Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101

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Transactions of the Royal Society of

Tropical Medicine and Hygiene
journal homepage: http://www.elsevier.com/locate/trstmh

The effect of pre-hospital care for venomous snake bite on outcome in

Nigeria
Godpower C. Michael a , Tom D. Thacher b,∗,1 , Mohammed I.L. Shehu a
a
Department of Family Medicine, Aminu Kano Teaching Hospital, PMB 3452, Kano, Nigeria
b
Department of Family Medicine, Jos University Teaching Hospital, PMB 2076, Jos, Nigeria

a r t i c l e i n f o a b s t r a c t

Article history: We studied pre-hospital practices of 72 consecutive snake bite victims at a hospital in north-
Received 2 March 2010 central Nigeria. The primary outcome assessed was death or disability at hospital discharge.
Received in revised form
Victims were predominantly male farmers, and in 54 cases (75%) the snake was identified
23 September 2010
as a carpet viper (Echis ocellatus), with the remainder unidentified. Most subjects (58, 81%)
Accepted 23 September 2010
Available online 28 October 2010 attempted at least one first aid measure after the bite, including tourniquet application
(53, 74%), application (15, 21%) or ingestion (10, 14%) of traditional concoctions, bite site
incision (8, 11%), black stone application (4, 5.6%), and suction (3, 4.2%). The majority (44,
Keywords:
rural health 61%) presented late (after 4 hours). Most (53, 74%) had full recovery at hospital discharge.
envenomation Three deaths (4.2%) and thirteen (18%) disabilities (mainly tissue necrosis) occurred. The use
viper of any first aid was associated with a longer hospital stay than no use (4.6 ± 2.0 days versus
Africa 3.6 ± 2.7 days, respectively, P = 0.02). The antivenom requirement was greater in subjects
first aid who had used a tourniquet (P = 0.03) and in those who presented late (P = 0.02). Topical
epidemiology application (Odds Ratio 15, 95% CI 1.4-708) or ingestion of traditional concoctions (OR 20,
95% CI 1.4-963) were associated with increased risk of death or disability. Ingestion and
application of concoctions were associated with a longer time interval before presentation,
a higher cost of hospitalization, and an increased risk of wound infection.
© 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.
All rights reserved.

1. Introduction mortality (without antivenom) is 10–20%.4 Echis ocellatus

Around the world, 5 million snake bites and 2.5 million
envenomations occur annually resulting in 125 000 deaths.
Most snake bites occur in rural tropical regions of sub-
Saharan Africa, Asia, and South America, where snakes are
abundant and human activities largely agrarian.1 In some
rural Nigerian hospitals up to 50% of the total bed capacity
may be occupied by snake bite victims at peak times of the
early rainy season and harvesting periods.2,3 The untreated
∗ Corresponding author. Tel.: +1 507 284 5307; fax: +1 507 284 5067.
E-mail address: thacher.thomas@mayo.edu (T.D. Thacher).
1
Department of Family Medicine, Mayo Clinic; 200 First Street SW,
Rochester, Minnesota 55905, USA.
(carpet viper) is responsible for 66% of bites in the Nigerian
savanna.2 It resides in semi-arid rocky terrain and is noc-
turnal, rarely entering human dwellings; human contact
is mainly accidental.3 Envenomation by the carpet viper
produces pain and local swelling accompanied by coag-
ulopathy. Many snake bite victims survive with physical
and psychological sequelae, like chronic ulceration, ampu-
tations, osteomyelitis, or limb deformities, largely due to
venom effects or inappropriate first aid.5 The high cost and
limited supply of antivenom has impeded global efforts to
improve hospital care of snake bite.5
Several pre-hospital practices, aimed at reducing and
delaying systemic absorption and spread of venom tox-
ins have been described.6,7 These include topical native
concoctions, tourniquet use, electric shock, cryotherapy,

