|Year : 2017 | Volume
| Issue : 1 | Page : 5-10
Incidence of snake bite and utilization of antivenom in the University of Benin Teaching Hospital Benin City, Nigeria
Sylvester Erhunmwonsere Aghahowa1, R Nosa Ogbevoen2
1 Department of Pharmacy, Accident and Emergency Centre, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Clinical, Accident and Emergency Centre, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||28-Sep-2018|
Mr. Sylvester Erhunmwonsere Aghahowa
Department of Pharmacy, Accident and Emergency Centre, University of Benin Teaching Hospital, PMB 1111, Ugbowo, Benin-City
Source of Support: None, Conflict of Interest: None
Background: Bite resulting from animals seems to be a neglected disease. Since there were cases reported as emergency our institution, there is need to assess the incidence and drug utilization. Objective: To assess the incidence of snake bite and utilization of antivenom over 12 years in the Accident and Emergency Centre of the University of Benin Teaching Hospital, Benin City, Nigeria. Materials and Methods: Data from medical record of snake bite and antivenom utilization between the year 2000 and 2011 were assessed from the centre after obtaining permission. Results: One hundred and thirty-six vials of polyvalent antivenom were utilized in the management of 129 patients that reported with snake bite. The victims were 103 (79.9%) males and 26 (20.2%) females within range of 2 years to 68 years (median, 34 years). The incidence was significantly higher among young adult males aged between 29 and 36 years. Limbs were the most common sites of bite and farmers were the most vulnerable which constituted larger proportion of 75 (58.14%) of unskilled workers. On arrival at the hospital, 90 (69.8%) of the victims had local tourniquet applied above the bitten sites. Their only description of snake was in color and size. Thirty-four patients visited herbalist before reporting to hospital. Oral quinolone (ciprofloxacin) and diclofenac were the most frequently used antibacterial and anti-inflammatory agents. Maximum duration of hospitalization was (102 ± 0.61 h). No death was recorded following snake envenomation and no adverse drug reaction during therapy. Conclusion: Adequate stocking of antivenom is strongly recommended during drug procurement because snake bite complications can be fatal if not promptly treated.
Keywords: Antivenom, envenomation, incidence, snake bite
|How to cite this article:|
Aghahowa SE, Ogbevoen R N. Incidence of snake bite and utilization of antivenom in the University of Benin Teaching Hospital Benin City, Nigeria. Niger J Exp Clin Biosci 2017;5:5-10
|How to cite this URL:|
Aghahowa SE, Ogbevoen R N. Incidence of snake bite and utilization of antivenom in the University of Benin Teaching Hospital Benin City, Nigeria. Niger J Exp Clin Biosci [serial online] 2017 [cited 2019 Feb 15];5:5-10. Available from: http://www.njecbonline.org/text.asp?2017/5/1/5/242442
Snakebite can be harmful if not promptly treated. Recent estimates, which are fragmentary, suggest that worldwide, venomous snakes cause 5.4 million bites, about 2.5 million envenomings and over 125,000 deaths annually. Of the 3000 or so snake species that exist in the world, about 600 are venomous. Specifically, four families of venomous snakes are found in Nigeria they are Viperidae, Elapidae, Colubridae, and Actraspididae but three species carpet viper (Echis ocellatus), black-necked spitting cobra (Naja nigricollis), and puff adder (Bitis arietans), belonging to the first two families, are the most important snakes associated with envenoming in Nigeria. Carpet viper venom contains a prothrombin-activating procoagulant, hemorrhagin, and cytolytic fractions which cause hemorrhage, incoagulable blood, shock and local reactions/necrosis. Data on morbidity and mortality are scarce in rural areas because of the lack of community-based surveys. The incidence is particularly high in rural areas of warm regions where snakes are abundant and human activities, mainly agricultural, increase the risks of man-snake contact. Our environment is not an exception to this phenomenon. Incidence may be less in environment where there is regular maintenance of bushes and use of protective wears. Previous studies have described clinical and epidemiologic features of fatal elapid snake bites, but none has compared fatal and nonfatal outcomes.,,, Pathogenesis is complex, and the harm or severity may be associated with the species of snake and the quantity of venom injected into an individual. Meanwhile, mortality rate has been reported to be higher in children owing to larger amount of toxin per body weight absorbed thus exposing them to neurotoxicity.,,,, Therapy requires multiple drugs such as anticholinesterase, antibiotics, and analgesics due to a wide spectrum of clinical symptoms.
