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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 391-395
Snake bite envenomation seen at a specialist hospital in Zamfara state, North-Western Nigeria


1 Nephrology Unit, Department of Medicine, Usmanu Danfodio University Teaching Hospital/Usmanu Danfodio University, Sokoto; Department of Medicine, Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria
2 Department of Paediatrics, Usmanu Danfodio University Teaching Hospital/Usmanu Danfodio University, Sokoto; Department of Paediatrics, Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria
3 Department of Medicine, Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria
4 Department of Medicine, North-West University Kano, Kano, Nigeria

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Date of Web Publication22-Jun-2017
 

   Abstract 

Introduction: Snake bite is an underreported public health problem in Nigeria, with a prevalence of 5 per 1,000 persons per year. Morbidity and mortality from snake bites is higher in developing than in developed countries. We aim to audit the clinical parameters, complications, and outcome of patients with snake bites admitted at our hospital. Materials and Methods: The study was a retrospective secondary data analysis whereby all children and adults managed for snake bite over a 2 and a half year period were included. Their case records were retrieved and relevant demographic and clinical information obtained and statistically analyzed using Statistical Package for the Social Sciences version 18. Results: Out of 5,375 admissions, 25 had snake bite giving an incidence of 0.00465 (4.65/1000). There were 17 (68%) children and 8 (32%) adults. Males were 18 (72%) giving a M:F ratio of 1.4:1. Mean age was 20.6 ± 14.36 with a range of 3–55 years. Most bites, 18 (72%) occurred on the lower limbs, during the day time 15 (65%) and happened in the farm. The highest prevalence of bite was between the months of May and August. Prior to presentation, 12 (48%) had received various interventions and features of envenomation including local swelling and pain (76%), prolonged clotting time (56%), bleeding from various sites (52%), while (32%) had various complications. All patients had antitetanus toxin, while 23 (92%) received antisnake venom. Majority of the patients were discharged 19 (76%), 4 (16%) signed against medical advice, and 1 (4%) absconded, while only 1 (4%) died. Conclusion: Snake bite in our environment commonly affects children and adolescents with majority of patients coming late to hospital. Protective clothing and health awareness campaigns to educate the community are urgent interventions needed to reduce the morbidity from snake bite.

Keywords: Antisnake venom, envenomation, snake bite

How to cite this article:
Sakajiki AM, Ilah GB, Lukman AAS, Yakasai AM. Snake bite envenomation seen at a specialist hospital in Zamfara state, North-Western Nigeria. Ann Trop Med Public Health 2017;10:391-5

How to cite this URL:
Sakajiki AM, Ilah GB, Lukman AAS, Yakasai AM. Snake bite envenomation seen at a specialist hospital in Zamfara state, North-Western Nigeria. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Nov 14];10:391-5. Available from: http://www.atmph.org/text.asp?2017/10/2/391/208730

   Introduction Top


Snake bite is an underreported serious public health problem in Nigeria, with a prevalence of 5 per 1,000 persons per year.[1] Morbidity and mortality from snake bites is higher in developing than in developed countries.[1] The common snakes associated with envenomation include the carpet viper (Echis ocellatus), black-neckedspitting cobra (Naja nigricollis), and puff adder(Bitis arietans).[1],[2] Bites are said to occur more often while victims are farming, herding or walking, fetching firewood in areas with dense foliage, during play in disused buildings or while exploring holes and crevices in search of animals.[1],[2] Most bites occur on the foot or hand with prevalence of bites higher in males than females.[1]

The carpet viper venom contains a prothrombin activating procoagulant, hemorrhagin, and cytolytic fractions which cause hemorrhage, incoagulable blood, shock and local reactions/ necrosis. The spitting cobra bite manifests with local tissue reaction and occasionally with bleeding from the site of bite. Cardiotoxicity and renal failure may occasionally occur following bites by the carpet viper and the puff adder.[2]

We document an audit of the clinical parameters, complications, and outcome of patients with snake bites admitted at our hospital.


   Materials and Methods Top


The study was conducted at a tertiary hospital located in North-Western Nigeria. The hospital serves as a referral center for other health care facilities within the state. The study was retrospective, covering a period of 2 and a half years (1st May 2013 to 30th October 2015). All children managed for snake bites at the emergency pediatric unit and adults managed for snake bites at the accident and emergency (A/E) or medical wards during the study period were included. Their case records were retrieved from the hospital medical record department. Demographic information, such as age, gender, and geographic location of the patients was extracted and entered into a predesigned study proforma data sheet. Other relevant clinical information obtained from the case records included place of bite, site of bite, features of envenomation, treatment given before hospitalization, use of antisnake venom (ASV), presence of adverse reaction to ASV, length of hospital stay, and outcome.

All patients received tetanus toxoid and those with envenomation received ASV. During the study period, patients were initially buying ASV from the hospital which later became free when the Federal Ministry of Health started providing it. The type of ASV used by the patients was either the polyvalent (Echi Tab Plus) or monovalent (Echi Tab G). Patients with severe anemia or hemorrhage were transfused accordingly.

