|
 
 |
| REVIEW ARTICLE |
|
| Year : 2019 | Volume
: 4
| Issue : 2 | Page : 37-44 |
|
Primary prevention of snakebite envenoming in resource-limited settings: A narrative review
Godpower Chinedu Michael1, Ibrahim Aliyu2, Bukar Alhaji Grema1
1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
| Date of Submission | 15-Mar-2019 |
| Date of Acceptance | 27-Apr-2019 |
| Date of Web Publication | 17-Jun-2019 |
Correspondence Address:
Dr Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Kano
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ed.ed_11_19
Background: Snakebite envenoming is a neglected tropical disease that accounts for preventable morbidity and mortality, especially in resource-limited settings. This review aimed at examining the snake and human behaviors that facilitate snake-human encounters and highlighting the primary preventive measures for snakebite and the resultant envenoming.
Materials and Methods: Google Scholar, Medline (via PubMed), and African Journal Online were searched from January 1959 to April 2019 for peer-reviewed studies addressing primary prevention of snakebite. We extended our search to grey literature from conference proceedings, documents from organizations, book chapters, and thesis.
Results: We found few studies in medical literature on community knowledge of the intrinsic characteristics of snakes (e.g., its unique venom apparatus for nutrition, defense and competition, and its habitat and activities); however, there is appreciable amount of studies on human activities associated with snakebite envenoming. Deservedly, more studies appear to focus on snakebite management (secondary and tertiary prevention) with inadequate emphasis on primary prevention of snakebite (which may be the only intervention in some resource-limited settings).
Conclusion: Synergy of efforts toward improving community knowledge of human behaviors associated with snakebite and snake behaviors may generate appropriate environmental and behavioral responses to curtail human-snake encounters. Hence, intensive promotion of primary prevention may be a useful approach toward reducing snakebite burden in resource-limited settings.
Keywords: Envenoming, human and snake behavior, primary prevention, rural health, snakebite
How to cite this article:
Michael GC, Aliyu I, Grema BA. Primary prevention of snakebite envenoming in resource-limited settings: A narrative review. Environ Dis 2019;4:37-44 |
| Introduction | |  |
Snakebite envenoming is a neglected tropical disease that accounts for many preventable injuries and deaths worldwide.[1],[2] Snakebite can occur everywhere except in the permanently frozen Arctic and Antarctic regions of the world and few islands (e.g., Iceland, Ireland, Greenland, and New Zealand);[3] however, snakebite envenoming is most common among agricultural workers, herders, children, and locals in impoverished communities of South Asia, Southeast Asia, and Sub-Saharan Africa.[4],[5] With frequent human-snake encounters in affected communities, it is expected that localities will be familiar with the offending snakes and will react appropriately toward preventing these encounters.[6],[7],[8] However, despite this anticipated familiarity, snakebite morbidity and mortality remain a concern.[1],[2],[9] Reports have attributed the current burden of snakebite envenoming to socioeconomic and environmental factors along with weak healthcare systems (including ineffective prevention programs) in affected communities.[10],[11],[12],[13],[14] Although deservedly most reports have predominantly been on the management of snakebite envenoming (secondary and tertiary prevention), only few reports like that of Tianyi et al. have centered on primary prevention of the disease.[15]
Primary prevention of a disease (defined by the World Health Organization as “actions aimed at avoiding the manifestation of a disease [including actions to improve health through changing the impact of social and economic determinants on health]; the provision of information on behavioral and medical health risks, alongside consultation and measures to decrease them at the personal and community level")[16] remains an important strategic intervention in reducing the burden of snakebite envenoming. Primarily, preventing a snakebite in the first instance precludes challenges such as inappropriate traditional interventions,[17] long delays before receiving proper treatment,[10] antivenom scarcity,[5],[18],[19],[20] and inadequate training of health workers on snakebite management[10],[11],[18],[21] often cited as facilitators of snakebite morbidity and mortality.
This narrative review, therefore, aimed at highlighting some snake behaviors, human activities that increase the risk of individuals and communities to snakebite incidents, and strategies for the primary prevention of envenoming, especially in resource-limited settings where most snakebite occurs. Care-seeking behaviors following a bite (secondary prevention) that aids in curtailing envenoming have also been highlighted. It is hoped that this review will become a useful resource to students, clinicians, and the general public residing in or traveling to areas where snakes are prevalent.
