How insufficient anti-snake venom, treatment centres fuels deaths in Nigeria

By Ojoma Akor (Abuja), Haruna Gimba Yaya (Gombe),  Richard P. Ngbokai (Kano), Mohammed I. Yaba (Kaduna), Hope Abah Emmanuel (Makurdi) & Risikat Ramoni (Lagos)   There are indications that thousands of Nigerians die yearly due to lack of anti-snake venom, treatment centres and manpower to treat the poison that comes with snakebites.   Despite the […]

By Ojoma Akor (Abuja), Haruna Gimba Yaya (Gombe),  Richard P. Ngbokai (Kano), Mohammed I. Yaba (Kaduna), Hope Abah Emmanuel (Makurdi) & Risikat Ramoni (Lagos)

 

There are indications that thousands of Nigerians die yearly due to lack of anti-snake venom, treatment centres and manpower to treat the poison that comes with snakebites.  

Despite the burden of snakebites in the country, only 5,000 anti venom are available for the over 20,000 victims annually in the country. Inadequate quantities of anti- snake venom in the country has been linked to poor survival and high mortality from snakebites.

Findings reveal that only very few health facilities are wholly dedicated to snake bite treatment in the country. Even the few available specialist treatment centres are bedeviled with challenges, such as stock out of anti-venom and inadequate beds for the large number of people coming there from different parts of the country.

Many public hospitals do not also have specific snake bite units. As a result of this, a lot of people have to travel far to access treatment within and outside their states. This has led to many preventable deaths, Daily Trust on Sunday gathered.

According to Fatai Oyediran, the programme manager, Snakebite Envenoming Programme of the Federal Ministry of Health, the effect of a snakebite depends on some factors, which include the specie of the snake involved, area of the body bitten, amount of venom injected and the health condition of the victim.

Symptoms of snakebite include increase in local pain (burning, bursting and throbbing), fang marks, local bleeding around the affected area, local infection and abscess formation, lymph node enlargement, nausea, vomiting and  generalised weakness.

 

Challenges of envenoming care

Oyediran lamented that as a result of lack of treatment centres, distance sometimes affects efforts towards rescuing victims of snakebite.

Speaking during a media dialogue organised by the United Nations Children’s  Fund (UNICEF), in collaboration with the Child Rights Information Bureau  (CRIB) of the Federal Ministry of Information and Culture in Ibadan, he said the challenges of snakebite envenoming care in the country include inadequate funding and late release of funds, inadequate partner’s support, low awareness, and inadequate political will, especially at state levels.

Others are inadequate data collection in states, inadequate training for health care workers, poor research funding, policy/training manuals yet to be finalised and non-production of anti-snake venom.  

Burden of snakebite in Nigeria

Nigeria is among the countries worst affected by snakebites in the world.  

The Minister of Health, Dr Osagie Ehanire, said the country presently records an average of 20,000 cases of snakebites annually.  

He said the country also recorded 2,000 deaths and about 1,700 amputations because of snakebites annually.    

Gombe State has the highest record of snakebites in Nigeria. Adamawa, Bauchi, Borno, Nasarawa, Plateau, Enugu, Kogi, Kebbi, Oyo, Benue and Taraba states also have high cases of snakebites, especially during planting and harvesting seasons.

Dr Ehanire said snakebite envenomation was a public health problem in Nigeria and that it is caused mainly by three species of snakes: the naja nigricolis (cobra), bitis arietans (puff adder) and echis ocellatus (carpet viper).

He said, “It affects the lives of many people, where most of the victims are rural women, children, peasant farmers, herdsmen and hunters. 

“The estimated number of snakebites in Nigeria is 174 /1,000m according to a survey conducted in 1994 by the Federal Ministry of Health. The carpet viper is responsible for 90 per cent of bites and 60 per cent of deaths.”  

The most recent estimated snakebites in Nigeria is 497/100,000 per year, according to a 2013 epidemiological survey by Habib et al.

The researchers said snakebites occured mainly during planting and harvesting seasons in Nigeria and lately increased as a result of excessive rainfall.

They called on private sector organisations, partners, the media and other stakeholders to contribute their quotas towards the control, prevention and treatment of snakebites by giving it due attention.

The permanent secretary in the Federal Ministry of Health, Abdullahi Mashi, revealed that over 60,000 cases of snakebite and 6,344 deaths were reported in Nigeria from January 2016 to December 2018, and some cases remained unreported because the victims were not taken to any health facility.

