Childhood Victims of Snakebites: 2000-2013

Case fatality rate and burden of snakebite envenoming in children - A systematic review and meta-analysis

Snakebite is a major public health problem with an estimated global burden of 5 million people per annum. Data on snakebite envenoming in children are very limited and is unclear whether there is a significant difference in severity between adults and children. We therefore conducted a meta-analysis of observational studies on snakebite in children to obtain a more precise estimate of case fatality rate (CFR) as well as to explore the differences in outcome between children and adults. Studies from all over the world reported until the end of February 2023 were included. Analysis was conducted consistent with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) criteria. Estimates were obtained from Random Effects Model (REM). Sub-analysis was conducted for studies from sub-Saharan Africa (SSA) to provide estimates for the continent. Adverse outcomes comprising composite endpoints (CE), defined as fatality and or complications, were compared between children and adults in sub-analysis of studies reporting on both groups. The annual burden and fatality of snakebite envenoming were derived based on lifetime prevalence of bite, meta-analysis estimates, and other data inputs. The pooled estimate of the CFR from 35 studies included worldwide was 1.98% [95%CI:1.38-2.58%] while the estimates from 6 studies within SSA was 2.43% (95%CI:0.67-4.20%). The odds of adverse outcomes were 2.52 times higher in children compared to adults. The estimated annual burden was 178,491 cases with 4346 deaths among children in SSA. These estimates compare favorably to those reported in the literature.

Exotic (non-native) snakebite envenomation in Japan: A review of the literature between 2000 and 2022

A limited number of studies have investigated the clinical characteristics of snakebite envenomation by exotic (non-native) snakes in Japan. This study reviewed the literature to determine the status and risk of bites by exotic pet snakes in Japan. We reviewed reports of snakebite due to exotic snakes in Japan published between 2000 and 2022, excluding reports of bites by snakes native to Japan, such as Gloydius blomhoffii, Rhabdophis tigrinus, and Protobothrops flavoviridis. During the study period, 11 exotic snakebites were recorded, involving 11 species. The majority of those bitten (10/11 cases) were male, all cases were hand injuries, and there were no fatalities. The snakes responsible belonged to the Colubridae (4/11 cases), Viperidae (4/11 cases), and Elapidae (3/11 cases) families. Cases of envenomation by G. brevicaudus, Bungarus candidus, and Dendroaspis angusticeps were of particular interest. Ten of the eleven patients developed local cytotoxic signs, and three developed "compartment syndrome," in which the surgeons performed decompressive incisions. Two bites from elapid snakes and one from a viperid snake resulted in respiratory failure. Antivenom was given in two cases. Complications were observed, such as acute kidney injury, rhabdomyolysis, coagulopathy, and residual dysfunction of the affected finger. Emergency rooms should be prepared to manage patients who have been bitten by exotic snakes, even though the number of reported cases is not high in Japan. Initial stabilization of patients is crucial, before a definitive diagnosis is made, as with native snakebite envenomation. Finger bites are reported in most cases, which may result in functional impairment of the fingers. In order to collect more comprehensive patient data in Japan, a reporting system for all snakebite envenomations should be considered.

Clinical Characteristics and Management of Snake Bite Injuries in the Jerusalem Area

Venomous snake bites can constitute medical emergencies, and without immediate care may be life-threatening. This study describes the characteristics and management of patients suffering from snake bite injuries (SNIs) in the Jerusalem area. A retrospective analysis of all patients who were admitted to the Hadassah Medical Center emergency departments (EDs) due to SNIs between 1 January 2004 and 31 March 2018 was conducted. During this period, 104 patients were diagnosed with SNIs, of whom 32 (30.7%) were children. Overall, 74 (71.1%) patients were treated with antivenom, 43 (41.3%) were admitted to intensive care units, and 9 (8.6%) required treatment with vasopressors. No mortality was recorded. On ED admission, none of the adult patients presented with an altered mental state compared to 15.6% of the children (p < 0.00001). Cardiovascular symptoms were observed in 18.8% and 5.5% of the children and adults, respectively. Fang marks appeared in all of the children. These findings underscore the severity of SNIs and the differences in clinical presentation between children and adults in the Jerusalem region.