The aim of this study was to assess retrospectively the incidence of snake bite and the pattern of antivenom utilization over 12 years at the Accident and Emergency Centre of the University of Benin Teaching Hospital, Benin City, Nigeria.
| Materials and Methods|| |
This 12-year retrospective study was undertaken at the Accident and Emergency Centre of the University of Benin Teaching hospital, Benin City, Nigeria, between 2000 and 2011. The centre is located in the south–south geopolitical zone along Benin-Lagos road. All reporting persons irrespective of whether urban and rural residents and other socioeconomic status, profession, are received at the centre. Referrals are also drawn from within the state and other neighboring states. The centre caters for both medical and traumatic cases at the first point of call. Any of which that necessitate hospitalization are further referred to consulting clinician for adequate management.
In this study, patients case files that reported with snake bite were assessed. Data collected were categorized as age, sex, occupation, site of bite, place of initial presentation, prior treatment, duration of hospitalization and outcome, type of snake, site of bite, duration of hospitalization, profession, number of polyvalent ampoules of antivenom and antibacterial utilized in 12 years. Severity of envenomation was regarded as hemorrhage, shock, local reactions, and necrosis as reported previously. The criterion for giving polyvalent antivenom was due to unidentified species of snakes reported. Patients with incomplete records were excluded from the study.
The data obtained were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Where necessary, they were computed as numbers, percentages, and mean ± standard deviation.
| Results|| |
Over 12 years at the Accident and Emergency Centre of the University of Benin Teaching Hospital Benin City, Nigeria, 129 patients that reported to have been bitten by snake had 136 vials of polyvalent antivenom as in [Table 1]. The victims were 103 (79.9%) males and 26 (20.2%) females range 2–68 years (median, 34 years). The incidences were significantly higher among young adults males aged between 29 and 36 years. High incidence of 57 (44.2%) patients was recorded in 2002. Lower limbs were the most common sites of bite and farmers were the most culprit of the 75 (58.14%) of unskilled workers. On arrival at the hospital, 90 (69.8%) of the victims had tourniquet applied above the site of bite. The use of motorcycle was commonly resorted as means of transportation to the hospital during the period. Thirty-four (26.4%) patients visited herbalist before reporting to the hospital. Most of the victims claimed that they were given herbal extract as local medication without knowing the constituents. There was no proper identification of the type and species of snake, the only description was in color and size. Some of the patients reported that their relatives killed the snake at the scene of bite. Other drugs used on arrival were anti-tetanus serum, antihistamine (promethazine), analgesics (tramadol, diclofenac, and acetaminophen), adrenaline, corticosteroids (prednisolone and hydrocortisone), and antibacterial (fluoroquinolones, sulfonamides, and penicillins) as supportive therapies due to wide array of clinical symptoms. These drugs were selected at the discretion of medical team on duty. Oral quinolone (ciprofloxacin) and diclofenac were the most frequently used antibacterial and anti-inflammatory agents, respectively. Anti-tetanus sera were utilized in all the victims after test doses were administered. No death was recorded from snake envenomation and no adverse drug reaction was reported during therapy. The maximum duration of hospitalization was 102 ± 0.61 h.
| Discussion|| |
The incidence of snake bite was rare compared to other emergency cases during the period of 12 years in the Accident and Emergency centre. This report is similar to previously reported in different regions of the country.,, Rare cases reported in the centre can be attributed to most victims resorting to traditional remedies as alternative therapies that are commonly practiced in the area. These seem similar to previous reports in few victims seeking medical attention.,, Extract from a medicinal plant Hemidesmus indicus R (2-hydroxy-4-methoxybenzoic acid) has been noted to have a potent anti-inflammatory, antipyretic, and antioxidant properties, particularly against Russell's viper venom., It has also been found to have some antibacterial activities as documented by some authors and some herbal extracts have been reported useful in some regions of Nigeria.,, The consultation of a traditional healers has been observed as a cause of delay and can expose most patients to dangerous intervention.,,, Improved sanitary condition of residential and nonresidential areas may have also contributed to the rare cases as observed in some years assessed. Most victims were farmers which constituted high proportion of unskilled workers; therefore, the incidence of bites can be attributed to occupational exposure as earlier reported. The use of tourniquet tied above the sites of bite which is a common practice. This is similar to earlier report.