| Materials and Methods | | |
Data for this review were obtained by searching Google Scholar, Medline (via PubMed), and African Journal Online from January 1, 1959, to April 22, 2019, for observational and experimental studies addressing primary prevention of snakebite. The keywords (in English language) for the search included but limited to “primary prevention of snakebite,” “primary prevention of snakebite envenoming,” “snake behavior,” “snakebite management,” “snake habitat,” “human activities associated with snakebite,” and “snakebite in humans.” This was done to obtain maximum number of studies that address the issues of primary prevention, knowledge of snakes/snakebite by stakeholders, snakes (species, defense, nutrition, seasonal preferences, etc.), human activities associated with snakebite, snakebite victims' care-seeking behavior, and recommendations for primary prevention of snakebite. The reference lists of obtained articles were also scanned for additional relevant studies using electronic search. We also searched for grey literature from conference proceedings, documents from organizations (e.g., World Health Organization), book chapters, and thesis. Studies published in other languages (except one in French) were excluded for lack of resources for translation. [Figure 1] shows the flow diagram of article selection for this review.
| Discussion | | |
Primary prevention of snakebite envenoming could be achieved through adequate community knowledge of snake and human behaviors that enhances snakebite incidents and snakebite envenoming. However, some reports show inadequate knowledge of local medically important snakes and effective snakebite management among stakeholders.[6] Studies have shown that about three-quarters of Sri Lankan farmers did not know that most local snakes were nonvenomous;[22] similarly, only one-third of internees of a medical college in India knew that only 70% of local snakes were venomous.[23] In addition, >60% of rural dwellers in a study in India could not identify locally venomous snakes;[24] less than half of the students in a study in West Bengal had good knowledge of snakebite first aid measures;[25] among tertiary hospital doctors in Northern Nigeria, only a quarter had adequate knowledge of local venomous snake species;[21] only 29% of the doctors in Hong Kong were confident in treating snakebite patients;[26] whereas 80.6% of health workers had poor knowledge of snakebite before a training program in Cameroon.[27] Furthermore, there are only few studies on community knowledge of snake behavior and activities as it relates to snakebite prevention.[6],[8],[28] Consequently, examining snake behavior and human activities associated with snakebite incidents has the potential of increasing community knowledge of snakes and snakebite. In addition, studies have shown that educational interventions improve snakebite management and prevention.[27],[29],[30]
Snake behaviors
Snake behavior is predicated on its survival. Hence, its activities are influenced by factors such as atmospheric temperature, nutrition, and defense.[31],[32] Snakes are ectotherms (that is, they control body temperature externally) and expose themselves to sunlight or withdraw into cool places depending on ambient temperature.[31],[33] Snakes are generally carnivores and eat a variety of items that include termites, rodents, birds, frogs, small deer, and other reptiles.[32],[33],[34],[35],[36],[37] They have specialized jaws and dental systems that enable them to eat their prey whole, eat preys as large as three times their heads' diameter, and hold their prey in their mouths without escaping.[31],[38],[39],[40] Similarly, venomous snakes from the families of Viperidae (vipers, adders, pit vipers, and moccasins), Elapidae (cobras, mambas, kraits, coral snakes, Australasian venomous snakes, and sea snakes), Atractaspidinae (burrowing asps), and Colubridae have modified teeth (fangs) through which highly potent venoms secreted from their oral glands are injected into their prey.[35],[36],[37] These venoms (with varying compositions) injected into preys are for subduing and killing them for nutrition, defensive mechanism against adversaries, and competition.[35],[36],[37],[41],[42] However, a few venomous snakes, in addition, spit their venom toward their victims (e.g., by African spitting cobras), resulting in venom ophthalmia in humans.[43]
Snakes are generally active in warm atmospheric conditions and tend to hibernate when it is cold.[31] When active, they move about looking for food. Humans are not one of their targets. They usually avoid humans, but human-snake encounters occur only when avoiding humans is inevitable or when humans tread upon them; this creates the incident of snakebite.[31]
However, despite the afore-mentioned behavior and characteristics and cycles of diurnal and seasonal activities known to determine the risk of snake-human encounters, snake behavior is still not completely understood.[37]
Human activities associated with snakebite
Like the snakes, human activities especially those related to snakebite envenoming are also predicated on survival and as such many of the human activities cannot be totally avoided, especially in rural areas where most snakebite occurs. However, some human activities have been associated with snakebite.
