News Media Coverage of Snakebite Incidence in Nepal during 2010–2022

Introduction

Snakebite, a neglected tropical disease [1], causes 1.8 to 2.7 million envenomings [2, 3] and 81,000 to 138,000 human deaths annually worldwide [4]. This has significant social and economic impacts in South Asia [2], particularly in India and Pakistan [5] from where remarkably high incidence of snakebite envenomings and deaths are reported. Similar impact can be expected in Nepal where about 20,000 to 37,661 people are bitten by snakes resulting in 1,000 to 3,225 deaths annually [6, 7]. However, there is an epidemiological knowledge gap due to inconsistent and incomplete hospital-based records of admitted snakebite cases [8, 9] and limitations of recently accomplished community-based snakebite studies [10]. While designing the cross-sectional survey in the 23 districts of terai region of Nepal [7], investigators excluded towns and cities from where snakebite envenomings and deaths are frequently reported [11, 12, 13, 14]. This exclusion of agrarian urban areas might distort estimation of the envenoming and mortality rate. Further, the findings from inadequately designed study could not represent the snakebites in the tropical and agrarian terai of Nepal. For the appropriate extrapolations signifying the representativeness of the snakebite burden in Nepal, the news media reported snakebite incidences can provide useful information required to evaluate the epidemiological situation in study areas and design more appropriate epidemiological studies of snakebites across terai, hills, and mountains of Nepal. In Nepal, at least 863 media publish news regularly mainly in Nepali, followed by English and indigenous languages [15]. Although the first print news media “Gorkhapatra” was published in 1858 [16], the online news media coverage of snakebite incidences have been rapidly increased nationwide, particularly after the reinstatement of multiparty democracy in 1990 [17]. Therefore, properly analyzed media-based information can be a cost-effective approach to understand the epidemiological situation in snakebite prone areas and determine the snakebite burden more reliably than the previous comprehensive studies.

Assessing news media-reported snakebite incidence can be a new approach for examining the burden of snakebites and envenomings in different provinces and districts where healthcare facilities are inadequate, although this approach has many advantages and some limitations [14, 18]. Since data from news media are typically available in near real-time and provide earlier estimates of epidemic issues [19], the trend of snakebite envenomings can be understood readily and cost- effectively by analyzing media-reported snakebites.

In Nepal, several communities [7, 20] and hospital- based studies Pandey DP, et al. [12, 21] provided snakebite incidence over less than two years. They did not depict annual variations in snakebites. Next, news media-based analyses included out-of-hospital cases and deaths that do not appear in a hospital-based data set [14] as well as snakebite incidence from urban to rural areas of Nepal [14]. However, there has yet to be an analysis of media-reported snakebite incidences in provinces and districts of this country.

Herein, we analyzed media-reported incidences of snakebites that occurred in Nepal during 13 years to know whether supra-annual variations in incidence of envenoming and deaths exist in this country, determine the prevalence of snakebite envenomings across the districts, provinces, climatic zones, and along the altitudinal gradients, and compare incidences of snakebites, envenomings, and deaths with the most updated reports of Nepal Government. Further, we aimed to determine the size of the population at risk of envenomings and associated deaths. Also, we aimed to know any association between snakebite envenomings and human population density in the snakebite prone districts of Nepal. Therefore, findings from this study can be used to make snakebite envenoming a serious issue in Nepal.

Results

A total of 43,482 snakebites were reported in 296 news articles published by 107 news media (Figure 3) during 2010 to 2022. This incidence was reported from across the terai, the hills, and the mountains (Figures 1 & 2) representing 53 districts, 36 STCs, eight hospitals (where antivenom supply was unclear), and four NPOs and across the altitudinal ranges from 62–2870 m asl [median: 174, CI: 178–214, IQR: 110–273 (Figure 4)] covering all provinces, all former development regions, including rural municipalities (i.e., rural areas) and municipalities (i.e., towns, cities, and suburb areas ).

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Only 11% (n = 4,593) of the total snakebites were envenomed (Figure 3). The majority of these envenomings occurred in Nepal’s lowlands (Figure 2). These envenomed cases represented 50 districts, 27 STCs, three hospitals (where the supply of antivenom was unclear), and four NPOs. These envenomings occurred across the altitudinal ranges from 62–2870 m asl [median: 179, CI: 185–245, IQR: 107–312 (Figures 3 & 4), with the highest incidence of envenomings in Jhapa (n = 225), followed by Dang (n = 63), Kanchanpur (n = 62), Saptari and Mahottari (n = 39 each), Taplejung and Rautahat (n = 23 each), Banke (n = 20), Sindhuli (n = 15), Baitadi (n = 13), Kailali, Morang, and Udayapur (n = 12 each) (Table 1).

