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A man in his thirties presented following Bitis nasicornis envenoming. His coagulation was assessed using rotational thromboelastometry (ROTEM). It identified a subtle abnormality, not detected using standard laboratory assessments of coagulation, and influenced ongoing management. The abnormality resolved following treatment with antivenom. There are few documented cases of using ROTEM to assess patients following haemotoxic envenoming. This case highlights some of the potential benefits and limitations of doing so.

There is a paucity of robust epidemiological data on snakebite, and data available from hospitals and localized or time-limited surveys have major limitations. No study has investigated the incidence of snakebite across a whole country. We undertook a community-based national survey and model based geostatistics to determine incidence, envenoming, mortality and geographical pattern of snakebite in Sri Lanka. The survey was designed to sample a population distributed equally among the nine provinces of the country. The number of data collection clusters was divided among districts in proportion to their population. Within districts clusters were randomly selected. Population based incidence of snakebite and significant envenoming were estimated. Model-based geostatistics was used to develop snakebite risk maps for Sri Lanka. 1118 of the total of 14022 GN divisions with a population of 165665 (0.8%of the country's population) were surveyed. The crude overall community incidence of snakebite, envenoming and mortality were 398 (95% CI: 356-441), 151 (130-173) and 2.3 (0.2-4.4) per 100000 population, respectively. Risk maps showed wide variation in incidence within the country, and snakebite hotspots and cold spots were determined by considering the probability of exceeding the national incidence. This study provides community based incidence rates of snakebite and envenoming for Sri Lanka. The within-country spatial variation of bites can inform healthcare decision making and highlights the limitations associated with estimates of incidence from hospital data or localized surveys. Our methods are replicable, and these models can be adapted to other geographic regions after re-estimating spatial covariance parameters for the particular region.

Snakebite causes more than 1.8 million envenoming cases annually and is a major cause of death in the tropics especially for poor farmers. While both social and ecological factors influence the chance encounter between snakes and people, the spatio-temporal processes underlying snakebites remain poorly explored. Previous research has focused on statistical correlates between snakebites and ecological, sociological, or environmental factors, but the human and snake behavioral patterns that drive the spatio-temporal process have not yet been integrated into a single model. Here we use a bottom-up simulation approach using agent-based modelling (ABM) parameterized with datasets from Sri Lanka, a snakebite hotspot, to characterise the mechanisms of snakebite and identify risk factors. Spatio-temporal dynamics of snakebite risks are examined through the model incorporating six snake species and three farmer types (rice, tea, and rubber). We find that snakebites are mainly climatically driven, but the risks also depend on farmer types due to working schedules as well as species present in landscapes. Snake species are differentiated by both distribution and by habitat preference, and farmers are differentiated by working patterns that are climatically driven, and the combination of these factors leads to unique encounter rates for different landcover types as well as locations. Validation using epidemiological studies demonstrated that our model can explain observed patterns, including temporal patterns of snakebite incidence, and relative contribution of bites by each snake species. Our predictions can be used to generate hypotheses and inform future studies and decision makers. Additionally, our model is transferable to other locations with high snakebite burden as well.