Agricultural, hunting, and forestry activities
Snakebite has been associated with agricultural, hunting, and forestry activities.[5],[10],[11],[44],[45],[46],[47],[48],[49],[50],[51] Planting and harvesting activities increase human-snake encounter;[10] rural farmers accidentally tread upon these reptiles as their habitats are being exposed while preparing the ground for planting, weeding, or harvesting. This partly explains the seasonal nature of snakebite prevalence in agrarian communities.[52] Similarly, snakebites have been reported among workers in rubber plantations.[46],[53] Regarding livestock settings, poultry farms located near the home can attract snakes (especially cobras); snakebite in chickens has been documented in a poultry farm in Nigeria with 87.5% case fatality rate.[54] Hens incubating eggs were the most vulnerable to snakebite, and a large canopy of trees and bushes around the farm was another predisposing factor for snakebite.[54] Poultry workers can therefore be exposed snakebites. Herding, on the other hand, involves movement of animals from place to place in search of vegetation in many climes; this exposes the herders to snakebite.[10] Similarly, hunting of animals is another occupation or hobby that increases human-snake encounters when hunters search for games in the bush or poke holes or animal nests with bare hands.[10],[44] Hunters and their dogs have been bitten by venomous snakes (e.g., the neurotoxic Micrurus spp.) in Trinidad.[55]
Walking on bush paths/travelers
Walking along bush paths constitutes a significant risk for snakebite[44],[56] as snakes in activity could be encountered on the bush paths. This behavior is common in many rural communities where snakes are prevalent.[44],[56],[57] Snakebite in the bush was also reported in a case series by Tianyi et al. in Cameroon.[15] This often occurs during evening hours when victims hardly identify snakes on their path due to darkness.[57],[58] Furthermore, travelers, tourists, and hikers have had snakebites even though the risk of snakebite among these groups remains small.[59],[60]
Activities in and around the home
In rural communities where firewood is a major cooking fuel, firewood collection may constitute a high-risk activity.[56],[59] Firewood heap provides a hiding place for snakes and can be a source of rodents that in turn attracts snakes. Similarly, ant (or termite) mounds attract snakes and other animals on which snakes may feed on; heaps of building materials and refuse dumps, overgrown vegetation around the home, and tree branches touching the house constitute potential risk factors for snakebite around the home.[59] These conditions provide hiding places for snakes or rodents. Snakes can enter the home using the tree branches. Studies have also reported snakebite occurring while victims are asleep on the ground (inside or outside of the home), thus making this practice a high-risk activity in communities where snakebite is prevalent.[61],[62],[63] However, snakebite has also been reported in victims who were sleeping on furniture bed.[64] In addition, children especially toddlers are also at risk if they are left alone on the ground unattended.[65]
Miscellaneous activities
Those who keep or handle exotic/venomous snakes (including snake rescuers, snake keepers, zoo attendants, snake researchers, and venom extraction workers) are at risk of snakebite.[66],[67],[68],[69],[70] The cleaning of the snake environment, updating of exhibited snakes, and giving veterinary care to snakes put them in harm's way.[68] Among researchers in the Australian snakebite project-15, snakebite occurred during handling, catching, feeding of snakes, as well as when cleaning the cages in which the snakes were kept.[69] Similarly, snake charming which refers to the practice of hypnotizing a snake by playing an instrument and typically involves handling snakes or performing other dangerous acts has been associated with snakebite.[71],[72]
In addition, military operations involving training camps or combat operations which often occur in rocky, mountainous, and bushy areas laden with reptiles (snakes inclusive) have seldom been associated with snakebite among the US, Indian, Israeli, Chinese, British, and African military personnel.[73],[74],[75],[76],[77] Military personnel have been bitten on the buttocks and thigh while defecating in open camp fields and on the finger while cutting grass.[74] There have also been reports of snakebite following physical fights between child herders in the bush[78] and between traditional healers in the bush.[15] Similarly, conflicts, wars, and natural disasters (like flooding) often result in internally displaced persons and/or refugees; the displaced persons who live in camps are also exposed to animal bites.[79],[80] Flooding, for instance, displaces snakes from their natural habitats and increases the potential for human-snake encounters.[81]
Care-seeking behaviors after snakebite
Following snakebite, not all victims become envenomed. Some have dry bites, some spill their venom before it reaches the victim's body, in others their fang encounters a barrier (rubber boots, thick clothing, etc.) or spill the venom outside victim's body.[59] This is partly the basis for reassurance after a suspected snakebite. Furthermore, the care-seeking behavior of snakebite victims has been adequately reported. Many (including 50%–90% of snakebite victims in sub-Saharan Africa)[82] sought after traditional healers for first-line treatment; these traditional healers offer interventions such as tourniquet application, bite site incision, application of oral and topical concoctions, shock, suction of bite site, and cryotherapy.[17],[59],[83] Studies have not only questioned the efficacy of these traditional practices but also associated them with increased complications.[17],[83] As such, some envenomed victims find their ways to the hospital lately increasing adverse outcomes.[47] Unfortunately, many hospitals in rural areas where most snakebite occur are ill equipped to handle snakebite envenoming.[5],[59] There are no sustainable programs to ensure availability of affordable, effective snake antivenom (the mainstay of envenoming treatment) in most rural Sub-Saharan countries.[5],[10],[11],[19]
