolocation of the snake bite. We present summative information on select key variables from the SnakeMap registry (1 July 2015 to 30 June 2019). Twenty-eight hospitals from 6 states/territories entered 624 cases into the registry, including 419 dogs (67%) and 205 cats (33%). Bite time was available in 216 animals of which 90 (42%) were reported to be bitten in the 3 hours between 03:00 pm and 05:59 pm; median bite to presentation interval was 60 (interquartile range [IQR] 30, 211) minutes in dogs and 95 (IQR 41, 238) minutes in cats. Bites occurred in the owner's yard in 356 dogs (85%) and 53 cats (26%). A snake venom detection kit was used in 172 cases (28%) and antivenom was administered in 523 cases (85%). Most animals (n = 534, 88%) survived to discharge (median hospitalisation of 25 [IQR 16, 62] hours). SnakeMap effectively collects relevant clinical data from dogs and cats with presumed snake bite and provides locally specific information on the epidemiology of snake envenomation in small animals.

Snakebite envenoming from an Ecohealth perspective

Snakebite envenomings occur in complex ecological, social, economic, cultural, and political contexts. Hence, the understanding of this public health issue demands systemic and holistic approaches. Ecohealth constitutes a valuable paradigm to study snakebites, as it emphasizes on the close linkages between ecosystems, society, and health. This essay highlights some of the areas in the field of snakebite envenoming that could greatly benefit from an Ecohealth approach based on trans-disciplinary research, systems thinking, and the involvement of stakeholders at many levels. Ecohealth focuses not only on the generation of knowledge through research, but also in the translation of knowledge into actions.