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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 194-199

Clinical and demographic profile of patients with snakebite in a tertiary hospital in Ghana


1 Department of Internal Medicine, Tamale Teaching Hospital, Tamale, Ghana
2 Department of Paediatrics and Child Health, Tamale Teaching Hospital; Department of Paediatrics and Child Health, University for Development Studies, School of Medicine and Health Sciences, Tamale, Ghana
3 Department of Internal Medicine, Tamale Teaching Hospital; Department of Internal Medicine, University for Development Studies, School of Medicine and Health Sciences, Tamale, Ghana

Date of Submission21-Dec-2018
Date of Acceptance16-Apr-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Abdul-Subulr Yakubu
Department of Internal Medicine, Tamale Teaching Hospital, Box TL 16 Tamale
Ghana
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DOI: 10.4103/smj.smj_68_18

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  Abstract 


Background: Snakebite is a public health problem affecting mainly rural populations. Objective: To determine the clinical pro le, manifestation, and outcome of snakebite cases presenting to the Tamale Teaching Hospital in Northern Ghana. Materials and Methods: This is a hospital record-based retrospective descriptive study of all confirmed snakebite cases recorded at the Tamale Teaching Hospital over a 2-year period from January 2016 to December 2017. Relevant demographic and clinical information were extracted from patient folders and analyzed. Results: One hundred and nineteen snakebite cases were recorded. The mean age of the victims was 26.38 years, 69.7% being male. Snakebites were recorded all year round with a slight peak in November. Most bites occurred in the interval between 4:00 PM and 8:00 PM and the lower extremity was the most common site of bite (71.4%). The major symptoms of envenomation included coagulopathies (86.5%) and local swelling/ulceration (78.2%); 68.9% had both coagulopathies and local cytotoxicity. Cellulitis/infected wounds (35.3%) and anemia (21.0%) were the major complications reported. 96.6% of the snakebite cases received antivenom on presentation. There was an average delay of 36.42 h from bite before seeking hospital care. No mortality was recorded. The causative snake species was identified in only 6.7% of cases. Conclusion: Snakebite is a potentially life-threatening disease in developing countries such as Ghana and disproportionately affects rural farmers who are mostly active young males. It occurs all year round. More accurate data on snakebites in Ghana are needed for planning purposes and to ensure the continuous availability of antivenom.

Keywords: Antivenom, envenomation, Ghana, snakebite


How to cite this article:
Yakubu AS, Abdul-Mumin A, Adam A. Clinical and demographic profile of patients with snakebite in a tertiary hospital in Ghana. Sahel Med J 2019;22:194-9

How to cite this URL:
Yakubu AS, Abdul-Mumin A, Adam A. Clinical and demographic profile of patients with snakebite in a tertiary hospital in Ghana. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:194-9. Available from: http://www.smjonline.org/text.asp?2019/22/4/194/272148




  Introduction Top


Snakebite is a neglected public health problem affecting mainly rural populations where medical resources are often sparse. It may be termed an occupational disease, as farmers, plantation workers, herdsmen, hunters, or workers on development sites are mostly affected.[1] Unfortunately, many of these snakebite cases go unreported and are therefore not captured in official epidemiological statistics.[2],[3] Despite posing a major burden of disease globally, snakebite envenomation has often been underaddressed in health-care development efforts.[4],[5] The WHO formally listed snakebite envenoming as the highest priority recognized neglected tropical disease in June 2017.[6]

The exact extent and impact of the problem is difficult to determine due to lack of reliable epidemiological data in most countries and because most bites are not managed in hospitals.[2],[3],[7] Estimated global incidence of envenomation is in excess of five million a year, with about 100,000 of these cases developing severe sequelae.[1],[2],[5],[8] The inadequacy of available data, however, has resulted in a high variability in the global estimates of snakebite envenomation.[9] Among studies based on hospital records in sub-Saharan Africa, an average incidence of 56.4/100,000 and mortality of 1.35/100,000 were found in rural areas.[7] For most parts of Africa, the only available epidemiological data are from small areas, often chosen because of their notoriously high rates of snakebite.[3],[10] An early estimate in North-Eastern Nigeria reported a bite incidence of 500/100,000 population per year with a 12%–20% mortality.[10] In Northern Ghana, there were an estimated 86 envenomings and 24 deaths/100,000/year caused mainly by Echis ocellatus.[3] Studies in the Western [11] and Brong-Ahafo [12] Regions of Ghana found snakebite incidences of 82.8/100,000 and 92/100,000, respectively.