Oyediran also said, “Gombe State has the highest burden of snakebites in Nigeria, recording between 7,000 and 10,000 annually. We also have about 5,000 cases annually in Plateau State. Nsukka in Enugu State, Saki and Sapeteri in Oyo also record cases annually.”

Insufficient anti-snake venom

Anti-venom is very important in the treatment of snakebites, but what we have in Nigeria is not enough. Also, foreign anti-snake venom is said not to be easily accessible. It is also costly and sometimes of doubtful efficacy.

Oyediran said, “Snakebite, which is one of the neglected tropical diseases, is a concern because many victims are left untreated due to insufficient  anti venom.

He said the availability of anti-snake venom had been a challenge because of the dwindling budget witnessed in the past five years. He said only 5,000 vials of anti-snake venom were available annually in the country, adding that it is insufficient to treat the number of people affected.

“This is quite low compared to the number of cases recorded yearly. The anti-venom procured is being distributed to the states free of charge. One of the ways we encourage bridging of the gap is by encouraging the state government to procure some vials to help in the treatment,” he said, adding that it is expensive to treat a snakebite patient.

He said a vial of anti-snake venom would cost between N45,000 and N50,000 and a patient may need three vials or more to heal. This translates to N1billion to treat 20,000 patients with just a vial.

 “States like Gombe, Plateau and Katsina had in the past procured very little quantities of vials to breach the gap. The anti-venoms are procured internationally, although it is a product of joint research,” he said.

 

Huge funding gap 

There is paucity of funds for snakebites, envenomation treatment and research in the country.

A professor of Community Medicine and head of Translational Research Unit, Nigeria Snakebite Research and Intervention Centre, who is also a member of the African Snakebite Research Group, Professor Isa Sadeeq Abubakar, said funding for snakebite had been inadequate at all levels of governanment.

He said, “Generally, there is not enough funding for snakebite management. We rely on donors for funding.”

He said N131 million was budgeted for care in 2020 but only N98m was released.

He said only N110m was approved for snakebite before then, adding that there is a huge funding gap for snakebite envenomisation, and whatever is released is being managed by the programme.

Local production of anti-snake venom in Nigeria

Experts said local production of anti-snake venom in the country was key to addressing the inadequate available quantity, otherwise the country would continue to witness continuous rise in the cost of anti-venom.

Prof Abubakar appealed to the government to invest in the echitab anti- snake venom project, which has been on since early 1990s, for anti-venoms to be more affordable.

He said, “This is a project that involves the Nigerian government, Liverpool School of Tropical Medicine, Oxford University, a United Kingdom-based company called Therapeutic Antibody and a university in Costa Rica, which uses the venoms extracted from Nigerian snakes to produce the anti-venom. 

“Currently, the anti-venoms are manufactured abroad, but the ultimate aim of the project is technology transfer so that the production would be done in Nigeria. 

“Unless that is taken to completion, we will continue to experience periodic or perennial scarcity of potent anti-venoms, or even if available, they will continue to be prohibitively expensive.”

Also, Oyediran called for support for local manufacturing of anti-venom to make treatment affordable, available, accessible and cost effective for Nigerians who cannot afford to pay when they are bitten.

He said a proposal of N1.8billion made to the federal government by the Snakebite Envenoming Programme in 2006 was approved by former President Olusegun Obasanjo, but when his government ended, funds were not approved for setting up of local manufacturing plants.

 “Other moves to try and get resources to ensure that local manufacturing plants produce anti-venom have not been successful.

“We have not succeeded in getting a new approval from the government; rather, we were asked to look in the direction of a public-private-partnership arrangement.

“We are doing this currently with some of our partners. We have about five groups that have shown interest in the local manufacturing plants,” he said

 

No special facility for snakebite in Kano  

There is no special hospital for the treatment of snakebite in Kano. However, very few cases in the state are managed in various secondary health facilities spread across the 44 local government areas, while the most severe are referred to the Aminu Kano Teaching Hospital (AKTH).

Prof Abubakar identified shortage of manpower in managing snakebite cases in the state as one of the major drawbacks. He, nevertheless, said patients from other parts of the North go to the AKTH to access care because of the availability of anti- venom there.

He said some people would rather resort to alternative traditional medicine for treatment, which in many cases, would worsen the cases.