Among the reported envenomed cases, 695 snakebite deaths represented 43 districts, 19 STCs, and four NPOs. These envenomings occurred across the altitudinal ranges from 62–2866 m asl [median: 182, CI: 190–325, IQR: 110– 479 (Figures 3 & 4, Table 1), with the highest incidence of deaths reported from Dang (n = 59), followed by Kanchanpur (n = 57), Mahottari (n = 28), Jhapa (n = 24), Saptari (n = 22), Taplejung (n = 20), Baitadi and Udayapur (n = 12 each), and Rautahat (n = 11) (Table 1). The overall case fatality rate (CFR) was 15%.

We conjectured that at least 10,339 snakebites cause 2,113 envenomings and 101 deaths annually in Nepal (Table 2). The news media and Nepal Government sources did not differ regarding annual envenoming rates (AER, p-value = 0.287) and annual incidences of snakebite deaths (AISD, p-value = 0.926). However, they did differ in case fatality rate (CFR, p-value = 0.001) and annual incidence of envenomings (AIE, p-value = <0.0001, Table 2). Further, line graphs Figure 5 showed distinct yearly variations in incidences of snakebite envenomings and deaths in Nepal. Next, snakebite envenomings were weakly positively associated with human population density in Nepal (rho = 0.304, p-value = 0.032).

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Discussion

This comprehensive epidemiological study of Nepalese snakebite envenomings mentioned in news media provided a representative/comparable sample of all envenomings in Nepal (p-values for: AER = 0.287; AISD = 0.926). However, we found slightly greater annual CFR and AIE than the corresponding CFR and AIE reported by Nepal Government (Table 2). This could occur due to the high priority of journalists to expose envenomed and dead cases known from healthcare institutions as well as communities to the public. The government’s national database was based on hospitals where medical record systems were poor [9] or inadequate [25]. This epidemiological study is the most comprehensive because it illustrated incidences of Nepalese snakebite envenomings known for 13 years in the terai, hills, and mountains, representing all provinces, 50 districts and 27 STCs and highlighted deaths representing 43 districts and 19 STCs (Table 1, Figures 2 & 3). Next comprehensive study of 308 news media reported case reports with substantial information of envenomings also found similar influence of venomous snakebites in the terai, hills, and mountains, representing all provinces and 48 districts [14]. By analyzing the 308 envenomated case reports, Pandey and Thapa found snakebite fatalities from 43 districts [14] similar to this comprehensive analysis of snakebite incidence obtained from similar sources (Figure 3). But, other studies described the situations of snakebite envenomings and associated deaths from a maximum of 23 districts [7] or 15 district hospitals [6]. The altitudinal distribution of snakebite envenoming in our study was comparable to those reported in study of 308 news media reported envenomed case reports representing 48 districts of Nepal [14]. Although terai extending in between 60 m and 200 m asl (Figures 1, 2 & 4) is at the highest risk of envenoming and associated deaths, the districts located in the hills and mountains are also affected from snakebite-related fatalities perceptibly (Figures 1 & 2, Tables 1). In addition to the 23 districts of the terai region of Nepal [7] people inhabiting 20 other districts [Taplejung (n = 20 deaths), Baitadi (n = 12), Salyan (n = 7), Pyuthan (n = 6), Doti (n = 5), Achham (n = 4), Ilam (n = 4), Humla (n = 3), Bajhang, Dailekh, Palpa, and Sindhuli (2 deaths in each districts), Baglung, Dhadhing, Kathmandu, Lamjung, Parbat, Rasuwa, Rolpa, and Syangja (1 each)] were also affected by snakebite deaths (n = 77) frequently. Unlike the findings of seven snakebites and one death from Makawanpur District from November 2017 to April 2019 in a community survey [7], we found only one envenomed case. However, scores of envenomings and deaths in the top five districts Table 1 correspond to the report of incidence from the respective districts identified by Alcoba et al. [7]. However, around 85% of the national population is noticeably vulnerable to snakebite envenomings and at risk of snakebite deaths in aforementioned 50 districts of Nepal (Table 1). Therefore, the incidence rate reported by Alcoba et al. [7] from 23 districts along the lowlands of Nepal (where nearly half of the national population inhabits) cannot be generalized nationwide.

Since incidences of snakebite envenomings known from 50 districts Table 1 were positively associated with human population density in Nepal, the findings obtained by excluding urban areas having more than 20,000 people in the randomized cluster survey of snakebites in 23 districts located along the terai region [7] might not even represent those particular districts of Nepal. Such a biased study design might cause their findings of the lower influence of snakebite envenoming in the districts located in western terai compared to the eastern terai of Nepal [7]. On the contrary, we found the highest incidence of case fatalities from the Dang and Kanchanpur Districts located in western terai (Table 1).