0035-9203/$ – see front matter © 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.trstmh.2010.09.005
96 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101
Figure 1. Carpet viper (Echis ocellatus) with eggs.
black stone, pressure immobilization and incision of the
affected limb with or without suction.8,9 While use of these
measures remains controversial, some have justified their
use.8 Despite their use, the untreated mortality from ven-
omous snake bites still remains high.1 Some measures
currently practiced in Nigeria are imported regimes, and
their efficacy has not been adequately assessed in Nige-
ria, where snake species differ from other areas of the
world. For example, the black stone was originally from
India, and traditionally it is applied to the site of the snake
bite, where it adheres and extracts the venom and spon-
taneously detaches after the venom is extracted.10,11 A
retrospective study in Nigeria reported first aid measures
used by snake bite victims without assessing outcomes.12
The objectives of this study were to identify pre-hospital
treatment practices for snake bite, assess factors associated
with these practices, and compare the outcomes and hospi-
tal costs associated with different pre-hospital treatments.
2. Materials and methods
This study was conducted at the Comprehensive Health
Centre Zamko, a 22-bed rural hospital in central Nigeria,
between April and July 2006, during the peak snake bite
season. As a site of antivenom research, the facility receives
patients from neighboring communities within and out-
side the state. It has the largest case load of snake bites in
Nigeria, with an average of 100 snake bite cases annually.12
Although the black necked spitting cobra (Naja nigricollis)
and puff adder (Bitis arietans) are found in northern Nige-
ria, nearly all (96%) snake bites at this centre are due to the
carpet viper (Echis ocellatus, Figure 1).12 In the community,
the carpet viper is referred to as ‘izuwa’. Snakes were iden-
tified by comparison with the centre’s specimen collection
if the dead snake was brought to hospital, or by the report
of the patient or witnesses.
Approval for the study was obtained from the ethi-
cal committee of Jos University Teaching Hospital, which
provides oversight for the Comprehensive Health Centre.
Voluntary written informed consent was obtained from
each subject.
Consecutive patients with a history consistent with
snake bite were eligible for inclusion in the study. At admis-
sion, a standard questionnaire was administered by a single
investigator (GCM) and trained interpreter to each subject,
in English or one of the local languages (Hausa or Taroh).
A socioeconomic score for each victim was calculated by
assigning one point to every positive response for the proxy
measures of owning a car, owning a motorcycle, a well
in the household compound, zinc roof, and cement block
house, and finding the sum total. The whole blood clotting
test (WBCT) was performed on all subjects by allowing 2 mL
of blood obtained by venepuncture to stand in a clean, dry
glass tube at room temperature for 20 minutes. Coagulopa-
thy was considered present if blood remained unclotted
after 20 minutes. Snake bite was defined as the presence of
one or more of the following: fang marks, local pain and
swelling within 60 minutes of the bite, WBCT ≥20 minutes,
spontaneous bleeding, or neurotoxicity (ptosis, dysphagia,
or dyspnea). No envenomation was defined as presence of
fang marks without any other sign. All snake bite victims
were admitted, and those without envenomation were dis-
charged after 24 hours of monitoring, and their data were
included in outcome analysis.
At enrollment, the time of arrival and time of the bite
were obtained from the patient or family. Victims were
classified as presenting early (≤4 hours after bite) or late
(>4 hours after bite). Information was obtained regard-
ing first aid practices, including removal of victim from
snake striking distance, immobilization of the affected
limb, washing of bite site with soap and water, tourni-
quet application, incision of bite site, suction of bite site
(oral or extractor), application of native concoctions on
bite site, black stone application, electric shock and ban-
dage application. Vital signs were recorded, and the bite
site was carefully examined for fang marks. Evaluation for
spontaneous bleeding from gingiva, nose, bite site, and the
urinary and gastrointestinal tracts was performed. Signs
of neurotoxicity (ptosis, dysphagia, and dyspnea) were
assessed hourly for the first 12 hours, then daily. The lead-
ing edge of the swelling around the bite site was marked to
permit monitoring of progression. Arterial pulse, capillary
refill, light touch sensation and distal limb strength were
assessed on arrival and every 30 minutes for 12 hours, and
then daily. At discharge, any residual ulceration or func-
tional loss was noted.
The extent of edema was defined as mild (limited to
bite site), moderate (extending a few centimeters beyond
the bite site but not involving the whole limb) or severe
(involving the entire limb). Pain severity was defined as
mild (mild discomfort), moderate (more than mild dis-
comfort but not incapacitating) and severe (incapacitating
discomfort).
Haematocrit and WBCT were measured on admission.
WBCT was repeated 6-hourly for 12 hours then daily until
discharge. Antivenom was given intravenously to sub-
jects with evidence of systemic envenomation as 10 mL
of Echis monospecific antivenom (South African Institute
for Medical Research [SAIMR]). The SAIMR antivenom
was given free of charge to subjects through a govern-
ment funded national program. When SAIMR antivenom
supplies were exhausted, patients purchased polyspecific
antivenom (Fav-Afrique, Aventis Pasteur, Lyon or Costa
Rican) within or outside of the hospital, and 20 mL was
given. Patients unable to afford the first dose of antivenom
were withdrawn from the study.
 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101 97