Ethical clearance was obtained from the hospital ethical committee. Data were entered into Statistical Package for the Social Sciences version 18 [SPSS Inc, Chicago, USA] for data cleaning and analysis. Means and frequency tables were used to illustrate quantitative data. Chi-square or where necessary, Fisher's exact test was used to compare categorical variables. A P < 0.05 was considered statistically significant.


   Results Top


A total of 5,375 patients were managed during the study period of which 25 had snake bites giving an incidence of 0.00465 (4.65/1000). There were 17 (68%) children, while the remaining 8 (32%) were adults. Males were 18 (72%) and females were 7 (28%), giving a M:F ratio of 1.4:1. The mean age of the patients was 20.6 ± 14.36with a range of 3–55 years. Most of the patients were children and adolescents as shown in [Figure 1].
Figure 1: Age range of snake bite patients in years

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Majority of the bites occurred on the lower limbs 18 (72%), while 6 (24%) occurred on the upper limbs, only 1 (4%) occurred on the neck. Ten (40%) of the bites occurred on the farm, 8(32%) occurred at home, while the remaining 7(28%) occurred while walking. Although the snake was seen or killed in 17 (68%), none was brought to the hospital for identification of specie but 12 (48%) were described as possible vipers and cobras. Time of bite was documented for 23 patients, 15 (65%) occurred in the day time, while 8(35%) occurred at night. The highest prevalence of snake occurred between the months of May to August as shown in [Figure 2].
Figure 2: Percentage of patients with snake bite according to month

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Prior to presentation to the hospital, 12 (48%) had received various interventions which included ingestion of traditional concoctions, prolonged application of tourniquet to the affected limb, and local incisions. Majority of the patients 13 (52%) presented more than 24 hours after the bite, 8 (32%) presented less than 6 hours, 2 (8%) each between 6 –12 hours and 12–24 hours, respectively. The mean bite-to-hospital presentation time was 214.69 hours and ranged from 0.5 to 168 hours. All patients that came late had used traditional practices before arrival at the hospital.

[Table 1] shows the characteristics of the patients with respect to time of presentation. Patients presenting after 6 hours of bite significantly had prolonged whole blood clotting time (WBCT) compared with those presenting within the first 6 hours of bite. Late presentation was not significantly associated with adverse effects of ASV.
Table 1: Characteristics of patients with snake bite based on time of presentation to hospital

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A total of 19 (76%) patients presented with swelling and pain, 13 (52%) had bleeding (from bite site, hematuria, epistaxis, hematemesis, and gum bleeding), while 8 (32%) of the patients had various complications following envenomation as shown in [Table 2]. One (4%) patient had seizures which subsided after admission and the results of malaria microscopy, random blood glucose, and cerebrospinal fluid analysis for the patient were all normal.
Table 2: Characteristics of patients who came with life threatening complications following snake bite envenomation

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All patients had antitetanus toxin, while 23(92%) received ASV. And 15 (65%) received polyvalent ASV, while 8(35%) received monovalent ASV. All patients with WBCT >20 min had received ASV. All the eight patients with complication at presentation came late and had received polyvalent ASV. Only three (13%) of those that received ASV developed adverse reactions.

Majority of the patients were discharged 19 (76%), 4 (16%) signed against medical advice, 1(4%) absconded, while only 1 (4%) died. However, the patient that died received ASV 48 hours after presentation to the hospital due to lack of fund.


   Discussion Top


Over the 2 and a half year study period, 25 patients were managed for snake bite, this may not be a true reflection as not all victims of snake bite present to the hospital. More males were affected similar to the findings of Omogbai et al.,[3] Sani et al.,[4] Fadare and Afolabi,[5] and other studies.[6],[7] This can be explained by the fact that males are more adventurous; and in our environment they are involved in activities that expose them to snakes such as farming, herding, and playing in the bush when compared with females.

The mean age shows that snake bite is commoner among the young and active population, which is similar to other studies.[5],[6],[7] It is not surprising that a 55-year-old was bitten this is because older people still participate in farming or herding in our community. Majority of the victims were bitten on the lower limbs similar to findings in other studies.[3],[4],[5],[6],[7],[8],[9] This may be due to the fact that during farming or walking some people are bare footed or have minimally protective footwear. All the patients coming with life-threatening complications were bitten on the leg. This has implication for preventive and protective clothing and boots while farming or involvement inhigh-risk activities.

The highest prevalence of snake bite occurred between the months of May to August which coincided with the planting and harvesting period signifying intense farming activities. This is similar to earlier reports.[4],[5],[6],[7] Most bites occurred during the daytime, similar to the observation in Sokoto;[6] this may be due to the fact that the snakes were disturbed or stepped upon during farming activities or wandering around and also most people go about barefooted or with minimally protective footwear. For those bites that occurred around the home, over grown bushes in the home environment allow snakes to come in close contact with people.