Recommendation
Most experts and guidelines are unanimous in the following recommendations:
- Improving the awareness through health education on the risk of snakebite in communities and groups with the risk of snakebite[59],[60]
- Consistent wearing of fang-proof rubber or leather shoes (or boots) and long trousers should be encouraged.[5],[59] This has been shown to reduce snakebite morbidity and mortality among farmers.[84] This may also be applicable to those involved in agricultural, hunting, and forestry activities
- Poking holes and animal nests (where snakes may inhabit) should be avoided. Where this is necessary, poking with sticks is recommended[59],[85]
- A multipronged approach is recommended for preventing snake entry into poultry farms: covering all potential entry points (cracks or holes) on the wall, roof, and floor of the coop; clearing all grasses and tree branches around the coop; and avoiding left overs of chicken feeds, eggs, or snacks inside the coop as they attract both snakes and rodents (potential meal for snakes).[54] Poultry farmers are also advised to wear protective fang-proof boots while in their farms
- Those who walk along bush paths must be vigilant, carry a long stick to poke bush paths in front of them to scare snakes away, wear protective shoes and long trousers, and carry flashlight (torch, lamp, or lanterns) at night.[59] Clearing bushes on the shoulders of bush path also increases the ability of a potential victim to identify snakes
- Travelers must inquire in advance about the snake species in the areas they intend to visit.[60] Such information is usually available on the web. This information helps in promoting appropriate preventive behavior, dictate the emergency equipment and supplies to carry and dictate the most appropriate management should a bite take place.[86] They are advised to open and shake-out sleeping bags, boots, and clothing before use to dislodge hidden animals (snakes, scorpions, etc.) in them; to check the ground before sitting on tree bases; to wear boots, socks, and long trousers when walking in undergrowth or deep sand; to use a flashlight at night when walking, collecting firewood, or defecating, especially after heavy rain; and to be aware that snakes are common on the bank of streams, rivers, and lakes.[60] They are also advised to travel with a local guide who will easily identify camouflaged snakes; to sleep off the ground (camp bed); or to use a sewn-in groundsheet and mosquito-proof tent or sleep under insecticide-treated mosquito net that is well-tucked-in under their sleeping bag or mattress;[87] this will protect against night-prowling kraits (in Asia) or spitting cobras (in Africa) which often bite people while they are asleep on the ground[60]
- Around the home, heaps of building materials and refuse dumps should be avoided; handling woods from firewood heaps should be preceded by carefully poking with a long stick to expose any hidden snakes.[59] Clearing overgrown bushes and trees around the home in addition to good lightening is also essential. Regular checks for the presence of snakes in the home and sealing openings/cracks on the wall or doors should be routinely done. Experts have also advised that before stepping down from the bed at night, flashlight can be used to illuminate the environment around the bed to exclude the presence of a snake as stepping on the snake can result in a bite
- Snake handlers (e.g., venom extraction workers, zoo attendants, snake rescuers, and researchers) should receive proper training for their job description and made to adhere strictly to standard operating procedures;[88] color codes or legible signage can be used to delineate containers or shelves containing venomous from nonvenomous snakes in the zoo
- Snake charming (especially venomous snakes) should be discouraged[59],[72]
- Military operations should be preceded by snakebite awareness and prevention programs as well as programs on field management of snakebite.[73],[74],[75],[76],[77] Enforcement of measures such as wearing boots before leaving the barracks, checking boots with a stick for the presence snake, carrying torchlight and stick during dark hours, avoiding poking limbs into places outside one's visual field until it is checked with a stick, and maintaining camp sanitation has been found to reduce snakebite in military camps[89]
- In the event of snakebite, expeditious transfer of the immobilized victim to the nearest facility with the capacity to manage snakebite envenoming is recommended (secondary prevention). The use of pressure bandaging to immobilize the victim's limb (which aids reduce dissemination of the venom from the bite site) is limited by lack of expertise among those who should apply it in the field.[90],[91] Pressure bandage immobilization is controversial in viper bites due to the predominance of tissue swelling and necrosis associated with them.[59],[79]
Policy implication
Primary prevention of snakebite remains a vital strategy in curbing the menace of snakebite envenoming globally. Although we did include studies published in other languages, we believe that there are limited studies on community knowledge of snake behavior and may be an area for future research direction. Emphases on educational programs that target the community and particularly various groups whose activities increase human-snake encounters have the ability of changing the current narrative of snakebite envenoming. Workshops, trainings, and mass educational programs on the management of snakebite envenoming need to include robust packages on primary prevention to achieve the multipronged approach needed to reduce snakebite morbidity and mortality in many resource-limited settings. Finally, more studies are needed in the future to formally assess the effectiveness of the above recommendations in the prevention of snakebite incidents and snakebite envenoming.
