Daily Trust

A PHYSI­CIAN’S DI­ARY Snakebite — An­other ne­glected trop­i­cal dis­ease

- Health · Nigeria News · Nasarawa State · Maiduguri · Nigeria · West Africa · Africa · Benin · Cameroon · Ghana · Centre · Niger · Togo · Plateau State · Benue State · Gombe State

The first time I wit­nessed a pa­tient who had been bit­ten by a snake was dur­ing my days as a young house of­fi­cer. It was a slow Satur­day evening and I was on call at the ac­ci­dent and emer­gency ward. My prayers seemed to be work­ing that day as the af­ter­noon shift had been mostly calm, so calm in fact that I had the lux­ury of re­lax­ing on my chair while read­ing Jef­fery Archer’s ‘False Im­pres­sion’. I re­mem­ber be­cause I was so en­grossed in the book that I did not no­tice a mid­dle-aged man be­ing wheeled into the A&E by his rel­a­tives. They ap­peared ag­i­tated as they spoke above one an­other try­ing to re­late their dilemma.

Ap­par­ently, Mr Paul*, a 54-year-old farmer had been brought in from a vil­lage three hours away in Nasarawa state on ac­count of a snakebite he sus­tained the day be­fore. He had been bit­ten on his left foot and the limb was now swollen and ap­peared darker in com­plex­ion than the rest of his body. A dirty rag was tied to his left an­kle, pre­sum­ably by the rel­a­tives, to stop the spread of the venom. My mouth was dry and my hands were shak­ing as I ex­am­ined his foot, which had swollen to al­most twice its orig­i­nal size. There was ev­i­dence of two punc­ture marks, which I as­sumed was the site of the bite near his big toe and other scar­i­fi­ca­tion marks on the dor­sum of the foot that I was later told was made by a tra­di­tional ‘wan­zami’ (bar­ber) as a treat­ment for the bite. When the pain had be­come un­bear­able de­spite their in­ter­ven­tion, Paul’s sons had in­sisted on bring­ing him to the hos­pi­tal.

I tried to re­main calm but my brain had gone into panic mode try­ing des­per­ately to re­mem­ber the steps in­volved in the man­age­ment of snakebites. You have to un­der­stand, snake bites are not com­mon in Maiduguri and so, I had never en­coun­tered any case while in med­i­cal school. All I knew about snake bites was strictly the­ory and even that lit­tle knowl­edge was try­ing to dis­grace me! As I was re­sus­ci­tat­ing the pa­tient, one of his sons pro­ceeded to tell me how they had hunted down the snake in their farm and killed it upon hear­ing their fa­ther’s scream. As if that was not enough in­for­ma­tion, the man sud­denly dropped the sack he was hold­ing on my ta­ble to re­veal a dead snake. I nearly passed out from fright! I let out a pierc­ing scream and fled the premises. So much for the doc­tor on call. Need­less to say, I re­mained the butt of ev­ery­one’s joke un­til I fin­ished my in­tern­ship.

The sec­ond on-call, who is the more se­nior doc­tor, was called to sal­vage the sit­u­a­tion. He promptly re­leased the rag, which served as a tourni­quet and sta­bilised the limb. The site of the bite was cleaned and re­sus­ci­ta­tion con­tin­ued with In­tra­venous flu­ids and painkiller­s. Later, his blood work would show an ab­nor­mal clot­ting pro­file even as he started bleed­ing un­der his skin and from his gums. In fair­ness, when the man­age­ment of the hos­pi­tal was in­formed, des­per­ate ef­forts were made to pro­cure the EchiTAb an­tivenom but as with all things in Nige­ria, bureau­cracy and our ‘any­how­ness’, made it so that the an­tivenom ar­rived four days later when the pa­tient was al­ready haemo­dy­nam­i­cally un­sta­ble. He passed away ex­actly one week af­ter he was brought to the hos­pi­tal.

Snakebite en­ven­om­ing com­prises a ma­jor pub­lic health prob­lem among com­mu­ni­ties of the sa­vanna re­gion of West Africa, no­tably in Benin, Burk­i­naFaso, Cameroon, Ghana, Nige­ria and Togo. It ranks high as among the most ne­glected trop­i­cal health prob­lems es­pe­cially in Nige­ria where the in­ci­dence is about 497 per 100,000 pop­u­la­tion per year. In some ru­ral ar­eas along the Benue Val­ley, snakebite is the lead­ing cause of mor­bid­ity and mor­tal­ity, es­pe­cially among farm­ers, pas­toral­ists, hunters and chil­dren. The car­pet viper (Echis ocel­la­tus) has proved to be the most im­por­tant cause of snakebite mor­tal­ity and mor­bid­ity in Nige­ria and some of its symp­toms in­clude lo­cal swelling, bleed­ing and oc­ca­sion­ally necro­sis. Oc­ca­sion­ally, snakebite may lead to im­por­tant com­pli­ca­tions such as am­pu­ta­tion, blind­ness re­sult­ing from the fa­mous spit­ting co­bra venom, mis­car­riages, wound in­fec­tion, te­tanus and psy­cho­log­i­cal con­se­quences like anx­i­ety.

