Delays, fears and training needs: Perspectives of health workers on clinical management of snakebite revealed by a qualitative study in Kitui County, Kenya

Snakebites and Antisnake Venom Utilization in Ghana's Oti Region: A 6-Year Retrospective Study

Background: Snakebite is a global environmental and occupational hazard and a significant public health threat. In rural areas, snakebite cases often go unreported and undocumented due to the lack of access to well-structured healthcare facilities/infrastructure. In some cases, the need for antisnake venom (ASV) far outstrips supply, negatively affecting treatment outcomes. This study, therefore, assessed the epidemiological characteristics of snakebite cases, their management, and how antivenoms are utilised at the selected hospital in the Jasikan District Hospital. Methods: A 6-year retrospective study using secondary data from antivenom return forms (pharmacy records), clinical records (patient folders), the District Health Information Management System-2 (DHIMS-2) database, and consulting room registers was carried out in selected hospitals in the Jasikan District, Oti, Ghana. Results: The predominant symptom of snakebite was localised pain (71.4%). The snakebite commonly occurred at home (19%) and on farms (18%). Of the 98 snakebite cases, ASV was administered to 73 (74.5%) cases. Supportive treatment applied included prophylactic antitetanus immunoglobulin (ATS) (80.6%), prophylactic antibiotics (63%), corticosteroids (80.6%), and analgesics (63%). 95% (n = 94) of complete recoveries were recorded; three were discharged against medical advice, and one was mortality. The supply and use of antivenom were erratic throughout the months of high incidence, partly due to inconsistent availability at the Regional Medical Stores. The average ASV vials and hospital stay duration were 1.23 ± 0.86 vials and 2.67 ± 1.97 days, respectively. Although the peak of snakebites occurs in April, May, and June, the demand for antivenom in April and May exceeded supply. Conclusion: The outcome of most snakebite case management was appropriate, irrespective of inadequate ASV supply in certain months. The erratic antivenom supply should be aligned with seasonal and facility-use patterns to enhance regional snakebite management.

Snakebite Management: The Need of Reassessment, International Relations, and Effective Economic Measures to Reduce the Considerable SBE Burden

The sole treatment for snakebite envenomation (SBE), the anti-snake venom (ASV), suffers from considerable drawbacks, including side effects and limited species specificity. Additionally, despite its existence for more than a century, uniform availability of good quality ASV does not yet exist. The present review describes the journey of a SBE victim and highlights the global crisis of SBE management. A detailed analysis of the current ASV market has also been presented along with the worldwide snake distribution. The current production of country specific licensed ASV throughout the globe along with their manufacturers has been examined at the snake species level. Furthermore, a detailed analysis of on-ground situation of SBE management in antivenom manufacturing countries has been done using the most recent literature. Additionally, the export and import of different ASVs have been discussed in terms of procurement policies of individual countries, their shortcomings, along with the possible solution at the species level. It is interesting to note that in most countries, the existence of ASV is really either neglected or overstated, implying that it is there but unsuitable for use, or that it is not present but can be obtained from other countries. This highlights the urgent need of significant reassessment and international collaborations not just for development and production, but also for procurement, distribution, availability, and awareness. A PROMISE (Practical ROutes for Managing Indigenous Snakebite Envenoming) approach has also been introduced, offering simple, economical, and easy to adopt steps to efficiently alleviate the worldwide SBE burden.

Current Status and Influencing Factors of Snakebite Diagnosis and Treatment Knowledge Among Medical Staff in China: A Cross-Sectional Study

Objectives: This study aimed to determine the current status of the knowledge of diagnosis and treatment of snakebites among medical staff in China and its influencing factors. Methods: A cross-sectional survey of 12,581 medical staff was conducted in 12 provinces in China between June 2022 and February 2023. We analyzed the results using descriptive statistics, T-tests or analysis of variance, and a generalized linear model. Results: The average score of snakebite diagnosis and treatment knowledge among medical staff in China was 3.15 ± 2.15 out of a total score of 12. Through a generalized linear regression model, we found that gender, occupation, region, hospital level, work department, work tenure, training received in the diagnosis and treatment of snakebite, experience in snakebite diagnosis and treatment, availability of antivenom in the unit, and self-evaluation of snakebite treatment ability all affected the medical staff's scores of snakebite diagnosis and treatment knowledge. Conclusion: The knowledge level of snakebite diagnosis and treatment among Chinese medical staff is generally low, so it is imperative to conduct standardized snakebite diagnosis and treatment training for medical staff.