| Conclusion | | |
In communities where snakebite envenoming is prevalent, virtually every human activity can be associated with snakebite. However, examining and understanding snake and human behaviors that facilitates human-snake encounters and the crises of snakebite envenoming can be a useful approach in identifying primary preventive measures of the disease. These preventive measures may need to be promoted to play important roles in the efforts toward snakebite envenoming reduction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | |
| 3. | Bauchot R, editor. Snakes: A Natural History. New York: Sterling Publishing Co., Inc.; 1994. p. 220.  |
| 4. | Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: A literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008;5:e218. |
| 5. | Tochie JN, Temgoua MN, Njim T, Celestin D, Tankeu R, Nkemngu NJ. The neglected burden of snakebites in Cameroon: A review of the epidemiology, management and public health challenges. BMC Res Notes 2017;10:405. |
| 6. | Pandey DP, Subedi Pandey G, Devkota K, Goode M. Public perceptions of snakes and snakebite management: Implications for conservation and human health in Southern Nepal. J Ethnobiol Ethnomed 2016;12:22. |
| 7. | Moura MR, Costa HC, São-Pedro VA, Fernandes VD, Feio RN. The relationship between people and snakes in Eastern Minas Gerais, Southeastern Brazil. Biota Neotrop 2010;10:133-41. |
| 8. | Alves RR, Silva VN, Trovão DM, Oliveira JV, Mourão JS, Dias TL, et al. Students' attitudes toward and knowledge about snakes in the semiarid region of Northeastern Brazil. J Ethnobiol Ethnomed 2014;10:30. |
| 9. | |
| 10. | Chippaux JP. Snake-bites: Appraisal of the global situation. Bull World Health Organ 1998;76:515-24. |
| 11. | Habib AG. Public health aspects of snakebite care in West Africa: Perspectives from Nigeria. J Venom Anim Toxins Incl Trop Dis 2013;19:27. |
| 12. | Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in South Asia: A review. PLoS Negl Trop Dis 2010;4:e603. |
| 13. | Bhelkar SM, Chilkar SD, Morey SM. Study of snake bite cases admitted in tertiary care hospital in Nagpur. Int J Community Med Public Health 2017;4:1597-602. |
| 14. | Kularatne SA. Common krait ( Bungarus caeruleus) bite in Anuradhapura, Sri Lanka: A prospective clinical study, 1996-98. Postgrad Med J 2002;78:276-80. |
| 15. | Tianyi FL, Agbor VN, Tochie JN, Kadia BM, Nkwescheu AS. Community-based audits of snake envenomations in a resource-challenged setting of Cameroon: Case series. BMC Res Notes 2018;11:317. |
| 16. | |
| 17. | Michael GC, Thacher TD, Shehu MI. The effect of pre-hospital care for venomous snake bite on outcome in Nigeria. Trans R Soc Trop Med Hyg 2011;105:95-101. |
| 18. | Theakston RD, Warrell DA. Crisis in snake antivenom supply for Africa. Lancet 2000;356:2104. |
| 19. | Gutiérrez JM. Improving antivenom availability and accessibility: Science, technology, and beyond. Toxicon 2012;60:676-87. |
| 20. | Stock RP, Massougbodji A, Alagón A, Chippaux JP. Bringing antivenoms to sub-Saharan Africa. Nat Biotechnol 2007;25:173-7. |
| 21. | Michael GC, Grema BA, Aliyu I, Alhaji MA, Lawal TO, Ibrahim H, et al. Knowledge of venomous snakes, snakebite first aid, treatment, and prevention among clinicians in Northern Nigeria: A cross-sectional multicentre study. Trans R Soc Trop Med Hyg 2018;112:47-56. |
| 22. | Silva A, Marikar F, Murugananthan A, Agampodi S. Awareness and perceptions on prevention, first aid and treatment of snakebites among Sri Lankan farmers: A knowledge practice mismatch? J Occup Med Toxicol 2014;9:20. |
| 23. | Naskar S, Das D, Mukherjee A, Chowdhury R, Mitra K, Majumder DB. Knowledge on snake bite diagnosis and management among internees in a government medical college of Kolkata. J Dent Med Sci 2015;14:52-5. |
| 24. | Chincholikar SV, Bandana P, Swati R. Awareness of snake bite and its first aid management in rural areas of Maharashtra. Indian J Commun Health 2014;26:311-5. |
| 25. | Dasgupta A, Bandyopadhyay L, Das M. Effectiveness of health education in terms of knowledge acquisition on first aid measures among school students of a rural area of West Bengal. Med Res Chron 2014;1:84-91. |