Nige­ria’s fail­ure to con­front snakebite as a pub­lic health is­sue has greatly ham­pered its con­trol es­pe­cially in en­demic re­gions of this coun­try. The fact that snakebite is not an in­fec­tious dis­ease, nor is it con­ta­gious, has con­trib­uted sig­nif­i­cantly to it be­ing alien­ated from other ne­glected trop­i­cal dis­eases like lep­rosy, leish­ma­ni­a­sis and Try­panoso­mi­a­sis (sleep­ing sick­ness). Ad­di­tion­ally, Snakebite in Nige­ria does not get the at­ten­tion it de­serves be­cause of the fact that it af­fects mostly the poor­est of the poor who live in ru­ral ar­eas. Other fac­tors like the high cost of med­i­cal care, poor po­lit­i­cal will and weak ad­vo­cacy ef­forts fur­ther fuel the lack­adaisi­cal at­ti­tude to the bur­den of snakebite in Nige­ria.

Kal­tungo town of Gombe State has been fa­mous for cases of snake en­ven­o­ma­tion since the colo­nial era, when the snakebite treat­ment ward was first built in the 1940s. Dur­ing the late 1980s, dur­ing Gen­eral Ba­bangida’s regime, the Echitab group was estab­lished and man­dated to over­see the de­vel­op­ment of more ef­fec­tive anti-venom for the ben­e­fit of the coun­try at large, with the state-owned Gen­eral Hos­pi­tal Kal­tungo, serv­ing as the main host for the re­search group. In 2006, the Echi-tab Anti-venom that re­sulted from the work of the re­search group suc­cess­fully passed the clin­i­cal trial stage and was re­leased to the main­stream mar­ket. Un­for­tu­nately, de­spite the mem­o­ran­dum of un­der­stand­ing (MOU) that war­ranted for the trans­fer of tech­nol­ogy to the coun­try so as to ben­e­fit the gen­eral pop­u­la­tion, that never came to fruition due to the fail­ure of the Nige­rian Govern­ment to ful­fil her fi­nan­cial obli­ga­tions as con­tained in the MOU.

In Jan­uary, 2019, the Snakebite Treat­ment and Re­search Cen­tre, Kal­tungo was com­mis­sioned af­ter pro­tracted at­tempts to achieve that. Since then, the Cen­tre has con­tin­ued to pro­vide care to about 4,000 cases of snakebite every year, with over 51 per cent of these cases com­ing from all over the coun­try and even from neigh­bour­ing coun­tries like Camer­oun and Niger. De­spite this wide cov­er­age how­ever, Gombe State Govern­ment has re­mained its sole fi­nancier, re­sult­ing in gross un­der­fund­ing.

The cost of a vial of snake an­tivenom has a risen to a fac­tor of 10 over the past two decades and presently ranges from N8000 to N30,000 per vial de­pend­ing on the com­pany and where it is be­ing pur­chased. De­spite the 4,000 vials of an­tivenom do­nated to Nige­ria last year, the de­mand re­mains high and a per­pet­ual scarcity ex­ists for the an­tivenom es­pe­cially in places like Zamko CHC in Plateau and Kal­tungo Gen­eral Hos­pi­tal, Gombe where the in­ci­dence of snakebite is high and you can get up to 16 to 20 cases per day.

By all ram­i­fi­ca­tions, the bur­den of snake bite in Nige­ria is high and there­fore re­quires mul­ti­sec­toral col­lab­o­ra­tion with other state gov­ern­ments, the FG, NGOs as well as pri­vate or­gan­i­sa­tions to help in fund­ing the Snakebite re­search cen­tre. All ef­forts should be made to en­sure that peo­ple in the en­demic re­gions of the coun­try ben­e­fit from the prod­uct of the Echi-tab re­search group and are able to ac­cess treat­ment at an af­ford­able cost. As a pre­ven­tive mea­sure, pro­tec­tive cloth­ing, in­clud­ing boots and long trousers, should be worn whilst work­ing in snake-in­fested ar­eas. In ad­di­tion, com­mu­ni­ties must be in­formed and ed­u­cated about snakebite risks through the use of posters and leaflets. They should be of­fered re­al­is­tic solutions that mit­i­gate the haz­ards and em­power the peo­ple them­selves to help man­age the prob­lem in prac­ti­cal and sus­tain­able ways.

Snakebite en­ven­o­ma­tion is a ter­ri­ble thing to wit­ness. Since my en­counter with Paul* over 10 years ago, I have en­coun­tered a few more cases with each one giv­ing me ter­ri­ble night­mares. I can only imag­ine what doc­tors prac­tis­ing in ru­ral com­mu­ni­ties go through. Or maybe they have be­come de­sen­si­tised to the trauma, I don’t know. What I do know, how­ever, is that I will never for­give that man who dropped a dead snake on my desk years ago and made me the laugh­ing stock of the whole hos­pi­tal.

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