Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: ‘Every Life has Equal Value’

Snakebites are more frequent in the Brazilian Amazon than in other parts of Brazil, representing a high cost for the health system since antivenoms are only available through medical prescription from central municipal hospitals in most cases. The need for a cold chain and physicians usually restricts access to the only effective treatment of a snakebite, the antivenom. The complex topography of the rivers contributes to delays in treatment, and consequently increases the risk of severe complications, chronic sequelae and death. Thus, decentralization of antivenom treatment to primary healthcare facilities in the interior would increase access by indigenous population groups to proper healthcare. To standardize and evaluate the decentralization to low complexity indigenous healthcare units, we suggest the (i) development and validation of standardized operational procedures, (ii) training of professionals in the validated protocol in a referral health unit, (iii) implementation of the protocol in an indigenous healthcare unit, (iv) assessment of perceptions towards and acceptability of the protocol, and (v) estimation of the impact of the protocol’s implementation. We expect that antivenom decentralization would shorten the time between diagnosis and treatment and, as such, improve the prognosis of snakebites. As health cosmology among indigenous populations has an important role in maintaining their way of life, the introduction of a new therapeutic strategy to their customs must take into account the beliefs of these peoples. Thus, antivenom administration would be inserted as a crucial therapeutic tool in a world of diverse social, natural and supernatural representations. The information presented here also serves as a basis to advocate for support and promotion of health policy initiatives focused on evidence-based care in snakebite management

Older age and time to medical assistance are associated with severity and mortality of snakebites in the Brazilian Amazon: a case-control study

Submitted by Janaína Nascimento ([email protected]) on 2019-02-15T11:17:05Z No. of bitstreams: 1 ve_Feitosa_Esaú_etal_INI_2015.pdf: 1624394 bytes, checksum: df5b13cfa36f35b77b0def5f96203d08 (MD5)Approved for entry into archive by Janaína Nascimento ([email protected]) on 2019-02-15T13:12:37Z (GMT) No. of bitstreams: 1 ve_Feitosa_Esaú_etal_INI_2015.pdf: 1624394 bytes, checksum: df5b13cfa36f35b77b0def5f96203d08 (MD5)Made available in DSpace on 2019-02-15T13:12:37Z (GMT). No. of bitstreams: 1 ve_Feitosa_Esaú_etal_INI_2015.pdf: 1624394 bytes, checksum: df5b13cfa36f35b77b0def5f96203d08 (MD5) Previous issue date: 2015Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil / Fundação de Vigilância em Saúde do Amazonas. Núcleo de Sistemas de Informação. Manaus, AM, Brasil.Emory University. Department of Medicine. Atlanta, GA, USA.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.Universidade Federal do Amazonas. Instituto de Ciências Biológica. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil / Fundação Oswaldo Cruz. Instituto Leônidas e Maria Deane. Manaus, AM, Brasil.Fundação de Medicina Tropical Doutor Heitor Vieira Dourado. Departamento de Ensino e Pesquisa. Manaus, AM, Brasil / Universidade do Estado do Amazonas. Escola Superior de Ciências da Saúde. Manaus, AM, Brasil.The Amazon region reports the highest incidence of snakebite envenomings in Brazil. We aimed to describe the epidemiology of snakebites in the state of Amazonas and to investigate factors associated with disease severity and lethality. We used a nested case-control study, in order to identify factors associated with snakebite severity and mortality using official Brazilian reporting systems, from 2007 to 2012. Patients evolving to severity or death were considered cases and those with non-severe bites were included in the control group. During the study period, 9,191 snakebites were recorded, resulting in an incidence rate of 52.8 cases per 100,000 person/years. Snakebites mostly occurred in males (79.0%) and in rural areas (70.2%). The most affected age group was between 16 and 45 years old (54.6%). Fifty five percent of the snakebites were related to work activities. Age ≤15 years [OR=1.26 (95% CI=1.03-1.52); (p=0.018)], age ≥65 years [OR=1.53 (95% CI=1.09-2.13); (p=0.012)], work related bites [OR=1.39 (95% CI=1.17-1.63); (p6 hours [OR=1.73 (95% CI=1.45-2.07); (p6 hours [OR=2.01 (95% CI=1.15-3.50); (p=0.013)] were independently associated with the risk of death. Snakebites represent an occupational health problem for rural populations in the Brazilian Amazon with a wide distribution. These results highlight the need for public health strategies aiming to reduce occupational injuries. Most cases of severe disease occurred in the extremes of age, in those with delays in medical attention and those caused by Micrurus bites. These features of victims of snakebite demand adequate management according to well-defined protocols, including prompt referral to tertiary centres when necessary, as well as an effective response from surveillance systems and policy makers for these vulnerable groups

Characteristics of expert judges in the nominal group meeting.

Characteristics of expert judges in the nominal group meeting.</p

Types of health units according to capacity for snakebite management.

Types of health units according to capacity for snakebite management.</p

Final version of the minimal requirements checklist.

Final version of the minimal requirements checklist.</p

Snakebite envenoming care continuum in the Brazilian Amazon.

A) Care pathways for snakebite patients under the current antivenom distribution structure. B) Care pathways under the proposed antivenom decentralization to community health centers (CHCs). Figure built using https://openclipart.org/ as source of the images or icons.</p

Version of the minimal requirements checklist created by the steering committee for experts’ validation.

Version of the minimal requirements checklist created by the steering committee for experts’ validation.</p

Study design overview.

BackgroundCurrently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management.MethodsThis study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%.ResultsA valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility).ConclusionThis study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.</div

Summary item classifications as Essential or Desirable by clinical SBE procedure.

Summary item classifications as Essential or Desirable by clinical SBE procedure.</p