| 26. | Fung HT, Lam SK, Lam KK, Kam CW, Simpson ID. A survey of snakebite management knowledge amongst select physicians in Hong Kong and the implications for snakebite training. Wilderness Environ Med 2009;20:364-70. |
| 27. | Taieb F, Dub T, Madec Y, Tondeur L, Chippaux JP, Lebreton M, et al. Knowledge, attitude and practices of snakebite management amongst health workers in Cameroon: Need for continuous training and capacity building. PLoS Negl Trop Dis 2018;12:e0006716. |
| 28. | Pathak I, Metgud C. Knowledge, attitude and practice regarding snakes and snake bite among rural adult of Belagavi, Karnataka. Int J Community Med Public Health 2017;4:4527-31. |
| 29. | Pandey DP, Thapa CL, Hamal PK. Impact of first aid training in management of snake bite victims in Madi valley. J Nepal Health Res Counc 2010;8:5-9. |
| 30. | Gramza A, Temple S. Effect of education programs on the knowledge & attitudes about snakes in San Isidro de Upala, Costa Rica. J Kansas Herpetol 2010;33:12-8. |
| 31. | Greene HW. Snakes. The Evolution of Mystery in Nature. Berkeley: University of California Press; 1997. p. 131. |
| 32. | Pandey DP, Bhattarai P, Piya RC. Food spectrum of the Common Krait ( Bungarus caeruleus): An implication for snakebite prevention and snake conservation [Abstract]. In: Keyler DE and Sanchez EE (eds.), Abstract from Venom Week VI, 14–18 Mar 2018, Texas A&M University, Kingsville, Texas, USA. P. 315–334. Toxicon 2018;150:330-1. |
| 33. | Joshi HS, Mahmood SE, Joshi MC, Shaifali I, Srivastava PC. Clinico-epidemiological profile of snake bite cases in Western Nepal. TAF Prev Med Bull 2012;11:57-62. |
| 34. | Reeder TW, Townsend TM, Mulcahy DG, Noonan BP, Wood PL Jr., Sites JW Jr., et al. Integrated analyses resolve conflicts over squamate reptile phylogeny and reveal unexpected placements for fossil taxa. PLoS One 2015;10:e0118199. |
| 35. | White J. Bites and stings from venomous animals: A global overview. Ther Drug Monit 2000;22:65-8. |
| 36. | Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002;347:347-56. |
| 37. | Warrell DA. Snake bite. Lancet 2010;375:77-88. |
| 38. | Albright RG, Nelson EM. Cranial kinetics of the generalized colubrid snake Elaphe obsoleta quadrivittata. II. Functional morphology. J Morphol 1959;105:241-91. |
| 39. | Andjelkovic M, Tomovic L, Ivanovic A. Morphological integration of the kinetic skull in Natrixsnakes. J Zool 2017;303:188-98. |
| 40. | Cundall D. Activity of head muscles during feeding by snakes: A comparative study. Am Zool 1983;23:383-96. |
| 41. | Fry BG, Roelants K, Champagne DE, Scheib H, Tyndall JD, King GF, et al. The toxicogenomic multiverse: Convergent recruitment of proteins into animal venoms. Annu Rev Genomics Hum Genet 2009;10:483-511. |
| 42. | Fry BG, Casewell NR, Wüster W, Vidal N, Young B, Jackson TN. The structural and functional diversification of the Toxicofera reptile venom system. Toxicon 2012;60:434-48. |
| 43. | Chu ER, Weinstein SA, White J, Warrell DA. Venom ophthalmia caused by venoms of spitting elapid and other snakes: Report of ten cases with review of epidemiology, clinical features, pathophysiology and management. Toxicon 2010;56:259-72. |
| 44. | Madaki JK, Obilom R, Mandong BM. Clinical presentation and outcome of snake bite in patients at Zamko Comprehensive Health Centre, Langtang, Plateau state. Highland Med Res J 2004;2:61-5. |
| 45. | Pierini SV, Warrell DA, de Paulo A, Theakston RD. High incidence of bites and stings by snakes and other animals among rubber tappers and Amazonian Indians of the Juruá valley, Acre state, Brazil. Toxicon 1996;34:225-36. |
| 46. | Waldez F, Vogt RC. Ecological and epidemiological aspects of snakebites in riverside communities of the lower Purus river, Amazonas, Brazil. Acta Amaz 2009;39:681-92. |
| 47. | Esiéné A, Etoundi PO, Tochie JN, Metogo AJ, Minkande JZ. Severe Viperidae envenomation complicated by a state of shock, acute kidney injury, and gangrene presenting late at the emergency department: A case report. BMC Emerg Med 2019;19:26. |
| 48. | |
| 49. | Pandey DP. Epidemiology of snakebites based on field survey in Chitwan and Nawalparasi districts, Nepal. J Med Toxicol 2007;3:164-8. |