Abubakar said, “There may not be a need for special hospitals for snakebite treatment, but at least major hospitals in each health zone should have a well equipped treatment unit.  

He emphasized the need for health workers to be adequately trained in the treatment of snakebite cases.                                                                      

Benue working towards production of vaccines  

In Benue State, snakebite victims are treated in the Benue State University Teaching Hospital (BSUTH), Federal Medical Centre (FMC), Makurdi and a private facility, Bishop Murray Memorial Hospital, Makurdi.

The Commissioner for Health and Human Services, Dr Joseph Ngbea, said there were enough experts in the state to handle cases of snakebite and that plans were underway to ensure production of anti-snake venom in the state.

The commissioner, who noted that riverine areas of the state recorded high incidents of snakebites, advised inhabitants of such vicinities to be cautious of their environment.

Also, in April this year, the management of Bishop Murray Memorial Hospital disclosed that over 700 snakebite victims from different areas of the state survived after treatment in 2020.

The Reverend Father Peter Kpaleve, the health coordinator of the Catholic Dioceses of Makurdi in charge of the hospital said,

 

 

“Treatment of snakebite is quite expensive; and most times, those bitten are peasants who cannot afford the treatment. But they have been receiving free treatment because of the intervention of Governor Ortom.”

Availability of anti-venom in Lagos irregular

The Lagos State Government said anti-snake venom were provided for some health centres and general hospitals, especially those in rural communities, in areas as Epe and Badagry, where there are high incidents of snakebite.

A medical doctor in one of the primary health centres in Lagos Island, Zainab Musa, told our correspondent that although the state government provided anti-venom for the health centres in case of emergencies, it is not regular.

“We sometimes get it, but if there are no cases for some time, it will get spoiled, as every drug or injection has an expiry date. Most of the time, when we have cases, we refer them to the nearest general hospital.

“We also ask patients whose lives are at risk to buy anti-venom from any big pharmaceutical store and we then administer,” she said.

Also, Dr Moyo Adelaja, who works in another primary health care centre, said regular training was organised for health workers in the state to prepare them for any eventuality.

Lack of anti-venom facilities in Kaduna

There is no facility specifically meant for snakebite treatment in Kaduna State.

Daily Trust reported in January 2020 how an eight months pregnant woman died of snakebite at the Kinkinau area of Kaduna metropolis.

It was gathered that she was rushed to several hospitals within the metropolis but none had anti-snake venom to save her life.

Snakebites occur mostly in rural communities of the state, and local dwellers mostly use herbs to treat victims.

A resident of Udawa village, along the Kaduna-Birnin Gwari highway, Imam Husaini Umar, said rural dwellers used herbs because they realised that there were no anti-venom in primary health care centres in their villages.

Inside Kaltungo snakebite hospital, Gombe

As a result of unending battle with snakebites in Gombe State, a hospital was set up in Kaltungo for treatment. It is called Snakebite Treatment and Research Hospital. It was commissioned two years ago.

Hundreds of victims of snakebites besiege the hospital weekly from the six states of the North-East sub-region in search of anti-snake venom.

The hospital provides the anti-venom and other medication to all the victims of snakebite free of charge. This development resulted in high influx of patients from the North-East.

As a result of the increasing number of patients, the hospital often runs out of anti-venom needed to treat victims.

When our correspondent visited the facility in June, only few patients were on admission as a result of lack of anti-snake venom.

This is in spite of the fact that it is one of the peak months of snakebite cases because of farming activities.

Daily Trust on Sunday learnt that anti-snake venom was last supplied to the hospital some months earlier by the North-East Development Commission (NEDC), and the state government was yet to release fund for purchase of a new batch.

A patient on admission in the hospital said the facility usually recorded lower turn out of patients whenever there is shortage of anti-venom.

Kaltungo is located on the snake belt in West Africa, which in Nigeria covers Taraba, Adamawa, Gombe, Bauchi, Plateau and Kaduna states.

The area and its surroundings are known for notorious snakebites, a development that has made life difficult for people, considering the agrarian nature of the area.

The rocky area of the town also makes it habitable for snakes. A data obtained by Daily Trust on Sunday indicates that between January 2016 and December 2019, over 12, 227 victims were admitted in the hospital.

Findings revealed that common snakes found in the area are carpet viper, which is the most dangerous as it bites without provocation. It leads to bleeding in several places and passing of blood in urine and stool.