Antivenom administration was repeated six hours later Table 1

Characteristics of pre-hospital care for snake bite
if WBCT >20 minutes. Thereafter, WBCT was repeated daily,
and antivenom was given for WBCT >20 minutes. The initial Characteristic Frequency n = 72 %
dose was doubled in the case of severe bleeding diathesis First aid typea
(spontaneous bleeding from multiple orifices, severe pal- Tourniquet 53 73.6
lor, hypotension or seizures) and in those with evidence Topical concoction on bite 15 20.8
of compartment syndrome (tense muscle compartment, Ingestion of concoction 10 13.9
Incision of bite site 8 11.1
pain with passive muscle stretch, hypoesthesia and weak-
Black stone 4 5.6
ness). Polyspecific antivenom was given for suspected Suction device 3 4.2
cobra envenomation (neurotoxicity or inability to iden-
Time between bite and presentation (hours)
tify snake). Intravenous promethazine (25 mg for adults) 0-2.0 8 11.1
or chlorpheniramine (adults 10 mg and children 0.2 mg/kg) 2.1-4.0 20 27.8
was given as prophylaxis against antivenom reaction. Vital 4.1-6.0 16 22.2
signs were monitored every 15 minutes for the first hour 6.1-12.0 7 9.8
12.1-24.0 6 8.4
after administration of antivenom, and then 4-hourly.
>24 15 20.8
Subjects who developed early anaphylactic or late reac-
tions following antivenom administration were managed Mode of transport
Motor cycle 52 72.2
using epinephrine, intravenous fluids, hydrocortisone and
Car 13 18.1
promethazine. Intramuscular tetanus toxoid 0.5 mL was Bus 7 9.7
given to subjects who were unimmunized or unsure of
Cause of delay to hospital (n = 45 victims with delay >4 hours)
their immunization status, when their WBCT <20 minutes Distance from where bite occurred 18 40.0
to avoid haematoma formation. No vehicle 7 15.6
The bite site was assessed daily for evidence of infection No money 5 11.1
(defined as the presence of increasing swelling, ery- Father’s absence 5 11.1
Traditional healer visit 4 8.9
thema, warmth around wound, purulent discharge or fever
Other 6 13.3
48 hours after bite). Infection was treated with a broad
a
More than one first aid measure may have been used
spectrum antibiotic (ampicillin-cloxacillin). Debridement
of necrotic tissue, when indicated, was done from the
third day after the bite, and open wounds were dressed 3. Results
using hydrogen peroxide and Edinburgh University Solu-
tion (eusol). 3.1. Subject Characteristics
At hospital discharge patient status was recorded as
full recovery (defined as absent coagulopathy, absent limb Most snake bites (28, 38.8%) occurred in the two local
weakness, absent necrosis, absent or mild swelling), dis- government areas nearest the Comprehensive Health Cen-
ability (ulceration or functional impairment) or death. tre. Four bites (5.6%) occurred in neighboring states. The
Follow up assessment at one week after discharge included ages of victims ranged from 0.75 to 90 years with a mean
evaluation for bleeding, limb swelling, limb strength, (± SD) of 23.4 ± 15.7 years, with 52 (72.2%) males. Farming
serum sickness and limb ulceration. was the dominant occupation (36, 50%), and most victims
A minimum sample size of 60 subjects was targeted, (46, 69.9%) were of low socioeconomic class. The peak time
based on 80% power to detect a difference in complica- of snake bite was between 12:00 and 18:00, during the
tion rate with 95% confidence, assuming a complication heat of the day, while farming. Snakes were identified by
rate of 20% in those without a risk factor and 60% in those 54 (75%) victims as carpet vipers and the rest as unknown.
with a risk factor. However, during the scheduled study Half of the subjects brought the dead snake to hospital.
period 72 subjects were able to be recruited, providing
adequate power to detect an absolute difference of 34%, 3.2. Pre-hospital care
rather than 40%. The primary outcome measure was death
or disability at the time of discharge, while the cost and A total of 58 (80.6%) used some form of first aid after
duration of hospital stay and antivenom dose were sec- the snake bite. Tourniquet application, in combination with
ondary outcome measures. All data collected were entered other traditional treatments, was the predominant first aid
and analyzed with Epi Info 3.3.2 (CDC, Atlanta, GA, USA). measure adopted by 53 (73.6%) subjects (Table 1). Other
The t-test was used to compare mean values of continuous potentially harmful practices used included application of
variables. The Mann-Whitney test was used to compare native or traditional concoctions (containing unidentified
continuous variables with a skewed distribution, like the herbs, palm or olive oil, and other unknown ingredients)
cost of hospitalization. The X2 test was used to compare on the bite site, ingestion of native concoctions, incision,
the effect of early presentation and first aid practices on black stone, and suction of the bite site. All victims were
complication rates. Multiple linear regression was used removed from striking distance after the snake bite. How-
to simultaneously control for the effect of multiple vari- ever, none of the subjects immobilized the limb, applied
ables on the quantity of anti-snake venom used. Logistic a pressure bandage, used electrical shock or washed the
regression was used to examine the independent effect of bite site. Use of incision of the bite site as first aid was sig-
variables on the combined outcome of death or disability. nificantly associated with older age (39.9 ± 26.1 years for
