“Snakebite and Its Treatment in Rural Kenya,” A Symposium held November 11, 2006 in Watamu, Kenya
The Fifth Biannual Symposium on Snakebite and Its Treatment in Rural Kenya was held on Saturday, November 11, 2006. Convened at Hemingway’s Hotel in Watamu, the symposium drew attendees from all major northern coastal areas of Kenya, from Mombasa, Kilifi, Watamu, Malindi, and Lamu. The attendees included physicians, nurses, clinicians, tour operators, herpetologists, and several survivors of severe snake bites. All came to hear presentations made by local and international experts on the subject.
The purpose of the symposium was to clarify issues covering the reasons for snakebite, the frequency and distribution of its occurrence, descriptions of species and the effects of various venoms on the human body. Topics of discussion also included the pros and cons of various treatments for snakebite, from appropriate immediate first aid response through complete recuperation and rehabilitation from the physical damage sustained by snakebite victims.
The Symposium was hosted by the James Ashe Trust in cooperation with Bio-Ken Snake Farm, Watamu, with additional sponsorship from Hemingway’s Hotel. Guest speakers included Dr. E. Erulu, from the Watamu Nursing Home; Dr. B. Odthiambo from the Malindi Hospital; and world recognized expert in the field, Dr. David Warrell, Professor Emeritus of Oxford University, London, England. Also present as honored guest was Dr. Moses Chisale, Africa Representative of the World Health Organization (WHO).
The Symposium was opened by Royjan Taylor, Assistant Director of Bio-Ken Snake Farm, who introduced the speakers and noted the presence of Dr. Chisale. Dr. Chisale is presently engaged in developing official guidelines for treatment of snakebite in Africa for the World Health Organization. He was present at the Symposium to learn from the firsthand experience of concerned citizens and front line response teams in addressing the problems of snakebite patients in Kenya, better to inform himself and the WHO of the shortcomings of current systems and methods of response.
Dr. Warrell was the first speaker. His initial presentation, entitled “Envenoming by Snakebite in Africa,” explored the most common situations involving snakebite, reporting that most snakebites happen to children and to adult field workers engaged in the tasks of agriculture and forestry, for the most part poor peasants who can ill afford expensive medical treatment.
Most victims are bitten by snakes on their lower or upper limbs. Those who are bitten anywhere else on the body were usually bitten while sleeping on the floor, and frequently are bitten more than once. Dr. Warrell illustrated and described the mechanisms by which snakes envenom their victims, either as prey or for defensive purposes. He discussed the position of fangs in the mouths of snakes, the angles of ejection of venom, and the pressure under which venom is ejected. He went on to discuss the species commonly found in Kenya, their locations and general behaviours, and the likelihood of being envenomed by any of the toxic snakes in the country.
In a second session, Dr. Warrell discussed “Treatment of Snakebite in Africa.” He described the physiological responses to venoms which can include swelling, pain, numbness, tingling, blister formation, muscle deterioration, loss of sight, paralysis, and death. He explained the differences between cytotoxic and neurotoxic venoms and their actions, noting with interest that bites from snakes previously thought to have been possessed of one kind of venom have recently been discovered to display concurrent symptoms of other kinds of venoms. The conclusion was that snake venoms are far more complex than previously suspected. It is often difficult to discover the kind of snake from the symptoms of envenomation, and this factor makes appropriate treatment even more difficult.
Dr. Warrell’s talk included highly graphic images of wounds sustained by snakebite victims, some of whom recovered by virtue of appropriate medical treatment and others who did not survive the attacks. Dr. Warrell debunked a few myths about snakebite and its treatment, such as the obsolete and highly dangerous method of cutting and sucking the wound, applying tourniquets, and the use of the infamous ‘Black Stone.’ These are all practices that cause more damage than they do good. He talked about the pros and cons of pressure bandages to slow venom transport throughout the body and thus to minimize damage and prolong the life of the patient; more experiential data on this practice is needed to assess its value. He also spoke at length about antivenom and the risks of anaphalactoid shock and its reversal.
