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Corresponding author: Buddhika TB Wijerathne, MBBS, Dip. Public Health, MPH, MPhil, MRSPH, Dubbo Medical and Allied Health Group, Dubbo, NSW, Australia
The sloth bear (Melursus ursinus) is an omnivore that has been reported around most parts of South Asia. Although rare, sloth bear attacks can inflict potentially life-threatening injuries. This cross-sectional study analyzed 10 patients who had been mauled by sloth bears and who presented to rural hospitals in the Anuradhapura district of Sri Lanka between 2015 and 2019. All of the patients were male farmers. The human–bear encounters occurred in the jungle during the daytime. Ten victims sustained multiple soft tissue and bone injuries, mainly to the face and arms. The injuries ranged from minor abrasions to extensive deep lacerations and bone fractures. All of the patients were managed in the tertiary care hospital by multidisciplinary surgical teams. Sloth bear-inflicted wounds must be treated as major trauma. There is a need to formulate guidelines and train medical officers in managing animal-inflicted injuries in Sri Lanka.
Melursus ursinus (amended version of 2016 assessment).
The IUCN Red List of Threatened Species.2020; (https://dx.doi.org/10.2305/IUCN.UK.2020-1.RLTS.T13143A166519315.en. Accessed on 16 May 2022.)e.T13143A166519315
The Sri Lankan subspecies (Melursus ursinus inornatus) (Figure 1A and B ) is found primarily at low elevations (≤300 m) in open forests with lower human population densities.
Figure 1A and B, Sri Lankan sloth bear (Melursus ursinus inornatus) front & side view. C and D, sharp claws. (Figure 1A, C & D taken by author BTBW and Figure 1B taken by Dr. PADM Senarachchi, in Wilpaththu National Park in Sri Lanka).
The Sri Lankan sloth bear has a large head and powerful forefeet but weaker hindquarters. The average height of adult male is about 90 cm at the shoulder and female is about 60 cm.
They have powerful jaws and strong teeth with prominent canines. The claws and teeth can inflict terrible injuries. They have a fearsome reputation among farmers as an animal that attacks without provocation.
but details of injuries and medical management have rarely been documented. Almost all bear attacks occur in dry zones, and a significant number are in the Anuradhapura district.
Bear attacks can cause physical disability, which profoundly affects the earning capacity of victims, and concomitant physical disfigurements affect their psychosocial wellbeing.
The objectives of this study were to describe the demographics, clinical manifestations of injuries, and management outcomes of bear attack cases admitted to the Teaching Hospital Anuradhapura (THA) over 5 y.
Methods
A cross-sectional retrospective analysis of medical records of bear attack victims presented to the university surgical unit and clinic at THA from January 2015 through December 2019 was carried out. The clinical data of patients were extracted from the medical records by a medical officer within few days or weeks after leaving the hospital. Later, after informed consent, the patients were contacted over the phone and interviewed. The patient demographics, circumstances of the incident, the number of bears involved in the attack, injury profile, defensive strategy, first aid used, management, and complications were recorded. Descriptive statistics were calculated using an online calculator (QuickCalcsl; GraphPad Software). Ethical clearance was obtained from the ethics review committee of the faculty of medicine and allied sciences, Rajarata University of Sri Lanka. Data are presented as mean±SD with range.
Results
All 10 patients were male, 40±11 (20–53) y of age. There were 2 attacks in the northeast-monsoon season (Dec–Feb), 1 attack in the first inter-monsoon season (Mar–Apr), 5 attacks in the southwest-monsoon season (May–Sep), and 2 attacks in the second inter-monsoon season (Oct–Nov). Human and bear encounters occurred between 0730 and 1800. Six attacks occurred between 1200 and 1500. Nine attacks occurred in the jungle (unprotected areas), and 1 in a chena (swidden farming practiced in Asian countries). Six occasions involved a solitary bear. In 3 of these encounters, the victims were mauled while searching for fruits of the ironwood tree (Manilkara hexandra), the dragon’s eye tree (Dimocarpus longan), or for bee honey. These are all common sources of food for bears and humans.
Two attacks involved 2 bears. Two bears jumped on the victim from a close distance in the first attack, whereas 2 bears emerged from behind an anthill and attacked in the other instance. Two other incidents involved female bears accompanied by cubs.