Open tibia fractures result in substantial lifelong disability for patients, and are expensive to treat. As the injury typically affects young working men, the societal costs from open tibia fractures are likely to also be high in low income countries, but remain largely unknown. We therefore investigated the overall societal costs and cost-effectiveness of different orthopaedic treatments at one year following an open tibia fracture in Malawi. This study was a cost-utility analysis nested in a prospective cohort study from the healthcare- and societal-payer perspectives with a one-year time horizon. We obtained quality-adjusted life years (QALYs) from the EuroQoL 5 Dimension 3 Level (EQ-5D-3L) and patient lost productivity estimates at 6 weeks, and 3, 6, and 12 months post-injury. QALYs were calculated from utility scores were modelled within a hierarchical Bayesian multivariate modelling framework that jointly estimated individual-level trajectories in EQ-5D-3L scores and costs over follow-up. Direct treatment costs were obtained from a micro-costing study, and staff interviews at tertiary and district hospitals. Cost-effectiveness was reported in terms of societal cost per quality-adjusted life year (QALY). All costs were reported in 2021 United States dollars (USD). Between February 2021 and March 2022, 287 participants with open tibia fractures were included. There were substantial costs to participants one year following injury with 42% (n = 112) working with a median monthly household income of US$40 (IQR: US$7-90) compared to 89% (n = 255) working pre-injury, with a median monthly household income of US$60 (IQR: US$36-144). The posterior median of societal costs at one year varied between US$751 (80% credible intervals [CrIs]: US$-751-2,389) for treatment with plaster of Paris (POP) in a district hospital for a Gustilo III injury, to US$2,428 (80% CrIs: US$995-5027) for intramedullary nail in central hospital for a Gustilo III injury. The largest cost-effectiveness from a societal perspective was between an intramedullary nail and amputation for a Gustilo III injury with a posterior mean of US$2,290 (95%HDI: 36-4,547) per QALY. The main finding was that open tibia fractures result in significant costs to patients, the healthcare system and society in Malawi. Although the funding of orthopaedic treatment can be difficult in countries with very limited healthcare budgets, the costs to society of ignoring this issue are very high. A re-balancing of health budgets (including from government and donors) is needed to prioritise trauma care to reduce the growing societal economic burden from injury.

Health outcomes and causality are usually assessed with individual level sociodemographic variables. Studies that consider only individual-level variables can suffer from residual confounding. This can result in individual variables that are unrelated to risk behaving as proxies for uncaptured information. There is a scarcity of literature on risk factors for snakebite. In this study, we evaluate the individual-level risk factors of snakebite in Sri Lanka and highlight the impact of spatial confounding on determining the individual-level risk effects. Data was obtained from the National Snakebite Survey of Sri Lanka. This was an Island-wide community-based survey. The survey sampled 165,665 individuals from all 25 districts of the country. We used generalized linear models to identify individual-level factors that contribute to an individual's risk of experiencing a snakebite event. We fitted separate models to assess risk factors with and without considering spatial variation in snakebite incidence in the country. Both spatially adjusted and non-adjusted models revealed that middle-aged people, males, field workers and individuals with low level of education have high risk of snakebites. The model without spatial adjustment showed an interaction between ethnicity and income levels. When the model included a spatial adjustment for the overall snakebite incidence, this interaction disappeared and income level appeared as an independent risk factor. Both models showed similar effect sizes for gender and age. HEmployment and education showed lower effect sizes in the spatially adjusted model. Both individual-level characteristics and local snakebite incidence are important to determine snakebite risk at a given location. Individual level variables could act as proxies for underling residual spatial variation when environmental information is not considered. This can lead to misinterpretation of risk factors and biased estimates of effect sizes. Both individual-level and environmental variables are important in assessing causality in epidemiological studies.

Sri Lanka has a population of 21 million and about 80,000 snakebites occur annually. However, there are limited data on health seeking behavior following bites. We investigated the effects of snakebite and envenoming on health seeking behavior in Sri Lanka. In a community-based island-wide survey conducted in Sri Lanka 44,136 households were sampled using a multistage cluster sampling method. An individual who reported experiencing a snakebite within the preceding 12 months was considered a case. An interviewer-administered questionnaire was used to obtain details of the bite and health seeking behavior among cases. Among 165,665 individuals surveyed, there were 695 snakebite victims. 682 (98.1%) had sought health care after the bite; 381 (54.8%) sought allopathic treatment and 301 (43.3%) sought traditional treatment. 323 (46.5%) had evidence of probable envenoming, among them 227 (70.3%) sought allopathic treatment, 94 (29.1%) sought traditional treatment and 2 did not seek treatment. There was wide geographic variation in the proportion of seeking allopathic treatment from <20% in the Western province to > 90% in the Northern province. Multiple logistic regression analysis showed that seeking allopathic treatment was independently associated with being systemically envenomed (Odds Ratio = 1.99, 95% CI: 1.36-2.90, P < 0.001), distance to the healthcare facility (OR = 1.13 per kilometer, 95% CI: 1.09 to 1.17, P < 0.001), time duration from the bite (OR = 0.49 per day, 95% CI: 0.29-0.74, P = 0.002), and the local incidence of envenoming (OR = 1.31 for each 50 per 100,000, 95% CI: 1.19-1.46, P < 0.001) and snakebite (OR = 0.90 for each 50 per 100,000, 95% CI: 0.85-0.94, P < 0.001) in the relevant geographic area. In Sri Lanka, both allopathic and traditional treatments are sought following snakebite. The presence of probable envenoming was a major contribution to seeking allopathic treatment.