Snakebite envenoming in Brazilian children: clinical aspects, management and outcomes

Snakebite envenoming is currently considered a neglected tropical disease, which affects over 5 million people worldwide, and causes almost 150 000 deaths every year, as well as severe injuries, amputations and other sequelae. Snakebite envenoming in children, although proportionally less frequent, is generally more severe, and represents an important challenge for pediatric medicine, since they often result in worse outcomes. In Brazil, given its ecological, geographic and socioeconomic characteristics, snakebites are considered an important health problem, presenting approximately 30 000 victims per year, approximately 15% of them in children. Even with low snakebite incidence, children tend to have higher snakebite severity and complications due to the small body mass and same venom volume inoculated in comparison to adults, even though, due to the lack of epidemiological information about pediatric snakebites and induced injuries, it is difficult to measure the treatment effectiveness, outcomes and quality of emergency medical services for snakebites in children. In this review, we report how Brazilian children are affected by snakebites, describing the characteristics of this affected population, clinical aspects, management, outcomes and main challenges.

Epidemiological and clinical features of hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in children

BACKGROUND

Bites by the hump-nosed pit vipers (HNPV) of the genus Hypnale are the commonest type of venomous snakebites in Sri Lanka. Their bites frequently cause local effects while rarely causing systemic envenoming, that may include acute kidney injury and coagulopathy. There are 3 species of genus Hypnale including H. hypnale, H. zara and H. nepa from which latter two are endemic to Sri Lanka. Virtually all studies on HNPV bites in Sri Lanka are focused on adults except two studies in paediatric group. The aims of this study were to describe the epidemiology and clinical manifestations of HNPV bites in a group of children admitted to a tertiary care hospital in Sri Lanka.

METHODOLOGY/PRINCIPAL FINDINGS

This was a prospective observational study carried out in Teaching Hospital Ratnapura, Sri Lanka over 27 months commencing from May 2020 including all children aged up to 14 years with the history of HNPV bites. There were 40 (56%) HNPV bites, of them 28 (70%) were males. The age was 84 months (50.2-120 months). Majority (n = 21;52.5%) were bitten during day-time (06:00-17:59) in home gardens (n = 20; 50%) on lower limbs (n = 24;60%). Most children (n = 30;75%) were admitted to the medical facility < 4 hours after the snakebite [90 min (40-210 min)] and the hospital stay was 4 days (3-5 days). Local envenoming was observed in 38 patients (95%) and systemic effects developed in 4 patients (10%) as mild coagulopathy. Local effects include local pain (n = 30; 94%), swelling (n = 38;95%), blistering (n = 11;27.5%), necrosis at the site of bite (n = 11; 27.5%), regional lymph node enlargement (n = 8;20%) and local bleeding (n = 4;10%). For the local effects, surgical interventions were needed in 10 children (25%) and 3 (7.5%) of them developed acute compartment syndrome leading to fasciotomy. Leucocytosis (n = 28;78%) and eosinophilia (n = 9;27%) were the prominent laboratory findings. All got recovered except in patients with fasciotomy who got permanent scar.

CONCLUSIONS/SIGNIFICANCE

Hump-nosed pit viper bites mostly cause local effects and rarely systemic envenoming in children. Compartment syndrome is common in children following their bites.

Bites by exotic snakes reported to the UK National Poisons Information Service 2009-2020

Introduction: Snakebite is recognised as a neglected tropical disease and a cause of substantial morbidity and mortality. Whilst the most medically important snakes are typically native of Asia, Africa, Latin America and Oceania, the possibility of encountering these snakes is no longer limited by geography due to an increasing number of exotic (non-native) snakes being held in captivity.Methods: A retrospective review of snakebite enquiries to the UK National Poisons Information Service (NPIS) between 2009 and 2020. Enquiries about the European adder (Vipera berus) or where the identity of the snake was unknown were excluded.Results: There were 321 exotic snakebites in 300 patients involving 68 different species during this period. Ten patients were bitten on more than one occasion. The majority of patients (64.5%) were male. Most bites were inflicted by snakes of the family Colubridae (184/321, 57.3%); seventeen bites resulted in moderate symptoms (predominantly swelling of the bitten limb). There were 30 (9.3%) bites by Viperidae and 14 (4.3%) bites by Elapidae. All severe cases (n = 15) resulted from bites by either Viperidae (n = 10) or Elapidae (n = 5). Antivenom was given in 17 cases. One fatality was recorded.Conclusions: Despite their low incidence, exotic snakebites present a substantial challenge for UK healthcare professionals. Although rare, these bites typically occur in individuals (usually male) who keep snakes as part of their occupation or hobby and are therefore at risk of multiple bites. Bites can result in venom hypersensitisation and the risk of venom-induced anaphylaxis. Rapid access to expert clinical advice is available in the UK on a 24-hour basis through the National Poisons Information Service and is strongly recommended in all cases of exotic snakebite.