In 8 incidents, bears made a frontal attack; the victims sustained soft tissue injuries to the scalp, face, nose, ears, muscles, and buttocks and fractures to the upper and lower limbs and the mastoid and zygomatic bones. When they fell, the bear bit various parts of the body, causing multiple injuries. On 2 occasions, the victims were initially bitten on the leg. In the first instance, the bear charged for about 15 to 20 min, bellowing. The victim hit it with a wooden pole, and the bear fell and bit the patient’s left calf, which resulted in left common peroneal nerve injury followed by nerve palsy. On the other occasion, the victim nearly stepped on a bear lying on the ground and was bitten on the leg.
One patient developed cerebrospinal fluid rhinorrhea and pneumocephalus and was given empirical antibiotics to prevent meningitis. He did not developed meningitis during his hospital stay of 17 d. Nine patients were initially admitted to peripheral hospitals, and 1 to the THA. Upon admission to the peripheral hospital, the hemodynamic statuses of 6 patients were not recorded; 3 patients’ hemodynamic statuses were recorded. Two patients (Table 1, patients 05 and 10) were hemodynamically stable. One patient (Table 1, patient 01) had a blood pressure (BP) of 90/60 mm Hg and a pulse rate of 88 beats·min-1. Because both blood and blood products were not available in the peripheral hospitals, IV fluid resuscitation with crystalloid was started for this patient, whereas for the other 3 patients, IV access was established. Empirical IV antibiotics were administered to 5 patients, and another received oral antibiotics. Four out of 9 patients were given tetanus toxoid injections. Subsequently, all 9 patients were transferred to the THA within 40 to 100 min. At the time of admission to the THA, 9 out of 10 patients were hemodynamically stable. One patient (Table 1, patient 01) transferred from a peripheral hospital had a BP of 100/60 mm Hg and a pulse rate of 98 beats·min-1.
Table 1Summary of bear attack cases
Patient number
Age (y) and sex
Incidents
Injuries
Name of the primary/secondary care hospital. Initial vitals and medical/surgical management.
Initial vitals and management at tertiary care hospital.
Duration of hospital stay in days and outcome.
Month, year, time.
Nature of encounter, number of bears.
Medical
Surgical
01
43 M
Aug 2015, 1345.
A wild bear attacked the victim while he was searching for cattle in the jungle.
Two abrasions in right scapula region. Superficial lacerations in right scalp and right thumb. Deep lacerations in lateral right leg, left wrist, right scapular region (5 by 7 cm) & left scapula region (1 x 1 cm). Compound fractures in right fibula (Figure 2A) & distal phalanx of the right thumb.
Base Hospital Padaviya. Conscious and rational, PR 88 beats·min-1, BP 90/60 mm Hg, IV fluid, IV cefuroxime, IV metronidazole, IM pethidine, IM promethazine, IM tetanus toxoid.
Conscious and rational, PR 98 beats·min-1, BP 100/60 mm Hg, IV fluid, IV cefuroxime, IV metronidazole, IV gentamycin, blood transfusion—1 unit of red cell concentrate, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, ARV, RIG.
Wound toilet, all laceration sutured after cleaning.
6; survived.
02
53 M
Jan 2016, 1200.
The victim entered the jungle with 2 friends. A female bear with cubs attacked him on the face and bit his scalp. The 2 friends ran away, and then returned and chased the bear away.
Lacerations on right frontoparietal (1 x 1 cm), left frontoparietal (1 x 1 cm), nasal (1 x 1 cm), left hand, left thumb (2 x 4 cm), left thigh (10 x 4.5 cm), penile laceration (1 x 1 cm)
Divisional Hospital Galenbindunuwewa. Vitals were not recorded; IV fluid, IV cefuroxime, IM tetanus toxoid.
Conscious and rational, PR 80 beats·min-1, BP 120/70 mm Hg, IV metronidazole, IV gentamicin, PO cloxacillin, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, ARV, RIG.
Wound toilet lacerations sutured physiotherapy to the hand.
11; survived.
03
40 M
Nov 2016, 1800.
The victim went in search of cattle near a lake. A bear that was lying down attacked him.
Laceration in right arm (1 x 2 cm), right forearm (1 x 1 cm) right abdomen (1 x 1 cm, 2 x 2 cm, 6 cm) (Figure 2B)
Divisional Hospital Horowpathana. Conscious, rational, and in pain, vitals not recorded, IV fluid, IV cefuroxime, IM tetanus toxoid.
Conscious and rational, PR 88 beats·min-1, BP 130/60 mm Hg, IV cefuroxime, IV metronidazole, PO PPI, PO diclofenac sodium, PO paracetamol, ARV, RIG.
The victim went to pick dragon’s eye (Dimocarpuslongun) fruit with 4 people. The bear rushed in, bellowing. The victim hit it, the bear fell and bit his left leg.