Identifying key factors contributing to treatment costs for snakebite envenoming in private tertiary healthcare settings in Tamil Nadu, India

BACKGROUND

India suffers ~58,000 annual deaths due to snakebites. The 'Big Four' snakes (Russell's viper, Indian cobra, common krait, and saw-scaled viper) that are responsible for most bites cause diverse clinical effects. Delayed treatment increases the risk of serious complications and treatment costs. Although government hospitals offer free treatment for snakebites in India, most patients opt for private healthcare, which is an out-of-pocket expense as they often lack health insurance coverage. This study aims to analyse snakebite treatment costs in private tertiary care hospitals in Tamil Nadu, India and identifies the key factors contributing to treatment costs.

METHODOLOGY/PRINCIPAL FINDINGS

The treatment cost details for 913 snakebite victims were collected from 10 private tertiary care hospitals across Tamil Nadu. The data were classified into hospital, pharmacy, investigation, and laboratory costs, and analysed to determine various factors that contribute to the costs. The results demonstrate that the average treatment costs vary widely for different snakes. The hospital and pharmacy costs are higher than investigation and laboratory costs for all snakebites. Notably, Russell's viper bites cost significantly more than the bites from other snakes. Overall, the type of snake, nature of complications, specialist treatments required, and arrival time to hospitals were identified as some of the key factors for higher treatment costs.

CONCLUSIONS/SIGNIFICANCE

These data demonstrate that ~80% of snakebite patients can be treated with INR 100,000 (~GBP 1000 or USD 1200) or less. This study emphasises the urgent need to improve rural medical care by providing appropriate training for healthcare professionals and essential resources to facilitate early assessment of patients, administer the initial dose of antivenom and refer the patients to tertiary care only when needed. Moreover, the outcome of this study forms a basis for developing appropriate policies to regulate snakebite treatment costs and provide affordable medical insurance for vulnerable communities.

Barriers and opportunities for improving management of snakebites: Perspectives of healthcare workers in Northern Uganda

BACKGROUND

Snakebites are a neglected public health problem that pose a significant burden on affected individuals and communities in many sub-Saharan African countries, including Uganda. However, the barriers and facilitators to snakebite management within healthcare settings are not as well understood and well-documented. The aim of this study was to explore the experiences and perspectives of healthcare workers involved in handling snakebite incidents at individual and health system levels in Arua and Gulu districts in Northern Uganda. We sought to understand how healthcare workers manage snakebite cases, what challenges they encounter, and what opportunities they perceive for improvement.

METHODS

We conducted a qualitative study using in-depth interviews with 18 healthcare workers from different cadres, seniority levels, and facility types. We used iterative thematic analysis to explore the management procedures, challenges, and opportunities for snakebite management. Using thematic analysis, we identified the overarching themes and subthemes related to snakebite management and associated barriers and opportunities.

RESULTS

The main barriers to snakebite management identified by healthcare workers were inadequate knowledge and skills; limited availability of antivenom; lack of protocols for snakebite management; delayed treatment-seeking for patients; and poor referral systems. The main opportunities for improvement were regular in-service training; increasing public education and awareness about snakebite prevention and management; and increased funding and research.

CONCLUSION

This study highlights the need for interventions to address the identified barriers while leveraging the existing opportunities to enhance snakebite management in Uganda. Specifically, we recommend the provision of regular training and support to healthcare workers, developing clinical guidelines, and improving the availability of antivenoms.