P-values of 0.05 or less were considered significant. users versus 21.4 ± 12.8 years for nonusers, P = 0.04). Use
98 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101
Table 2
Risk of death or disability for various first aid measures and characteristics
Characteristic No. Death or disability (%)
Presenting time
Early (≤4 hours after bite) 28 3 (10.7)
Late (>4 hours after bite) 44 13 (29.5)
First aida
Tourniquet 53 14 (26.4)
Concoction applied to bite 15 8 (53.3)
Concoction ingestion 10 6 (60.0)
Incision 8 2 (25.0)
Blackstone 4 2 (50.0)
Suction 3 0
None 15 1 (6.6)
a
More than one first aid measure may have been taken
of black stone was also significantly associated with older
age (52.8 ± 29.6 years for users versus 21.7 ± 13.0 years for
nonusers, P = 0.02). Application of a traditional concoction
on the bite site was significantly associated with female
gender (46.7% females for users versus 21.1% females for
non users, P = 0.04).
3.3. Presentation to the hospital
The majority of victims (48, 66.6%) presented for their
first treatment at the Comprehensive Health Centre. Most
(45, 62.5%) presented late (more than 4 hours after the
bite). Timing of presentation after the bite ranged from
1-308 hours with a median of 5.0 hours. Reasons for late
presentation included a long distance to the hospital (18,
40%), lack of transportation (7, 15.6%), no money (5, 11.1%),
father’s absence (5, 11.1%), treatment by traditional healer
(4, 8.9%), lack of awareness of available treatment at the
hospital (2, 4.4%), treatment at the church (2, 4.4%) and
belief that the snake was not venomous (2, 4.4%). Most
patients (52, 72.2%) rode a motorcycle for transport to the
hospital. The median time to presentation was 5 (4-20)
hours in those who used any first aid and 4 (3-6) hours
in those who did not (P = 0.13).
All subjects had features of snake bite on admission,
and nearly half presented with spontaneous bleeding
(Supplementary Table 1). A total of 23 (32%) had anaemia
(haematocrit <35%), and two received blood transfusions.
3.4. Outcomes
Most (61, 84.7%) subjects received antivenom prior to
discharge (Supplementary Table 1). Of these, 52 (72.2%)
required antivenom on admission, and 9 (12.5%) developed
coagulopathy later in the hospital course. Only 6 (9.8%)
subjects had antivenom within four hours of the bite, and
the median interval between bite and commencement of
antivenom was 11 hours. The median antivenom quantity
used by subjects was 20.0 mL.
Most (53, 73.6%) subjects had full recovery at hospi-
tal discharge, but 3 (4.2%) subjects left against medical
advice without full recovery. Death occurred in 3 subjects,
resulting from spontaneous bleeding from multiple sites or
seizures and coma, probably due to intracranial bleeding.
During hospitalization, 30 subjects (41.7%) were treated
Odds Ratio 95% Cl P value
1
3.5 0.90-14 0.06
4.7 0.58-212 0.16
15 1.4-708 0.01
20 1.4-963 0.009
4.3 0.18-275 0.53
13 0.39-823 0.11
0 0-182 1.0
1.0
for wound infection with antibiotics and wound dressings.
Disability was present in 13 subjects (18%) at discharge,
including limb ulceration and limp, sublingual haematoma
with restricted tongue movement, and knee joint stiffness.
Twenty subjects (27.8%) did not return for the one week
follow up appointment, but all 13 with disability at hos-
pital discharge returned. One had residual limb ulceration
and one had residual joint stiffness that was improving.
The mean duration of hospitalization was 4.4 ± 2.2 days,
ranging from 1-12 days. The cost of hospitalization ranged
from 200 naira (US$1.54) to 33 710 naira (US$259.30) with
a median of 1549 naira (US$11.92).
Late presentation was not significantly associated with
disability or death (Table 2). Among the first aid measures,
topical application (OR 15, 95% CI 1.4-708) or ingestion
of concoction (OR 20, 95% CI 1.4-963) were significantly
associated with increased risk of death or disability. The
median (interquartile range [IQR]) time to presentation in
those who topically applied a traditional concoction was
29 (5-141) hours compared with 5 (3-8) hours in those
who did not. Similarly, the median (IQR) time to presen-
tation in those who ingested a concoction was 16.5 (6-42)
hours compared with 5 (3-10) hours in those who did
not. In a logistic regression analysis, late presentation was
no longer significantly associated with death or disability
when controlling for the application or ingestion of tradi-
tional concoctions.
The proportion of subjects whose cost of hospitaliza-
tion was less than 1000 naira (US$7.70) was significantly
greater among those who did not use first aid than in those
who did (57.1% versus 25.9%, respectively, P = 0.02). As
shown in Table 3, the median cost was significantly greater
among subjects who applied or ingested traditional con-
coctions than in those who did not. A significantly greater
median cost was associated with delayed presentation than
early presentation to hospital (P = 0.04).
The use of any first aid was associated with a longer
duration of hospital stay than non use (4.6 ± 2.0 days versus
3.6 ± 2.7 days, respectively, P = 0.02). The mean duration
of hospitalization was significantly longer in those who
used a tourniquet than in those who did not (4.6 ± 2.0
days versus 3.7 ± 2.5 days, respectively, P = 0.04). The mean
duration of hospitalization was significantly shorter in
those who incised the bite site than in those who did not
(2.9 ± 1.6 days versus 4.6 ± 2.2 days respectively, P = 0.03).
 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101 99

