Ymkje Stienstra

Background: Snake envenoming (SE) remains an important public health problem, disproportionately affecting impoverished rural communities in tropical and subtropical regions. Although previous attempts have been made to quantify the global burden of SE, accurate, up-to-date data remain scarce. Here we present a comprehensive re-evaluation of the global burden of snakebite, 17 years after our initial estimate. Methods and findings: A new literature review was conducted on snakebites, SE and mortality published in any language, up to March 31, 2025, to update the knowledge accumulated since our first global burden estimate. Based on country- and region-level aggregated data, and hospital and community-based survey data, we modelled SE and mortality burden in relation to geographic location. Explanatory variables were selected to reflect the underlying social and natural environmental conditions. Low and high estimates of the global snakebite burden were calculated using geostatistical models that produced individual-country estimates, accounting for possible underreporting of data when appropriate. We estimate that at least 2.1 million envenomings and 274,000 deaths occur globally each year due to snakebites, and our high estimates suggest up to 7 million envenomings and 513,000 deaths annually. Low-income countries exhibit the highest incidence and mortality rates, with sub-Saharan Africa accounting for 45% of global envenomings and deaths, nearly three times the incidence observed in South Asia. These estimates suggest that previous burden estimates could substantially underestimate the scale of the problem. The main limitations of this study are the scarcity and heterogeneity of empirical data in many countries and the reliance on modelling assumptions to estimate burden in settings with limited or no direct observations. Conclusions: Snake envenoming is a significant cause of morbidity and mortality globally, with sub-Saharan Africa, South Asia, and Southeast Asia being the most severely affected regions. Further improvement in the quality of epidemiological data is required for more accurate estimates of the global burden, particularly in sub-Saharan Africa.

Introduction: Snakebite envenoming is a neglected tropical disease (NTD) of public health concern in Kenya. Its true burden remains elusive with an over-reliance on health facility-based data and geographically limited community surveys. This study aimed to generate data on snakebite burden in Kenyan communities and to capture the variation in incidence rate across the country by integrating snakebite incidence questions into nationwide Mass Drug Administration (MDA) campaigns for other NTDs. Methods: A cross-sectional community survey was conducted, nested within MDA campaigns targeting trachoma, schistosomiasis and soil transmitted helminths. Data collection spanned from July 2022 to August 2023. Incidence rates per 100,000 person-years were calculated, and correlation between snakebite incidence and population density was assessed. Community survey data were compared to the reported snakebite cases in health facilities by the Kenya Health Information System (KHIS). Results: A total of 13,117,754 individuals from 17 counties participated in the MDA surveys, representing 27.6% of Kenya’s total population. Across these counties, 4,667 snakebite cases were reported over the previous year, with a slightly higher incidence rate among males (39.3 cases per 100,000 inhabitants) compared to females (32.2 cases per 100,000 inhabitants). County-level incidence rates varied, with Turkana County reporting the highest incidence rate (412.9 cases per 100,000 inhabitants) and Vihiga County recording the lowest (3.7 cases per 100,000 inhabitants). Discrepancies existed between health facility attendance reported by community members and numbers reported by KHIS. Conclusion: Integration of snakebite data collection with MDA campaigns allowed rapid and highly cost-effective data capture from a quarter of Kenya’s population. The community data demonstrated considerable variation in incidence rates and discrepancies with hospital-based data. This informs resource allocation for treatment and prevention and emphasizes the need for robust integrated approaches to assess the burden of snakebite envenoming both in health facilities and communities.

: In Eswatini, bites from snakes with cytotoxic venoms inflict substantial morbidity on humans through blistering, swelling, and tissue necrosis. Despite its widespread use, there is little evidence regarding the efficacy of antivenom in preventing snakebite-induced tissue damage. We conducted a prospective observational study in nine hospitals in Eswatini to describe and quantify symptoms of local tissue toxicity. Our secondary aim was to examine the use of antivenom. Data from 125 snakebite patients with extensive or rapidly progressive swelling were analyzed. The median increase in circumference of envenomed limbs was 12%. Necrosis developed in 31 (25%) patients, primarily in distal extremities. Seventy patients (56%) received South African Institute for Medical Research (SAIMR) Polyvalent antivenom (South African Vaccine producers, Johannesburg South Africa), which was administered for indications related to local tissue damage. Upon hospital presentation, patients treated with antivenom exhibited slightly more severe swelling. Ten out of 11 patients with necrosis upon admission received antivenom. At least seven patients developed necrosis after admission despite previous antivenom therapy. In this nonrandomized observational study, no relationship was observed between the rate at which swelling receded and antivenom treatment. Adverse reactions to antivenom occurred in 49% of patients. Although our analysis has its limitations, it emphasizes the compelling need for research into the indications for and outcomes of antivenom treatment for local tissue damage.

