Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006

ORIGINAL PAPER The Journal of Venomous Animals and Toxins including Tropical Diseases ISSN 1678-9199 | 2012 | volume 18 | issue 2 | pages 217-224

EpidemiologicalprofileofsnakebitesinRiodeJaneiro,Brazil,2001-2006

Machado C (1), Bochner R (2), Fiszon JT (3)

(1) Vital Brazil Institute (IVB), Niterói, Rio de Janeiro State, Brazil; (2) Institute for Communication and Scientific and Technological Information on Health (ICICT), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Rio de Janeiro State, Brazil; (3) Sergio Arouca National School of Public Health (ENSP), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Rio de Janeiro State, Brazil.

Abstract: All snakebites registered in Rio de Janeiro state, Brazil, between 2001 and 2006 were analyzed. Of these, the snake species involved was identified in 2,431 cases, most of which were caused by Bothrops (2,347). Most victims were male (78.4%) and the age group most frequently attacked was between 20 and 39 years (38.4%). As for severity, 1,118 (45.9%) were classified as minor, 748 (30.7%) as moderate, and 209 (8.6%) as severe. Progression towards complete cure occurred in 1,567 patients; 39 had sequelae; three died; and clinical outcomes were not monitored in 822 cases. The time between bite and first medical attention was less than three hours in 74.6% of cases. Most occurred in municipalities with vast areas of preserved Atlantic Forest: Angra dos Reis (208), Rio de Janeiro (197), Parati (186), Teresópolis (134), and Petrópolis (110).Accidentfrequencywashighest between November and April,in whichthe daily average is practically twice that observed in other months. Although results show that Rio de Janeiro state has a good level of medical care, it could be improved by creating multidisciplinary teams that include doctors, biologists, and nurses. The Vital Network for Brazil helps to promote a stimulating environment for this type of training, with both traditional courses and distance learning. Training hours must be increased to improve the skills of professionals responsible for victim care.

Key words: snakebites, envenomation, snake bite epidemiology, information systems. INTRODUCTION

Accidents caused by venomous snakes are a serious public health issue in tropical countries, especially in Latin America. It is estimated that 2,500,000 accidents with venomous snakes occur annually in the world; approximately 125,000 are lethal (1-9). The Brazilian Health Department (10) estimates that approximately 26,000 snakebites occur each year in Brazil. According to Lira-da- Silva et al. (11), this is an underestimate because of inadequacies in data collection, and a large insufficiency in the number of notifications. Although the majority of snakebites occur in northern Brazil, most records come from the south and southeast regions, where most of the populationisconcentrated,andwherethequality of health care and information systems are much better (12, 13). Rural areas are more affected by snakebites, presenting high morbidity and mortality rates. This is due to higher exposure of the population toriskareas,andtodifficultiesinaccessinghealth centersthatcanprovidesnakeantivenom,theonly specific treatment for these accidents. Numerous victims suffer permanent consequences due to the necrotic action of venoms. And there are also psychological consequences. The economic impact of these accidents is considerable, because most victims are young (14). The information on number of accidents

Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006 per region, types of venom, deaths and the consequences of accidents are essential for evaluating the problem and developing public policies aimed at reducing the number of accidents,andimprovingmedicalhelpforvictims. The importance of recording snakebites has been a concern since Vital Brazil’s time (1865-1950) (15). The first epidemiological study on ophidism in Brazil was made in 1901 by Vital Brazil: he collected the number of deaths from venomous snakebites in São Paulo state (SP). Since then, little progress has been made on the knowledge of ophidism in Brazil, because information on accidents was scarce and recording not mandatory. Beforethe1980s,studiespresentingsignificant information and detailed epidemiological data were published by Penteado (16), Amaral (17), Barroso (18) and Fonseca (19). Due to shortages in serum production in 1985, the Brazilian Ministry of Health stated that notification of snakebites were mandatory from 1986 onward. Later, itsinclusion in ahealthinformationsystem for episodic accidents became mandatory as well. Since then, it became possible to follow the evolution of these accidents. More and more epidemiological studies on snakebites have been conducted in Brazil, especially at a regional level (13, 20-40). The small amount of research on snakebite epidemiology in Rio de Janeiro state, Brazil, justifies the analysis of the available information, and comparison of subsequent results with existing studies from the rest of the country.

