New publication! Snakebite victim profiles and treatment-seeking behaviors in two regions of Kenya: results from a health demographic surveillance system in Tropical Medicine and Health (BMC)
Permanent injury from a puff adder bite, Kenya, 2016
Back in 2016 or so, I nearly stepped on a headless and very dead spitting cobra on an island in Homa Bay, Kenya. The locals apparently weren’t satisfied with simply decapitating it, but smashed the head to bits presumably so it couldn’t come back to life and bite someone. That gave me a hair brained idea to do a research project on snakebites and I’m proud to say that the results of that work have been published today.
This work was a team effort under the auspices of the Nagasaki University Institute of Tropical Medicine. It couldn’t have happened without the incredible contributions of researchers, students and local partners,in Kenya, Japan and the United States.
Elated.
“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.”
Short review of the literature on Snakebites in Kenya
There really isn’t much out there. I found 15 papers on PubMed and Web of Science. I am looking for more.
Case studies
(Davidson, 1970; Erulu, Okumu, Ochola, & Gikunju, 2018)
I found two case reports. The first was from 1970 documenting a case of a white woman being bitten in Voi when a black-necked spitting cobra (Naja nigricollis) entered her bed at night. She received prompt care of polyvalent antivenom, travelled to Mombasa the next day, received treatment again and was relatively mobile within a week. It too three months for a hole in her foot to finally heal and for normal sensation to return to her toes.
The second documented a bite from a black mamba (Dendroaspis polylepis) in Watamu. A 13-year-old boy presented to Watamu Hospital with labored breathing, frothing at the mouth, severe ptosis, pupils non-responsive with unreadable blood pressure and elevated heat rate. He was administered the SAVP polyvalent antivenom and the boy recovered.
Hospital based surveillance and clinician surveys
(Coombs et al., 1997; Ochola, Okumu, Muchemi, Mbaria, & Gikunju, 2018; M. Okumu et al., 2018; M. O. Okumu et al., 2019; Ooms et al., 2020)
Coombs, et al gathered data from four areas of Kenya using Ministry of Health records. It was found that bite cases varied by region. Documented deaths are rare. The incidence rate of snakebites varied by region, with Kakamega being low and areas like Samburu and Baringo being high. Documentation of snake bites was often incomplete. Many bites were recorded as “Other” in hospital records. Though environmental factors and habitats account for some variation in bite incidence rates, a lack of coordination of health facilities and inconsistent record keeping might also be a factor. Authors conclude that surveillance capacity needs to improve and that community should be educated to identify bites and provide appropriate treatment (i.e. only using tourniquets for neurotoxic bites from snakes like mambas.) Transport and proximity are noted as barriers to treatment.
Ochola, et al. Study on snakebites from four hospitals including Kakamega Provincial, Makueni District and two others. Two year retrospective study of hospital records form 2007-2009. 176 total bites, 91 in 2009. Bites peaked at 1-15 years of age, 132/176 bites occurred on the lower extremities. 49/176 were given antivenom. Most bites occurred in the dry season, in the bush and in the evening. Mortality was 2.27%. Authors found that antivenom was often not available, and use was inconsistent. Patients presented to hospitals 2 to 6 hours after the bite, mostly due to travel distance. 75% if clinicians believe that patients saw traditional healers before arriving at the hospital. Manual laborers at highest risk.
Ooms et al. study of health care workers in three countries including Kenya. HCWs reported that there was no gender disparity in snakebite victims, that most victims are between 21 and 30 and that most people are bitten when conducting farm related activities or walking. Only 12% of HCWs received training in snakebite management. Only 20% claimed that medicines were available. Snakebite incidence occurred in both urban and rural areas of all countries. Half of all respondents claimed that people seek traditional treatments before coming to formal facilities.
Okumu et al Paper on general poisonings. Snakebites are only one part of the paper but make up 33% of all cases that appeared at Jaramogi Oginga Odinga Teaching and Referral Hospital. Antivenom used in 58% of all snakebite case. “Black snakes” accounted for 37% of bites. Victims were not able to identify snake species in 38.6% of bites.
