The burden of treating snake bite victims

According to the official World Health Organisation (WHO) website, snakebites are a neglected public health issue in many tropical and subtropical countries. The site states that about 5.4 million snake bites occur each year, resulting in 1.8 to 2.7 million cases of envenoming (a potentially life-threatening disease that typically results from the injection of a mixture of different toxins (‘venom’) following the bite of a venomous snake). 

There are between 81,410 and 137,880 deaths and around three times as many amputations and other permanent disabilities each year. Most of these occur in Africa, Asia and Latin America. For example, in Asia, up to two million people are envenomed by snakes each year, while in Africa there are an estimated 435,000 to 580,000 snake bites annually. 

The highest burden occurs in countries where health systems are weakest and medical resources are limited. As such, in 2017, WHO categorised snakebite envenoming a Neglected Tropical diseases (NTD).

Local efforts
In 2018, Uganda integrated snakebite envenoming into the country’s NTD programme because there is limited data on the burden of snakebites and snakebite envenoming in Uganda. 

As such, a team of scientists from the School of Public Health Makerere University obtained a research fund worth Shs200m from the University Research Fund Initiative in a bid to carry out field studies in order to guide prevention, control and management strategies.

The team, led by the Principal investigator Dr John B Ddamulira, shared their research results in a meeting held on February, 17, highlighting types of venomous and non-venomous snakes in the country and the incidence of snakebites including health facility coverage. 

Snakebites
Dr Susan Kizito, a member of the team notes that the importance of having data on snakebites is to determine the burden of snakebite and snakebite envenoming in Uganda, the incidences as well as characterising snakebite envenoming.
The scientists carried out case studies in the districts of Gulu, Kamuli, Kasese, Mubende, Nakapiripirit and got data from 29 health facilities including  regional referral hospitals and Health Centres IV,II and III.

In total, 40 people were interviewed and these included health team members, community resource persons and health workers. The community survey covered 54 villages and 1,080 households with the persons interviewed in the age bracket of 25-54. 67 per cent represented men and farmers.

The incidence of snake bites indicated that among the 1,080 households, the frequency of snake bites for the last 15 months occurred to 341 people. The statistics of the number of patients who report to hospitals in the selected districts indicates that Gulu District had the highest number of patients (177,985).

Types
James Ntulume, a consultant at Snakes Uganda, says irrespective of age, snakebites can be fatal. He notes that Uganda has more than 80 Species and 75 per cent of these are non-venomous.

Ntulume says venomous snakes include the Egyptian cobra, black mamba, black forest cobra, blanding tree snake, which are neurotoxic (the level of toxicity is acute). The Gaboon viper,  puff adder,  black necked spitting cobra and rhinoceros viper also exhibit cytotoxic venoms  while the vine tree/twig snake have heamotoxic venom.

The non-venomous snakes include among others Battersby, house snake, blind snake, spotted bush snake and rock python. These snakes are common in all geographical regions of the country but some snake types are more frequent in one district/region than another. A case in point is the Egyptian cobra in Arua and the rock python in Nakapiripirit.

Avoiding snakes
In case you see a snake do not panic. Gently move steps away from it in order to observe its features, size and colour. Also, keep other people away and safe. Call rescue teams, especially officials of Uganda Wildlife Authority to take the snake to a safe place. Only kill it if it is absolutely necessary.

To keep snakes away from your home, Ntulume says it is important to keep houses rodent free, clear bushes in the surrounding and keep rubbish far from homes. Also, items such as firewood, tarpaulins,  building blocks  must be kept far from the house.

Treatment 
Dr Ddamulira says before any treatment can be given, medical personnel must ascertain the type of venom that was injected by the snake. Scientists recommend two types of antivenomous serums. One is the Samir Antivenom manufactured in South Africa with each vial costing about Shs1m although clinics may charge Shs2m.

The other is Antvenome vaccines from India which vary from one manufacturer to another. These include snake venom anti serum IP and 5ml-10ml Alopathic Snake venom among others.

He, however, advises the government to partner with pharmaceutical companies to ensure anti-venom vaccines are manufactured from the country to suit the types of snakes here.

Management 
Dr Ddamulira explains that most snakebites are managed at regional referral hospitals at a rate of 48 per cent although Health Centre III facilities see relatively more cases at a rate of 20 per cent. Private hospitals receive less patients due to cost factor.

Most victims are bitten by snakes at night while walking along foot paths and in houses and in most cases, the snakes are not seen.
The mortality rate according to the survey is at 560 per 100,000, hospital cases indicate 40 per cent of snakebite medical records did not document the treatment outcome.

Symptoms 
According to the survey carried by the scientist where 1,090 people were interviewed, about 70 per cent experienced swelling, pain (61 per cent), bleeding (49.2 per cent), fang marks (49 per cent), blistering (19.3 per cent and others symptoms such as vomiting and paralysis (16.5 per cent).
What not to do
The scientists warn against harmful practices such as application of herbs such as tourniquet and black stone, making small cuts around the bitten area, sucking the bitten site and electrocution of the bitten wound among others such as washing the area with water and paraffin. 

Challenges 
In the survey, no health facility had a health worker trained on snakebite management. “We have never had any training with regard to snakebites, I think this is brought about by snakebites not being taken as a serious issue yet some people die from them,”  a health worker in  Arua hospital notes.
Also, about 93 per cent of the facilities have no standard operating procedures on emergency care of snakebite victims.

Recommendations 
● The experts recommend that it is important to disseminate sensitisation materials on snakes and snakebites such as flyers and manuals with key messages.
●There should also be development and distribution of guidelines and protocols on management of snakebites and emergency care, including training of health workers.
●Making snake anti-venoms and drugs for supportive management more accessible by purchasing relatively cheaper antivenomous.
●Improve the surveillance in snakebite management by establishing health systems to capture data and report snakebite incidences.

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