Also, cobra, which normally bites after provocation, as well as other types of snakes, is found in the area.

According to the principal medical officer of the hospital, Dr Suleiman A. Mohammed, rainy season is the peak period of snakebites. He added that averagely, they received 10 new patients on a daily basis.

He said about 70 per cent of patients that visit the hospital are treated with a single dose of anti-snake venom, except in rare cases of multiple bites or those that didn’t come to the hospital immediately after they were bitten.

Dr Mohammed said, “The Gombe State Government provides the anti-venom we use in treating patients. The state is carrying the burden of drugs used in treating patients from all the states in the North-East, which is not supposed to be so.”

He advised victims and their relatives to report cases to the nearest medical centre immediately, to ensure prompt treatment.

He also called on the public, especially farmers and herders, to always take precaution while going into the bush, to avoid being bitten.

Challenges facing Kaltungo hospital

 Apart from the shortage and frequent stock-out of the anti-venom, manpower is another area the hospital has challenges. It was gathered that there are not enough staff to cater for numerous patients trooping to the 15-bed capacity hospital for treatment.

He said patients would come to the hospital after spending weeks taking herbal medicines.

Dr Mohammed added that the hospital needs expansion and completion of the remaining two phases.

“The first phase is the hospital itself, while the second phase is the research centre. Although we are currently doing some research, we don’t have places to keep live snakes for the programme.

“The current research is just minimal, bordering on the efficacy of the anti-venom on the patients that come to the hospital early and those that come late,” he said.

Patients

A 14-year-old Maryam Ali was bitten by a snake while she was helping her parents on their farm at the outskirts of their village in Gombi Local Government Area of Adamawa State. She was brought to the hospital two days after the incident. 

At the male ward of the same facility, Usman Habu, 18, was in great pain with a wound in his leg.

 Habu said he was clearing his farm in Karim Lamido Local Government Area of Taraba State one morning when a snake bit him in his leg. He abandoned the farm and rushed back home, where a herbalist attended to him. However, after spending two days and his condition was not getting better, his parents rushed him to the hospital.

Lamdio Saleh, 26, had mild pains. He was brought to the hospital the very day he was bitten by a snake while he was clearing his farm in preparation for the raining season.  

Also, a 35-year-old Lola Musa said cases of snakebite had caused a setback for farmers in the town because no one wants to be a victim. 

Musa appealed to the state government to find a lasting solution to the frequent issue of stock-out of anti-venom.

Yunusa Garba Sabo, 50, another resident, told our correspondent that the hospital had been helpful to Kaltungo and the neighbouring villages.

The commissioner for health in the state, Dr Habu Dahiru, said the policy of the state had been a free supply of anti-snake venom to victims. The ministry has a budget line, which is meant to be released regularly to procure vaccines, he said.

According to him, the stock-out of anti-venom is as a result of high influx of patients at peak periods of snakebites, as well as referrals from other hospitals in the state and neighbouring states.

“But we have a plan to replenish, especially now that the demand is high. We don’t stop at just providing, we also make request to partners like the NEDC and the federal government to ensure that the supply is maintained,” he said.   

On manpower, he said there was plan to recruit more staff, as the current ones are overstretched. He added that laboratories, clinics and wards would be expanded to make the place a standard hospital and research centre.

How to prevent snakebites

The programme manager, Snakebite Envenoming Programme, Oyediran, advised the public to always clean their surroundings and also use camphor to scare snakes away.

“Fumigate every three months, with snake repellent or normal chemical. The normal chemicals can drive them away but will not kill them. Don’t put remnants of food close to your house because rats will come and the snakes will come to eat the rats.  It is the balance of the ecosystem,” he said.

He advised against using tourniquet on snakebite victims to avoid complete shortage of blood supply to the brain.

“The issue of a tourniquet is not right. It is better to use an ordinary handkerchief to allow some blood to flow to the brain.   If you tie a tourniquet and blood is not circulating and going to the brain, that will kill the victim or induce a coma.

“The brain needs oxygen, which is in the blood. That is why we say don’t knot and don’t use your mouth to suck the venom because there have been instances where somebody accidentally swallowed the venom. Don’t put incision or a black stone, there is no scientific proof that they work,” he added.

He also advised Nigerians, especially rural dwellers, to plant species of plants that repel snakes, discourage dumping of refuse near homes and rearing animals and birds that attract snakes.