Snakes and Blunders

The 10^th Bio-Ken International Snakebite Seminar, Watamu

Published Daily Nation 29 November 2016

Useful Snake contacts in Kenya: 0718 290324 Bio-Ken Snake Farm www.bioken.com  www.antivenomtrust.com   www.snakebiteinitiative.org

13-year-old Menza Benjamin was picking up cashewnuts on the ground when he felt a burning hot bite on his leg followed by another. He started to vomit and broke out in a cold sweat. Close to his hut he fainted. He never saw the snake.

That was three years ago and he’s lucky to be alive, sitting at the snakebite seminar held in Watamu early November.

Royjan and Boniface who had been called by these villagers to catch a snake in the roof of one of their huts. It was a green mamba. Royjan and Boniface took some time to talk to them and answer their questions. Picture copyright Royjan Taylor

What saved Menza was the speed with everything that followed. His uncle saw him and immediately put him on a pikipiki and took him 12 kilometers to the Bio-Ken Snake Farm.  By the time they reached the snake farm, the boy was already showing rapidly advancing symptoms of black mamba bite. He was rushed by car – along with a supply of suitable antivenom to the local private hospital where he was treated by the hospital’s founder, Dr. Erulu, also present at the seminar.

Black mambas are among the fastest and deadliest snakes in the world. A bite requires urgent urgent attention.

On the other hand, in May this year a farmer tilling his farm in Maungu near Voi was bitten and brought to Voi in a matatu by his relatives – a 30 minute drive. From the symptoms, the doctors pinned it down to a puff adder – again one of Africa’s most venomous snakes. He had been bitten on the middle finger.

The doctor administered an antivenom immediately. Despite this, the patient’s condition deteriorated. Another antivenom shot was administered. On the fourth day the patient died from severe internal bleeding.

On reviewing the file, it was realised that despite receiving two shots of antivenom, the patient died.

“It was a preventable death,” states the medic relating the case at the seminar. The cause of death was that the antivenom used was not a suitable brand.

In Menza’s case, the boy was lucky. He received the correct antivenom from the James Ashe Anti-Venom Trust (JAAT) – an arm of Bio-Ken Snake Farm – that is supplied to the Kilifi county hospital. The farmer died of the ineffective antivenom currently stocked in Kenyan hospitals that is totally ineffective for snake bite victims in Kenya.

“In Kilifi county there has been no case of a child dying from a snake bite because of the antivenom,” states Dr Shebe Mohammed, a researcher at Kenya Medical Research Institute in Kilifi. “And this is despite three to four children brought to the county hospital every month.”

Snakebites

The fact is that almost every snake can bite but most bites are from harmless non-venomous snakes. Venom is used by snakes for a quick knock-down so that the prey does not get away and to break down the tissue to make it easier to digest– and not to kill humans.

The success of losing no child to venomous snake bites is because everyone – including the local mganga (traditional healer) – in Kilifi county knows of the Bio-Ken Snake Farm and the availability of good quality antivenom from it. The traditional healers know their snakes – the venomous from the non-venomous. They ‘treat’ the non-venomous bites with charms and chants for a chicken and a few hundred shillings. The patient oblivious of the difference between the bites pays, relieved to be ‘treated’ successfully. But when it comes to venomous snakebites, the mganga inevitably refer the snakebite victims to the ‘mzungu’ at the snakefarm. It’s proved to be a working relationship.

Bio-Ken Snake Farm was founded by the reptilian guru, the late James Ashe with his wife Sanda in 1980. Years after retiring as curator of the snake park at the Nairobi Museum, the couple settled in Watamu as Kenya’s coastal strip is rich in reptilian wonders. Since then, Bio-Ken has expanded into research and public awareness run with passion by Ashe’s protégée, Royjan Taylor who joined Bio-Ken in 2002.  The bi-annual snake seminars started 21 years ago, attract a global audience. Unfortunately the only people absent at most snake seminars are policy makers from government institutions.

“Taylor set up JAAT to meet the increasing need for good antivenom when the seminars and training of local doctors and nurses convinced people that they really CAN be saved from dangerous bites,” tells Sanda.

Anti-Venom

“Snakebites are complicated,” explains Tom Menge, toxicologist and chief pharmacist at Kenyatta National Hospital, Kenya’s largest referral hospital. Venomous snakebites require the correct anti-venom, followed by care.

