Snakebite envenomations and access to treatment in communities of two indigenous areas of the Western Brazilian Amazon: A cross-sectional study.

BACKGROUND: The indigenous populations of Brazil present poor health indicators and a disproportionate prevalence and case-fatality rate of neglected tropical diseases, including snakebite envenomations (SBEs). This study aims to estimate access to medical care for SBEs and analyze the barriers that prevent victims from accessing healthcare in indigenous communities in two health districts located in the Western Brazilian Amazon. METHODOLOGY/PRINCIPAL FINDINGS: This cross-sectional study used semi-structured interviews to collect data from individuals who experienced SBEs in the Upper Rio Solimões and Upper Rio Negro indigenous health districts. Of the 187 participants, 164 (87.7%) reported that they had access to healthcare and received assistance in a hospital in the urban area of the municipalities. Frequency was 95.4% in the Upper Rio Solimões SIHD, and 69.6% in the Upper Rio Negro SIHD (P<0.0001). The study found that the availability of indigenous medicine as the only choice in the village was the main reason for not accessing healthcare (75%), followed by a lack of financial resources and means of transportation (28.1%). Four deaths were reported from SBEs, resulting in a case-fatality rate of 2.1%. CONCLUSIONS/SIGNIFICANCE: In the study areas, there are records of SBE patients who did not receive medical attention. Availability of pre-hospital emergency transport using motorboats, a greater number of hospitals and better navigability of the Solimões River and its tributaries would make access easier for indigenous people living in the region of the Upper Solimões River. The implementation of cross-cultural hospital care needs to be considered in order to reduce the resistance of indigenous populations in relation to seeking treatment for SBEs.

Children Growing Up with Severe Disabilities as a Result of Snakebite Envenomations in Indigenous Villages of the Brazilian Amazon: Three Cases and Narratives.

Snakebites are a major public health problem in the Brazilian Amazon and may lead to local complications and physical deficiencies. Access to antivenom treatment is poorer in indigenous populations compared to other populations. In this study, we report three cases of long-term severe disabilities as a result of Bothrops atrox snakebites in indigenous children, according to the narratives of the parents. The three cases evolved to compartment syndrome, secondary bacterial infection and extensive necrosis. The cases are associated with delayed antivenom treatment due to very fragmented therapeutic itineraries, which are marked by several changes in means of transport along the route. The loss of autonomy at such an early stage of life due to a disability caused by a snakebite, as observed in this study, may deprive children of sensory and social experiences and of learning their future roles in the community. In common to all cases, there was precarious access to rehabilitation services, which are generally centralized in the state capital, and which leads to a prolonged hospitalization of patients with severe snakebite, and distances them from their territory and family and community ties. Prospective studies should be conducted in the Amazon that estimate the burden of disabilities from snakebites in order to formulate public policies for the treatment and rehabilitation of patients through culturally tailored interventions.

Children growing up with severe disabilities as a result of snakebite envenomations in indigenous villages of the brazilian amazon: three cases and narratives

Snakebites are a major public health problem in the Brazilian Amazon and may lead to local complications and physical deficiencies. Access to antivenom treatment is poorer in indigenous populations compared to other populations. In this study, we report three cases of long-term severe disabilities as a result of Bothrops atrox snakebites in indigenous children, according to the narratives of the parents. The three cases evolved to compartment syndrome, secondary bacterial infection and extensive necrosis. The cases are associated with delayed antivenom treatment due to very fragmented therapeutic itineraries, which are marked by several changes in means of transport along the route. The loss of autonomy at such an early stage of life due to a disability caused by a snakebite, as observed in this study, may deprive children of sensory and social experiences and of learning their future roles in the community. In common to all cases, there was precarious access to rehabilitation services, which are generally centralized in the state capital, and which leads to a prolonged hospitalization of patients with severe snakebite, and distances them from their territory and family and community ties. Prospective studies should be conducted in the Amazon that estimate the burden of disabilities from snakebites in order to formulate public policies for the treatment and rehabilitation of patients through culturally tailored interventions.

Validation of a Culturally Relevant Snakebite Envenomation Clinical Practice Guideline in Brazil.

Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study).

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

Snakebites in “invisible populations”: a cross-sectional survey in riverine populations in the remote western Brazilian Amazon

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants’ demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2–49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4–39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.

