Public Health Strategies to Improve Snakebite Treatment
There are over 3,000 species of snakes in the world; most bite, 600 are poisonous; some 200 are medically important (World Health Organization). In 1954, Swaroop and Grab published the most comprehensive analysis to date of the global distribution and prevalence of snakebites. By their own admission, their data represented but a rough estimate of the worldwide prevalence of snakebites; nevertheless, the magnitude of the snakebite problem in certain areas of the world was immediately apparent to the World Health Organization. The highest figures reported were for Asia, followed by those for South America.
Later research (Gutierrez, 2010; and Williams, 2011) also found a wide global and regional variation in morbidity and mortality by snakebite. Asia, with 2 million envenomings and 100,000 deaths a year, continues to top the list. A recent study in India attributed 45,900 annual deaths to snakebites (Mohapatra, 2011), accounting for nearly half the deaths by snake envenoming in Asia.
Africa trails second at 500,000 envenomings and 20,000 deaths (Appiah, 2012). Nonetheless, Nigeria has one of the highest rates of snakebites cases in the world, with 174 out of 100,000 hospitalizations attributed to snakebite envenoming alone (Paramonte, 2007).
Discussion
The high mortality rate from snakebite envenomings in developing countries can be blamed on a complex interplay of factors: ecology, society, politics, and money. But basically, death by snakebite is a burden of the poor (Gutierrez, 2010).
These deaths are unacceptable. The global community can help reduce mortality and morbidity by snakebite in developing countries through public health programmes aimed at prevention and education, and by the establishment of effective treatment protocols.
Prevention
The general approach to the elimination of a disease is to, first identify; and then, try to eliminate the cause. This approach will not work with snakebites because our goal can never be to eliminate all vipers; instead, we must learn to respect their habitats and coexist with them. One way of doing that is to learn to distinguish between poisonous and non-poisonous snakes, and then learn the habits of the venomous snakes so that we can avoid them (Mohapatra, 2011).
Thus, prevention must be the first line of defense. In their “Guidelines for the Prevention and Clinical Management of Snakebite in Africa,” the World Health Organization details a number of preventive steps that a potential victim can take to minimize the risk of snakebite, either at home or outdoors. Some of their recommendations are outlined below.
Around the home. Snakes naturally prefer their own habitats, but during climate extremes, like monsoons, snakes are attracted into and around homes. Most are not poisonous, or mildly so, and pose no threat; and in fact, play important roles in the control of disease carrying vermin (Paramonte, 2007). Thus, the general use of poisons against snakes is not recommended; and, there are better solutions.
Inside the home. There are a number of protective measures and preemptive strategies that a person can use to reduce the risk of snakebites inside the home. First, people should avoid attracting snakes into the house. Food is the main reason snakes leave their habitat. Thus, chickens, or any other small animals, should not be indoors, especially at night; and food should be kept safe from rodents. Second, the house should be safeguarded against the entry of snakes; roofs are a favorite access, and these should be patched; windows must be closed at night. Third, many snakes hunt at night; beds must be raised high off the floor, and equipped with mosquito nets. Sleeping under a mosquito net can sharply decrease the number of snake envenomings (Chappuis, 2008).
Outside the home. Here too, food is the main attraction to snakes. Animals should be kept away from the house, and chickens should be cooped at night, as these attract predators. Water sources also attract animals; thus, water supplies should be stored separate from the house. The area around the house must be clear of vegetation or rubbish as these provide a hiding area for snakes. Protective footwear is recommended around the home. Special measures should be taken to protect the safety of children; they cannot be allowed to go about unattended.
Outdoors. The farther from home the higher the risk of snakebites. Rural communities spend most of their time outdoors—farming, tending livestock, gathering wood, and harvesting food. Still, there are preventive measures that can reduce the risk of snakebite even outdoors.
First, protective clothing and footwear should be worn to reduce potential striking targets for snakebites. Second, close attention must be paid when walking through terrain that might harbor venomous snakes. Snakes attack when scared or provoked—poking at a snake, or any such things, is not good practice. Tall vegetation, low branches, or the sticking of hands into holes—hiding places for snakes—are also to be avoided. Third, firewood should not be gathered at night; many of the venomous snakes are nocturnal and visibility at dark is poor.
