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.
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.
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.
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]).
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.
(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.
(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.
(Anne-Sophie, Neil, & Aida, 2017; Eucabeth & Augustine, 2017; Omara, 2020; B. O. Owuor & Kisangau, 2006; Bethwell O. Owuor, Mulemi, & Kokwaro, 2005)
(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