Snakebite: the true disease burden has yet to be determined Venomous snakes are a significant cause of morbidity and mortality, particularly in tropical and subtropical countries in Africa, Asia, Oceania and Latin America. Most snake bites occur in the rural tropics, and result in a high medical and economic toll. The reasons include poor access to [often suboptimal] health services, scarcity of effective and safe antivenom (AVS), survival with disability, and the economic impact of disabled young victims [1]. Despite this, snakebite has not received due attention and the main reason for this is the paucity of sound epidemiological data with which to make the case. Difficulties in obtaining accurate data on snakebiteSnakebite mainly occurs in the poorest countries of the world that are least able to deal with the problem [2]. Data on snakebite are based mainly on hospital returns or incomplete central databases. Bites and associated mortality are underreported because many victims do not seek treatment in government health facilities, preferring traditional treatments. Studies from rural Nigeria and Kenya have reported that only 8.5% and 27% of snakebite victims, respectively, sought hospital treatment [3,4]. In rural Bangladesh only 3% of victims went directly to a medical doctor or hospital [5].Two qualitative studies, investigating beliefs regarding snakebite and their influence on health seeking behavior in Sri Lanka found that people living in four rural communities believed that Ayurvedic treatment was effective for snakebite [6,7]. Common misconceptions regarding hospital treatment were based mainly on misinformation regarding AVS therapy. Traditional healers were respected and perceived to be able to cure snakebite, and although many people may finally seek treatment in a hospital, they would first consult a traditional healer. Similar situations are likely to be common to many countries where health-seeking behaviour, health beliefs and access to health care are not optimal.The incidence of snakebite varies seasonally (e.g. high during agricultural activity) and geographically. Studies from India and Bangladesh have clearly shown increased rates of bites during periods of high rainfall and flooding [5,8]. Therefore, data obtained during seasonal surveys would not represent true annual incidence. Marked regional variations in incident snakebite deaths have been demonstrated in a recent nationwide survey conducted in India [8].This type of geographical variation in snake bites is seen even in small countries like Sri Lanka [9]. In the face of such heterogeneity, localised surveys will not reflect true national or regional values [3].Estimates of snakebite mortality are based mainly on hospital data, because other recording systems are unavailable or unreliable in most

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Outcomes from pneumococcal meningitis (PM) are worse than meningococcal meningitis (MM), particularly in settings with high HIV-1 prevalence, but the reasons are unknown. We compared inflammatory responses between PM and MM in Malawian adults.As compared to MM (n=27, 67% HIV-infected, mortality 11%), patients with PM (n=440, 84% HIV-infected, mortality 54%) were older, had strikingly lower CSF WCC, higher pro-inflammatory cytokine concentrations and higher mortality.PM is characterized by significantly lower CSF WCC, but greater inflammation and higher mortality compared to MM. Mechanistic understanding of blunting of the CSF leukocyte response in PM in-vivo is required.