| 50. | Majumder D, Sinha A, Bhattacharya SK, Ram R, Dasgupta U, Ram A. Epidemiological profile of snake bite in South 24 Parganas district of West Bengal with focus on underreporting of snake bite deaths. Indian J Public Health 2014;58:17-21. [ PUBMED] [Full text] |
| 51. | Kipanyula MJ, Kimaro WH. Snakes and snakebite envenoming in Northern Tanzania: A neglected tropical health problem. J Venom Anim Toxins Incl Trop Dis 2015;21:32. |
| 52. | Pandey DP, Vohra R, Stalcup P, Shrestha BR. A season of snakebite envenomation: Presentation patterns, timing of care, anti-venom use, and case fatality rates from a hospital of Southcentral Nepal. J Venom Res 2016;7:1-9. |
| 53. | Stahel E. Epidemiological aspects of snake bites on a Liberian rubber plantation. Acta Trop 1980;37:367-74. |
| 54. | Lawal S, Abdu PA, Jonathan GB, Hambolu OJ. Snakebites in poultry. Vet Hum Toxicol 1992;34:528-30. |
| 55. | Nishioka SA, Silveira PV, Menzes LB. Coral snake bite and severe local pain. Ann Trop Med Parasitol 1993;87:429-31. |
| 56. | Madaki JK, Obilon RE, Mandong BM. Pattern of first aid measures used by snakebite patients and clinical outcome at Zamko Comprehensive Health Centre, Langtang, Plateau state. Niger Med Pract 2005;48:10-3. |
| 57. | Ogunfowokan O. Bite-to-hospital time and morbidity in victims of viper bite in a rural hospital in Nigeria. Afr J Prim Health Care Fam Med 2012;4:1-7. Available at: < https://phcfm.org/index.php/phcfm/article/view/371>. [Last accessed on 2019 Apr 13]. |
| 58. | Michael GC, Grema BA, Aliyu I. Potential barriers and facilitators of snakebite envenoming reduction in rural North Central Nigeria: Results of focus group discussions with snakebite survivors and caregivers. Niger Frontline Med J 2018;1:15-21. |
| 59. | |
| 60. | |
| 61. | Ariaratnam CA, Sheriff MH, Theakston RD, Warrell DA. Distinctive epidemiologic and clinical features of common krait (Bungarus caeruleus) bites in Sri Lanka. Am J Trop Med Hyg 2008;79:458-62. |
| 62. | Rodrigo C, Kirushanthan S, Gnanathasan A. Prevention of krait bites by sleeping above ground: Preliminary results from an observational pilot study. J Occup Med Toxicol 2017;12:10. |
| 63. | Nkwescheu A, Mbasso LC, Pouth FB, Dzudie A, Billong SC, Ngouakam H, et al. Snakebite in bedroom kills a physician in Cameroon: A case report. Pan Afr Med J 2016;24:231. |
| 64. | Pandey DP. Venomous Snakes of Medical Relevance in Nepal: Study on Species, Epidemiology of Snake Bite and Assessment of Risk Factors of Envenoming and Death. PhD thesis, Faculty of Biosciences, Goethe University, Frankfurt, Germany; 2015. |
| 65. | Sani UM, Jiya NM, Ibitoye PK, Ahmad MM. Presentation and outcome of snake bite among children in Sokoto, North-Western Nigeria. Sahel Med J 2013;16:148-53. [Full text] |
| 66. | Pandey DP, Ghimire A, Shrestha BR. Retrospective documentation of a confirmed White-Lipped Green Pit Viper ( Trimeresurus albolabris Gray, 1842) bite in the South-central hills of Nepal. Wilderness Environ Med 2019;30:79-85. |
| 67. | Greene S, Galdamez LA, Tomasheski R. White-Lipped tree viper ( Cryptelytrops albolabris) envenomation in an American viper keeper. J Emerg Med 2017;53:e115-8. |
| 68. | Isbister GK, Hooper MR, Dowsett R, Maw G, Murray L, White J. Collett's snake ( Pseudechis colletti) envenoming in snake handlers. QJM 2006;99:109-15. |
| 69. | Isbister GK, Brown SG; ASP Investigators. Bites in Australian snake handlers – Australian snakebite project (ASP-15). QJM 2012;105:1089-95. |
| 70. | Powell RL, Sanchez EE, Pérez JC. Farming of venom: Survey of snake venom extraction facilities worldwide. Appl Herpetol 2006;3:1-10. |
| 71. | |
| 72. | Kabir A. Biography of a snake charmer in Saidpur, Bangladesh. MOJ Biol Med 2018;3:151-2. |
| 73. | Shiau DT, Sanders JW, Putnam SD, Buff A, Beasley W, Tribble DR, et al. Self-reported incidence of snake, spider, and scorpion encounters among deployed U.S. military in Iraq and Afghanistan. Mil Med 2007;172:1099-102. |
| 74. | Singh J, Bhoi S, Gupta V, Goel A. Clinical profile of venomous snake bites in North Indian military hospital. J Emerg Trauma Shock 2008;1:78-80. [ PUBMED] [Full text] |
| 75. | Haviv J, Huerta M, Shpilberg O, Mimouni D, Ash N, Grotto I, et al. Field treatment of snakebites in the Israel defense forces. Public Health Rev 1998;26:247-56. |