Laceration to right fibular region (5 x 10 cm) (Figure 2C) and peroneal nerve palsy.
Not recorded during the admission.
Conscious and rational, IV piperacillin, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, IM tetanus toxoid, ARV, RIG.
Wound toilet suturing of muscle and skin; neurology follow-up.
5; survived.
05
27 M
Jun 2017, 1330.
The victim went into the jungle searching for “Palu” fruit (ironwood, Manilkarahexandra). A female-bear with 2 cubs bit the left arm and thigh.
Frontal scalp laceration, multiple lacerations on right and left arm (length not recorded in datasheet), left ear laceration.
Divisional Hospital Thanthirimale. PR 76 beats·min-1, BP 110/70 mm Hg, IV co-amoxiclav, IV metronidazole, PO diclofenac sodium, PO paracetamol.
Conscious, rational, and in pain, PR 88 beats·min-1, BP 110/70 mm Hg, IV co-amoxiclav, IV metronidazole, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, IM tetanus toxoid, ARV, RIG.
Wound toilet and delayed primary suturing (suturing of left extensor muscles and left ear laceration).
5; survived.
06
39 M
Jul 2018, 1230.
The bear attacked the victim on the right hand and left leg.
Laceration in right hand dorsum and palm; left leg lateral side, multiple; length not recorded.
Base Hospital Padaviya. Vitals were not recorded, IV co-amoxiclav, IV gentamycin, IV metronidazole, tetanus toxoid.
Conscious, rational, and in pain, IV co-amoxiclav, IV metronidazole, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, ARV, RIG.
Wound toilet and delayed primary suturing.
2; survived.
07
20 M
Oct 2018, 1500.
On his way home from a chena (a farm in the jungle), 2 bears came behind him and attacked him. He fell and pretended to be dead. The bears left him. He walked back to the chena.
Facial laceration extend to nasal cavity 2 cm (septal cartilage separated), right facial laceration, right pinna evulsion, laceration in posterior triangle, right temporalis muscle laceration (through and through laceration), buccal laceration.
Directly brought to THA.
Conscious and rational, PR- 90 beats·min-1, BP 140/90 mm Hg, blood transfusion—1 unit of red cell concentrate, IV cefuroxime, IV metronidazole, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, IM tetanus toxoid, ARV, RIG.
Laceration and trapezius and temporalis muscles sutured. Devitalized tissues excised. Ear and nose lesions sutured. Septum placed between vestibule mastoid fixation.
11; survived.
08
50 M
Jan 2019, 0730.
On the border of a chena, 2 bears attacked, and 1 jumped at him.
Bilateral eyelid laceration, visual acuity normal, no globe injury, CSF rhinorrhea, forehead laceration (5 x 5 cm), occiput laceration (5 x 3 cm), right pinna laceration (1 x 2 cm), right forearm laceration (2 x 5 cm), right thigh posterior laceration (1 x 2 cm), right radioulnar fracture, right elbow dislocation, zygomatic fracture.
Divisional Hospital Ranorawa. Initial management not recorded by the medical officer.
IV piperacillin, IV metronidazole, fucidic acid eye ointment, chlorampenicol eye ointment, betadine cream to scalp, blood transfusion—1 unit of red cell concentrate, PO PPI, PO diclofenac sodium, PO tramadol, PO paracetamol, IM tetanus toxoid, ARV, RIG.
Facial and scalp reconstruction done; right wrist wound toilet with K wire; POP B/S elbow relocated; ORIF of Zygomatic fracture; bilateral orbital reconstruction done; forehead flap necrosis; wound debridement done.
17; survived.
09
39 M
May 2015, 1000.
The victim went to collect bee honey in the jungle and was attacked by a bear.
Lacerations in left posterior forearm below elbow (1 x 1 cm), (2 x 1 cm), (2 x 4 cm).
Base Hospital Kebithigollewa. Initial management not recorded by the medical officer.
Conscious and rational, PR 78 beats·min-1, BP 120/80 mm Hg, IV cefuroxime, IV metronidazole, PO PPI, PO diclofenac sodium, PO paracetamol, IM tetanus toxoid, ARV, RIG.
Wound toilet and delayed primary suturing.
3; survived.
10
37 M
May 2019, 13.30.
The victim went to the jungle to collect wood with 2 friends. The bear attacked, the victim fell face down, and 2 friends chased the bear away.
Scalp laceration in right parietal region (12 cm). Occipital laceration 5cm, left arm 3 lacerations, (2 × 2 cm, 4 × 6 cm, 1 × 4 cm), right palm 3 lacerations (2 cm, 2 cm, and 4 cm)
Base Hospital Kebithigollewa. PR 78 beats·min-1, BP 110/70 mm Hg, IV metoclopramide, PO cloxacillin, PO metronidazole, IV fluid.