“The antivenom registered in Kenya is by the Pharmacy and Poisons Board (PPB).

“As it’s registered there, the assumption is that PPB has verified the antivenom.”

It’s the crux of the problem. The antivenom available in the country is proving to be in-effective.

One theory is that it was approved based on dubious data presented to PPB by the manufacturer.

It speaks volumes of the ineptness of the board because anybody dealing in snakebites knows that venom varies from snake to snake – even within the same species – depending on the region it is from.

“Producing anti-venoms is challenging,” continues Menge, “because it requires venom from the snakes of all ages, different eco-zones and also during different seasons.”

In Kenya, there is no facility to manufacture antivenoms. JAAT purchases the effective South African-made antivenom for the safety of the Bio-Ken snake handlers. It also provides the antivenom on a non-profit making basis, on request and in consultation with doctors treating dangerous snakebites.  It’s what saved Menza’s life. But it’s expensive – a 10cc vial costs USD 200 – and a recommended dose varies between two and four vials.

“The challenge is that an unregistered product cannot be used in a public institution like KNH – whether it works or not – to avoid litigation. The World Health Organization (WHO) therefore has the responsibility to set higher standards of antivenom production from start to finish,” stresses Menge.

The situation in Kenya is frightening.

Neglected Tropical Disease

“The declining availability of high quality antivenom in sub Saharan Africa is a real and unnecessary tragedy, and constitutes a major neglected global health concern. The amount of suitable antivenom marketed in these countries has fallen to crisis levels, representing only a fraction of the amount required,” reads a research paper titled Consequences of Neglect: Analysis of the Sub-Saharan African Snake Antivenom Market and the Global Context by Nicholas I. Brown published in 2012 in the journal PLoS.

 Snakebite is also labelled ‘neglected tropical diseases’ by WHO and hence receives little funding or opportunities for research, innovation or business interest.

Added to that, a snake bite in tropical developing countries – Africa, Asia, South America – is an occupational hazard in the poorer segment of the society: women who walk barefoot for miles in search of water, peasants working in farms, pastorals on the move with their livestock and children at play in rural homesteads.

“The highest risk group is the productive age – 15 to 30 years old because they are more active,” states Dr David Williams who wears many caps. He is CEOof Global Snakebite Initiative, head of Australian Venom Research Unit at Melbourne University and head of the toxicology centre at University of Papua New Guinea. He’s well-travelled in sub-Saharan Africa and shows horrific images of snakebite victims in Africa, India and Papua New Guinea with rotting flesh, amputated limbs or paralysed.

“The cost to the community to look after the person is enormous and collectively it’s billions of dollars in lost productivity.”

He continues. “We don’t know how big the problem is in Africa. There is no system in place to collect data.” It is estimated that 85 per cent of snakebite victims opt for traditional healers because antivenom in hospitals is deemed ineffective.

“Yet good anti-venom is extremely effective,” says Williams. “But because the market is not regulated, the antivenoms available are not for African snakes.”

And the wrong antivenom kills the victim.

The harsh reality is that manufacturing high-quality antivenom makes little business sense – unless the government steps in with funding.

Opportunities

Compared to other medical conditions such as AIDS, malaria and TB in developing countries, snakebites are a drop in the ocean and hence government funding is allocated to diseases deemed more pressing.

It’s an approach that needs to be changed. Until the late Princess Diana took up the cause of landmine victims, it was an issue largely ignored and unknown. Similarly, says Williams, snakebite victims need a political voice, become a public issue and be dealt with at grassroot level.

“Antivenoms must be listed as essential medicine on the WHO list which obligates member countries to stock them. At the same time there is need for research into effective antivenoms involving researchers from home countries.

“There are opportunities if countries worked regionally such as those in eastern Africa – Kenya, Rwanda, Ethiopia, Tanzania, and Uganda – because these require the same antivenoms. It would then make business sense to have one procurement system to order a large quantity from a manufacturer because that makes it cheaper to produce.

“Ten years ago, we started with nothing in Papua New Guinea where there is just one doctor for every two hundred thousand people. Now we manufacture our own antivenom.”