The highest incidence of snakebite in Africa occurs in the West African savannah region where most of the morbidity and mortality is due to carpet or saw-scaled viper, E. ocellatus.[3],[10],[13],[14],[15] Envenoming by the carpet viper causes a clinical syndrome with painful local swelling, tissue damage, and coagulopathy. Bites may be complicated by disfigurement, mutilation, tissue destruction, amputation, blindness, disability, and psychological consequences.[16] Other species implicated in serious envenomation in this region include the spitting cobras (Naja spp.) and puff adders (Bitis arietans).[16]

We seek to add to the currently available knowledge by ascertaining the pattern, clinical profiles, and manifestations of snakebite envenomations presenting to a teaching hospital in Northern Ghana.


  Materials and Methods Top


This was a hospital record-based retrospective descriptive study of all confirmed snakebite cases recorded at the Tamale Teaching Hospital in Northern Ghana. Ethical approval (TTHERC/07/07/18/01) dated July 4, 2018, was obtained from the Tamale Teaching Hospital Ethical Review Committee. All the procedures have been carried out as per the guidelines given in the Declaration of Helsinski 2013. The case records of patients presenting with snakebite through the Emergency or Outpatient Departments of the Tamale Teaching Hospital were retrieved for the study period (from January 2016 to December 2017). These included patients admitted to the Medical and Paediatric Departments. Detailed information regarding demographics, site of bite, place of bite, type of envenomation, type of snake (if identified), bite-to-hospital time, prehospital care, and treatment outcome were extracted from the folders and reviewed. The opinion of treating physician was taken with regard to identification of the type of snake responsible for the bite. We excluded cases in which the cause of the bite was in doubt by the treating physician.

The data collected were entered and analyzed with the Statistical Package for the Social Sciences (SPSS), version 20 (SPSS, IBM Corp., Armonk, NY, USA). Data analysis was done using descriptive statistics and results were presented as means ± standard deviation for continuous variables and frequency (percentages) for discrete variables.


  Results Top


A total of 119 patients were included in the study. This comprised 83 (69.7%) males and 36 (30.3%) females, with a male-to-female ratio of 2.3:1. [Figure 1] summarizes the age and sex distribution of the snakebite victims. The mean age of the study participants was 26.38 ± 16.46 years with most participants (30.3%) aged between 11 and 20 years. The ages of snakebite victims ranged from 2 years to 87 years. Almost three-quarters (71.5%) of snakebite victims were between 11 and 40 years of age. The mean age of males was 26.76 ± 17.08 years, whereas the mean age of females was 25.50 ± 15.11 years.
Figure 1: Age and sex distribution of snakebite victims

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More than half (52.1%) of the victims of snakebite were farmers or herdsmen [Table 1]. Student/pupils constituted the second largest group (30.3% of snakebite victims). For the cases in which the exact time of the bite was available, most of the bites (39.3%) occurred between the hours of 4 pm and 8 pm. A clear majority (73.9%) of the bites occurred outdoors, whereas 11.8% occurred inside the house of the victims. Most of the outdoor bites occurred while the victims were working on the farm or walking in the bush (48.7% of all bites) and the majority sustained the bite (71.4%) on the lower limb. [Table 1] summarizes the occupation of the snakebite victims and the time, place, and site of the bite.
Table 1: Occupation of victims and circumstances of snakebite

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[Figure 2] is a bar chart showing the monthly distribution of the snakebites. November recorded the highest number of cases of 13 (10.9%) followed by April and March (10.1%), whereas January and July witnessed the least number of cases (4.2%).
Figure 2: Monthly distribution of snakebite cases

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Clinical or laboratory evidence of coagulopathy (including the 20-min whole-blood clotting time [20WBCT]) was present in 103 (86.5%) of the snakebite victims. Local swelling or ulceration was present in 93 (78.2%) of them, whereas 68.9% had both local cytotoxicity and a coagulopathy. There were no documented cases of neurotoxicity or myotoxicity. Five cases had no evidence of local or systemic envenomation following the snakebite. [Table 2] summarizes the clinical manifestation and site of bite of the victims in addition to the delay in presentation and duration of hospital stay. Close to a third of the victims presented within 3–6 h of the bite with more than half presenting within 24 h of the bite. Only 13 (10.9%) presented within 2 h of the snakebite with a similar proportion presenting after 3 days (72 h). The average time elapsed before presentation to the hospital was 36.42 h (min: 1 h and max: 504 h). The mean duration of hospital stay was 4.67 ± 2.98 days, with a range of 1–16 days.
Table 2: Clinical profile of snakebite cases