PR 84 beats·min-1, BP 110/70 mm Hg, PO cloxacillin, PO metronidazole, PO PPI, PO diclofenac sodium, PO paracetamol, tetanus toxoid, ARV, RIG.
Wound cleaning and suturing done.
4; survived.
M, man; PR, pulse rate; BP, blood pressure; IV, intravenous; IM, intramuscular; PO, per oral; PPI, proton pump inhibitor; ARV, anti-rabies vaccine; RIG, rabies immunoglobulin; THA, Teaching Hospital Anuradhapura; CSF, cerebrospinal fluid POP, plaster of Paris; ORIF, open reduction and internal fixation.
All had x-rays of their limbs and chest, but 2 patients who had sustained extensive facial and scalp injuries had CT scans of the skull, brain, and face.
Intravenous fluids were continued for 4 patients and started for others to maintain IV access. The IV antibiotics were administered empirically to cover gram-positive, negative, and anaerobes. All were given nonsteroidal anti-inflammatory drugs and proton pump inhibitors in combination with paracetamol. An opioid was added for 6 patients. Tetanus toxoid was administered to the 5 patients who did not receive it at the peripheral hospital. Due to the risk of contracting rabies, all patients were immunized against rabies (immunoglobulin followed by a course of rabies vaccine).
After initial management, the wounds were explored; the devitalized tissues were excised, and the wounds were thoroughly irrigated with normal saline under general anesthesia and aseptic conditions in the operating theater. In 6 cases, primary suturing was done. In the remaining 4, wounds were dressed in 10% povidone-iodine-soaked gauze. Delayed primary suturing was performed for 3 patients (Table 1, patients 05, 06, and 07) within 24 to 48 h, but in 1 patient, the timing of suturing was not recorded. Two patients (Table 1, patients 07 and 08) with extensive soft tissue injuries and fractures were managed by teams of plastic, oromaxillofacial, orthopedic, and otolaryngology surgeons. One of them was managed in the intensive care unit for 1 d, in anticipation of breathing problems due to significant facial edema.
Patient 1 had tachycardia and a BP of 100/60 mm Hg on admission to the THA. Two others (Table 1, patients 07 and 08 ) lost blood in the perioperative period. These 3 patients had blood transfusions (1 unit of red cell concentrate each) to compensate for blood loss. The hospital stay was 7±5 (2–17) d. Two patients (Table 1, patients 07 and 08 ) who sustained multiple severe injuries were kept in the hospital for 11 and 17 d, respectively.
While in the hospital, 1 patient developed flap necrosis of the scalp and another developed common peroneal nerve palsy. None of the patients died from their injuries.
Discussion
Dwindling forest cover, increased population density, and encroachment on traditional bear habitats has led to a rise in human–bear encounters, causing increased mortality and morbidity of both humans and bears. A study carried out in the dry zone of Sri Lanka showed that the number of bear attacks on humans doubled every 5 y for the past 20 y.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
In South Asian countries, men are the primary income earners. They visit forests to gather livestock, hunt, and collect nontimber forest products. They tend to travel alone and walk deeper into the forest than women, thus increasing the probability of encountering bears.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
All of the encounters took place in unprotected areas (not in national parks or wildlife sanctuaries), indicating that bears venture from the protected areas to forage for food. Most human activities leading to conflict with bears happen during the daytime in the jungle. A single bear attacked in the majority of our cases, and similar patterns were observed in other studies.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
A single person and a solitary bear traveling in the jungle would not make much noise; therefore, the likelihood of encountering each other is high. In the encounters where cubs accompanied a female bear, she would have attacked without provocation to protect her offspring. The occasions on which two bears were involved were close encounters; therefore, the bears would have been startled, leading to an unprovoked attack.
In most of the incidents, the bear made a frontal attack; it was upright and made sweeping motions with its paws leading to facial and scalp injuries. This is typical of sloth bear attacks.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
Nine encounters were sudden, where the bear and the victim surprised each other; hence, these attacks could have been defensive. Sloth bears share the same habitats used by other large carnivores
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
In 4 of our patients, IV access was established at primary care hospitals. All of these patients sustained extensive injuries. Their condition may have deteriorated while being transferred since it took considerable time to transfer patients to the tertiary care hospital. Therefore, it was vital to establish IV access/IV fluid resuscitation at first contact to prevent or mitigate hypovolemia. Ideally the first patient should have had blood transfusion in the primary care hospital, but these hospitals do not have facilities to store blood and blood products.