A painful journey to antivenom: the therapeutic itinerary of snakebite patients in the Brazilian Amazon

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient’s admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

O brincar no hospital: uma self de enfermeiros que atuam em unidade pediátrica / Playing in hospital: a self of nurses acting in a pediatric unit / Jugando en el hospital: una self de enfermeiras trabajando en una unidad pediátrica

Objetivo: Conhecer a importância da atividade do brincar sob a ótica do enfermeiro durante o cuidado à criança hospitalizada. Metodologia: Estudo descritivo-exploratório prospectivo, qualitativo. Realizou-se entrevista semiestruturada em unidade pediátrica de referência de um município no estado do Amazonas, no mês de janeiro de 2015. Participaram cinco enfermeiras que atuam na unidade pediátrica. Da análise, emergiram categorias temáticas: "A importância do brincar no olhar da Enfermagem como Direito da Criança." e "Obstáculos para inclusão da brincadeira no assistir à criança hospitalizada". Resultados: O brincar é relatado pelas enfermeiras como uma atividade ímpar durante a hospitalização. Entretanto, referem não inseri-lo por desconhecerem como realizá-lo, valorizando apenas procedimentos técnicos em suas ações de enfermagem, engessando o cuidado durante seu atendimento. Conclusão: O brincar em clínica pediátrica deve ser uma atividade inserida no plano de cuidados dos enfermeiros (AU).

Objective: To know the importance of playing activity from the nurse's point of view during the care of hospitalized children. Methodology: Prospective, qualitative descriptive exploratory study. A semi-structured interview was carried out in a pediatric reference unit in a municipality in the state of Amazonas, in January 2015. Participants were five nurses who work in the unit. From the analysis, thematic categories emerged: "The importance of playing in the view of Nursing as the Right of the Child." And "Obstacles for the inclusion of playing in assisting hospitalized children". Results: Playing is reported by nurses as a unique activity during hospitalization. However, they refer not to insert it because they do not know how to do it, valuing only technical procedures in Nursing actions, plastering care during their assistance. Conclusion: Playing in a pediatric clinic should be an activity included in the nurses' care plan (AU).

Objetivo: Conocer la importancia de la actividad de juego desde el punto de vista de la enfermera durante el cuidado de niños hospitalizados. Metodología: Estudio exploratorio prospectivo, cualitativo, descriptivo. Se realizó una entrevista semiestructurada en una unidad de referencia pediátrica en un municipio del estado de Amazonas, en enero de 2015. Participaron cinco enfermeras que trabajan en la unidad. Del análisis, surgieron categorías temáticas: "La importancia de jugar desde la perspectiva de la Enfermería como el derecho del niño". Y "Obstáculos para la inclusión del juego en la asistencia a niños hospitalizados". Resultados: Las enfermeras informan que el juego es una actividad única durante la hospitalización, sin embargo, se refieren a no insertarlo porque no saben cómo hacerlo, valoran solo los procedimientos técnicos en las acciones de Enfermería, echan atención durante su cuidado. Conclusión: Jugar en una clínica pediátrica debería ser una actividad incluida en el plan de atención de enfermeira (AU).

Educação em saúde para acompanhantes de pacientes internados / Health education for companions of hospitalized patients

Objetivo: relatar a experiência da educação em saúde sobre a biossegurança realizada aos acompanhantes de pacientes portadores de doenças infectocontagiosas internados em um hospital de referência em infectologia no Amazonas. Método: estudo descritivo, tipo relato de experiência, realizado com acompanhantes de pacientes portadores de doenças infectocontagiosas em uma unidade de referência em infectologia. Resultados: foram realizados 49 encontros com um registro de participação de 488 ouvintes. Quase a totalidade (89,6% dos acompanhantes entrevistados) informou nunca ter tido a oportunidade de participar de um programa de educação em saúde em outros hospitais. A dúvida mais frequente dos ouvintes, antes dos ensinamentos de biossegurança, foi de não saberem quais medidas realizar para não levar microrganismos existentes no ambiente hospitalar para dentro de suas residências. Conclusão: os dados confirmam a importância de disponibilizar, aos acompanhantes, os cuidados de biossegurança, a partir de uma linguagem simples e didática, para que o conhecimento se torne acessível e entendível, assim, promovendo mudanças de hábitos positivos no ambiente hospitalar.(AU)