A systematic review of reports on aquatic envenomation: are there global hot spots and vulnerable populations?

Envenomation by aquatic species is an under-investigated source of human morbidity and mortality. Increasing population density along marine and freshwater coastlines increases these incidents. Specific occupational groups - including commercial fishery workers, fisherfolk, marine tourism workers, and researchers - rely on aquatic resources for their livelihood. While diverse venomous aquatic species exhibit a broad array of habitats worldwide, they are most abundant in the tropics. Specific tropical regions present historic "hot spot" areas of concern for occupational groups with heightened risk of aquatic envenomation. Towards the overall objective of characterizing the health burden of aquatic envenomations, this review seeks to define (1) vulnerable, high-risk populations and (2) geographic hot-spot regions. To formally assess these metrics, a systematic literature review was performed where inclusion criteria requirements were peer-reviewed, published, epidemiological studies with defined denominators from January 1, 2000, to July 31, 2024, on the topic of human envenomation by aquatic species. Fifty-three articles met the inclusion criteria. Excluded articles were comprised of case reports, news and magazine articles, and those in languages aside from English, French, Portuguese, and Spanish. Most of the included articles examined emergency department and poison-control datasets that reported few overall envenomations (< 1%) from populations with physical and financial access to medical care. In contrast, datasets surveying beachgoers or fisherfolk directly, and life-guard incident reports, demonstrated that aquatic envenomation is an important source of injury for these groups and settings (envenomation frequency mean: 71%, median: 80%). Reports on additional high-risk groups, including marine and aquatic biologists, military personnel etc., and in key high-risk geographic regions including Thailand, Indonesia, and other Indo-Pacific countries were missing from the reviewed literature. Socio-demographic data were also largely missing from the literature. This systematic review highlights critical gaps where further research is needed, especially in under-represented regions and vulnerable populations.