Many victims may have employed this technique as a means of reducing the spread systemically. However, this can increase local complications by increasing tissue anoxia and triggering severe systemic envenoming after their removal. This has been strongly discouraged by most experts., Since many of the victims were rural dwellers, the use of boots and leathers wears should be recommended because the lower limbs were the most common part of the body were mostly involved as seen in this study. Many victims and their relatives could only describe the color of snake without knowing the local or scientific name. It was observed that some of the snakes were killed at the scene of bite and most onlookers never saw the importance of the identifying the snake which would have been useful during therapy. The inadequacy in documentation of the species of snake can be attributed to previous experiences at the event of bite. Rescuers appeared to be more interested in seeking prompt medical attention rather than killing and identifying the species. “Flight” and emotional disturbance can adversely influence patients' report and therapy. Adequate means of transportation through the use of motorcycles; and as claimed by most victims, aided in the access to prompt medical services. Some delays have been reported in some regions of Nigeria which ultimately led to amputation. It is however advised that when any snake bite is encountered, prompt report should be made to the nearest clinic for adequate management.
Health education will ameliorate these scourges in endemic societies. Protective wears and first-aid measures are important as earlier observed. Long duration of hospitalization may be associated with severity and eye envenomation thus resulted in conjunctivitis and corneal ulceration as earlier reported. Meanwhile, uveitis and hypopyon have been reported to be the resultant effect of deep corneal ulceration.
The utilization of polyvalent anti-snake sera may be due to the nonidentification of the type of snake. However, there are reports that monovalent antivenom although ideal and less used, is less likely to cause reactions because of the monovalent constituent.,, Follow-up was lacking in this study because perception that the ultimate process in resolving problems associated with snake bite is through traditional means. Meanwhile, specific antivenom has been tried against some species of snake., Moreover, clinical safety has been established with polyvalent antivenom., Furthermore, it has been established that there is no significant differences in low- and high-dose schedule in the management of patients with severe neurotoxic snake envenoming. It is interesting to note that good response has been documented with monospecific antivenom in some regions of Nigeria., The bite can be so devastating when it is by poisonous snakes. Tolerability to antisera may have been difficult to quantify being that most patients were given anti-anaphylactic agents in anticipation of adverse reaction at initiation of therapy. Other drugs used were anti-tetanus sera, antihistamine (promethazine), analgesics (tramadol, diclofenac, and acetaminophen), adrenaline, corticosteroids (prednisolone and hydrocortisone), and antibacterials (fluoroquinolones, penicillins, and sulfonamides) as supportive therapies due to wide array of clinical presentation. The parenteral forms of most drugs were used at the initiation of therapy and the oral dosage forms of the analgesics and antibacterials were given on discharge. However, effective management whether supportive or therapeutic suggested by various authors have been observed to follow a similar pattern. Meanwhile, prophylactic promethazine has been reported to be ineffective in preventing anaphylaxis from antiserum against Bothrops envenomation. Ciprofloxacin was the most frequently used antibacterial followed by cefuroxime. This can be attributed to their bactericidal and broad spectrum of activities due to microbes at the site of bite and the mouth of snake. The bases for anti-tetanus used in all the victims could be justified due to the report of tetanus following snake bite.
Studies in different countries due to the saw-scaled or carpet viper (Echis carinatus), green pit vipers (Trimeresurus albolaris and Trimeresurus macrops), Naja Kaouthia, and Calloselasma rhodostoma bites have provided useful idea in therapy., However, decisions by clinicians may have been influenced by suspected extent of envenomation and the suspected species of snake.
| Conclusion|| |
The incidence of snake bite was observed as one of the medical emergencies reported at the centre. It is recommended that all bite resulting from snake should be treated promptly because complications arising from the event can be harmful due to wide spectrum of clinical reports., Therefore, preventive measures through health education and adequate stocking should be paramount to achieve an effective health-care delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
Habib AG, Gebi UI, Onyemelukwe GC. Snake bite in Nigeria. Afr J Med Med Sci 2001;30:171-8.
