A model of empowering paramedics in snakebite management and research in a resource poor setting 10

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A model of empowering paramedics in snakebite
management and research in a resource poor
setting 10 years outcome

• Sharma SK1, Chappuis F2, Loutan L2, Shah C3
• 1Department of Internal Medicine, BPKIHS, 3Damak
  Red Cross Snakebite Treatment Center, Nepal and
  2Travel and Migration Medicine Unit, Geneva
  University Hospital

GICT261108
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Snake bites in Nepal

• Snake bites are an important health problem in
  Nepal where 80 of the population live in the
  rural area
• In the southern Teraï plain (Low-land), cobras
  and kraits are the most dangerous species
  encountered (neurotoxic venom)
• Access to life saving anti-venoms and facilities
  to administered it is limited
• Existing epidemiological data from hospital-based
  statistics ? underestimation of the true impact
  of snake bites

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THE CASE OF NEPAL
Total population
27 million
Per capita GDP
US 240
80 population
US 2 per day
Human Dev Index rank
136/177
No national health insurance (patient pay for
treatment)
80 people lives in rural area Agriculture main
stay of economy
Nurses
9000
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Referral System in Health Structure of
Nepal Sub-Health-post Primary Health Care
Center District Hospital Zonal
Hospital Tertiary Care Center
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• SHP first contact point
• No doctor, No Antivenom
• Primary Health Center
• 90 no doctor, No Antivenom (few exceptions)
• District hospital
• gt50 hospital has doctors
• Many will not treat snakebite cases
• Antivenom available, if snakebite is treated
• Zonal Hospital
• Antivenom Available
• Some do not treat snakebite victims e.g. Mechi
• Emergency mostly attended by HA

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Snakebite victims died without treatment as even
Zonal Level Hospital in certain region (e.g.
Mechi Zonal Hospital) do not treat snakebite
victim

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• Snakebite Treatment Center NRC - Damak
• A six week training course organized for Health
  Assistant
• Training provided with simple clinical decision
  guideline
• Six HA received training in 1998 (had some
  exposure before)
• 2 to 4 days reinforcement of training in
  subsequent years
• Access to telephonic consultation with faculty
  of medicine of BPKIHS (only tertiary care
  university hospital in Eastern Nepal)
• All records were kept in a structured case
  record forms

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Problem-based learning Case history of a
patient

• 22-yr-old female presented to Snakebite
  Treatment Centre/hospital with history of bite by
  snake while working on field
• Q1 Is it snakebite?
• Q2 What are the snakes that are available in
  this area?
• Q3 What is the earliest sign of envenomation?
• Q4 Dose regimen of Antivenom (10 vials as IV
  infusion (2ml/min in 500 ml Saline as bolus for
  neurotoxic)
• ..
• Illustration with photographs and bedside
  demonstration

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• Recommended Key Drugs Equipment
• Antivenom (Polyvalent from India)
• Adrenaline 1ml amps
• Neostigmine Methyl Sulphate 0.5mg amps
• Atropine 0.6mg amps
• H1 antihistamine (chlorheniramine)
• Hydrocortisone
• I V fluid
• IV canula
• IV Drip
• Glass test tubes, (rarely needed)
• Resuscitation bag/Kit

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• Antivenom and essential other medicines procured
  by NRC ( Nepalese Government local purchase)
  
• Protocol-based management done
• Early identification of adverse reactions
• Wound management referred to nearby AMDA
  hospital/BPKIHS

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• We wanted to compare with national data
• However, No proper data at National Level
• National mortality decrease from 19 in 2000
  to14 in 2004
• 1000 envenoming and 200 death (Dr Thapa
  personnel commu)
• Discrepancy between ministry of health report
  and EDCD

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Poor Hospital records system

• Snakebite in Nepal, 2000
• Ministry of Health report - 480
  bites
• - 22 deaths
• 10 hospitals of eastern Nepal - 4078
  bites - 81 death
• Sharma SK, Toxicon 2003, MoH Report, 2000

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A review of outcome management done 10 hospital
in eastern Nepal in 2000
Sharma SK et al. Toxicon 2003 285289, Sharma SK
et al Trop Doctor 200420-22
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• From 2002
• Training in snakebite for HA for 3 weeks
  organized during rainy season x 3 sessions
  conducted
• Total of 30 HA trained
• Management driven by simple protocol for
  neurotoxic envenomation
• Referral insisted if necessarily for
  Ventilatory support is anticipated
• Transport by Ambu bag
• (Possibly training for intubation next year)

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Mortality Comparison due to Snake envenoming
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• Involvement on some epidemiological study and
  community-based education and intervention in
  mortality reduction due to envenoming by
  snakebite
• As enumerator
• As community educator
• Results of some studies

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Villages surveyed
? Damak Red Cross Health Centre
Study 1
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Incidence

• 1817 households visited in December 2001 (10550
  inhabitants)
• 143 snake bites reported during the 14 months
  period
• ? annual incidence of snake bites
  1162/100000
• ? annual incidence of probable venomous bites
  604/100000