Table 3
Comparison of cost and duration of hospitalization of snake bite victims

First Aid measurea n Median cost of P valuec Median duration of P valuec

hospitalization (naira)b hospitalization (days)

Tourniquet
Yes 53 1745 0.27 5 0.04
No 19 1080 3

Concoction applied to bite

Yes 15 4290 0.04 5 0.60
No 57 1370 4

Concoction ingestion
Yes 10 7690 0.02 4 0.84
No 62 1375 4

Incision
Yes 8 1255 0.55 2.5 0.03
No 64 1549 4

Blackstone
Yes 4 1255 0.65 2.5 0.09
No 68 1549 4

Suction
Yes 3 1178 0.68 6 0.70
No 69 1500 4

Any first aid

Yes 57 1790 0.04 5 0.02
No 15 870 3

Presenting time
Early (≤4 hours after bite) 28 1085 0.03 4 0.75
Late (>4 hours after bite) 44 1975 4
a
More than one first aid measure may have been used
b
At the time of the study $US1 = 130 naira; c As determined by Mann-Whitney test

However, there was no significant difference in the mean infection. A greater antivenom requirement and longer
duration of hospitalization between early and delayed pre- hospital stay were associated with tourniquet use.
sentation (4.2 ± 1.8 days versus 4.5 ± 2.4 days respectively, Venomous snake bite still remains a preventable cause
P = 0.75). of morbidity and mortality. A retrospective study of 103
As shown in Table 4, the antivenom requirement was
significantly greater in subjects who had used a tourni-
Table 4
quet (P = 0.03) and in those who presented late (P = 0.02).
Antivenom requirement for the various groups
Both of these factors remained significant in a linear regres-
sion model. Topical application of traditional concoction to Groups Median (IQR) antivenom P value
requirement (mL)
the bite site and ingestion of traditional concoctions were
significantly associated with six-fold and four-fold greater Tourniquet
odds of wound infection, respectively (Table 5). Late pre- Yes 20.0 (20-40) 0.03
No 20.0 (10-20)
sentation was associated with three-fold greater odds of
wound infection. Incision
Yes 25.0 (0-35) 0.71
When we compared those with or without an identified
No 20.0 (20-35)
snake species, there were no significant differences in out-
comes. No deaths occurred in the group with unidentified Suction
Yes 50.0 (0-60) 0.45
snake species.
No 20.0 (20-30)

Black stone
4. Discussion Yes 30.0 (15-35) 0.71
No 20.0 (15-35)
We found that the commonest pre-hospital first aid Concoction applied to bite
in a Nigerian rural health centre was tourniquet applica- Yes 30.0 (20-50) 0.07
tion. Topical application of traditional concoctions to the No 20.0 (10-30)

bite site, ingestion of traditional concoctions, bite site inci- Ingestion of concoction
sion, suction and use of black stone were other measures Yes 30.0 (20-30) 0.13
employed. Ingestion and application of concoctions were No 20.0 (10-40)