Emergency Department Visits by Pediatric Patients for Snakebites

OBJECTIVES

Few studies have examined pediatric emergency department (ED) visits for snakebites. This study sought to examine characteristics of pediatric patients presenting to EDs nationally in the United States for snakebites.

METHODS

This retrospective cohort study obtained data from the Nationwide Emergency Department Sample for 2006 to 2014. Pediatric patients sustaining a snakebite were identified with International Classification of Diseases, Ninth Revision, E-codes E905.0 or E906.2. Data extracted included age, sex, insurance, disposition, hospital trauma designation, ED charges, and geographic region. Comparative analyses were performed for patients younger than 10 years and aged 10 to 17 years.

RESULTS

There were 24,388 ED visits from 2006 to 2014 by pediatric patients for snakebites: 10,554 were younger than 10 years, and 13,834 were aged 10 to 17 years. Males comprised 62% and 67% of the respective age cohorts. Most patients (younger than 10 years, 68%; aged 10-17 years, 63%) experienced snakebites in the South. Only 14% of those younger than 10 years and 10% of those aged 10 to 17 years were treated at a level 1 trauma center, whereas 50% and 54%, respectively, were treated at hospitals with no trauma designation. The majority of patients were discharged from the ED (younger than 10 years, 72%; aged 10-17 years, 80%). The mean ED charges for snakebite victims younger than 10 years were $5363 and for those aged 10 to 17 years were $4618. Medicaid was the primary insurer of younger patients, whereas private insurance was more common in older patients.

CONCLUSIONS

Most pediatric snakebites are seen in nontrauma centers and in the South region and are more commonly male. Most patients were discharged from the ED, with a small percentage being admitted or transferred to another facility.

Predictors of FabAV use in copperhead envenomation

CONTEXT

Crotaline snake envenomation is a serious medical condition affecting thousands of Americans each year. Variation in the treatment of Crotaline snakebites exists among physicians in the United States. Management of copperhead snakebites is controversial with some experts advocating minimal intervention, rarely necessitating antivenom use and, even more rarely, surgical intervention. This study assessed the use of Crotaline Polyvalent Immune Fab antivenom (Ovine) (FabAV) and explored factors influencing the decision to prescribe antivenom for copperhead envenomation in patients in Northeastern Oklahoma.

METHODS

A retrospective cohort study examining electronic medical records of patients with copperhead snakebites from July 1, 2014 to August 31, 2019. Data collected included: patient demographics, transfer information, snake species, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities, and treatment strategy. Associations between patient variables and treatment were evaluated using the chi-square test of independence, median test, and logistic regression analysis. Associations were statistically significant if p < 0.05.

DISCUSSION

Of the 130 patients bitten by a copperhead, a majority (75%) received FabAV. Symptoms of copperhead envenomation were mostly limited to the progression of tissue damage. Predictors of treatment with FabAV included progression of venom effects across major joints, younger age, comorbidities, and upper extremity bites.

CONCLUSIONS

Patients who have multiple comorbidities, upper extremity bites and progression of venom effects across major joints are more likely to be treated with FabAV. The high usage of FabAV at the study site underscores the need for continued work to optimize the use of antivenom for copperhead envenomations.

Snake bite associated with acute kidney injury

Acute kidney injury (AKI) is a well-known life-threatening systemic effect of snake envenomation which commonly happens secondary to snake bites from families of Viperidae and Elapidae. Enzymatic toxins in snake venom result in injuries to all kidney cell types including glomerular, tubulo-interstitial and kidney vasculature. Pathogenesis of kidney injury due to snake envenomation includes ischaemia secondary to decreased kidney blood flow caused by systemic bleeding and vascular leakage, proteolytic degradation of the glomerular basement membrane by snake venom metalloproteinases (SVMPs), deposition of microthrombi in the kidney microvasculature (thrombotic microangiopathy), direct cytotoxic action of venom, systemic myotoxicity (rhabdomyolysis) and accumulation of large amounts of myoglobin in kidney tubules. Clinical features of AKI include fatigue, loss of appetite, headache, nausea, vomiting, oliguria and anuria. Monitoring of blood pressure, fluid balance, serum creatinine, blood urea nitrogen and serum electrolytes is useful in managing AKI induced by snake envenomation. Early initiation of anti-snake venom and early diagnosis of AKI are always desirable. Biomarkers which will help in early prediction of AKI are being explored, and current studies suggest that urinary clusterin, urinary neutrophil gelatinase-associated lipocalin, and serum cystatin C may play an important clinical role in the future. Apart from fluid and electrolyte management, kidney support including early and prompt initiation of kidney replacement therapy when indicated forms the bedrock in managing snake bite-associated AKI. Long-term follow-up is important because of chances of progression towards CKD.

