A prospective cohort study of the effectiveness of the primary hospital management of all snakebites in Kurunegala district of Sri Lanka

Abstract

IntroductionSri Lanka records substantial numbers of snakebite annually. Primary rural hospitals are important contributors to health care. Health care planning requires a more detailed understanding of snakebite within this part of the health system. This study reports the management and epidemiology of all hospitalised snakebite in the Kurunegala district in Sri Lanka.MethodologyThe district has 44 peripheral/primary hospitals and a tertiary care hospital-Teaching Hospital, Kurunegala (THK). This prospective study was conducted over one year. All hospitals received copies of the current national guidelines on snakebite management. Clinical and demographic details of all snakebite admissions to primary hospitals were recorded by field researchers and validated by comparing with scanned copies of the medical record. Management including hospital transfers was independently assessed against the national guidelines recommendation. Population rates were calculated and compared with estimates derived from recent community based surveys.ResultsThere were 2186 admissions of snakebites and no deaths in primary hospitals. An additional 401 patients from the district were admitted directly to the teaching hospital, 2 deaths were recorded in this group. The population incidence of hospitalized snakebite was 158/100,000 which was significantly lower than community survey estimates of 499/100,000. However there was no significant difference between the incidence of envenomation of 126/100,000 in hospitalised patients and 184/100,000 in the community survey. The utilisation of antivenom was appropriate and consistent with guidelines. Seventy patients received antivenom. Anaphylactic reactions to antivenom occurred in 22 patients, treatment reactions was considered to be outside the guidelines in 5 patients. Transfers from the primary hospital occurred in 399(18%) patients but the majority (341) did not meet the guideline criteria. A snake was identified in 978 cases; venomous snakebites included 823 hump-nosed viper (Hypnalespp), 61 Russell’s viper, 14 cobra, 13 common krait, 03 saw scaled viper.ConclusionsPrimary hospitals received a significant number of snakebites that would be missed in surveys conducted in tertiary hospitals. Adherence to guidelines was good for the use of antivenom but not for hospital transfer or treatment of anaphylaxis. The large difference in snakebite incidence between community and hospital studies could possibly be due to non-envenomed patients not presenting. As the majority of snakebite management occurs in primary hospitals education and clinical support should be focused on that part of the health system.

Vulnerability to snakebite envenoming: a global mapping of hotspots

“… 6 Although health system indicators and accessibility metrics act as generalised correlates for a location's ability to respond to cases, these measures will possibly underestimate or overstate local vulnerabilities in some settings. Existing analyses of health systems show variation both nationally and subnationally in treatment-seeking behaviours, 49 , 50 quality of primary point of care visits and referrals, 51 and general practitioner knowledge about the condition. 52 However, the external validity of these existing surveys is unknown.…”

A prospective analysis of adherence to standard treatment guidelines in management of snakebite in a tertiary care teaching hospital of rural Bengal, India

“…[5][6][7] But this data is widely believed to be an under-reported. 8,9 India reports highest mortalities due to snakebite. 10 In India, polyvalent ASV is produced by hyper immunising horses against venoms of four common species of snake i.e.…”

“…Till date there are very few recent studies looking for its adherence and its relation to its outcome, but such study was never conducted in Bankura district of West Bengal which has a high prevalence of snakebites and related deaths. 8,13 The objective of this study was to evaluate the adherence to the guidelines of the new protocol on snakebite management prospectively so that the benefits and the drawbacks of the new protocol could be evaluated.…”

Compliance with National Snakebite Treatment Guidelines in Rural Sri Lankan Hospitals: A Cluster Randomized Controlled Trial of a Brief Educational Intervention

“…Snakebite is considered a neglected tropical disease [1]. In Sri Lanka, there are approximately 40,000 hospital admission following snakebites reported annually [2], [3].In a nationwide community based study which included snakebite victims who did not present to hospital there was more than 80,000 bites annually [4]. Most of the envenoming results from the land snakes such as Russell's viper (Daboia russelii), Hump-nosed pit viper (Hypnale species), Common krait (Bungarus caeruleus), Saw-scaled viper (Echis carinatus) and Cobra (Naja naja) [5],[6], [7].In the year 2018, the overall in hospital mortality from snakebite was 1.63 per 1000 admissions [2] and there were 464 deaths in Sri Lanka [4].…”

“…The majority of snakebites present to primary hospitals of the island manned by non-specialist medical doctors. A sizable proportion of patients are then transferred to secondary or tertiary care hospitals where specialists are available for further care [3]. Thus, primary care hospital plays a pivotal role in clinical management of patients that decides the burden of morbidity and mortality in snakebite.…”