| 76. | Chen C, Gui L, Kan T, Li S, Qiu C. A survey of snakebite knowledge among field forces in China. Int J Environ Res Public Health 2016;14. pii: E15. |
| 77. | Wilkins D, Burns DS, Wilson D, Warrell DA, Lamb LE. Snakebites in Africa and Europe: A military perspective and update for contemporary operations. J R Army Med Corps 2018;164:370-9. |
| 78. | Michael GC, Aliyu I, Grema BA. Viper bite on the neck following a fight. Sudan Med Monit 2015;10:133-6. [Full text] |
| 79. | |
| 80. | Warner GS. Increased incidence of domestic animal bites following a disaster due to natural hazards. Prehosp Disaster Med 2010;25:188-90. |
| 81. | Janani S, Maheshwaran EG, Leenu J, Samuel T, Raveen R. Rescue and rehabilitation of snakes during the floods of November and December 2015 at Chennai Tamil Nadu, India. Int J Zool Stud 2016;1:10-3. |
| 82. | Chippaux JP. Evaluation of the epidemiological situation and capacities in charge of ophidian envenomation in Francophone sub-Saharan Africa. Bull Soc Pathol Exot 2005;98:263-8. |
| 83. | Michael GC, Aliyu I, Grema BA, De-kaa NLP. Prehospital care practices for venomous snakebites in resource-limited settings: A narrative review. Arch Med Health Sci 2017;5:237-41. [Full text] |
| 84. | Pe T, Myint AA, Kyu KA, Toe MM. Acceptability study of protective boots among farmers of Taungdwingyi Township. Myanmar Health Sci Res J 1998;10:57-60. |
| 85. | |
| 86. | Boyd JJ, Agazzi G, Svajda D, Morgan AJ, Ferrandis S, Norris RL. Venomous snakebite in mountainous terrain: Prevention and management. Wilderness Environ Med 2007;18:190-202. |
| 87. | Chappuis F, Sharma SK, Jha N, Loutan L, Bovier PA. Protection against snake bites by sleeping under a bed net in Southeastern Nepal. Am J Trop Med Hyg 2007;77:197-9. |
| 88. | |
| 89. | Chauhan K, Nayar KR. An epidemiological study of snake bites in an area in the foothills of the North Western Himalayas. Med J Armed Forces India 1995;51:270-2. |
| 90. | Cheng AC, Currie BJ. Venomous snakebites worldwide with a focus on the Australia-Pacific region: Current management and controversies. J Intensive Care Med 2004;19:259-69. |
| 91. | Avau B, Borra V, Vandekerckhove P, De Buck E. The treatment of snake bites in a first aid setting: A systematic review. PLoS Negl Trop Dis 2016;10:e0005079. |
[Figure 1]
| This article has been cited by | | 1 |
Lifetime prevalence and knowledge of snakebite among graduates in Nigeria |
|
| Godpower C Michael, Bukar A Grema, Auwal A Bala, Abdulgafar L Olawumi, Aisa A Gana, Jeremiah K A Madaki, Abdulrazaq G Habib | | Transactions of The Royal Society of Tropical Medicine and Hygiene. 2023; | | [Pubmed] | [DOI] | | | 2 |
Assessing knowledge and awareness regarding snakebite and management of snakebite envenoming in healthcare workers and the general population: A systematic review and meta-analysis |
|
| Afsana Afroz, Bodrun Naher Siddiquea, Aishwarya Narendra Shetty, Timothy N. W. Jackson, Andrew D. Watt, Wuelton M. Monteiro | | PLOS Neglected Tropical Diseases. 2023; 17(2): e0011048 | | [Pubmed] | [DOI] | | | 3 |
How beliefs in traditional healers impact on the use of allopathic medicine: In the case of indigenous snakebite in Eswatini |
|
| Sarah Nann,Abdulrazaq G. Habib | | PLOS Neglected Tropical Diseases. 2021; 15(9): e0009731 | | [Pubmed] | [DOI] | | | 4 |
Promoting co-existence between humans and venomous snakes through increasing the herpetological knowledge base |
|
| Anita Malhotra,Wolfgang Wüster,John Benjamin Owens,Cameron Wesley Hodges,Allwin Jesudasan,Gnaneswar Ch,Ajay Kartik,Peter Christopher,Jose Louies,Hiral Naik,Vishal Santra,Sourish Rajagopalan Kuttalam,Shaleen Attre,Mahmood Sasa,Carlos Bravo-Vega,Kris A. Murray | | Toxicon: X. 2021; : 100081 | | [Pubmed] | [DOI] | | | 5 |
Clinical assessment and pathophysiology of Bothrops venom-related acute kidney injury: a scoping review |
|
| Polianna Lemos Moura Moreira Albuquerque,José Hicaro Hellano Gonçalves Lima Paiva,Alice Maria Costa Martins,Gdayllon Cavalcante Meneses,Geraldo Bezerra da Silva Júnior,Nicholas Buckley,Elizabeth De Francesco Daher | | Journal of Venomous Animals and Toxins including Tropical Diseases. 2020; 26 | | [Pubmed] | [DOI] | |
|
 |
|
|
|
![[JOURNAL_FULL_NAME]](images/logo.gif){kind=logo}
Search Pubmed for