Okumu, 2019 Paper on cost of snakebite treatment. 127 snakebite victims attending JOOOTRH between January 2011 and Dec 2016. Most victims were 13024 years of age, 64 were female, 94 were from rural areas, 92 were bitten on the lower limbs. 49 bitten at night, 43 attempted to self-treat, median time to the hospital was 4.5 hours. Outcomes included cellulitis, compartment syndrome, gangrenous foot, psychiatric disorder and death. 1-5 days in the hospital. Median cost $26. Authors call for public health programs to educate the public on how to identify and treat snakebites.
Treatment seeking
(Snow et al., 1994)
Retrospective study of 4,712 households. Most bites were not from venomous snakes. Most people identified both venomous and non-venomous snakes as being potentially venomous. 68% of people sought treatment from traditional healers. Authors suggest that traditional healers be integrated int primary health care and hospital-based systems. Household heads were approached and administered a questionnaire in Kilifi and ask to retrospectively report bites. Out of 4,712 visits there were 121 case of snake bite reported, 57% were male. Most were Giriama. 55% were bitten at night. A73% on the foot. 94% bitten outdoors. Only 39% could reliably describe the snake. No deaths were recorded. 79% performed some kind of first aid immediately after the bite. 88% sought treatment, with 78% visiting the healer. Only 29% visited a hospital. There was evidence to suggest clustering of bites.
Indigenous knowledge
(Anne-Sophie, Neil, & Aida, 2017; Eucabeth & Augustine, 2017; Omara, 2020; B. O. Owuor & Kisangau, 2006; Bethwell O. Owuor, Mulemi, & Kokwaro, 2005)
Antivenoms/Medicines/Chemistry
(Benson, Mohamed, Soliman, Hassan, & Abou Mandour, 2017; Harrison et al., 2017; Omara, 2020)
Anne-Sophie, D., Neil, D. B., & Aida, C.-S. (2017). Medicinal Plant Trade in Northern Kenya: Economic Importance, Uses, and Origin^sup 1. Economic Botany, 71(1), 13.
Benson, R. A., Mohamed, N. M. A., Soliman, M., Hassan, M., & Abou Mandour, M. A. (2017). Application of k 0-INAA for the determination of essential and toxic elements in medicinal plants from West Pokot County, Kenya. Journal of Radioanalytical and Nuclear Chemistry, 314(1), 23. Retrieved from https://link.springer.com/content/pdf/10.1007%2Fs10967-017-5370-3.pdf
Coombs, M. D., Dunachie, S. J., Brooker, S., Haynes, J., Church, J., & Warrell, D. A. (1997). Snake bites in Kenya: a preliminary survey of four areas. Transactions of the Royal Society of Tropical Medicine and Hygiene, 91(3), 319-321. doi:10.1016/s0035-9203(97)90091-2
Davidson, R. A. (1970). Case of African cobra bite. British medical journal, 4(5736), 660-660. doi:10.1136/bmj.4.5736.660
Erulu, V., Okumu, M., Ochola, F., & Gikunju, J. (2018). Revered but Poorly Understood: A Case Report of Dendroaspis polylepis (Black Mamba) Envenomation in Watamu, Malindi Kenya, and a Review of the Literature. Tropical medicine and infectious disease, 3(3), 104. doi:10.3390/tropicalmed3030104
Eucabeth, O. a.-M. a., & Augustine, A. (2017). Identity Construction in Three AbaGusii Bewitchment Narratives. International Journal of Society, Culture & Language, 5(1), 29.