Community members and healthcare workers' priorities for the control and prevention of snakebite envenoming in Ghana

INTRODUCTION

Snakebite is one of the most neglected tropical diseases. In Ghana, there has been a limited interest in snakebite envenoming research despite evidence of high human-snake conflicts. In an effort to meet the World Health Organisation's (WHO) 2030 snakebite targets, the need for research evidence to guide policy interventions is evident. However, in setting the research agenda, community and healthcare workers' priorities are rarely considered.

METHODS

Three categories of focus groups were formed in the Ashanti and Upper West regions of Ghana, comprising of community members with and without a history of snakebite and healthcare workers who manage snakebite patients. Two separate focus group discussions were conducted with each group in each region. Using the thematic content analysis approach, the framework method was adopted for the data analysis. A predefined 15-item list of potential snakebite-associated difficulties and the WHO's 2030 snakebite strategic key activities were ranked in order of priority based on the participants' individual assessment.

RESULTS

Both acute and chronic effects of snakebite such as bite site management, rehabilitation and mental health were prioritised by the community members. Health system challenges including training, local standard treatment protocols and clinical investigations on the efficacy of available antivenoms were identified as priorities by the healthcare workers. Notably, all the participant groups highlighted the need for research into the efficacy of traditional medicines and how to promote collaborative strategies between traditional and allopathic treatment practices.

CONCLUSION

The prioritisation of chronic snakebite envenoming challenges by community members and how to live and cope with such conditions accentuate the lack of post-hospital treatment follow-ups for both mental and physical rehabilitation. To improve the quality of life of patients, it is essential to involve grassroots stakeholders in the process of developing and prioritising future research agenda.

Identifying high snakebite risk area under climate change for community education and antivenom distribution

Snakebite is one of the largest risks from wildlife, however little is known about venomous snake distribution, spatial variation in snakebite risk, potential changes in snakebite risk pattern due to climate change, and vulnerable human population. As a consequence, management and prevention of snakebite is hampered by this lack of information. Here we used habitat suitability modeling for 10 medically important venomous snakes to identify high snakebite risk area under climate change in Iran. We identified areas with high snakebite risk in Iran and showed that snakebite risk will increase in some parts of the country. Our results also revealed that mountainous areas (Zagros, Alborz, Kopet-Dagh mountains) will experience highest changes in species composition. We underline that in order to improve snakebite management, areas which were identified with high snakebite risk in Iran need to be prioritized for the distribution of antivenom medication and awareness rising programs among vulnerable human population.

Healthcare practitioners' knowledge of snakebite management and associated factors in high-burden, low-resource settings in Uganda

BACKGROUND

Snakebites cause significant morbidity and mortality in Uganda. Effective management of snakebites requires knowledge of the appropriate first aid measures, as well as knowledge of the appropriate antivenom to use, but little is known about familiarity with effective snakebite management techniques and associated factors among healthcare practitioners (HCPs) in Uganda.

METHODS

In May 2022, we collected data on sociodemographic characteristics, knowledge of snakebite first aid, envenomation signs, diagnosis and antivenom administration among 311 HCPs from two snakebite high-incidence districts in Uganda using a semi-structured questionnaire.

RESULTS

Of the 311 HCPs, 64.3% had ever treated snakebite cases, 87.1% were confident to provide supportive treatment, but only 9.6% had ever been trained on snakebite management. Overall, 22.8% of HCPs had high knowledge of snakebite management. Higher education (at least degree vs certificate; PR=2.21 95% CI 1.508 to 4.56), older age (30-45 vs <30 y; PR=1.97, 95% CI 1.22 to 3.21) and previous training (PR=1.82, 95% CI 1.08 to 3.05) were associated with high knowledge of snakebite diagnosis and management.

CONCLUSIONS

Overall, knowledge of snakebite management was limited. Training, level of education and age of the HCP all had an impact on knowledge. Deliberate efforts are required to increase HCPs' knowledge of snakebite case care in high-burden regions to manage incident cases.

