CME
GUEST EDITORIAL

 

Introductory editorial: Snakebite CME series

 

 

This introduction and editorial addresses the latest approaches to safe management of snakebite in South Africa (SA), and shares the evidence and expert consensus from the recent SA Snakebite Symposium (SASS) meeting held in July 2022.

Snakebite is recognised by the World Health Organization (WHO) as a neglected tropical disease.^[1-3] Due to poor-quality data accrual, statistics on snakebite in SA, with the dichotomous health system, and limited specific data on trauma in the District Health Information System, there are no accurate incidence data of snakebite in general and serious or fatal envenomation in particular, although estimates and formulae to calculate the numbers are available.^[4] The WHO estimates that data on bites and deaths for Africa as a whole reflect over 200 000 bites and more than 30 000 deaths annually.^[4]

SA has over 170 species of snakes, but of these around 20 comprise the 'dangerous and deadly' category. Regarding management of snake envenomation, the WHO Africa document is now more than 10 years old, covers aspects of management that are not specific to SA and mentions treatment options that may no longer be accepted or available.^[1]

Furthermore, treatment strategies that apply to snake envenomation from the Americas, Middle East, Asia and Australasia are inappropriate for Africa, owing to species and venom-action variance, or the significant antivenom differences. There have been a number of local publications, case reports and retrospective studies over the recent decades, reported between 2005 and 2021, but no consolidated national advisory document since the Shrire et al^[4] publication, through the SA Vaccine Providers group in 1996.^[4-19]

In an attempt to address this shortfall, the SASS was arranged held in Nelspruit on 29 and 30 July 2022 with the aim to address gaps in the management of snakebite in the local environment. This followed from the similar meetings held in eSwatini that resulted in a Swazi National Document for management of snakebite focused on their local snake species.^[20]

The National Snakebite Advisory Group (listed at the end of this editorial along with the SASS panel) was already in existence to assist in clinical advice, medical support and optimising patient management after snakebite.^[21] This group is a voluntary team of medical, veterinary and herpetology experts with an interest in snakebite management of both humans and animals. Their mission is to be available to offer timely support to treating medical teams, emergency service personnel and poison centres around SA. This group enthusiastically endorsed the SASS and also engaged numerous clinical groups and professional societies to support and endorse the recommendations that were agreed upon at the SASS as the national consensus document.

Resulting from the multidisciplinary 2-day meeting and the many pre-meeting online round-robin sessions, a set of consensus diagnosis and treatment guidelines are proposed on the current best local available evidence for both human and animal envenomation. This series of CME articles focuses on the human treatment guidelines and is presented in a format that addresses the entire patient journey. The articles commence with the layperson or non-professional 'first-aider' level, along with the pre-hospital emergency care aspects. The emergency department and in-hospital definitive management - both medical and surgical - follows. This includes recent developments in the understanding of particularly cytotoxic envenomation and surgical care, which are included in the recommendations.

T C Hardcastle

Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital (lALCH) and KwaZulu-Natal Department of Health; Department of Surgical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal; National Snakebite Advisory Group, Durban, South Africa hardcastle@ukzn.ac.za

Collaborators of the SASS Consensus Group

Mr Arno Naude - independent herpetologist: Snakebite Assist

Mr Chris Hobkirk - SASS organising committee, Lowveld Venom Suppliers

Mr Chris Cooke - herpetologist, Hoedspruit Reptile Centre

Mr Johan Marais - herpetologist, African Snakebite Institute

Prof. Che Waldon - Department of Zoology, North West University

Mr Nick van der Walt - emergency care practitioner, Access Professional Development

Prof. Timothy Craig Hardcastle - trauma surgeon, University of KwaZulu-Natal (UKZN)

Prof. Andreas Engelbrecht - emergency medicine specialist

Dr Vidya Lalloo - emergency medicine specialist, University of Pretoria

Dr Christoffel Bell - family medicine doctor, Mosvold Hospital, KwaZulu-Natal

Ms Mande Toubkin - GM Netcare Emergency, Trauma and Transplant, Netcare Head Office

Mr Kaleb Lachenicht - emergency care practitioner, Rocket Helicopter Emergency Services

Prof. Kenneth D Boffard - trauma surgeon, Johannesburg

Ms Maqshuda Kajee - registered nurse, SASS co-ordinating committee

Dr Morne Strydom - Department of Clinical Pharmacology, University of Pretoria

Mr Jason Seale - reptile curator, Hartebeespoortdam Snake and Animal Park

Mr Andrew Sheahan - emergency care practitioner with an interest in environmental medicine