Snakebite incidence shows both spatial and temporal variation. However, no study has evaluated spatiotemporal patterns of snakebites across a country or region in detail. We used a nationally representative population sample to evaluate spatiotemporal patterns of snakebite in Sri Lanka. We conducted a community-based cross-sectional survey representing all nine provinces of Sri Lanka. We interviewed 165 665 people (0.8% of the national population), and snakebite events reported by the respondents were recorded. Sri Lanka is an agricultural country; its central, southern and western parts receive rain mainly from Southwest monsoon (May to September) and northern and eastern parts receive rain mainly from Northeast monsoon (November to February). We developed spatiotemporal models using multivariate Poisson process modelling to explain monthly snakebite and envenoming incidences in the country. These models were developed at the provincial level to explain local spatiotemporal patterns. Snakebites and envenomings showed clear spatiotemporal patterns. Snakebite hotspots were found in North-Central, North-West, South-West and Eastern Sri Lanka. They exhibited biannual seasonal patterns except in South-Western inlands, which showed triannual seasonality. Envenoming hotspots were confined to North-Central, East and South-West parts of the country. Hotspots in North-Central regions showed triannual seasonal patterns and South-West regions had annual patterns. Hotspots remained persistent throughout the year in Eastern regions. The overall monthly snakebite and envenoming incidences in Sri Lanka were 39 (95%CI: 38-40) and 19 (95%CI: 13-30) per 100 000, respectively, translating into 110 000 (95%CI: 107 500-112 500) snakebites and 45 000 (95%CI: 32 000-73 000) envenomings in a calendar year. This study provides information on community-based monthly incidence of snakebites and envenomings over the whole country. Thus, it provides useful insights into healthcare decision-making, such as, prioritizing locations to establish specialized centres for snakebite management and allocating resources based on risk assessments which take into account both location and season.

Snakebite envenoming is among the top five emergency health conditions in northern Ghana. Among the four genera of snake species classified to be of highest medical importance, species with haemotoxic venom are responsible for about 90% of all snakebite case presentations in the region. However, there is a dearth of clinical data on signs and symptoms of envenoming, treatment practices and health outcomes. We examined the signs and symptoms of envenoming and clinical management practices at referral hospitals in northern Ghana. Medical records of patients reporting on account of snakebite between 2016 and 2020 at the Wa Municipal Hospital in the Upper West region and the Baptist Medical Centre in the North East region of Ghana were reviewed. Demographic characteristics, patients' clinical data and management practices were analysed and evaluated taking into consideration the national standard treatment guideline. A total of 2,684 records of patients reporting on account of snakebite were accessed at both health facilities over the five-year period. 91% of the patients were admitted to the ward. Swelling, severe pain and bleeding were the most common clinical signs upon presentation. A total of 1,670 (64.7%) of all the patients tested had at least one abnormal blood clotting result suggesting haemotoxicity. Antivenom was administered to 84.3% of the patients. Antibiotics were administered to 70.5% with amoxicillin with clavulanic acid, flucloxacillin and metronidazole accounting for 59.2% of all antibiotics administered. The recorded case-fatality rate was 1.9%. The annual hospital attendance rate on account of snakebite to the Wa Municipal Hospital and the Baptist Medical Centre is estimated at 55 persons per 100,000 population per year. Mortality was low, with antivenom available to most of the patients. More evidence is needed on the indication and dosing of antivenom and to improve appropriate ancillary care.