Dr. Warrell stressed the need for more and higher quality data from the field, impressing upon his audience the need for complete case histories taken by trained medical personnel as patients are treated. His call for improved record keeping and reporting systems was echoed by surgeon Dr. B. Odthiambo in his presentation “Snakebite Pattern and Workload in Malindi.”
Dr. Odthiambo had compiled statistics from the last five years which clearly demonstrated that until very recently, virtually no records of snakebite and its treatment had been made. He showed that although the incidence of snakebite may not be on the rise in certain areas, it far exceeds the incidence of bites from other animals including dogs, hippos and crocodiles. The incidence of snakebite locally is far higher for children than for adults, as innocent children step and reach into areas likely to conceal venomous snakes. This factor also explains why most victims are bitten on their limbs rather than on the trunk or near the head.
Dr. Odthiambo also documented improved recovery rates of patients treated with antivenom over those who do not receive this medication. It was generally noted by the audience that lack of antivenom in rural clinics as well as poor or non-existent training of local personnel is a major factor in the amount of physical damage sustained by a patient once bitten by a venomous snake. Correct discernment of the snake species is important to improved treatment of snakebite, often expedited when family members kill the snake and bring it to hospital with the victim in need of treatment. The time it takes to transport a bite victim to hospital is another deterrent to prompt and effective treatment. Many patients are delayed seeking treatment by poor roads, lack of vehicles, and the distance to the nearest treatment centre.
Dr. Warrell spoke also about venom structure and the production of antivenom. He reported that the need is for location specific antivenom. Snakes of the same species who come from different places have venoms containing different properties. Location specific monovalent antivenom is preferable when the snake species can be identified with certainty, as it reduces the risk of reactions to other antivenom components; however, polyvalent antivenom is more convenient to acquire, maintain and use from the physician’s point of view, especially in cases where the species cannot be identified.
Dr. Warrell’s most important message was that the entire continent of Africa is in a state of crisis with regard to the supply of antivenom. Costs of production have been driven high by the US FDA, who insist on ever increasing standards of quality control and production methods for their domestic products. The price for a single dose of antivenom for treating rattlesnake bite in the US can be as high as US$ 6,000. African and Indian antivenom producers cannot compete with such high standards and costs, yet less expensive and potentially comparable methods cannot be used for fear of accusation of practice with double standards. Patients who are victims of snakebite have no resources of note and simply cannot pay for such expensive treatment. This simple truth places the burden of costs onto a government already overloaded with other socio-political issues of far greater concern than a child or adult in severe distress from snakebite situated far, both physically and economically, from metropolitan areas.
Dr. Warrell reported a new technique for antivenom involving dissolution of immunoglobulin molecules in caprylic acid, a much less expensive method of antivenom production than any prior enzyme digestive procedure.
Yet, now there are only two antivenom producers for the entire continent, one in South Africa and another in Egypt, neither of which can supply enough antivenom to serve the needs of Africa. Administration of antivenom, preparation for and treatment of anaphalactoid shock, and other appropriate treatment procedures at the hands of qualified and competent medical personnel can reduce the loss of life and limb, the maiming and the reduction in quality of life for many of Africa’s poorest people. Urgently needed are:
- heightened governmental responsibility,
- a steady and reliable supply of antivenom and trained personnel to administer it, and
- community outreach to rural areas with instruction on how best to avoid snakebite, prevention of snakebite through education being a most desirable goal.
The Symposium closed with a presentation by Mrs. Sanda Ashe on recent activities of the James Ashe Trust. She reported continued publication and distribution of the popular “Simple Steps” brochure, now available in English, Swahili, French and German. More recently, she has published a new booklet on the proper procedures for treatment of snakebite in Kenya. This document is intended to support regional health facilities and requires distribution. It can be purchased for 150 Kenya shillings. Mrs. Ashe noted that the Trust is in much in need of support, both in terms of community participation and funding. Contributions may be made payable to:
James Ashe Trust
c/o Bio-Ken Snake Farm Laboratory and Research Centre
P.O. Box 3
Watamu, Kenya
Report prepared by Dena Crain