Practical Review of the Management of Animal Bites

Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans.

METHODS

A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist.

RESULTS

The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment.

CONCLUSIONS

Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.

Wilderness Medicine

With more families spending time outdoors or embarking on wilderness adventures, pediatricians may be tasked with providing appropriate counseling to parents and children. Although the breadth of wilderness medicine can be extensive, this article will focus on preventive measures, common injuries, and injury treatment options in an outdoor environment. [Pediatr Ann. 2021;50(6):e234-e239.].

Paediatric snakebite envenoming: the world's most neglected 'Neglected Tropical Disease'?

Snakebite disproportionally affects children living in impoverished rural communities. The WHO has recently reinstated snakebites on its list of Neglected Tropical Diseases and launched a comprehensive Strategy for the Prevention and Control of Snakebite Envenoming. In the first of a two paper series, we describe the epidemiology, socioeconomic impact and key prevention strategies. We also explore current challenges and priorities including the production and distribution of safe and effective antivenom.

Epidemiology of fatal snakebites in the United States 1989-2018

BACKGROUND

There are 5000-10,000 snake envenomations annually in the United States. Fortunately, few are fatal. In this study we review the epidemiology of fatal snakebites.

METHODS

Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018 were reviewed. Additional cases that were not reported to the AAPCC were identified by reviewing Wikipedia and by searching PubMed and online news outlets using various combinations of relevant keywords.

RESULTS

We identified 101 fatal bites from native snakes. Rattlesnakes accounted for 74 (90.2%) of the 82 deaths for which the species was known or which occurred where rattlesnakes are the only native crotalids. There were five fatalities attributed to copperheads, two due to cottonmouths, and one caused by an eastern coral snake. Males were disproportionately affected. The median age for victims was 40 years old. In cases for which data were available, many of the snake interactions were intentional, e.g. religious services, animal husbandry, and attempting to kill the snake.

CONCLUSIONS

Death following envenomation from a native U.S. snake is unlikely, particularly if medical attention is sought promptly. Rattlesnake envenomations are more likely to be fatal than bites from other species. Intentionally engaging with a venomous snake raises the risk of incurring a fatal bite, as does concurrent alcohol or drug use. Age less than 12 years old does not appear to be a risk factor for a fatal outcome, while elderly patients may have a slightly increased risk of death.

The "T's" of snakebite injury in the USA: fact or fiction?

Background

Venomous snakebites can result in serious morbidity and mortality. In the USA, the "T's of snakebites" (testosterone, teasing, touching, trucks, tattoos & toothless (poverTy), Texas, tequila, teenagers, and tanks) originate from anecdotes used to colloquially highlight venomous snakebite risk factors. We performed an epidemiologic assessment of venomous snakebites in the USA with the objective of evaluating the validity of the "T's of snakebites" at a national level.

Methods

We performed a retrospective analysis of the National Emergency Department Sample. Data from January 1, 2016 to December 31, 2016 were obtained. All emergency department (ED) encounters corresponding to a venomous snakebite injury were identified using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Primary outcomes were mortality and inpatient admission. Demographic, injury, and hospital characteristics were assessed. Data were analyzed according to survey methodology. Weighted values are reported.

Results

In 2016, 11 138 patients presented to an ED with a venomous snakebite. There were 4173 (37%) persons aged 18 to 44, and 7213 (65%) were male. Most snakebites were reported from the South (n=9079; 82%), although snakebites were reported from every region in the USA. Only 3792 (34%) snakebites occurred in rural counties. Persons in the lowest income quartile by zip code were the most heavily represented (n=4337; 39%). The most common site of injury was the distal upper extremity (n=4884; 44%). Multivariate analysis revealed that species of snake (OR=0.81; 95% CI 0.73 to 0.88) and older age (OR=1.42; 95% CI 1.08 to 1.87) were associated with hospital admission. There were <10 inpatient deaths identified, and no variables were predictive of death.