Harrison, R. A., Oluoch, G. O., Ainsworth, S., Alsolaiss, J., Bolton, F., Arias, A. S., . . . Casewell, N. R. (2017). Preclinical antivenom-efficacy testing reveals potentially disturbing deficiencies of snakebite treatment capability in East Africa. PLoS Negl Trop Dis, 11(10), e0005969. doi:10.1371/journal.pntd.0005969
Ochola, F. O., Okumu, M. O., Muchemi, G. M., Mbaria, J. M., & Gikunju, J. K. (2018). Epidemiology of snake bites in selected areas of Kenya. Pan Afr Med J, 29, 217. doi:10.11604/pamj.2018.29.217.15366
Okumu, M., Patel, M., Bhogayata, F., Olweny, I., Ochola, F., & Onono, J. (2018). Acute Poisonings at a Regional Referral Hospital in Western Kenya. Tropical medicine and infectious disease, 3(3), 96. doi:10.3390/tropicalmed3030096
Okumu, M. O., Patel, M. N., Bhogayata, F. R., Ochola, F. O., Olweny, I. A., Onono, J. O., & Gikunju, J. K. (2019). Management and cost of snakebite injuries at a teaching and referral hospital in Western Kenya. F1000Res, 8, 1588. doi:10.12688/f1000research.20268.1
Omara, T. (2020). Plants Used in Antivenom Therapy in Rural Kenya: Ethnobotany and Future Perspectives. J Toxicol, 2020, 1828521. doi:10.1155/2020/1828521
Ooms, G. I., Van Oirschot, J., Waldmann, B., Von Bernus, S., Van Den Ham, H. A., Mantel-Teeuwisse, A. K., & Reed, T. (2020). The Current State of Snakebite Care in Kenya, Uganda, and Zambia: Healthcare Workers’ Perspectives and Knowledge, and Health Facilities’ Treatment Capacity. The American Journal of Tropical Medicine and Hygiene. doi:10.4269/ajtmh.20-1078
Owuor, B. O., & Kisangau, D. P. (2006). Kenyan medicinal plants used as antivenin: a comparison of plant usage. J Ethnobiol Ethnomed, 2(1), 7. doi:10.1186/1746-4269-2-7
Owuor, B. O., Mulemi, B. A., & Kokwaro, J. O. (2005). Indigenous Snake Bite Remedies of the Luo of Western Kenya. Journal of Ethnobiology, 25(1), 129-141. doi:10.2993/0278-0771(2005)25[129:Isbrot]2.0.Co;2
Snow, R. W., Bronzan, R., Roques, T., Nyamawi, C., Murphy, S., & Marsh, K. (1994). The prevalence and morbidity of snake bite and treatment-seeking behavior among a rural Kenyan population. Annals of Tropical Medicine and Parasitology, 88.
“Homicidal Snakebite in Children”
Currently, I’m doing a research project on snakebites and found this gem in the literature, of which there is little:
“Snake bites are common in many regions of the world. Snake envenomation is relatively uncommon in Egypt; such unfortunate events usually attract much publicity. Snake bite is almost only accidental, occurring in urban areas and desert. Few cases were reported to commit suicide by snake. Homicidal snake poisoning is so rare. It was known in ancient world by executing capital punishment by throwing the victim into a pit full of snakes. Another way was to ask the victim to put his hand inside a small basket harboring a deadly snake. Killing a victim by direct snake bite is so rare. There was one reported case where an old couple was killed by snake bite. Here is the first reported case of killing three children by snake bite. It appeared that the diagnosis of such cases is so difficult and depended mainly on the circumstantial evidences.”
When does a person “ask” someone to “put his hand inside a small basket harboring a deadly snake?” Does that ever happen? Apparently so.
Apparently a man killed his three children using a snake.
It gets better:
“In deep police office investigations, it was found that the father disliked these three children as they were girls. He married another woman and had a male baby. The father decided to get rid of his girl children. To achieve his plan, he trained to become snake charmer and bought a snake (Egyptian cobra). The father forced the snake to bite the three children several times and left them to die. At last, he burned the snake.”
Paulis, M. G. and Faheem, A. L. (2016), Homicidal Snake Bite in Children. J Forensic Sci, 61: 559–561. doi:10.1111/1556-4029.12997
A visit to the local witchdoctor: treating snakebites in Kwale, Kenya
Wound from a puff adder bite
Humans have had to deal with the threat of snakebites as long as humans have existed. While deaths from snakebites are rare, the outcomes are so severe and the nature of the animal so mysterious, that humans have developed all sorts of ways of dealing with them.
Witchdoctors, or Mganga as they are known in East Africa, are the first line for snakebite treatment here. The Waganga are fairly useless for treating many serious health issues, but they have carved out a niche for themselves for a few public health problems.