Clarithromycin extended-release (CLA-ER) was used as companion drug to rifampicin (RIF) for Mycobacterium ulcerans infection in the intervention arm of a WHO drug trial. RIF enhances CYP3A4 metabolism, thereby reducing CLA serum concentrations, and RIF concentrations might be increased by CLA co-administration. We studied the pharmacokinetics of CLA-ER at a daily dose of 15 mg/kg combined with RIF at a dose of 10 mg/kg in a subset of trial participants, and compared these to previously obtained pharmacokinetic data. Serial dried blood spot samples were obtained over a period of ten hours, and analyzed by LC–MS/MS in 30 study participants—20 in the RIF-CLA study arm, and 10 in the RIF-streptomycin study arm. Median CLA C_max was 0.4 mg/L—and median AUC 3.9 mg*h/L, following 15 mg/kg CLA-ER. Compared to standard CLA dosed at 7.5 mg/kg previously, CLA-ER resulted in a non-significant 58% decrease in C_max and a non-significant 30% increase in AUC. CLA co-administration did not alter RIF C_max or AUC. Treatment was successful in all study participants. No effect of CLA co-administration on RIF pharmacokinetics was observed. Based on our serum concentration studies, the benefits CLA-ER over CLA immediate release are unclear.

Background: Tuberculosis (TB), and especially its drug resistant forms, is responsible for not only significant mortality, but also considerable morbidity, still under‐quantified. This study used four Patient‐Reported Outcome Measures (PROMS) to assess the status of persons affected by drug‐susceptible and drug‐resistant TB during their TB treatment or after treatment completion, in Romania, the highest TB burden country in the EU.Methods: People affected by TB in two different regions in Romania were included during and after treatment, following a cross‐sectional design. PROMs used were SF‐36, EQ‐5D‐5L, WPAI and the app‐based audiometry screening tool ‘uHear.’ Descriptive statistics and relevant statistical tests were used to compare groups between themselves and with the general Romanian population.Results: Both patients with drug‐susceptible and drug‐resistant TB experience, with drug‐resistant patients experiencing statistically significantly more pain and hearing loss. PROMs show some improvement in the after‐treatment group; however, compared with the general Romanian population for which data were available, all groups scored lower on all outcome measures.Conclusion: PROMs offer the possibility of obtaining a more comprehensive view of patients' status, by involving them directly in the medical process and could guide a rehabilitation strategy.

Snakebite envenoming is a debilitating neglected tropical disease disproportionately affecting the rural poor in low and middle-income countries in the tropics and sub-tropics. Critical questions and gaps in public health and policy need to be addressed if major progress is to be made towards reducing the negative impact of snakebite, particularly in the World Health Organisation (WHO) Africa region. We engaged key stakeholders to identify barriers to evidence-based snakebite decision making and to explore how development of research and policy hubs could help to overcome these barriers. We conducted an electronic survey among 73 stakeholders from ministries of health, health facilities, academia and non-governmental organizations from 15 countries in the WHO Africa region. The primary barriers to snakebite research and subsequent policy translation were limited funds, lack of relevant data, and lack of interest from policy makers. Adequate funding commitment, strong political will, building expert networks and a demand for scientific evidence were all considered potential factors that could facilitate snakebite research. Participants rated availability of antivenoms, research skills training and disease surveillance as key research priorities. All participants indicated interest in the development of research and policy hubs and 78% indicated their organization would be willing to actively participate. In conclusion, our survey affirms that relevant stakeholders in the field of snakebite perceive research and policy hubs as a promising development, which could help overcome the barriers to pursuing the WHO goals and targets for reducing the burden of snakebite.

Background: Migrants in low tuberculosis (TB) incidence countries in the European Union (EU)/European Economic Area (EEA) are an at-risk group for latent tuberculosis infection (LTBI) and are increasingly included in LTBI screening programmes. Aim: To investigate current approaches and implement LTBI screening in recently arrived migrants in the EU/EEA and Switzerland. Methods: At least one TB expert working at a national level from the EU/EEA and one TB expert from Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: Experts from 32 countries were invited to participate (30 countries responded): 15 experts reported an LTBI screening programme targeting migrants in their country; five reported plans to implement one in the near future; and 10 reported having no programme. LTBI screening was predominantly for asylum seekers (n = 12) and refugees (n = 11). Twelve countries use 'country of origin' as the main eligibility criteria. The countries took similar approaches to diagnosis and treatment but different approaches to follow-up. Six experts reported that drop-out rates in migrants were higher compared with non-migrant groups. Most of the experts (n = 22) called for a renewed focus on expanding efforts to screen for LTBI in migrants arriving in low-incidence countries. Conclusion: We found a range of approaches to LTBI screening of migrants in the EU/EEA and Switzerland. Findings suggest a renewed focus is needed to expand and strengthen efforts to meaningfully include migrants in these programmes, in order to meet regional and global elimination targets for TB.