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Majority of the victims (67.2%) made a good recovery without complications [Table 3]. Twenty-one (17.6%) had residual complications at the time of discharge, whereas 16 (13.4%) requested discharge against medical advice. No snakebite-related deaths were recorded during the study period. The most common complications documented were cellulitis/infected wounds and anemia. [Table 4] summarizes some of the complications encountered during their inpatient management, most of which resolved by the time of discharge. The case of intraocular bleed was a 26-year-old female who developed endophthalmitis and was left with residual vision loss in both the eyes, whereas the patient with intracerebral hemorrhage (with intraventricular extension of the bleed) was a 30-year-old farmer who still had residual hemiparesis when he requested to be discharged against medical advice on account of financial constraints. The patient with suspected compartment syndrome was managed nonsurgically; his arm was salvaged.
Table 3: Treatment outcomes

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Table 4: Complications of snakebite (n=119)

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The offending snake was positively identified as a viper in the few instances that this was possible (only eight cases, representing 6.7% of cases). [Figure 3] shows a carpet viper (E. ocellatus) that was brought to the hospital by one of the snakebite victims.
Figure 3: Saw-scaled/carpet viper (Echis ocellatus), responsible for most bites in sub-Saharan Africa (brought to hospital by one of the victims in this study)

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The application of herbs was a common initial intervention employed by snakebite victims before presentation to the hospital. Forty-five (37.8%) of the snakebite victims applied local medicine or herbs to the bite site (with or without scarification marks) prior to hospital attendance. One hundred and fifteen (96.6%) of the snakebite cases received antivenom on presentation. The mean dose of anti-snake venom was 73.07 ± 44.86 milliliters. Only 8 (6.7%) had any form of reaction to the anti-snake venom administered.


  Discussion Top


Available data suggest that the highest incidences of snakebites are recorded in Southeast Asia and sub-Saharan Africa which are mostly developing countries.[3],[17] Snakebites tend to be high in areas which have agriculture as the major occupation of the people. This makes the northern parts of Ghana a typical place plagued by the phenomenon of snakebites and its attendant complications. We found that males are bitten about twice as often as females. This could be related to the fact that males are more commonly engaged in the high-risk outdoor occupations of farming and herding. In Europe where the incidence of snakebite is a rare occurrence, coupled with a lesser male population, males were still more affected by the menace than females.[18]

The snakebite victims in our study are generally young with a mean age of 26.38 years which is consistent with that found in similar studies in other parts of Ghana.[11],[12] This is the age group that is most active economically and is involved in active farming. Studies in India have shown a similar pattern where young active males are mostly afflicted.[19],[20],[21],[22] The high proportion of farmers among the snakebite victims corroborates the notion that snakebite is essentially an occupational disease of farmers, herdsmen, and hunters [1],[17] as the nature of their work brings them close to the natural habitat of these snakes. This is borne out by the higher frequency of bites on the lower limbs and the fact that about half of these bites occurred on the farm. Majority of the bites occurred between the hours of 4 pm and 12 midnight which may be related to reduced visibility and the feeding pattern of the offending snake (emerging in the evenings to look for prey).

Literature shows that majority of the snakebites are on the lower extremities.[21],[23] We found that 71.4% of snakebites occurred on the feet or legs. This may be attributed to inadequate use of protective footwear by farmers who accidentally trod on these snakes. Chippaux J-P, however, showed that both the upper and lower limb bites were recorded at an equal frequency in Europe, whereas bites in other parts of the body were very rare.[18]

Coagulopathies were the most prominent clinical feature among victims, with a prevalence of 86.5% in the study sample; local swelling, blistering, or ulceration (cytotoxicity) were present in 78.2%. More than two-thirds presented with both local swelling and evidence of coagulopathy. This pattern of envenomation is consistent with the envenomation pattern of the most common snake species implicated in this environment (carpet viper or E. ocellatus).[10],[14],[15] The coagulopathy is attributable to the venom's prothrombin and Factor X activators as well as hemorrhagins that directly damage the vessel endothelial basement membrane, leading to disseminated intravascular coagulopathy.[3] The 20WBCT is a reliable, simple, rapid, “all-or-nothing” test of blood coagulability which can be done at the bedside and correlates well with fibrinogen concentration.[3] Neuroparalysis, which has been shown to be a common serious presentation of snakebite envenomation in India,[19],[24] was not documented during the study period. The complications recorded were mostly related to blood loss, infection at the bite site, and impaired hemostasis.