Wounds would have been contaminated with soil and other elements because of the ferocity of the altercations. Indications for antibiotic therapy are contamination, infected bites, fresh, large penetrating wounds, or full-thickness skin punctures.
Bear bites fulfill these criteria. Anticipating infections by aerobes and anaerobes, the patients received empiric broad-spectrum antibiotics. A tetanus toxoid was given, either at the peripheral hospital or the THA. Bears can potentially transmit rabies.
Some injuries required special investigations and multidisciplinary team involvement. Therefore, bear attack victims should ideally be managed in a tertiary care hospital.
None of our patients died from their injuries. In comparison, in an Indian study, the mortality rate was 2 to 11%.
This difference could be because of several reasons. In Sri Lanka, some victims might have died or gone missing in the jungle, or there may have been under-reporting because victims who engage in illegal activities (eg, poaching or growing cannabis) would not come to the hospital for treatment.
The patient with pneumocephalus and cerebrospinal fluid rhinorrhoea was given empheric antibiotics and did not developed meningitis. This is in contrast to a Nepali study, in which a patient with pneumocephalus came to the hospital 24 h after the incident and subsequently developed meningitis.
Medical officers should be trained to identify the patients who are more prone to developing meningitis after bear attacks and administer antibiotics without undue delay.
This study raises a few important points in managing patients sustaining bear attacks in Sri Lanka. There is a lack of uniformity in the management. The most probable reasons are the nonavailability of necessary equipment and medications, lack of knowledge, and the absence of clear protocols and guidelines at the peripheral hospitals. A practical problem is the unavailability of data due to deficiencies in record keeping; as data are essential in making guidelines, improvements in record keeping must be addressed. Guidelines for the management of animal bites, especially with regards to IV access, administration of tetanus toxoid, antibiotics, analgesics, control of hemorrhage, and expedited transfer to a tertiary care hospital should be developed and implemented. Furthermore, ensuring the continuous availability of essential medications, dressings, and other equipment is a necessity. Medical officers and the supporting staff working in peripheral hospitals should be trained in the initial management of acute trauma patients. At the tertiary care centers, protocols should be made on subsequent management regarding investigations, timely referrals, multidisciplinary team approaches, timing, and the extent of wound management.
Conserving the Sri Lankan bear while reducing the mortality and morbidity to the humans is a daunting task. Minimizing human–bear encounters is the key strategy. Even though there is no consensus on the best protective action against sloth bear attacks, several measures could be adopted to mitigate human–bear conflicts. People can make noises while traveling in areas where encounters with bears are more likely, or when searching for common food sources, such as bee honey and fruits. In fact, the Veddas (indigenous people living in Sri Lanka) either shout or chant in loud voice when they travel in bear-infested terrain, giving bears ample warning to move away.
When venturing into a forest, travel as a group and when moving apart, keep in touch with each other by verbal communication or visual sighting. If a bear is seen at a distance, avoid it by quietly moving out of the way.
Finally, communities should be educated regarding the unique status and value of the Sri Lankan sloth bear and the vital role it plays in maintaining ecological balance.
Limitations
The limitations in our study were that, compared with other studies, our numbers were small, making the comparisons and conclusions challenging. Another limitation of this study was the retrospective nature of some of the events, which were subjected to recall bias. There were also a few inadequacies in the data because of gaps in record maintenance. A few patients did not come for follow up or respond despite repeated attempts to contact them.
Conclusion
In our study, the attacks occurred during daytime, across all seasons, in the forest or its vicinity. Most of these encounters were unexpected. The majority of the attacks were frontal, leading to extensive soft tissue injuries in the upper torso.
Acknowledgments
The authors especially thank the editorial team and the anonymous reviewers of Wilderness & Environmental Medicine journal for their valuable comments and suggestions to improve this manuscript.
Authors Contributions: Study concept (SPBT); management of patients (SPBT, AS, VC); literature review and drafting and editing of the manuscript (SPBT, BTBW); all authors approved the final manuscript.
Financial/Material Support: None.
Disclosures: None.
References
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Melursus ursinus (amended version of 2016 assessment).
The IUCN Red List of Threatened Species.2020; (https://dx.doi.org/10.2305/IUCN.UK.2020-1.RLTS.T13143A166519315.en. Accessed on 16 May 2022.)e.T13143A166519315
Characteristics of human - sloth bear (Melursus ursinus) encounters and the resulting human casualties in the Kanha-Pench corridor, Madhya pradesh, India.
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