both significantly associated with a longer time interval Late presentation (>4 hours after bite)
before presentation to the hospital, a greater risk of death Yes 20.0 (20-45) 0.02
No 20.0 (5-30)
or disability, a higher cost of hospitalization, and wound
100 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101
Table 5
Risk of wound infection for various first aid measures
First aid measure n Wound Infection (%)
Tourniquet 53 23 (43)
Concoction applied to bite 15 11 (73)
Ingestion of concoction 10 7 (70)
Incision 8 5 (63)
Black stone 4 3 (75)
Suction 3 1 (33)
Presentation
Early (≤4 hours after bite) 28 7 (25)
Late (>4 hours after bite) 44 22 (50)
patients admitted for snake bite in the same centre
recorded no deaths and 3.9% with tissue necrosis, but 52%
presented to the centre within three hours of bite.12 In
contrast, in our study we found that 61% arrived late with
a median interval between bite and antivenom adminis-
tration of nine hours. Despite an established treatment
protocol, free antivenom and trained staff, death occurred
in 4.2% and complications in 22% of victims. During the
study, the supply of antivenom was inconsistent, and fam-
ily members of patients had to travel long distances to
purchase antivenom before administration. Less than 10%
of victims received antivenom within four hours of the
bite. Although not directly comparable to the cytotoxic
effect of viper bites, patients systemically envenomed by
Papuan taipans (Oxyuranus scutellatus canni) who received
antivenom within four hours had hastened resolution of
neurotoxic symptoms and shorter hospital stays.9
Attempts at first aid were a common practice after snake
bite, confirming the observations in a previous study.12
Similar to a study in Nepal,8 we found that tourniquet
use was the most common form of first aid used. Tourni-
quet use in viper bite increased the antivenom requirement
and duration of hospitalization. Tourniquet use is known
to cause an increase in local complications by increasing
tissue anoxia and it may trigger severe systemic envenoma-
tion after removal. Consequently, its use has been strongly
discouraged by experts.13,14 We found that one-quarter of
subjects who used a tourniquet developed complications.
The use of incision as first aid in this study was asso-
ciated with shorter duration of hospitalization. Incision
of bite site or limb as first aid has been associated with
adverse effects such as tissue damage, haemorrhage and
infection.15 We do not believe that incision was respon-
sible for a shorter hospital stay. We suspect that subjects
who incised the bite had other unmeasured confounding
characteristics that were responsible for their shorter hos-
pitalization. Alternatively, subjects who used incision may
have avoided potentially more harmful practices, like use
of a tourniquet. Suction was rarely used by victims in our
study. Suction use is controversial and has limited efficacy,
especially when applied five minutes after the bite, and
increases the risk of skin necrosis if applied after thirty
minutes.15–17
While it is well documented that application of tra-
ditional herbs, animal dung, mud and ashes to the bite
site or ingestion of alcohol have been used as first aid,7,8
the ingestion of other traditional concoctions is not well
described. In a four-year retrospective prevalence study at
Odds Ratio 95% Cl
17 0.6-5.0
6.0 1.7-21
4.2 1.0-18
2.8 0.6-13
4.9 0.5-49
0.7 0.06-8.5
1.0
3.0 1.1-8.5
a hospital in north eastern Nigeria, 2.9% of patients who
ingested herbs presented with jaundice possibly induced
by the unidentified herbs.18 We found that victims who had
ingested concoctions had a much greater risk of complica-
tions compared with those who did not, suggesting that
this is a potentially dangerous practice. However, none of
the study subjects developed jaundice. The increased risk
of wound infection associated with application of concoc-
