ABSTRACT
Incidence of snakebite is high in Africa and is characterized by an amazing heterogeneity of factors, related to the great diversity of both the snake fauna and human activities. Composition of snake populations varies according to the climate and environment. Important anthropogenic modications of the environment-increasing tremendously over the last 30 years-have led to rearrangements in both the composition of the snake populations and the demography of individuals. Some
I. Introduction .......................................................................................................................... 454 II. Individual and Snake Encounter Components ..................................................................... 455 A. Description of Snake Fauna from Sub-Saharan Africa ................................................. 455 B. Human Activities Related to Snakebite Risk ................................................................. 456 C. Epidemiology of Snakebites ........................................................................................... 457 1. Surveys in Health Centers ......................................................................................... 457 2. Household Surveys .................................................................................................... 457 3. Therapeutic Choice and Treatment of Snakebites ..................................................... 457 4. At-Risk Populations ................................................................................................... 458 5. Evaluation of Therapeutic Needs .............................................................................. 459 III. Clinics and Treatment of Envenomations ............................................................................ 461 A. Symptoms ....................................................................................................................... 461 1. Clinical Heterogeneity of Envenomations ................................................................. 461 2. Elapid Envenomations ............................................................................................... 461 3. Viper Envenomations ................................................................................................ 462 B. Treatment of Envenomation ...........................................................................................463 C. Logistical and Socioeconomic Aspects..........................................................................464 IV. A Proposal for a Plan of Action ...........................................................................................465 A. Dening AV Quality Standards .....................................................................................465 1. Effectiveness ..............................................................................................................466 2. Safety .........................................................................................................................466 3. Stability .....................................................................................................................466 4. Accessibility ..............................................................................................................466 B. Identifying At-Risk Populations .....................................................................................466 C. Ensuring a Supply of AV ................................................................................................ 467 D. Health Personnel Training ..............................................................................................468 E. Information to the Public ...............................................................................................468 V. Conclusions ..........................................................................................................................468 References ......................................................................................................................................469
species are attracted to human-modied environments, such as industrial plantations, while others are deterred. Thus, some locations show higher densities of venomous species than are represented in the natural environment. Several epidemiologic methods are used to evaluate the quantitative and qualitative importance of snakebites. Retrospective or prospective surveys in health centers evaluate the use of health facilities by the victims and the severity of the envenomations. However, a major underestimation of snakebite incidence occurs as a consequence of poor attendance of health centers, which are often very scarce. Many victims do not have the time to reach a hospital or prefer to consult traditional practitioners. Efcient household surveys, which consist of questioning the population directly, could correct the estimate of the incidence and mortality and give a more realistic evaluation of snakebite importance. Moreover, household surveys allow evaluation of level of dependence on traditional medicine (which involves ~40 to 80% of bites, depending on location). These types of surveys are now standardized. Envenomation represents a neglected public health problem in Africa. Actual incidence of snakebites varies from 100 to 650 bites for 100,000 inhabitants per year, and annual mortality can exceed 10 deaths per 100,000 inhabitants in rural areas, resulting in an estimation of more than 1 million bites and 25,000 deaths per year for the whole of sub-Saharan Africa. Delay of treatment is also a characteristic of African snakebites and can exceed 24 hours; for some victims, this delay may be 1 or 2 weeks. This is the consequence of complex care-seeking behavior, health center scarcity, and the lack of condence of African populations generally toward equipment and capacity of health centers, which appear to them inappropriate for treating snakebites. Antivenom is typically of exceptionally limited availability, but the only effective treatment is antivenom administration. For the last decade, concerted efforts have been made to improve the accessibility of antivenom in Africa, and greater access will decrease morbidity and mortality tremendously.