Our survey in Western Kenya confirms that nearly 100% of people who have been bitten by a snake visit the Mganga, regardless of whether they visit a formal health facility or not.
I went and sat down with an established Mganga here in Kwale and he was gracious enough to answer all of my questions openly and (mostly) honestly.
Hello, thank you for taking the time to speak with me today. Is English OK?
No, my English is not very good. Can we do this through a translator?
Of course. So, what happens when a patient comes in for treatment for a snakebite?
When the patient comes in, I first apply the “njiwe na njoka” (lit: snake stone). The stone sucks all the poison out of the wound. When you put it on the bite, it will stick. When the stone has absorbed all the poison, it will fall off.
What do you mean? Like it just sticks to the flesh without tying it?
Yes, if there is poison, the stone will stick to the body. When all the poison is gone, the stone will fall off. After it is done, I take the stone and wash it with milk several times and then use it again for the next patient.
What is the snake stone? Is it like a rock? I’ve seen people use charcoal in the villages. They tie it to the wound, it doesn’t appear to stick on its own.
No, this is different. This is a stone from the snake. The stone is in the skull of the snake, like that of a fish.
(Note: I did not know this, but some species of snakes have otoliths, like most fish. Snakes (and fish) are deaf in the traditional sense. The otolith is a piece of calcium which grows as the animal ages and sit on top of a bed of nerves. When there are vibrations, the otolith vibrates, stimulating the nerve bed so that the animal can “hear” motion around it. Not all snakes have otoliths but some species of burrowing snakes do.)
Where do you get the stone? Can you just buy it in the market?
The snake stones come from the Maasai, from big snakes in Maasai land. My teacher travels to Maasai land to get them and brings them back.
If the wound is fresh, I apply the stone. However, if it has been two or three days since the bite, I can’t use the stone anymore. Then I have to use a special medicine made from herbs and crushed snake heads. I mix it all together, then crush it into a powder and keep in a gourd.
When the patient comes in, I use a new razor blade to make small scratches on the wound. Then I rub the powder in it and bandage the wound. The wound will try to heal over time, so you have to make the scratches to be able to apply the powder.
Do you use the razor blade again?
No, I always use a new blade. (He was emphatic on this point.)
What is the powder made from?
Snakeheads. When we kill a snake, we keep the heads to make the powder. We mix it with roots, bark and leaves from special plants from deep in the forest. My teacher is a security guard in one of the forests and can get them when he can find them.
Wait, so your teacher is a forest ranger? Can’t he get by being an Mganga?
Yes. He is a forest ranger.
So he took the job so that he can get the plants from the forest whenever he needs them.
(Silence)
OK, so how many bites do you see per month?
It depends, some months I get more than others but mostly one every three months or so.
Do you refer them to the health facility for formal treatment?
Yes, I do. I treat them, then they go to the facility, then they come back to me. (I’m suspicious on this point, though the Mganga in question appears more together than most.)
Is there a religious component to this?
Well, there are two kinds of bites, those where the snake just bites and there is no witchcraft and those where someone has used magic to send the snake to bite you.
How do you know the difference?
If the bite heals quickly, there is no witchcraft. But if the bite is treated and does not improve then there is definitely witchcraft involved. At that time, I have to use powerful magic to get rid of the curse.
What do you do?
I send the snake back to the person who applied the curse. When we hear that someone nearby has been bitten, we know who applied the curse.
(Note: this is not uncommon. Witchcraft is often associated with hatred and revenge but the person applying the curse risks becoming cursed themselves. It is possible that snakebites are seen as a never ending battle of malevolent spiritual forces. What this does is sow distrust among people, even families and the Mganga is seen as the only cure. The result is that the Mganga are never without work.)
How did you learn this craft?
I was sick for a long time with stomach and head problems. I went to the hospital and it never got better so then I went to an Mganga. I improved. The Mganga suggested that I become on and I started training under him.
Thank you very much for your time.
Snake Bites in Kwale, Kenya: Into the Field
We just spent the day driving around Kwale looking for snakes, and/or people who had been bitten by snakes. As the last post showed, snakebites are a persistent problem along the Kenyan Coast, with more then 5% of the households we survey indicating that at least one person in the household had been bitten in the past two years.