An oceanic country in the Pacific north of Australia, Papua New Guinea is listed as a developing country.

“We now run nation-wide courses, up-skill health workers, have dedicated snakebite clinics and ambulances, clinical research laboratory and follow good manufacturing practices from start to finish ensuring that the product is safe to use on the snakebite victim,” tells Diana Barr, Technical Support Officer of the Papua New Guinea Snakebite Project – University of Melbourne.

The success rate in PNG for treating venomous snakebites is close to 100 per cent.

Snake Smart

The fact that every snake can bite does not mean that every victim dies. Very few snakes are venomous.

“70 per cent of snakebites are preventable if people wore shoes,” states Barr. “It’s cheaper than a snakebite.

“Teaching First Aid, producing posters of local snakes and training health care workers on how to physically handle snakebite victims and doing play backs minimizes further injury.”

If the anti-venom doesn’t work, one suggestion was to send it to the county office that supplied it – and ask for something that works- because every life matters.

The Mobile Phone Revolution

It’s revolutionized snakebite treatment. Taking pictures and forwarding them to doctors for fast advice and help is helping many lives that might have been lost or maimed forever. Whatsapp is another popular mode of being in the loop.

First Aid for Snakebite Victims

SPEED is of essence. Be CALM

1. Get away from the snake
2. Doing something is not always better than doing nothing
3. Remove tight clothes, belts, jewellery
4. Treat every snakebite as potential medical emergency – better safe than sorry
5. Transport

First aid for non-neuro toxic snakebite

1. Immobilize patient
2. Just put pressure on the area
3. Do not apply any dressing
4. Get to the doctor

First aid for neuro-toxic snakebite

1. Apply pressure – the correct pressure that is firm but not tight or loose
2. Immobilise patient
3. Monitor breathing
4. Turn on left side to drain fluid from lungs
5. Get to hospital

Snake Myths

Never use a tourniquet – it traps the venom, causing tissue damage and necrosis (tissue death – and possibly death of victim. Even without snake venom, a tourniquet cutting off blood circulation means death of tissue below the tourniquet, followed by amputation.

Never cut the flesh,  NOR use charms like black stones and alcohol.

Never suck ‘poison’ from a snakebite because you could poison yourself.

See a snake – walk away.

Snakes help keep the number of rodents low otherwise farmers have to use large quantities of anti-pesticides to kill rodents – which we eventually consume down the food chain.

Public Awareness

“It’s all down to awareness,” says Alex Mutiso, environmental manager at Tullow Oil operating in Turkana. The firm has a dedicated snake handler from Bio-Ken at the oil fields. “We catch up to two carpet vipers a day which are released away from the camp.”

Strict but simple guidelines at camp are adhered to – such as not leaving shoes outside, checking before you wear them, not walking in the dark and so on. The on-site medic has never had to treat a venomous snake bite.

But for Winnie Bore, the pharmacist at KNH, watching snake bite victims succumb to snakebites led her to become an activist and found Snakebite-Kenya a year ago to provide antivenom in rural areas, help rehabilitate victims disabled or visually impaired by snakebites and develop a research programme simply because there is very little information on snakebites in Kenya.

“There was a man from Tharaka-Nithi who lost his leg because he received the antivenom too late. It was preventable but by the time he got it, the leg was rotting. It had to be amputated. I felt l had to help communities deal with snakebites.”

Snakebite Statistics

Every year, according to GSI, snakebite claims some 125,000 lives globally. It affects the lives of around 4.5 million people worldwide; seriously injuring 2.7 million men, women and children.

Millions more die from malaria, AIDS, TB and road accidents.

Statistics of deaths by snakebite in Kenya – according to Sanda Ashe, there is no way at all with the current lack of detailed data to estimate.

But there will have been surges in bites and deaths where large areas of virgin land are being cleared of bush and forest. People come into contact with snakes more than in long-established inhabited areas.

What seemed like an increase of snakebites turned out to be more people coming in for help as they got to hear about Bio-Ken, rather than just dying at home, unrecorded.

The Big 5 in the African Snake World –  Boomslang , Puff Adder and other large vipers and species of small carpet viper species, cobras and the mambas.  Highly venomous, they play an important and fascinating role in African eco-systems, and rarely live up to their bad image as aggressive killers.