tions to the bite sites that we observed has been previously
documented.19 The association of traditional concoction
ingestion with wound infection that we found may be
related to a longer delay before presentation among those
who utilized traditional concoctions. Seeking care from a
traditional healer for snake bite is associated with delayed
presentation to the hospital and exposes them to useless
or dangerous practices.8,14,20 However, we found that dis-
tance from where the bite occurred to the hospital was the
predominant reason for delayed arrival. Less than 10% of
victims initially sought care from a traditional healer. The
causes for late presentation are not likely to be independent
of one another.
There was no association between late presentation
and primary outcome (death or disability), suggesting that
there was no time at which antivenom could be considered
ineffective after snake bite.9 Late presenters tended to have
more severe envenomation and required greater quantities
of antivenom, which contributed to their increased cost of
hospitalization. Other investigators in west Africa found
that a delay in consultation did not affect the prevalence
of bleeding, coagulopathy, or the number of administered
antivenom doses.21
Among the limitations of this study, we cannot exclude
selection bias. Those who presented to the hospital with
snake bite may differ in important ways from those who did
not present to hospital after snake bite. Those with dry bites
or minimal envenomation may have not been recruited due
to improvement with first aid. Unmeasured confounding
variables that are associated with both the exposure and
the outcome may lead to spurious associations. The study
was also limited by its sample size. The number of subjects
in the subgroups that practiced some forms of first aid was
small, which may account for a lack of statistical power to
find significant effects of these practices on outcomes.
Traditional first aid measures for viper bites, like use
of tourniquets and traditional concoctions, potentially
contribute to morbidity and mortality in rural Nigerian
communities. Delays in antivenom administration due to
late presentation and erratic antivenom supply are also
 G.C. Michael et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (2011) 95–101
additive factors. Community education on appropriate
actions after snake bite, including limb immobilization,
cleansing the bite site with soap and water and rapid
transport of victims to the hospital could reduce the com-
plications from viper bites in Africa.
Authors’ contributions: GCM was involved in the concep-
tion, design, data collection, analysis, interpretation and
drafting of the manuscript of this study. TDT was involved
in the conception, design, analysis, interpretation, drafting
of manuscript and revising of the paper and was the chief
supervisor of the study. MILS was involved in the plan-
ning and supervision of the study and in critical revision
of the manuscript. GCM and TDT are the guarantors of the
manuscript.
Acknowledgements: The authors are grateful to Drs Bukar
A. Grema and Ahmed Loh for their support and advice
and to Dr A. Solomon for ensuring the availability of free
antivenom. We appreciate Ms O. Ifeoma for laboratory
support and Mr Nambut for his helpful interaction with
community leaders. We acknowledge Drs Ofakunrin and
Chidi for their efforts in the snake bite prevention campaign
and in focus group discussions.
Funding: Antivenom was provided by the Nigerian Fed-
eral Government-Echitab Study Group.
Conflicts of interest: None declared.
Ethical approval: Ethical Committee of Jos University
Teaching Hospital.
Appendix A. Supplementary data
Supplementary data associated with this arti-
cle can be found, in the online version, at
doi:10.1016/j.trstmh.2010.09.005.
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