It wasn’t difficult to find them.
Snakes are universally feared all over Africa and the associations with witchcraft make it a common topic of discussion. Everyone knows someone who has been bitten. They often know all the details, including where it happened and what occurred following the bite. It’s never a happy story.
We went deep into Kinango, an extremely rural area west of Kwale Town and found a friendly lady who seemed to know everything about everyone. She was incredibly jolly, pulled out some plastic chairs for us to sit under and cracked jokes the whole time. I even got to copy her collection of Sangeya music which she had recorded on her phone (another post but you can hear some of it here) at some local music festivals. In total I got more than five hours of live Sengeya and Chilewa music. In the music world, these would be called “field recordings.” Here, this is just music she cooks and cleans to.
Switching back and forth between snakes and Sengenya (in Africa it seems to be possible to have multiple conversations at once), she told us about a kid who had been bitten two days previous. She even told us where to find her, so off we went.
The child was collecting firewood around a mango tree near her home, when she was suddenly bitten by a large green snake, not once but three times on the foot. The snake bit once skated away, decided it wasn’t enough and came back and bit her twice more.
Ants had moved into the dead tree and hollowed out the area underneath. Presumably, the snake moved in previously and came out to warm up during the day.
The mother thankfully took the child immediately to Kinango Hospital and treated was administered. The child was given a three day course of antivenom injections and charcoal was wrapped around the wounds to absorb any venomous discharge. Though the child complains of some numbness in the area, it looks as if there won’t be any permanent damage. Thankfully.
Snake bite (species unknown). Note the charcoal. Victim is a 10 year old girl.
We were also told of an old woman who had been bitten more than 20 years ago, and was badly scarred, figured out where she was and off we went again.
As we pulled up a friendly young lady came out to greet us, and showed us the way to the house out back. In the distance, we could see an old lady walking with a limp. Otherwise, she was completely fit and seemed to be cutting her own firewood with a panga.
She brought us out some chairs and sat down to chat. In 1992, she had been out back collecting firewood (a pattern) and was bitten on the foot by puff adder, one of the deadliest snakes in the world. She was bitten on the foot, and became immobile for nearly a week. A series of witch doctors were brought in, who administered charcoal rubbed into small cuts in the skin.
Necrosis set in, and watery blood erupted out of the wound site. A large number of maggots appeared. Finally, someone had the good sense to take her to the hospital, where she spent an entire year.
The details were unclear, but it appeared that the gangrene was so severe that multiple infections were presents. They likely had her on intravenous antibiotics for an extended amount of time. Despite this, the foot did not heal. Some Christian missionaries came, and convinced her to convert to Christianity, which, she claimed, improved her condition. This is likely coincidental.
Puff Adder wound. Note the permanent curvature of the foot. She continues to have to wrap it and use topical medication, 24 years following the bite.
The doctors suggested a skin graft to improve the foot, but she refused. Necrosis was so deep that it permeated the bone and the foot is permanently curved as a result. The leg still shows sign of swelling even more than 24 years after the bite. In most cases, they probably would have simply amputated.
The lady was born in 1948, bore ten children, one of which was born just as she was bitten. She was unable to breast feed or care for the child. Regardless, the daughter has two children of her own now.
Snakebites are bad news. In this woman’s case, the disregard for proper medical care simply made a bad situation worse. She is truly lucky to be alive. If she had died, it is doubtful that the Mgangas would have admitted any responsibility.
Puff Adder victim, born in 1948. Ten kids. Still going strong.
Snakebites in Kwale, Kenya
I sent our DSS out looking for snake bites, and they found them! We simply asked households if anyone in the household had been bitten by a snake in the past five years. More then 5% of them said “yes” and since we know the locations of the households, we were able to make this cool map. Note that the snake bites tend to cluster around two large areas and are noticeably absent from others.
Kenya hosts many varieties of extremely poisonous snakes included the Puff Adder, the Black and Green Mamba and the spitting Cobra. Snakes are universally feared here and often killed on sight by the locals.
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