Discussion

Some of the "T's of snakebites" may be valid colloquial predictors of the risk for venomous snakebites. Based on national data, common demographics of venomous snakebite victims include lower income, Caucasian, and adult men in the South who are bit on the upper extremity. Understanding common demographics of venomous snakebite victims can effectuate targeted public health prevention messaging.

Level of evidence

IV.

Adverse Events in the Efficacy of Crotalidae Polyvalent Immune Fab Antivenom vs Placebo in Recovery from Copperhead Snakebite Trial

OBJECTIVE

To compare the incidence of hypersensitivity reactions following copperhead envenomation treated with Fab antivenom (FabAV) or placebo.

METHODS

Patients with copperhead snakebites received treatment and follow-up in a prospective, randomized, double-blind, placebo-controlled trial of FabAV or placebo. The treatment allocation ratio was 2:1 (FabAV:placebo). All of the included patients received at least one dose of study treatment. We reviewed all treatment-emergent adverse events (AEs) using a previously published scale to classify likely hypersensitivity reactions as mild, moderate, or severe.

RESULTS

We enrolled 74 patients at 13 sites. Forty-five patients received FabAV, and 29 patients received placebo. Five FabAV patients and 4 placebo patients had moderate envenomations; the rest were mild. Twenty-five FabAV patients and 8 placebo patients had at least 1 AE. Mild skin reactions occurred in 11 (24%) FabAV patients (pruritis, urticaria, rash, ecchymosis, erythema) and 1 (3%) placebo patient (pruritis). Moderate gastrointestinal AEs occurred in 7 (16%) FabAV patients (nausea, vomiting, constipation, diarrhea, oral paresthesia) and in 2 (7%) placebo patients (nausea). Respiratory AEs occurred in 3 (7%) FabAV patients (dyspnea, pulmonary embolism, nasal congestion, sneezing) and no placebo patients. Hypotension occurred in 1 patient in each group.

CONCLUSIONS

In a randomized controlled trial of FabAV for copperhead bites, the incidence of hypersensitivity reactions was low. Most reactions were mild skin reactions.

Snakebites Treated in North Carolina Emergency Departments, October 2013-September 2015

INTRODUCTION

North Carolina (NC) is home to more than 30 species of indigenous venomous and nonvenomous snakes. Snakebites can cause debilitating and potentially fatal injuries. However, there is a lack of current information available describing the incidence of snakebites in NC. Therefore, we performed this study of snakebites treated in NC emergency departments (EDs) using the statewide syndromic surveillance system, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT).

METHODS

This was a descriptive epidemiologic study characterizing NC ED visits collected by NC DETECT between October 1, 2013 and September 30, 2015 with an assigned International Classification of Diseases, 9th Revision, Clinical Modification code or keyword indicating a snakebite.

RESULTS

Over the 2-year period, the absolute count of snakebite-related ED visits was 2080 visits with an incidence rate of 10.4 visits per 100 000 person-years (95% confidence interval: 10.0-10.9). The frequency of snakebite was highest during the summer months and evening hours. Men had higher incidence rates of snakebite-related ED visits than women, and residents of the Coastal Plain geographic region of NC had higher incidence rates than persons in other regions.

CONCLUSIONS

The current study indicated that snakebites are common injuries treated at NC EDs, with a strong seasonal and geographic component. Additional research is needed to further characterize the circumstances associated with snakebites for the development of preventive measures and public health education.

Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites

OBJECTIVES

Published reports have suggested that the concurrent use of alcohol or drugs occurs among some snakebite victims, but no national assessment of such data exists.

METHODS

We used data from US poison control centers collected during telephone calls in calendar years 2000-2013 to compare snake envenomations with concomitant use of drugs, alcohol, or both to snakebites lacking such use.

RESULTS

A total of 608 snakebites with 659 instances of concomitant alcohol/drug use were reported, which represent approximately 1% of 92,751 snakebites reported to US poison control centers. An annual mean of 48 snakebites with concomitant use of alcohol/drugs was reported, compared with a mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most cases involved men, peaked during the summer months, and involved copperheads or rattlesnakes, which mirrored overall trends. Snakebite victims who also used alcohol/drugs were more likely than victims with only a snakebite reported to be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was the most common reported concomitant substance, but other substances were reported.

CONCLUSIONS

Snakebites with concomitant use of alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite envenomations reported annually to US poison control centers; however, snakebite victims also reporting alcohol/drug use are more likely to be bitten by rattlesnakes, be admitted to a healthcare facility, and die.