Dealing with snakebite in rural Cameroon: A qualitative investigation among victims and traditional healers.

BACKGROUND: Snakebite is a neglected tropical disease (NTD) affecting rural and remote populations globally, who are additionally burdened by poverty and the lack of effective healthcare systems. Delayed healthcare and use of traditional treatments are very frequent. The purpose of our study was to explore perceptions of snakes, impact of snakebite, and knowledge and opinions of different snakebite treatments with the aim of identifying opportunities for improving snakebite management. METHODS: This is a qualitative descriptive study based on semi-structured interviews with 21 snakebite victims and 4 traditional healers in 4 villages of Akonolinga health district, Center Region, Cameroon. Analysis focused on describing participants' perceptions of snakes, the impact of snakebite on the victims' lives, and their opinions of different treatment options. RESULTS: Respondents were fearful of snakes and knowledgeable about envenoming symptoms and treatments. The experience of snakebite led to increased vigilance and avoidance behaviours, which sometimes resulted in financial loss for the victims. A range of traditional treatments were described, including tourniquets, black-stone application and medicinal plant decoctions. However, opinions were ambivalent regarding their efficacy, depending especially on previous personal experiences. Still, traditional treatments were said to be more available and cheaper than hospital care, and in particular, than antivenom. Nevertheless, most victims preferred hospital treatment if the financial and transportation barriers were lifted. Both snakebite victims and traditional healers were of the opinion that collaboration between health services and traditional healers could help to improve snakebite management and outcomes. CONCLUSION: Our study shows that snakebite victims are in favour of using antivenom for the treatment of snakebite and would welcome better access to it. However, its current unavailability and high cost pushes them to turn to traditional treatments. On the other hand, traditional healers are in favour of collaborating with health facilities. These results are very encouraging for the improvement of snakebite management in Cameroon along the lines of the WHO Snakebite Envenoming Strategy for Prevention and Control: ensuring access to safe and effective treatment, and increasing partnership and coordination between communities, traditional healers, and conventional caregivers.

What is the impact of snakebite envenoming on domestic animals? A nation-wide community-based study in Nepal and Cameroon.

Snakebite envenoming is a life-threatening disease in humans and animals and a major public health issue in rural communities of South-East Asia and sub-Saharan Africa. Yet the impact of snakebite on domestic animals has been poorly studied. This study aimed to describe the context, clinical features, treatment, and outcomes of snakebite envenoming in domestic animals in Nepal and Cameroon. Primary data on snakebite in animals were recorded from a community-based nation-wide survey on human and animal snakebite in Nepal and Cameroon (Snake-byte project). Mobile teams collected data on snakebite in humans and animals in 13,879 and 10,798 households in Nepal and Cameroon respectively from December 2018 to June 2019. This study included 405 snakebite cases (73 in Nepal and 332 in Cameroon) in multiple types of animals. An interview with a structured questionnaire collected specific information about the animal victims. Snake bites in animals took place predominantly inside and around the house or farm in Nepal (92%) and Cameroon (71%). Other frequent locations in Cameroon were field or pasture (12%). A large diversity of clinical features was reported in all types of envenomed animals. They showed either a few clinical signs (e.g., local swelling, bleeding) or a combination of multiple clinical signs. Only 9% of animal victims, mainly cattle and buffaloes and less frequently goats, sheep, and dogs, received treatment, predominantly with traditional medicine. The overall mortality of snakebite was 85% in Nepal and 87% in Cameroon. Results from this nationwide study show an important impact of snakebite on animal health in Nepal and Cameroon. There is a need for cost-effective prevention control strategies and affordable snakebite therapies in the veterinary field to save animal lives and farmer livelihood in the poorest countries of the world. The WHO global strategy to prevent and control snakebite envenoming supports a One Health approach, which may help develop integrated solutions to the snakebite problem taking into account human and animal health.

Snakebite epidemiology and health-seeking behavior in Akonolinga health district, Cameroon: Cross-sectional study.