Warrell DA. WHO/SEARO guidelines for the clinical management of snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999;30 Suppl 1:1-85.
Sharma SK, Khanal B, Pokhrel P, Khan A, Koirala S. Snakebite-reappraisal of the situation in Eastern Nepal. Toxicon 2003;41:285-9.
Trevett AJ, Lalloo DG, Nwokolo N, Kevau IH, Warrell DA. Analysis of referral letters to assess the management of poisonous snake bite in rural Papua New Guinea. Trans R Soc Trop Med Hyg 1994;88:572-4.
Bawaskar HS, Bawaskar PH. Profile of snakebite envenoming in Western Maharashtra, India. Trans R Soc Trop Med Hyg 2002;96:79-84.
Looareesuwan S, Viravan C, Warrell DA. Factors contributing to fatal snake bite in the rural tropics: Analysis of 46 cases in Thailand. Trans R Soc Trop Med Hyg 1988;82:930-4.
Rusell FE. Snake Venom Poisoning. Philadelphia: J.B. Lippincott Company; 1980. p. 235-85.
Hansdak SG, Lallar KS, Pokharel P, Shyangwa P, Karki P, Koirala S, et al.
A clinico-epidemiological study of snake bite in Nepal. Trop Doct 1998;28:223-6.
Adesunkanmi AR, Akinkuolie AA, Badru OS. A five year analysis of death in accident and emergency room of a semi-urban hospital. West Afr J Med 2002;21:99-104.
Adesunkanmi AR, Oginni LM, Oyelami AO, Badru OS. Epidemiology of childhood injury. J Trauma 1998;44:506-12.
Snow RW, Bronzan R, Roques T, Nyamawi C, Murphy S, Marsh K, et al.
The prevalence and morbidity of snake bite and treatment-seeking behaviour among a rural Kenyan population. Ann Trop Med Parasitol 1994;88:665-71.
Pugh RN, Theakston RD, Reid HA. Malumfashi endemic diseases research project, XIII. Epidemiology of human encounters with the spitting cobra, Naja nigricollis
, in the Malumfashi area of Northern Nigeria. Ann Trop Med Parasitol 1980;74:523-30.
Alam MI, Gomes A. Adjuvant effects and antiserum action potentiation by a (herbal) compound 2-hydroxy-4-methoxy benzoic acid isolated from the root extract of the Indian medicinal plant 'Sarsaparilla
' (Hemidesmus indicus
R. Br.). Toxicon 1998;36:1423-31.
Alam MI, Gomes A. Viper venom-induced inflammation and inhibition of free radical formation by pure compound (2-hydroxy-4-methoxy benzoic acid) isolated and purified from Anantamul
R. BR) root extract. Toxicon 1998;36:207-15.
Kumar GS, Jayaveera KN, Ashok Kumar CK, Umachigi PS, Vrushabendra Swamy BM, Kishore Kumar DV. Antimicrobial effects of Indian medicinal plants against acne-inducing bacteria. Trop J Pharm Res 2007;6:717-23.
Abubakar MS, Sule MI, Pateh UU, Abdurahman EM, Haruna AK, Jahun BM, et al
. In vitro
snake venom detoxifying action of the leaf extract of Guiera senegalensis
. J Ethnopharmacol 2000;69:253-7.
Adzu B, Abubakar MS, Izebe KS, Akumka DD, Gamaniel KS. Effect of annona senegalensis rootbark extracts on Naja nigricotlis nigricotlis
venom in rats. J Ethnopharmacol 2005;96:507-13.
Scirè A, Tanfani F, Bertoli E, Furlani E, Nadozie HO, Cerutti H, et al.
The belonging of gpMuc, a glycoprotein from Mucuna pruriens
seeds, to the Kunitz-type trypsin inhibitor family explains its direct anti-snake venom activity. Phytomedicine 2011;18:887-95.
Sawai Y, Toriba M, Itokawa H, de Silva A, Perera GL, Kottegoda MB. Study on deaths due to snakebite in Anuradhapura District, Sri Lanka. Snake 1984;16:7-15.
Theakston RD, Phillips RE, Warrell DA, Galagedera Y, Abeysekera DT, Dissanayaka P, et al.