Ms Thea Litchke-Koen - eSwatini Antivenom Foundation

Dr Sara Padidar - eSwatini Antivenom Foundation and University of eSwatini

Mr Jonathan Leeming - independent venom specialist Ms Hiral Naik - Save the Snakes SA

Dr Jessica Briner - veterinarian, Briner Veterinary Services

Dr K G M de Kramer - veterinarian, Rant-en-Dal Hospital and Onderstepoort, University of Pretoria

Dr Jo-Anne Gibb - veterinarian, Vet on 66

Prof. Andrew Leisewitz - veterinarian, internal medicine, Onderstepoort, University of Pretoria Mr Michael Perry - herpetologist

Members of the National Snakebite Advisory Group (affiliations listed if not listed above)

KwaZulu-Natal/Eastern Cape region: Prof. Timothy Hardcastle

Dr Jenna Taylor - anaesthesiologist, IALCH, UKZN and Department of Health, KZN

Dr Sharadh Garach - chief, Emergency Medicine, UKZN, Ngwelezana Hospital, Department of Health, KZN Dr Christoff Bell

Dr John Bruce - surgeon, Greys Hospital and Department of Surgery, UKZN

Prof. Damian Clarke - trauma director, Netcare St Annes, Greys Hospital and Department of Surgery, UKZN

Prof. George Oosthuizen - chief surgeon, Ngwelezana Department of Health, KZN/UKZN Gauteng/Free State region:

Prof. Dries Engelbrecht - head of Department of Emergency Medicine, University of Pretoria

Dr Vidya Lalloo

Mr Jason Seale

Mr Arno Naude - independent herpetologist, Snakebite Assist, Pretoria

Ms Mande Toubkin

Western Cape:

Dr Cindy Stephen and colleagues - National Poison Centre, Cape Town Swaziland:

Ms Thea Litschka-Koen (eSwatini Antivenom Foundation)

Dr Jonathan Pons - ophthalmologist, eSwatini

Other:

Mr Michael Perry - herpetologist, African Reptiles and Venom

Mr Johan Marais

Mr Chris Hobkirk

Ms Hiral Naik

Ms Maqshuda Kajee

 

References

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2. Williams DJ, Faiz MA, Abela-Ridder B, et al. Strategy for a globally coordinated response to a priority neglected tropical disease: Snakebite envenoming. PLoS Negl Trop Dis 2019;13(2):e0007059. https://doi.org/10.1371/journal.pntd.0007059        [ Links ]

3. World Health Assembly. Addressing the burden of snakebite envenoming. 71st World Assembly. WHA, 2018.         [ Links ]

4. Schrire L, Muller GJ, Pantanowitz L. The diagnosis and treatment of envenomation in South Africa. Rietfontein: South African Vaccine Producers, 1996.         [ Links ]

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13. Wium L. Neurotoxic snake bite in pregnancy. Obstet Med 2021;14(3):187-189. https://doi.org/10.1177/1753495X211019236        [ Links ]

14. Pach S, Le Geyt J, Gutierrez JM, et al. Paediatric snakebite envenoming: The world's most neglected 'neglected tropical disease'? Arch Dis Child 2020;105(12):1135-1139. https://doi.org/10.1136/archdischild-2020-319417        [ Links ]

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16. Buitendag JJP, Variawa S, Wood D, Oosthuizen G. An analysis of paediatric snakebites in north-eastern South Africa. S Afr J Surg 2021;59(3):97-101.         [ Links ]

17. Variawa S, Buitendag J, Marais R, Wood D, Oosthuizen G. Prospective review of cytotoxic snakebite envenomation in a paediatric population. Toxicon 2021;190:73-78. https://doi.org/10.1016/j.toxicon.2020.12.009        [ Links ]

18. Wagener M, Naidoo M, Aldous C. Wound infection secondary to snakebite. S Afr Med J 2017;107(4):315-319. https://doi.org/10.7196/SAMJ.2017.v107i4.12084        [ Links ]

19. Pattinson JP, Oosthuizen G, Tilbury CR, Wood D. Approaches to snake envenomation in Southern Africa. In: Mackessy SP, ed. Handbook of Venoms and Toxins of Reptiles. 2nd edition. London: CRC Press, 2021.         [ Links ]

20. Kingdom of eSwatini. National Snakebite Management Guidelines. eSwatini Antivenom Foundation, 2021.         [ Links ]

21. Specialised snakebite advisory team launched in SA. Medical Academic, 2018. https://www.medicalacademic.co.za/wound-care/specialised-snakebite-advisory-team-launched-in-sa/ (accessed 1 June 2022).         [ Links ]