Study 1
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Outcome

• 20 patients died ? case-fatality rate (all snake
  bites) 14
• ? case-fatality rate (envenomed bites) 27
• ? annual mortality 162/100000

Study 1
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Factors associated with death

• Location of bite indoor ? CFR 31 (p
  0.006)
• Activity resting ? CFR 38 (p
  0.01)
• Time of bite 0 6 am ? CFR 40 (p
  0.02)

Study 1
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Outcome in survivor of snakebite

• Wound requiring dressing and/or surgery 32
• A scar with deformity 7
• Chronic wound 5
• Cost of management
• Out of pocket expences (mean) 69 US

Study 1
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Protection against Snake Bites by Sleeping under
a Bed Net in Southeastern Nepal

• To determine if the use of bednets or other
  factors
• does influence the risk of snake bite during sleep

Study 2
Chappuis F, Sharma SK et al Am J Trop Med Hyg
2007 197-199
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Results

• 56 cases and 56 matched controls were included
• Case-fatality rates among cases 21.4
• Floor (ground versus 1st floor) and location of
  sleep (bedroom, terrace, veranda, etc) were not
  identified as risk factors
• Sleeping on a cot versus sleeping on the floor
• RR of 0.25 (95 CI 0.03-1.25) p 0.11
  (McNemar test)

Study 2
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Results bednets

• 91.1 of controls vs 17.9 of cases used
  bednets at the time of bites (only 3.2
  impregnated with insecticides lt 6m)
• Matched analysis
• RR 0.0 (95CI 0.0 0.09) p lt 0.00001
  (McNemar exact test)

Study 2
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Study 3 Objective

• To test the impact of
• - community-based health education and
• - promotion of transport of victims by motorbike
• to decrease case-fatality rate of snake bites in
  rural Nepal

Study 3
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Methods
2003
2004
Rainy season
Rainy season
Pre-intervention survey
Intervention
Post-intervention survey
Study 3
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Kerabari

Chulachuli
Damak RC Centre
Ithara
Rajghat
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Methods Intervention

• Community-based education
• 2-3 sessions per village 1 final session in
  February-March 04
• Message focused on rapid transport by motorbike
  to Damak Red Cross HC (or other hospital)
• 5000 small information leaflets distributed
• 500 large leaflets with slogans such as
•  bitten by snake catch motorbike volunteers
  reach Damak save life ! 

Study 3
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Methods Intervention

• Promotion of transport by motorbike
• Call for volunteers (motorbike owners)
• 10 volunteers by village included in the
  program
• Cost of gasoline reimbursed by the project (5-7
  /transport)

Study 3
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Results

• Pre-intervention
• 11177 households visited (60759 people)
• 305 snake bites in 298 households during 2003
  rainy season
• Intervention
• Health education as scheduled
• 141 victims transported by motorbike by
  volunteers
• Post-intervention
• 10916 households visited (59383 people)
• 187 snake bites in 185 households during 2004
  rainy season

Study 3
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Results

• Incidence (6 months) of snake bites
• Pre-intervention 503/100000
• Post-intervention 315/100000
• Relative risk (2004/2003) 0.625 (p
  lt0.001)
• Why such a decrease ?
• Decreased density of snakes (climatic factors) ?
• Impact of the project (increased awareness) ?

Study 3
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Outcome

• Case-fatality rates of snake bites
• Pre-intervention 32/305 10.5
• Post-intervention 1/187 0.5
• Relative risk of fatal outcome (2004 / 2003)
• 0.051 (p lt 0.0001)

Study 3
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Conclusion

• Snake bites are a major public health problem in
  the rural Nepal
• Structured training of paramedics to treat
  snakebite envenoming had good impact in
  reduction of snakebite and snakebite related
  mortality in rural community in eastern Nepal
• This also helped genesis of hospital based data
  through proper data keeping
• Helped educate people in the rural community
• Some training enable them to assist in
  epidemiological and intervention reserach in
  snakebite
• This model may be useful for managemnet of
  snakebite in rural area where snakebite is
  common and doctors are few
• Motorbike Ambulance

Study 3
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Acknowledgements Dr Nilhambar Jha Dr
Shekhar Koirala Mr Chandra Shah Dr Patrick
Bovier Dr Louis Loutan Dr Man Bh Budathoki,
President , Nepal Red Cross Center -
Damak Fonds de péréquation des HUG Sonisca
Foundation GICT for support to present this
paper And all the volunteers
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Thank you for your attention !
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Knowledge deficit in management of snakebite

• 36 doctors working in emergency department of
  various parts of the country were interviewed
  when they join BPKIHS residency program
• Graduate from Nepal, India, Bangladesh and
  Pakistan
• 40 were unaware of first clinical manifestation
  on neurotoxicity
• 75 did not know the initial dose of ASV
• All continued ASV while patients on mechanical
  ventilation