Perspectives on snakebite envenoming care needs across different sociocultural contexts and health systems: A comparative qualitative analysis among US and Brazilian health providers

With the advancements in therapeutics and available treatment options, almost all deaths and permanent disabilities from snakebite envenoming (SBE) are preventable. The challenge lies in implementing these evidence-based treatments and practices across different settings and populations. This study aims to compare data on provider perceptions of SBE care across health systems and cultural contexts to inform potential implementation science approaches. We hypothesize different health systems and cultural contexts will influence specific perceived needs to provide adequate snakebite care within central tenets of care delivery (e.g., cost, access, human resources). We previously conducted exploratory descriptive studies in the US and Brazil in order to understand the experience, knowledge, and perceptions of health professionals treating SBE. In the US, in-depth interviews were performed with emergency physicians from January 2020 to March 2020. In BR, focus group discussions were conducted with health professionals from community health centers at the end of June 2021. The focus group discussions (BR) were originally analyzed through an inductive thematic analysis approach. We conducted a secondary qualitative analysis in which this codebook was then applied to the interviews (US) in a deductive content analysis. The analysis concluded in August 2022. Brazil participants were physicians (n=5) or nurses (n=20) from three municipalities in the State of Amazonas with an average of three years of professional experience. US participants were emergency physicians (n=16) with an average of 15 years of professional experience. Four main themes emerged: 1) barriers to adequate care on the patient and/or community side and 2) on the health system side, 3) perceived considerations for how to address SBE, and 4) identified needs for improving care. There were 25 subthemes within the four themes. These subthemes were largely the same across the Brazil and US data, but the rationale and content within each shared subtheme varied significantly. For example, the subtheme "role of health professionals in improving care" extended across Brazil and the US. Brazil emphasized the need for task-shifting and -sharing amongst health care disciplines, whereas the US suggested specialized approaches geared toward increasing access to toxicologists and other referral resources. Despite similar core barriers to adequate snakebite envenoming care and factors to consider when trying to improve care delivery, health professionals in different health systems and sociocultural contexts identified different needs. Accounting for, and understanding, these differences is crucial to the success of initiatives intended to strengthen snakebite envenoming care. Implementation science efforts, with explicit health professional input, should be applied to develop new and/or adapt existing evidence-based treatments and practices for SBE.

Snakebite victim profiles and treatment-seeking behaviors in two regions of Kenya: results from a health demographic surveillance system

INTRODUCTION

Snakebites are a major cause of permanent injury and death among poor, rural populations in developing countries, including those in East Africa. This research characterizes snakebite incidence, risk factors, and subsequent health-seeking behaviors in two regions of Kenya using a mixed methods approach.

METHODS

As a part of regular activities of a health demographic surveillance system, household-level survey on snakebite incidence was conducted in two areas of Kenya: Kwale along the Kenyan Coast and Mbita on Lake Victoria. If someone in the home was reported to have been bitten in the 5 years previous to the visit, a survey instrument was administered. The survey gathered contextual information on the bite, treatment-seeking behavior and clinical manifestations. To obtain deeper, contextual information, respondents were also asked to narrate the bite incident, subsequent behavior and outcomes.

RESULTS

8775 and 9206 households were surveyed in Kwale and Mbita, respectively. Out of these, 453 (5.17%) and 92 (1.00%) households reported that at least one person had been bitten by a snake in the past 5 years. Deaths from snakebites were rare (4.04%), but patterns of treatment seeking varied. Treatment at formal care facilities were sought for 50.8% and at traditional healers for 53.3%. 18.4% sought treatment from both sources. Victims who delayed receiving treatment from a formal facility were more likely to have consulted a traditional healer (OR 8.8995% CI [3.83, 20.64]). Delays in treatment seeking were associated with significantly increased odds of having a severe outcome, including death, paralysis or loss of consciousness (OR 3.47 95% CI [1.56; 7.70]).

CONCLUSION

Snakebite incidence and outcomes vary by region in Kenya, and treatment-seeking behaviors are complex. Work needs to be done to better characterize the spatial distribution of snakebite incidence in Kenya and efforts need to be made to ensure that victims have sufficient access to effective treatments to prevent death and serious injury.