04012nas a2200397   4500000000100000008004100001260003700042653002400079653005700103653002500160653002300185100002000208700001300228700001200241700001400253700001600267700002300283700001400306700001900320700001300339700001200352700001500364700001300379700001400392700001500406700001100421700001400432700001600446700001600462245012800478856009900606300000900705490000700714520287900721022001403600       2024                            d  bPublic Library of Science (PLoS)10aInfectious Diseases10aPublic Health, Environmental and Occupational Health10aSnakebite envenoming10aBrazilian Amazonia1 aSerrão-Pinto T1 aStrand E1 aRocha G1 aSachett A1 aSaturnino J1 aSeabra de Farias A1 aAlencar A1 aBrito-Sousa JD1 aTupetz A1 aRamos F1 aTeixeira E1 aStaton C1 aVissoci J1 aGerardo CJ1 aWen FH1 aSachett J1 aMonteiro WM1 aMaduwage KP00aDevelopment and validation of a minimum requirements checklist for snakebite envenoming treatment in the Brazilian Amazonia  uhttps://journals.plos.org/plosntds/article/file?id=10.1371/journal.pntd.0011921&type=printable  a1-220 v183 a<p><strong>Background:</strong> Currently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management.</p>

<p><strong>Methods:</strong> This study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%.</p>

<p><strong>Results:</strong> A valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility).</p>

<p><strong>Conclusion:</strong> This study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.</p>
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