BACKGROUND: Snakebite envenoming causes 81,000-138,000 annual human deaths and pain, terror, or disability in 4.5-5.4 million victims. Accurate community-based epidemiological data is scarce. Our objective was to assess snakebite incidence, mortality, and health-seeking behavior, in an affected health district of Cameroon. METHODS: We conducted a cross-sectional multicluster household survey in Akonolinga health district, Centre Region, Cameroon, from October to December 2016. Using probability-proportional-to-size, 20 villages were randomly selected, then, all inhabited households were systematically selected. Annual incidence and adjusted odds-ratio for predictors were estimated. FINDINGS: Among the 9,924 participants, 66 suffered a snakebite during the past year: the resulting incidence is 665 (95%CI: 519-841) per 100,000 inhabitants per year. Victims were aged 5-75y (median: 34y), 53% were male and 57% farmer-cultivators. Two children died (case-fatality rate: 3%); 39 (59%) presented severity signs, including 2 (3%) neurotoxic syndromes, 20 (30%) systemic digestive syndromes, and 17 (26%) severe cytotoxic syndromes. Non-severe cases included 20 (30%) mild cytotoxic syndromes and 7 (11%) dry bites. Only two victims (3%) received antivenom. 59 (89%) used family traditional practices, 25 (38%) traditional healers, and 31 (47%) consulted health facilities. Median delays to these three care-options were 5, 45, and 60 minutes, respectively. Traditional treatments included incisions (n = 57; 86%), tourniquets (n = 51; 77%) and black-stones (n = 44; 67%). The two last procedures were also used in health facilities (n = 18). Consulting traditional healers was associated with severity (adjusted-OR: 19.6 (2.5-156), p = 0.005) and complications (aOR: 17.3, 2.4-123, p = 0.004). Long-term disabilities were subjective psychological trauma (n = 47; 71%), finger amputation (n = 1; 2%), ankylosis (n = 1; 2%) and chronic pain (n = 1; 2%). CONCLUSIONS: We observed alarming levels of snakebite incidence, mortality, antivenom scarcity, and use of traditional medicine. It could represent several thousands of victims at national level. We suggested conducting a country-wide study, and improving antivenom supply, first-aid training, for traditional healers and health professionals.

Single-dose oral ciprofloxacin prophylaxis as a response to a meningococcal meningitis epidemic in the African meningitis belt: A 3-arm, open-label, cluster-randomized trial.

BACKGROUND: Antibiotic prophylaxis for contacts of meningitis cases is not recommended during outbreaks in the African meningitis belt. We assessed the effectiveness of single-dose oral ciprofloxacin administered to household contacts and in village-wide distributions on the overall attack rate (AR) in an outbreak of meningococcal meningitis. METHODS AND FINDINGS: In this 3-arm, open-label, cluster-randomized trial during a meningococcal meningitis outbreak in Madarounfa District, Niger, villages notifying a suspected case were randomly assigned (1:1:1) to standard care (the control arm), single-dose oral ciprofloxacin for household contacts within 24 hours of case notification, or village-wide distribution of ciprofloxacin within 72 hours of first case notification. The primary outcome was the overall AR of suspected meningitis after inclusion. A random sample of 20 participating villages was enrolled to document any changes in fecal carriage prevalence of ciprofloxacin-resistant and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae before and after the intervention. Between April 22 and May 18, 2017, 49 villages were included: 17 to the control arm, 17 to household prophylaxis, and 15 to village-wide prophylaxis. A total of 248 cases were notified in the study after the index cases. The AR was 451 per 100,000 persons in the control arm, 386 per 100,000 persons in the household prophylaxis arm (t test versus control p = 0.68), and 190 per 100,000 persons in the village-wide prophylaxis arm (t test versus control p = 0.032). The adjusted AR ratio between the household prophylaxis arm and the control arm was 0.94 (95% CI 0.52-1.73, p = 0.85), and the adjusted AR ratio between the village-wide prophylaxis arm and the control arm was 0.40 (95% CI 0.19‒0.87, p = 0.022). No adverse events were notified. Baseline carriage prevalence of ciprofloxacin-resistant Enterobacteriaceae was 95% and of ESBL-producing Enterobacteriaceae was >90%, and did not change post-intervention. One limitation of the study was the small number of cerebrospinal fluid samples sent for confirmatory testing. CONCLUSIONS: Village-wide distribution of single-dose oral ciprofloxacin within 72 hours of case notification reduced overall meningitis AR. Distributions of ciprofloxacin could be an effective tool in future meningitis outbreak responses, but further studies investigating length of protection, effectiveness in urban settings, and potential impact on antimicrobial resistance patterns should be carried out. TRIAL REGISTRATION: ClinicalTrials.gov NCT02724046.