Except in rare cases, when a dead snake is brought to the hospital with its victim, the identification of the offending snake is usually difficult or impossible.[3] Identification of the particular snake species responsible for the bite allows the attending physician to identify the cause of envenomation and predict potential complications. The causative species was identified in only 6.7% of cases in this study, all of which were vipers.

Late presentation to the hospital characterizes snakebite cases in Africa [2],[7] with many resorting to herbal treatment immediately following the bite. About two-thirds of the snakebite victims in this study presented within 24 h of the bite. The average time of presentation following the bite in our sample was 36.42 h (range: min: 1 h and max: 504 h), which is much longer than the 3.6 h quoted by a study in the Brong-Ahafo Region of Ghana.[12] This may reflect a difference in health-seeking behavior between our samples. More than a third (37.8%) of the snakebite victims in this study applied local herbs to the bite site prior to hospital attendance, which may account for the relatively longer bite-to-hospital time and the high wound infection rate.

Snakebites were recorded all year round over the study period with a slight peak in the month of November. A 2014 study in the Brong-Ahafo Region of Ghana showed that the highest number of snakebite cases was recorded during the months of April, June, and November.[12] The incidence of bites due to E. ocellatus in Northern Nigeria and Ghana has been shown to peak between March and June in other studies [13],[14] and has been shown to peak with increased agricultural activities.[15]

Antivenoms are the only effective specific treatments or antidotes for snakebite.[3],[8] The case-fatality rate of E. ocellatus, the species associated with most serious envenomations in this region, in the absence of treatment is about 10%–20%.[5],[10] Hence, prompt access to a facility capable of administering appropriate antivenom is of paramount importance in cases of snakebites. The rate of antivenom administration in this sample (96.6%) is much higher than that reported by a similar study in Ghana [12] which might explain the absence of snakebite-related deaths over the study period. It was, however, found that even though antivenom was initiated in an overwhelming majority of the cases, a few patients were unable to purchase additional doses on account of the high cost when the antivenom was unavailable in the hospital. The therapeutic effect of these antivenoms procured outside the hospital is sometimes doubtful as they may not target locally prevalent snake species coupled with the fact that their storage conditions cannot be fully guaranteed.[5],[6],[15]

The hospital-based nature of this study is one of its limitations. Since a lot of snakebite victims may not present to the hospital, a large well-designed community-based study would have produced a better picture of the rate of envenomation and a comparison of the characteristics of those who present to the hospital and those who do not. Furthermore, as in many retrospective studies, there were some missing data. Nevertheless, this study provides useful information on the basic profile of snakebite envenomation presenting to a tertiary hospital and could form the basis of further studies to examine the full extent and impact of the menace of snakebite which will hopefully guide resource allocation to tackle it effectively.


  Conclusion Top


Snakebite is an occupational and environmental health hazard that disproportionately affects rural farmers who are mostly active young males. It occurs all year round and manifests commonly with local swelling and clotting abnormalities. Early use of antivenom in the appropriate setting is a key to reduce the morbidity and mortality associated with snakebites. Public education emphasizing the importance of the use of protective gear by farmers may help reduce the incidence of snakebites while seeking timely medical care following a snakebite may reduce morbidity attributed to this condition. Accurate data on snakebite are important for planning purposes and ensuring the continuous availability of antivenom treatment. There is a need for case documentation and reporting of the snakebite incidence and determinants in the Northern Region of Ghana since most of its population are rural and are at risk of snakebites.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. WHO/SEARO Guidelines for the clinical management of snakebite in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999;30 Suppl 1:1-85.  Back to cited text no. 1
    
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Chippaux JP. Snake-bites: Appraisal of the global situation. Bull World Health Organ 1998;76:515-24.  Back to cited text no. 2
    
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Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock 2008;1:97-105.  Back to cited text no. 8
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Warrell DA, Arnett C. The importance of bites by the saw-scaled or carpet viper (Echis carinatus): Epidemiological studies in Nigeria and a review of the world literature. Acta Trop 1976;33:307-41.  Back to cited text no. 14
    
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Visser LE, Kyei-Faried S, Belcher DW, Geelhoed DW, van Leeuwen JS, van Roosmalen J. Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: The importance of quality surveillance. Trans R Soc Trop Med Hyg 2008;102:445-50.  Back to cited text no. 15
    
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