Community-based audits of snake envenomations in a resource-challenged setting of Cameroon: case series
Tianyi?et?al. BMC Res Notes
Community-based audits of?snake envenomations in?a?resource-challenged setting of?Cameroon: case series
Frank?Leonel Tianyi 0 1
Valirie Ndip Agbor 2
Joel Noutakdie Tochie 3
Benjamin Momo Kadia 4 5
Armand Seraphin Nkwescheu 6 7 8
0 Mayo Darle Sub? divisional Hospital , Banyo, Adamawa Region , Cameroon
1 Mayo Darle Sub? divisional Hospital , Banyo, Adamawa Region , Cameroon
2 Ibal Sub? divisional Hospital , Oku, North West Region , Cameroon
3 Faculty of Medicine and Biomedical Sciences, University of Yaounde? I , Yaounde?, Cam? eroon
4 Foumbot District Hospital , Foumbot , Cameroon
5 Grace Community Health and Development Association , Kumba , Cameroon
6 Cameroon Society of Epidemiology? CaSE , P.O. Box 1411, Yaounde? , Cameroon
7 Laboratory of Public Health Biotechnology and Research, Biotechnology Centre, Univer? sity of Yaounde? 1 , Yaounde? , Cameroon
8 Research Foundation for Tropical Diseases and Environment?REFOTDE , Buea , Cameroon
Background: Snakebites are a major cause of mortality and morbidity worldwide with the highest mortality burden in poor rural areas of sub? Saharan Africa. Inadequate surveillance systems result in loss of morbidity and mortality data in these settings. Although rarely reported in these resource? constraint environments, community? based audits are recognised pivotal tools which could help update existing data and indicate key public health interventions to curb snakebite? related mortality. Herein, we present two cases of snakebite? related deaths in a rural Cameroonian community. Case presentations: The first case was a 3? year? old female who presented at a primary care health centre and was later referred due to absence of antivenom serum (AVS). However, she had an early fatal outcome before getting to the referral hospital. The second case was an 80? year? old traditional healer who got bitten while attempting to kill a snake. He died before hospital presentation. Conclusion: Community? based audits help identify key intervention points to curb snakebite mortality in high? risk rural areas like ours. From our audits, we note a remarkable absence of affordable AVS in rural health facilities in Cameroon. We recommend frequent community health education sessions on preventing snakebites; continuous training modules for health personnel from high? risk areas; training traditional healers on the importance of AVS in managing cases of snakebite envenoming, and the need for timely hospital presentation; and setting up context? specific approaches to rapidly transport snakebite victims to hospitals.
Snakebite; Deaths; Audit; Rural; Case series; AVS; Cameroon
Snake bites represent a major public health problem,
disproportionately affecting poor rural communities [
Snakebite-related mortality has been associated with low
socioeconomic indicators like poverty, while rural
agricultural activities have been strongly linked with
snakebite incidence, with farmers and children representing
the most vulnerable groups .
The highest worldwide incidence of snakebites has
been recorded in Asia, Latin America and sub-Saharan
Africa (SSA) [
]. The snakebite-associated mortality in
Latin America has reduced over the last decade due to
the implementation of effective snakebite management
systems, including the development of locally effective
antivenom sera (AVS) [
]. Unlike Latin America, optimal
snakebite management in SSA has been retarded by
several obstacles, such as high costs of AVS, lack of
government funding and incentive, deficient surveillance system
for snakebites and poor healthcare-seeking behaviour of
snake-bitten patients [
1, 2, 4
Mortality data and circumstances surrounding the
death of snakebite victims are often difficult to come by
in research [
]. National health reporting systems and
hospital based studies grossly underestimate the actual
burden of snakebite envenomings [
community-based studies are invaluable in appreciating
the circumstances surrounding a snakebite incident and
the difficulties associated with access to quality
healthcare, all cumulating in the death of the victim [
Consequently, community-based audits could complement
hospital records in identifying and tailoring specific
public health interventions to curb snakebite-related
]. In addition, community-based audits are easy to
carry out, less costly and could help to actively involve
the community in snakebite management [
A search of PUBMED with key words; ?audit?,
?snakebite?, ?deaths?, ?community-based interview? or
?Cameroon?, revealed just a single article wherein a
community-based audit was carried out for a
snakebiterelated death in Cameroon [
]. We present two
community-based audits on snakebite-related deaths in the
Mayo-Darl? health area, Adamawa Region, Cameroon.
We sought to describe the circumstances surrounding
the deaths of these victims, which permitted us to
identify practical points through which we could ameliorate
snakebite management and reduce snakebite-related
mortality in rural Cameroon.