The distribution of snakebite envenoming and associated deaths in the terai Figure 2 corresponds to the snakebite risk map published by Epidemiology and Disease Control Division, Nepal Government (EDCD) [26]. However, several hilly districts Figure 2 were not included in that snakebite risk map recommended by Nepal Government [22, 26] and previous studies were mainly based in terai region of Nepal. Our findings disclosed increased incidences of snakebite envenomings in the hills and mountains of Nepal. However, further study is needed to know whether this increase in snakebite envenoming in the hills and in some parts of mountains are associated with the impact of global warming and climate change. [27].

The snakebite envenomings and associated fatalities in the subtropical and temperate regions (Figures 1 & 2) suggest transcending of venomous snakes from tropical regions, probably due to the increment of road transport in the Chure and Mahabharat ranges of Nepal (Figure 1). Snakes could be transferred along with goods carried in trucks. Further, global warming might support their flourishing in those regions [27]. The incidences of envenomings also depend on the human population density and abundance of venomous snake species. Our findings of weak association of snakebite envenomings and human population density (rho = 0.304, p-value = 0.032) may not guarantee that more risks of envenomings in more densely populated areas. It is because the information of envenomings due to venomous snakebite might not be quickly disseminated in rural and urban areas where human population density is varied. Next, snakebite envenomings may be reported with the same accuracy in more densely populated areas as in more sparsely populated areas and with worse medical infrastructures. Therefore, more sophisticated research is needed to know the impact of human population density, transport, and effects of climate changes on envenomings in Nepal’s subtropical and temperate regions.

Although the incidence vary depending on the species of snake involved in envenoming [28], most of the envenomings occurred in tropical areas than in subtropical and temperate regions (Figures 1 & 2). Unlike the findings in a cross-sectional survey in villages of 23 districts of the terai region of Nepal [7], such envenomings occurred mainly in far- and mid-western Nepal [12]. Although the recall bias in community-based surveys might cause this variation, our findings correspond to the distribution and diversity of nocturnal medically relevant snake species distributed in Nepal [11, 12, 29, 30]. The geographical locations of reported deaths (Figure 2) signify the snakebite hotspots in tropical to temperate regions of Nepal. The case fatality rate (CFR) is noticeably higher than that is reported in a cross-sectional survey carried in rural areas of 23 districts across the lowlands in Nepal [7]. In Shukraraj Tropical and Infectious Disease Hospital, Teku, Kathmandu, more snakebite cases visited the hospital seeking snakebite treatment for the fiscal year 2014 (n = 420) than in 2013 (n = 248). Next, the Lumbini Zonal Hospital, Butwal, also experienced increased snakebite deaths in 2017 compared to 2016’s case fatality. These periodic increments were supported by the corresponding reports of snakebite incidence for 2013 and 2014 and 2016 and 2017, respectively (Table 2, Figure 5). The maximum incidence of snakebite envenoming during 2017 (Table 2, Figure 5) might be associated with the effects of over-flooding because the increased incidence of snakebites during flooding was reported elsewhere [31, 32, 33, 34]. Among the envenomed case reports mentioned in two news articles, there were instances of one snakebite envenoming and four deaths in areas deluged with a flood in 2017: one death in Siraha District’s Sakhuwanrkatti Rural Municipality, three deaths of envenomed patients from Saptari District’s Hanumannagar Kankalini Municipality (n=2) and Krishna Sabaran Rural Municipality (n=1); one envenomed case from Saptari’s Tilathi Koiladi Rural Municipality was referred to BPKIHS where the patient was under treatment, meantime. In the monsoon of 2017, from the flood-affected areas of Saptari, 36 snake-bitten people (uncategorized) were admitted to Gajendra Narayan Singh Sagarmatha Hospital in Rajbiraj within two weeks after the flooding.

Similarly, from the flood-affected Biratnagar of Morang District, 25 uncategorized snakebite patients were admitted daily to Koshi Hospital in Biratnagar. Within two weeks of the same year’s monsoonal flood-affected areas of Banke District in western Nepal, 15 envenomed cases and 27 uncategorized cases were admitted in Nepalgunj-based Bheri Hospital. In addition to the flood-affected districts, other districts having inundated areas during heavy monsoonal rainfall are indicated by blue ellipses (Figure 2). Saptari and Mahottari in the eastern Nepal and Dang and Kanchanpur districts in the western Nepal were affected by flooding, which might cause many envenomings in these districts (Figure 2, Table 1). Overall, the rainfall and flooding patterns might cause fluctuations in the annual incidences of snakebite envenomings and associated deaths in the lowlands and other regions of Nepal. However, a longitudinal, prospective study of envenomings and deaths is necessary to confirm regional or nationwide supra-annual variation of snakebite envenoming in Nepal.

