INTRODUCTION: Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. METHODS: We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert's clinical severity grading score, and antivenom therapy. RESULTS: The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. CONCLUSIONS: The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.

Centre for Clinical Physiology Faculty of Medicine University of Ljubljana Ljubljana Slovenia

Centre for Clinical Toxicology and Pharmacology University Medical Centre Ljubljana Ljubljana Slovenia

Clinic of Anesthesiology and Intensive Care Toxicology Unit Central Clinical Hospital of the Medical University of Łódź Łódź Poland

Clinic of Toxicology University Hospital for Emergency Medicine N 1 Pirogov Sofia Bulgaria

Clinical Department of Infectious Diseases University Hospital of Split Split Croatia

Department of Pharmacology Toxicology and Therapeutics University BHF Centre for Cardiovascular Science University of Edinburgh Edinburgh UK

Department of Toxicology Péterfy Hospital Budapest Hungary

General University Hospital Prague Czech Republic

National Poison Centre Military Medical Academy Medical Faculty University of Defense Belgrade Serbia

National Toxicological Information Centre University Hospital Bratislava Slovakia

Nofer Institute of Occupational Medicine Łódź Poland

Poison Centre Institute for Medical Research and Occupational Health Zagreb Croatia

School of Medicine University of Split Split Croatia

Toxicological Information Centre Department of Occupational Medicine 1st Faculty of Medicine Charles University Prague Czech Republic

University hospital for infectious diseases Dr Fran Mihaljević Zagreb Croatia

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