A 3-year-old female from the Mbem tribe in the
Adamawa Region of Cameroon, died on the 20/04/2017
at about 6:00?pm following a snakebite. The child was
living with her grandparents who had left her at home with
her cousins and gone to the farm. The oldest cousin was
9?years old. The children went to harvest palm kernels in
a bush nearby their house when they saw an unidentified
snake species. Upon seeing the snake, they ran leaving
behind the little girl. They later came back and took her
home, but since there was no adult around, they reported
to no one. About 3?h later, the child presented an
inability to stand, talk and open her eyes properly. The children
then notified the neighbour who was a 25-year-old
nursing mother. The lady upon arrival found the child lying
inert on the floor with breathing difficulties. Her left leg
was almost twice the size of the right one. She quickly
applied a tourniquet on the left thigh and called the
grandparents of the child, after which she set out
immediately for the hospital.
On arrival to the health centre about 4? h after the
snakebite incident, the child was unconscious with a
Blantyre score of 1/5. Her left leg was almost twice the
size of the right one and there was a weakly tied
tourniquet on the left thigh. She had one episode of a
generalized tonic?clonic convulsion while at the hospital.
Initial management consisted of a bolus of 20? ml/
kg of Ringer?s lactate, anti-tetanus serum 750? IU
subcutaneously, and dexamethasone 4? mg
intramuscularly. The most qualified personnel on duty was a nurse
assistant with no formal training on snakebite
management and reporting. A lack of AVS at the health centre
prompted referral to the nearest health facility with an
available stock of AVS, which was about 4?h away,
separated by un-motorable roads. The child died less than
30?min after leaving the health centre.
An 80-year-old male, who was the main traditional
snakebite healer in the village died from snake
envenomation on the 4/10/2016. He was shelling corn in his
barn at home when he noticed an unidentified snake
species. With his son, they tried to kill the snake. During the
attempt, he was bitten on the left leg. They however
succeeded in immobilising the snake, which they thought
was dead. The victim then tried to behead the snake
(probably to use as traditional remedies), and was
re-bitten on his left hand. He succeeded in beheading the snake
(Fig.? 1) (later identified as a cobra, probably of from the
Naja melaoleuca species). Immediate case management
at home consisted of the application of traditional
topical ointments on the wounds, and ingestion of oral herbal
concoctions. Thirty minutes later, he complained of an
inability to stand and difficulties in speaking. This was
followed by a progressive decrease of consciousness. His
son decided to transport him to the nearest health facility
which was a primary healthcare centre, seven kilometres
away. The son carried him on his back and attempted to
run the distance. The victim however died about 30?min
after they had left the house.
We present two cases of snakebite-related deaths in
rural Cameroon. The first case, a 3-year-old female who
got bitten while playing with her siblings and died in the
course of referral after failing to receive AVS at a health
centre. The second, an 80-year-old male who got bitten
while attempting to kill a snake in his home.
Community-based audits were carried out to identify the
circumstances surrounding the deaths of these snakebite
Snakebites are a significant cause of mortality in
]. An estimated 266 snakebite related deaths
are reported annually from high-risk zones like northern
Cameroon . Mortality data on snakebite is scarce in
Cameroon, majority of which are obtained from
hospitalbased sources [
]. Consequently, the values obtained
usually underestimate the true burden of this neglected
health problem in most communities [
]. This is
worrisome because mortality is an important health
]. Information on the circumstance surrounding
the death of snake-bitten victims could go a long way to
improve on snakebite case management with a
reduction in snakebite-related deaths. Rural areas account for
97% of snakebite-related deaths, however, these regions
contribute little to the epidemiological picture of
snakebite mortality [
]. This is because of poor health seeking
behaviours, with most patients preferring traditional and
herbal medicine to modern medicine, and also, many
victims die before getting to the hospitals [
cases are unaccounted for by health statistics and
underestimate the mortality burden from snakebite
envenoming . In the Mayo-Darle health area, a review of
the monthly morbidity and mortality reports revealed
no case of snakebite death in the past 5? years [
was clearly not the case as evident in our report. Our
series points out the need to intensify community-based
research to better elucidate the burden of snakebites in
Cameroon. Community-based audits permit us to
better appreciate the immediate run of events leading to the
death of these patients. Hence, we could plan locally
adequate interventions to prevent snakebite deaths.
Children with their high rates of outdoor activities
could easily encounter snakes and suffer snakebite
]. Owing to their small body surface areas,
they are at an increased risk of severe envenomation
due to a greater amount of venom injected per unit
body mass [
]. In an earlier study in Cameroon,
the snakebite-related mortality of children < 5? years of
age was 7.1% [
]. The years of life lost (YLL)
following the death of a child significantly increases the burden
of snakebites making snake envenoming a health
priority in this population . Similarly, the elderly are at an
increased risk of severe outcomes following snakebites.
This is due to an increased prevalence of co-morbid
conditions in this population [
]. Both of our patients
constituted a vulnerable population hence snakebites in
these populations should be considered as a matter of
urgency, for which prioritized optimal management
cannot be overemphasized.