Envenoming by the common krait (Bungarus caeruleus
) and Sri Lankan cobra (Naja naja naja
): Efficacy and complications of therapy with Haffkine antivenom. Trans R Soc Trop Med Hyg 1990;84:301-8.
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.
Paul VK. Animal and insect bites. In: Sigh M, edtior. Medical Emergencies in Children. 2nd
ed. New Delhi: Sagar Publications; 1993.
Warrel DA. Venoms, Toxins and poisons of animals and plants. In: Wealtherall DJ, Ledingham JG, Warrell DA, edtiors. Oxford Textbook of Medicine. 3nd
ed., Vol. 1. Oxford: Oxford University Press; 1996.
Sharma SK, Chappuis F, Jha N, Bovier PA, Loutan L, Koirala S, et al.
Impact of snake bites and determinants of fatal outcomes in Southeastern Nepal. Am J Trop Med Hyg 2004;71:234-8.
Abubakar SB, Habib AG, Mathew J. Amputation and disability following snakebite in Nigeria. Trop Doct 2010;40:114-6.
Warrell DA, Ormerod LD. Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis
) in Nigeria. Am J Trop Med Hyg 1976;25:525-9.
Philip E. Snake bite and scorpion sting. In: Srivatava RN editor. Pediatric and Neonatal Emergency Care. Jaypee Brothers; New Delhi: 1994. P. 227-34.
Sweetman SC, Blake PS, Brayfield A, McGlashan JM, Neathercoat GC, Parsons AV. Martindale The Complete Drug Reference 36Th ed. London: Pharmaceutical Press.2009. P. 2029-30.
Abubakar SB, Abubakar IS, Habib AG, Nasidi A, Durfa N, Yusuf PO, et al.
Pre-clinical and preliminary dose-finding and safety studies to identify candidate antivenoms for treatment of envenoming by saw-scaled or carpet vipers (Echis ocellatus
) in Northern Nigeria. Toxicon 2010;55:719-23.
Segura A, Villalta M, Herrera M, León G, Harrison R, Durfa N, et al.
Preclinical assessment of the efficacy of a new antivenom (EchiTAb-plus-ICP) for the treatment of viper envenoming in sub-Saharan Africa. Toxicon 2010;55:369-74.
Chippaux JP, Lang J, Eddine SA, Fagot P, Rage V, Peyrieux JC, et al.
Clinical safety of a polyvalent F(ab')2 equine antivenom in 223 African snake envenomations: A field trial in cameroon. VAO (Venin afrique de l'ouest) investigators. Trans R Soc Trop Med Hyg 1998;92:657-62.
Warrell DA, Ormerod LD, Davidson NM. Bites by puff-adder (Bitis arietans
) in Nigeria, and value of antivenom. Br Med J 1975;4:697-700.
Agarwal R, Aggarwal AN, Gupta D, Behera D, Jindal SK. Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming. Emerg Med J 2005;22:397-9.
Meyer WP, Habib AG, Onayade AA, Yakubu A, Smith DC, Nasidi A, et al.
First clinical experiences with a new ovine fab Echis ocellatus
snake bite antivenom in Nigeria: Randomized comparative trial with institute pasteur serum (Ipser) Africa antivenom. Am J Trop Med Hyg 1997;56:291-300.
Warrell DA, Davidson NM, Greenwood BM, Ormerod LD, Pope HM, Watkins BJ, et al.
Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus
) in Nigeria. Q J Med 1977;46:33-62.
Fan HW, Marcopito LF, Cardoso JL, França FO, Malaque CM, Ferrari RA, et al.
Sequential randomised and double blind trial of promethazine prophylaxis against early anaphylactic reactions to antivenom for Bothrops
snake bites. BMJ 1999;318:1451-2.
Malasit P, Warrell DA, Chanthavanich P, Viravan C, Mongkolsapaya J, Singhthong B, et al.
Prediction, prevention, and mechanism of early (anaphylactic) antivenom reactions in victims of snake bites. Br Med J (Clin Res Ed) 1986;292:17-20.
Premawardhena AP, de Silva CE, Fonseka MM, Gunatilake SB, de Silva HJ. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: Randomised, placebo-controlled trial. BMJ 1999;318:1041-3.