Finally, never attempt to pick up what might appear to be a dead snake—often a snake is simply stunned and will strike when disturbed. Hospitals are full of patients with snakebites from “dead” snakes.
Education
Recently, the World Health Organization placed snakebite envenoming into the category of Neglected Tropical Diseases (NTD)—over half a century after it first recognised the magnitude of the problem in developing countries. This NTD status is an important step in the education of the world community. Global health organizations pay special attention to NTDs when allocating their resources, for these diseases primarily affect poor populations in desperate need of funding (Mohapatra, 2011).
Public education. In addition to the prevention of snakebites, communities must be prepared to deal with snakebites. There is a significant fear factor associated with snakebites that often leads to fatal decisions. The first thing people need to understand is that not all snakes are venomous. The second is that not all bites from venomous snakes result in an envenoming. The third is that even when an envenoming occurs not all envenomings are fatal. But the most important thing they need to learn is to seek medical care immediately. Only a person with knowledge of snakebites can provide proper medical treatment (Appiah, 2012)
First aid. One of the biggest challenges in the treatment of snakebites is that often a person is bitten far from any medical facility. Thus, it is important for community members to know the basics of first aid. A critical point to stress is that when in doubt, do nothing. A significant number of fatalities have been attributed, not to the direct effect of the venom itself, but to secondary factors related to the initial choice of treatment (Stock, 2007).
Effective treatment. By far the most effective treatment for snakebite envenoming is the proper administration of antivenoms. Unfortunately, most communities lack the resources to stock their medical facilities with a proper supply of antivenom vaccines (Appiah, 2012).
Government education. There is no need to point out the correlation between the risk of death by snakebite and the amount a government spends on healthcare. Everyone knows this, but the reality is that developing governments simply lack the resources to finance the cost of snakebite. So, when dealing with government education, we must turn to the education of those governments that can help finance the healthcare of less fortunate countries (Gutierrez, 2010).
The only alternative available for some developing countries is the establishment of programmes that help the regulation and distribution of whatever resources may lie at hand.
Medical staff education. Not all snake envenomings are alike. Depending on the species, a health care practitioner may be faced with a cytotoxic, haemorrhagic, neurotoxic, or myotoxic envenoming; or, perhaps some combination (Stock, 2007; Paramonte, 2007; Mohapatra, 2011; and Appiah, 2012). Depending on the envenoming, a health care practitioner must choose the type of treatment. Unfortunately, most health care professionals lack proper training in the handling of snakebites.
Training. Training medical staff on snakebite treatment is rather complicated. Many bite victims in rural communities first turn to a traditional healer and only visit a Western-style hospital when the healer’s treatment fails. So in addition to the envenoming, medical practitioners must also deal with the consequences of inadequate or even life-threatening treatments. What complicates matters even more is that even with adequate training there is little medical staff can do when they lack the means to deliver proper treatment (Appiah, 2102; and Williams, 2011).
Treatment. The treatment of snakebite envenoming is a therapeutic challenge. Only antivenoms can reduce the morbidity and mortality by snakebite but these are not available in the quantities necessary to combat snakebites. The key is to improve the production of effective and safe antivenoms, perhaps by helping countries that cannot afford it produce their own specific immunogens locally (Stock, 2007; and Williams, 2011).
Conclusion
Morbidity and morality by snakebite is a well-documented problem affecting poor communities in developing countries. Here, we discussed preventive and educational measures, and medical programmes to combat this problem.
On the surface, the solutions are easy. But it is far from easy to implement these measures. Take the mosquito net, as an example. A single mosquito net may cost the equivalent of a month’s wages in one of these impoverished rural communities (Chappuis, 2007). The same hold for beds or footwear or even the “locking” of windows. Often windows—if there are windows—are just holes in walls.
The point here is that in offering any viable solutions one must first grasp the extent of the challenge facing these populations. One thing we did not cover is that some envenomings occur during the consumption of meat from a venomous snake. This tends to happen more often during the monsoon, when food is scarce and snakes aplenty. Again, snakebite is a burden of the poor.
In closing, the best solution, if not the only solution, is for the global community to establish an aggressive anti-snakebite programme. One such programme was established in 2008—the Global Snakebite Initiative. But according to its website, the initiative is still in the process of developing a “workplan of projects” (Appiah 2012).
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