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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 37-44

Primary prevention of snakebite envenoming in resource-limited settings: A narrative review


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 Submission15-Mar-2019
Date of Acceptance27-Apr-2019
Date of Web Publication17-Jun-2019

Correspondence Address:
Dr Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ed.ed_11_19

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  Abstract 


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

How to cite this URL:
Michael GC, Aliyu I, Grema BA. Primary prevention of snakebite envenoming in resource-limited settings: A narrative review. Environ Dis [serial online] 2019 [cited 2022 Jul 5];4:37-44. Available from: http://www.environmentmed.org/text.asp?2019/4/2/37/260512




  Introduction Top


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 Top


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.
Figure 1: Flow diagram of article selection

Click here to view



  Discussion Top


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:

  1. Improving the awareness through health education on the risk of snakebite in communities and groups with the risk of snakebite[59],[60]
  2. 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
  3. Poking holes and animal nests (where snakes may inhabit) should be avoided. Where this is necessary, poking with sticks is recommended[59],[85]
  4. 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
  5. 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
  6. 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]
  7. 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
  8. 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
  9. Snake charming (especially venomous snakes) should be discouraged[59],[72]
  10. 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]
  11. 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 Top


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.



 
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