Most snakebites occur in rural areas with limited
resources to manage severe cases of envenomation [
]. Despite this high incidence of snakebites in rural
areas, the knowledge of health personnel on its
management remains inadequate. Indeed, according to a national
survey conducted in 2015, a majority of Cameroonian
health personnel were not versed with the latest
snakebite case management options . One of our victims
succeeded in getting to a health centre, and was attended
to by a nurse assistant who had no formal training in
snakebite management. In the era of modern medicine,
with the availability of safe AVS and effective
ancillary treatment, it is unacceptable for a snakebite victim
to be offered sub-optimal care in a health facility. The
recent inclusion of snakebite envenomings in the list of
neglected tropical diseases is an important step towards
reducing preventable deaths from snakebite
]. This has to be accompanied by national
efforts to identify gaps and provide solutions to
shortcomings in snakebite management in their countries
. Some countries like Kenya have developed local
guidelines to improve snakebite management, especially
in high-risk areas [
]. This problem is being addressed
by the Cameroon Society of Epidemiology which
organised various training seminars for health personnel on
snakebite management [
]. However, more efforts are
required to reach personnel in the most remote villages,
especially areas with high incidences of snakebites.
Furthermore, the same victim could not benefit from AVS
which was not available at the health centre. She died in
the course of referral.
In the absence of affordable snake AVS in some rural
areas in Cameroon [
1, 12, 23
], it is important to seek
alternative means to decrease morbidity and mortality
from snakebites [
9, 10, 20
]. One of such ways is to invest
in community education and prevention of snakebites
13, 14, 20
]. Both of our victims found themselves in
compromising situations and suffered snake
envenomation as a consequence. We propose a continuous training
of selected health personnel. They will in-turn identify
key community actors and community representatives,
which they will train on the importance of preventing
snakebites. In our rural poor-setting, the challenges
associated with snakebite management can be tackled if the
following specific interventions are put into place. Firstly,
children should not be left playing unsupervised and
should avoid areas where they could be at risk of
snakebites such as forests, palm trees, etc. Secondly, pictures
of local venomous snakes should be made available to
the general population so that they can take appropriate
measures to avoid snakebites when confronted with such
snakes. Thirdly, high-risk actions such as beheading or
attempts to kill snakes by inexperienced persons should
be discouraged. Furthermore, emphasis should be made
on the appropriate health-seeking behaviour following
snakebites, particularly timely presentation to health
1, 14, 20
]. This permits rapid assessment of the
severity of the snakebite envenoming and the need for
snakebite AVS, thereby ensuring timely management of
patients with a consequential decrease in morbidity and
mortality from snakebite envenomings. In SSA, 50?90%
of snakebite victims seek a traditional healer for
firstline treatment [
]. Traditional healers could play a key
role in improving management of snakebite victims [
Training them to rapidly recognize signs of severe
envenoming could help reduce the delay in presentation to
health facilities as they could constitute a crucial starting
point for referral to health facilities. Associating
alternative medicine (traditional healers) to modern medicine in
snakebite case management could help reduce mortality
and morbidity in poor rural settings [
]. Moreover, most
snakebites often occur at locations far off from the
]. A rapid transportation system has been proven
to significantly reduce mortality from snakebites [
Hence, it is important to get these victims to the hospital
as soon as possible using appropriate means of
transportation. The son of one of our victims attempted to carry
his father on the back and run a distance of seven
kilometres to the nearest health centre. This might have played
a part in his demise. For this reason, it is crucial to put in
place locally adapted algorithms or referral mechanisms
to rapidly transport such victims to health facilities. A
partnership between hospitals and local associations of
motorbike riders to rapidly transport snakebite victims in
exchange for financial motivation may be a good starting
In conclusion, community-based audits help identify
key intervention points to curb snakebite mortality in
high-risk rural areas like ours. From our audits, we note
a remarkable absence of AVS in rural health facilities in
Cameroon. We recommend frequent community health
education sessions on preventing snakebites;
continuous training modules for health personnel from high-risk
areas; training traditional healers on the importance of
AVS in managing cases of snakebite envenoming, and
the need for timely hospital presentation; and setting up
context-specific approaches to rapidly transports
snakebite victims to hospitals.
SSA: sub?Saharan Africa; AVS: anti? venom serum.
FLT: managed the patient, conception of data collection tools, acquisition of
data and write up of the initial manuscript, VNA, BMK, JNT, acquisition of data
and critical revision of manuscript, ASN revision of data collection tools, the
initial manuscript and supervision of the final version of the paper. All authors
read and approved the final manuscript.
We wish to thank the family members of the victims for accepting to tell us
their side of the story thereby making this publication possible.
The authors declare that they have no competing interests.
Availability of dataset and materials
Consent to publish
Written informed consent was obtained from the parents of patient 1 and
from the son of patient 2 for publication of this Case series and any accompa?
Ethics approval and consent to participate
The Cameroon Society of Epidemiology contributed financially for the field
Springer Nature remains neutral with regard to jurisdictional claims in pub?
lished maps and institutional affiliations.
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