Venomous Snake Bite Injuries at Kitui District Hospital
College Of Health Sciences, University of Nairobi
Snake bites are a neglected public health issue in poor rural communities, and the true burden of snake bites is not known. Kitui County has a high incidence of snake bites and no functional snake bite control programs exists. Diagnostic tests for snake species identification are not available and management mainly relies on clinical findings and administration of polyvalent antivenin. This study sought to describe common presentation patterns and treatments offered for snake bites at Kitui District Hospital, and to characterize the causative venomous snakes.
Patients and methods
This was a prospective case series carried out over a period of 8 months. Patients presenting at the hospital with snake bites were included in the study. A pre set questionnaire inwaswasadministeredredbybydoctors inin the surgical team
A total of 70 patients were recruited. The M:F ratio was 1:1.4, and an age range 4-60y (median 8y). 51.4% were school going children who lived in houses mostly made of earthen bricks and thatch (n=38, 54.3%). The relationship between local names and physical description of the snakes, and scientific identification from the description and clinical presentation was significant(p=0.05). Most patients achieved complete recovery (n=62, 88.6%) No death was recorded.
Snake bites are common in Kitui County. In spite of the high rates of compartment syndrome and focal gangrene, all the patients were managed locally with excellent outcomes.
Care-givers need better training and sensitization. Formulation of regionalized guidelines fed by evidence-based data is needed. Improved infrastructure including a regional centre of excellence, and education will be the best preventive strategy.
Management of snake bites is variable from region to region due to different fauna existing in different environments. This variation can be high even in the same country. It is therefore quite difficult to prescribe a uniform algorithm for managing snake bites. This is compounded by unavailability of proper resources and lack of prioritization of snake bites, amid infectious diseases and trauma. Snake bites therefore tend to become a neglected albeit important cause of morbidity in developing countries (1).
Kitui County has a higher incidence of snake bites as compared to studies done in other districts (2,6). Coombs showed an average incidence of 13.8/100000 population (2). In 2011, hospital records show that there were 129 patients with snake bites who were attended to at the District Hospital within the year, giving an estimated incidence of 25.8/100000 (129 cases per 500000 county population). The true worlldwiide burden of snake bites is not known due to misreporting (3,4). There is also a seasonal variation in incidence (5). Snow reported a mortality rate of 6.7/100000 in Kilifi,, representing 0..7% of all deaths(6)(6).Mortality.-ityn sinsnakebitesbitesis isnotnotcommon,but some studies have reported 15 adult snakebite fatalities per 100000 populatioin per year (6,, 7,, 8)..
ThereThereareare numerous venomous snakee species residentt in the county (9).. All the three major types of of snakessnakeswererepresrepresented..However, the cobrasras (elapidae) and adders (viperidae) are more frequently implicatedlicated in snake bites in Kitui.. Medically importantportant snakes local to Kituii include the puff adder (Bitis arietans),, the black necked cobra (Naja nigricolis), and the black mamba (Dendroaspis polylepis)ylepis). It is difficult to differentiate between the black necked cobra and the red spitting cobra (Naja pallida) from from description alone, but the distribution of the red description alone, but the distribution of the red
cobra is more northerly (9).
There are no protocols for managing snake bites available specific to the region, most health workers using general management principles. Prevention of snake bites is based majorly on educating people on how to avoid conflict with the animals, and how to give first aid to victims of snake bites. Myriad types of first aid have been described, including application of tourniquets, snake stones, herbal antivenins, milk, potassium permanganate and bloodletting (10). Ogunbanjo showed gaps in management of snake bites in rural hospitals where necessary medications like tetanus toxoid are not administered and all patients receive unnecessary medications like promethazine (11). Antivenin administration is indicated only if serious manifestations of envenomation are evident(12). There has never been a population or hospital based documented research from Kitui County, and thus this audit will aim at providing a baseline on patterns of snake bites seen at the district hospital and to identify the causative venomous snakes.
Materials and methods
Most victims lived in houses made of locally manufactured bricks and thatch or iron sheets 38 (54.3%), followed by mud and thatch 27(38.6%). Only 5 residences were made of stone and iron sheets (7.1%). Most patients (45.7%) came from Kitui Central where the hospital is located, while the others came from other regions within the catchment area. Fig 1 below shows the activities patient were undertaking at the time of bite.
Design: Consecutive case series.
Setting: Kitui District Hospital in Kitui County, Kenya. It serves as a referral District Hospital in the larger Kitui County with a catchment population in excess of 500,000 inhabitants
Inclusion criteria: All patients with a history of having been bitten by a snake, and confirmed with identifiable fang marks, presenting at Kitui District Hospital
Exclusion criteria: Other animal bites, non-venomous snake bites with no fang marks.
Procedure: All patients attended to at the district hospital, with a history of snake bite, within the study period were included (from the outpatient department and surgical wards). A Pretested questionnaire was then administered. They were then followed up until the time of discharge from the hospital. All treatment procedures done on them were recorded in the questionnaire.
Data handling: Data was captured using Microsoft Excel and analyzed using SPSS. Categorical variables were summarized by frequency and percentage, while continuous variables were summarized by mean and standard deviation.
The study was con