Features of envenomation among our patients included pain and local swelling, prolonged WBCT with or without spontaneous hemorrhage. These are similar to what has been reported by other studies.[3],[4],[10] Swelling and bleeding were common among patients coming late and may explain the higher number of subjects with severe anemia among those with late presentation.

All patients were given tetanus toxoid and some with tetanus antitoxin, this is essential in snakebite because of the nature of the bites and the fact that snakes carry pathogenic organisms including Clostridium tetani as part of their normal oral microflora.[3] Tetanus can complicate snake bites as four cases were reported by Habib.[11] Most of the patients with envenomation received polyvalent ASV which is in contrast to what was reported by Lar-Ndam et al.,[9] where 88.9% received monovalent ASV. It can be explained by the fact that the snake species were not identified.

Mortality from snake bite is low especially when patients present early to the hospital. Our study recorded only one death and this may be attributable to late presentation. Many studies have reported no mortality following snake bite.[3],[4],[5],[9] Mortality attributable to snake bites is however lower than that caused by other diseases.


   Conclusion Top


Snakebite victims that presented to our hospital in Gusau, Zamfara state, North-Western Nigeria were mostly males, majority were children and adolescents. While bites were common outdoors, people staying indoors were also vulnerable. Due to the availability of ASV at the time of admission, mortality was low despite significant morbidity and complications.

The information derived here could guide design of interventions to reduce the burden of snake bite envenomation in Nigeria. The use of protective clothing and boots while farming is advisable for prevention against snake bite. Communities should be educated on the need to clear their surroundings and avoid time wasting traditional practices to reduce the morbidity and mortality from snake bite envenomation.


   Limitation of the study Top


The study being retrospective had limitation of inability to ascertain the outcome of those that signed against medical advice thus morbidity and mortality reported in this study may be an underestimation of the reality. Another limitation is inability to use clotting factors or cryoprecipitate as they are not available in our hospital. Due to the small number of patients, it may limit the strength of statistical analysis, hence making it difficult to generalize results.

Acknowledgement

The authors wish to acknowledge the contributions of nursing staff of the A/E unit and the emergency pediatric unit of ASYBSH for their support in the course of this work

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Onyiruika AN. Snake-bite poisoning in childhood: Approach to diagnosis and management. Pediatrics Today 2012;8:11-21.  Back to cited text no. 1
    
2.
Habib AG, Gebi UI, Onyemelukwe GC. Snake bite in Nigeria. Afr J Med Sci 2001;30:171-8.  Back to cited text no. 2
[PUBMED]    
3.
Omogbai EKL, Nworgu ZAM, Imhafidon MA, Ikpeme AA, Ojo DO, Nwako CN. Snake bites in Nigeria: A study of the prevalence and treatment in Benin City. Trop J Pharmaceutical Res 2002;1:39-44.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
  [Full text]  
5.
Fadare JO, Afolabi OA. Management of snake bite in resource challenged setting: A review of 18 months experience in a Nigerian hospital. J Clin Med Res 2012;4:39-43.  Back to cited text no. 5
    
6.
Njoku CH, Isezuo SA, Makusidi MA. An audit of snake bite injuries seen at the Usumanu Danfodio University Teaching Hospital Sokoto, Nigeria. Niger Postgrad Med J 2008;15:112-5.  Back to cited text no. 6
    
7.
Chaudhari TS, Patil TB, Paithankar MM, Gulhare RV, Patil MB. Predictors of mortality in patients of poisonous snake bite: experience from a tertiary care hospital in Central India. Int J Crit Illn Inj Sci 2014;4:101-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Cavazos MED, Garza CT, Guajardo-Rodriguez G, Hernandez-Montelongo BA, Montes-Tapia FF. Snake bites in pediatric patients, a current view. 2012; In: Öner Özdemir, editor Complementary Pediatrics. Available from: http://www.intechopen.com/books/complementary-pediatrics/snake-bites-in-pediatric-patients-a-current-view. [Last accessed on 2015 Dec 16].  Back to cited text no. 8
    
9.
Lar-Ndam N, Pitmang SL, Madaki AJK, Dawam JA. Snake bite among Nigerian children: The Zamko experience. J Med Res Pract 2013;2:77-9.  Back to cited text no. 9
    
10.
Ogala WN, Obaro SK. Venomous snake bites in children in the tropics: The Zaria experience. Nig Med Pract 1993;26:11-13.  Back to cited text no. 10
    
11.
Habib AG. Tetanus complicating snake bite in northern Nigeria: clinical presentation and public health implications. Acta Tropica 2003;85:87-91.  Back to cited text no. 11
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Correspondence Address:
Aminu Muhammad Sakajiki
Nephrology Unit, Department of Medicine, Usmanu Danfodio University Teaching Hospital/Usmanu Danfodio University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.208730

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