In Nepal, a minimum of 10,339 snakebites occur annually resulting in 2,113 envenomings and 101 deaths (Table 2). We considered the highest snakebite incidences and associated consequences for a particular year in our incidence dataset to be the estimation of minimum incidence for this country. Our estimate of a minimum annual incidence of snakebite is, however, greater than the annual total snakebites reported by Department of Health Services (DOHS) during the fiscal years 2013 to 2021 (Table 2). Similarly, our estimation of annual CFRs is also greater than corresponding reports of DOHS during the fiscal years 2013 to 2018 (Table 2). But, the estimated AER is comparable with the reports of DHOS during the fiscal years 2015 to 2016 (Table 2). We inferred that our minimum estimation of annual incidence of snakebites and associated consequences can be increased because of several factors influencing on the snakebite incidence and its recording. Firstly, there were no mentions of dry bites at all in our data records, which indicated that news reporters might include dry bites either in category of nonvenomous snakebites or uncategorized snakebites (Figure 3). The incidences of nonvenomous snakebites may represent nonvenomous as well as dry bites. Next, 76% of snakebite incidences were uncategorized (Figure 3). This might include venomous, nonvenomous, and dry bites. Therefore, the annual incidence of snakebites and associated consequences in Nepal can be greater than our aforementioned estimates of snakebite burdens. The huge number of uncategorized snakebite incidences Figure 3 suggests the need of empowering journalists to define envenomed, non-envenomed, and dry bites consulting with related authorities and experts. Improved reporting of this neglected tropical issue can be analyzed in future by prospective researchers for more precise estimation of snakebite burden in Nepal and understanding the trend of envenomings annually and by different level of localities. There is potential of increasing annual snakebite burdens in Nepal if news reporters are empowered to define available snakebite information as envenomed, non-envenomed, and dry bites while reporting in news articles. Overall, our findings are important for policy makers in Nepal and other countries where the geo-climates and patterns of snakebite incidences and associated consequences are analogous.

Limitations

We estimated the maximum snakebite incidences and associated consequences Table 2 to be the minimum incidences because news media might not cover all snake bitten and envenomed cases and our eligible incidence related data could represent only a subset of all snakebites, envenomings, and associated deaths from Nepal. Several snakebites that occurred in the remote areas might not be reported in the news media. Likewise, the search keys and engines that we used retrospectively might cause missing of the news reporting of incidence of snakebites, envenomings, and deaths. Therefore, snakebite incidences can be increased by searching news media data prospectively using additional search strategies. Further, there was possible that our estimations of incidences could be influenced if journalists reported these incidences without consulting with authorities in healthcare systems or the patients or other eyewitnesses.

Conclusions

People inhabiting or working in 50 districts of Nepal are vulnerable to snakebites and associated consequences. Snakebite envenomings mostly affected tropical areas of this country, particularly in Lumbini and Sudurpaschim provinces and Dang and Kanchanpur Districts. Compared to the past records, case fatality rate has been decreased in Nepal. However, incidences of envenomings and fatalities in the hills and mountains are challenges for snakebite management in Nepal. Therefore, the snakebite risk map recommended by Nepal Government should be immediately updated for the effective and efficient snakebite management nationwide. This improvement supports medical authorities in antivenom distribution and estimating healthcare personnel requirements and their appropriate deployment in the snakebite affected areas. The patterns of heavy rain and flooding might influence on supra-annual variations of snakebite envenomings and deaths. However, additional research is needed to confirm association of supra-annual variations with rainfall and flooding patterns. Moreover, our findings can also be used to design and conduct more effective and knowledge-based educational interventions in high snakebite prone flood affected provinces and districts to reduce snakebite mortality substantially. Empowerment of journalists is essential to improve prospective snakebite reporting in news. Subsequently, the improved case reports in news supports to carry out more sophisticated research cost-effectively in Nepal and elsewhere having similar impact of snakebites.

Acknowledgments

We would like to thank Gita Subedi Pandey and Narayan

B. Thapa for their support to search and find news media- reported snakebites and data management. Further, we are grateful to anonymous reviewers for their comments.

Author Contributions

Study design and concept (DPP); data analysis (DPP); initial drafting of the manuscript (DPP, BC); multiple revisions of the manuscript (DPP, BC, AD, RKB); critical revisions of the manuscript (DPP); final approval of manuscript (DPP). All authors approved the final manuscript. DPP is guarantor of the paper.

Funding

None

Conflicts of Interests

None

Data availability

The data that support the findings of this study are available upon request from the corresponding author, DPP.