MATERIALS AND METHODS

On November 28, 2010, information held by the Notifiable Diseases Information System (SINAN) on snakebites that occurred in Rio de Janeirostatebetween2001and2006wascollected. The study period is explained by the following: 2001 was the first year in which information was available online, and 2006 was the most recent year in which information appears consolidated, without the need for further revision. Only accidents involving aggressive venomous snakes were recognized and taken into account. Cases in which the snake was identified as non-venomous were ignored. In order to analyze the monthly distribution of accidents in each period, independent of the

JVenom AnimToxins inclTrop Dis | 2012 | volume 18 | issue 2 number of days in the month, a daily average for accidents was established using the following formula: number of accidents recorded during a month divided by number of days in that month. Even though only secondary data provided by SINAN was analyzed without identifying any of the victims, the present study was submitted to andapprovedbytheEthicsCommitteeonHuman Research,of Joaquim Venancio Polytechnic Health School, Oswaldo Cruz Foundation (Fiocruz) (protocol number 2011/0128).

RESULTS

According to SINAN, 2,431 snakebites were registered in Rio de Janeiro state between 2001 and 2006. Table 1 shows the distribution of these accidents by snake genera and age group, gender, and education level of victims. It also indicates elapsed time between the accident and first medical attention, and clinical data on the severity and evolution of the envenomation. Figure 1 shows the municipalities with higher number of notifications. In the period, more than one hundred accidents occurred in the following cities: Angra dos Reis (208 cases), the capital Rio de Janeiro (197), Parati (186), Teresópolis (134), and Petrópolis (110). Municipalities where the incidence of snakebites was higher were: Trajano de Moraes (115.7 per 100,000 inhabitants), Parati (97.5), Varre-sai (71.6), and Duas Barras (71.3). The 20 to 39 years age group had the highest number of victims, 934 cases; 760 males (81.3%), 173 females (18.5%); in only one case the victim gender was not specified (Figure 2). Accidents were more frequent between November and April (Figure 3). In the figure, it is possible to observe that increase in daily average of accidents follows a seasonal rhythm, with values doubling between 2002 and 2006.

DISCUSSION

The predominance of Bothrops snakebites (96.5%) recorded in Rio de Janeiro state reflects the national situation (10). This pattern has also been described for several states including Amazonas, Amapá, Roraima, Ceará, Sergipe, Bahia, Paraíba, and Goiás (13, 22, 31-33, 35, 37- 39). Nearly 35% of all cases in Rio de Janeiro state were concentrated in five regions: Angra

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219 Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006

Table 1. Distribution of snakebites by snake genera; age group, gender, and education level of victims; elapsed time between accident and first medical attention; and case classification and evolution (Rio de Janeiro state, 2001 to 2006)   Genus of the snake Total Variable Bothrops Crotalus Micrurus Lachesis Victim’s age group <1 year 1-4 5-9 10-14 15-19 20-39 40-59 60-64 65-69 70-79 80 and over Unknown 20 30 95 174 181 896 682 104 86 68 10 1 – 2 – 1 3 32 21 2 2 2 1 – – – 2 – 3 4 2 2 – – – – – – – – 1 2 2 – – – – – 20 32 97 175 188 934 707 108 88 70 11 1 Victim’s gender Male Female Unknown 1844 498 5 47 19 – 10 3 – 4 1 – 1905 521 5 Education level of the victim None 1-3 years 4-7 years 8-11 years 12 or more years Does not apply Unknown 140 323 485 126 35 115 1123 4 5 11 7 – 2 37 1 – 3 1 1 2 5 – – 3 – – – 2 145 328 502 134 36 119 1167 Elapsed time between the bite and first medical care 0-1 hours 1-3 hours 3-6 hours 6-12 hours 12 or more hours Unknown 885 871 194 62 51 284 19 24 8 2 3 10 8 2 1 – 1 1 2 2 1 – – – 914 899 204 64 55 295 Classification of the case Minor Moderate Severe Unknown 1083 726 193 345 27 20 14 5 6 1 2 4 2 1 – 2 1118 748 209 356 Evolution of the case Cure Cure with sequelae Death Unknown Total 1514 39 2 792 2347 41 – 1 24 66 9 – – 4 13 3 – – 2 5 1567 39 3 822 2431 Source: MS/SVS/SINAN

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Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006 JVenom AnimToxins inclTrop Dis | 2012 | volume 18 | issue 2 220 Figure1.SpatialdistributionofsnakebitesinRiodeJaneirostatebetween2001and2006(source:MS/SVS/ SINAN). Figure2.FrequencyofsnakebitesbyagegroupandgenderinRiodeJaneirostatebetween2001and2006 (source: MS/SVS/SINAN).

Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006 dos Reis, Rio de Janeiro, Parati, Teresópolis, and Petrópolis. This can be explained by the concentration of population living in the capital, and by the concentrated area of natural forest in the other four municipalities. Municipalities withmorethan50accidentscontainedimportant conservation units (national and state parks), the natural habitat of most venomous snakes. In the 20-59 year age group, the higher frequency of accidents in males (81.3%) can be explained by occupation, as most accidents happened in rural areas where men work (2). Similar results for affected males were found in different states from different regions of Brazil, varying from 82.1% in the river Purus riverine community of Amazonas to 53.1% in the north of Minas Gerais state (27, 19). Albuquerque et al. (13) found that in Paraíba state 73.2% of victims were male. Another study on Bothrops snakebites in Paraíba state by Oliveira et al. (38) showed a 75.1% predominance of male victims in that region, following the national average. The seasonal snakebite pattern in Rio de Janeiro state can be explained by the fact that snakes are ectothermic animals that need a high temperature for thermoregulation, which is

JVenom AnimToxins inclTrop Dis | 2012 | volume 18 | issue 2 fundamental for satisfactory metabolism. This same characteristic has been observed in the states of Goiás and São Paulo, and in the regions of northern Minas Gerais and city of Juiz de Fora (27, 30, 32, 36). In the Campina Grande region, Paraíba state, and the state of Ceará,the periods in which most accidents happened were from July to November and April to September, which is substantially different from the rest of the country (28, 31). Seasonal accident distribution has already been mentioned in several articles on ophidism in Brazil, mainly in the Amazon area (22, 23, 29). According to Lemos et al. (28), as far as the northeastisconcerned,especiallythecountryside, there may be a direct relationship between the increasing number of accidents and harvest time, as well as the higher rainfalls in the area, characterizing them as work-related accidents. In fact, this increase coincides with the migration of rural workers to the fields. Knowledge on snake seasonality highlights the months in which there are higher risks of accidents. This is extremely important as it alerts healthcare providers, helps establish distribution strategies and control of antivenom stocks in health centers, and

221 Figure3.MonthlydistributionofsnakebiteaveragesinRiodeJaneirostatebetween2001and2006(source: MS/SVS/SINAN).

Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006 stimulates preventive education campaigns. In RiodeJaneirostate,45.9%oftheaccidentscaused by snakes during the study period were classified as minor. In the consulted literature, snakebite seriousness in Brazil is generally considered moderate, as in the states of Bahia and Goiás and the regions of Juiz de Fora (Minas Gerais state) and Rio Branco (Acre state), or minor, as in the regions of northern Minas Gerais, northwest São Paulo and Campina Grande (Paraíba state) (25, 27, 28, 30, 32, 34, 39). Concerning snakebites, the time between bite and first aid is known to be crucial for optimal treatment outcome. Studies have shown that the average time between accident and first aid in Rio de Janeiro state is better than the time recommendedbytheHealthMinistrytoguarantee efficient treatment, below six hours (10). In this study, only 4.8% of the cases were actually treated six hours or later after the accident and almost all cases evolved to full cure. In most Brazilian states, the average time betweenaccidentandfirstaidwasbelowsixhours. Only northern regions exceeded this Health Department recommended time, including Amapá, the riverine communities of the river Purus and other cities of Amazonas state, and some areas of Araguaia (Tocantins state) (22, 24, 29, 35). This delay in commencing first aid is probably due to the geographic configuration of these regions, and by the lack of transportation, oftenbyboatoralongdifficulttracks.Thesituation for victims in Amazonas is more serious, since patientsarriveatthehospitalmorethansixhours after accidents and health professionals do not offer serotherapy. This practice has no scientific basis (22). Ofthe2,431accidentsinRiodeJaneiro,14.6% were not classified regarding severity and the evolutionwasunknownornotrecordedin33.8%. Thesedata,andthefactthat83.0%ofvictimswere medically treated in less than six hours, suggest adequate distribution of health centers providing serotherapy, and a possible substandard level of data recording. It is important to highlight the problems found in recording snakebiteinformationall over Brazil. Reports showing a lack of information about the identity of the snake causing the accident are common: for example, in the state of Paraíba, this information was missing in more

JVenom AnimToxins inclTrop Dis | 2012 | volume 18 | issue 2 than 29% of cases (13). Failures in recording antivenom administration were also observed as well as inappropriate application of anti-Crotalus antivenom in a case of Bothrops envenomation and antivenom application in non-venomous accidents (25, 30, 34,35, 39). Data available by SINAN do not allow us to evaluate similar parameters in this study. Although our results show that the state of Rio de Janeiro has a good level of medical care, it could be improved by creating multidisciplinary teams with doctors, biologists, and nurses. The Vital Network for Brazil creates a stimulating environment for conducting this training, with both traditional and distance learning courses (41). The number of training hours must be increased to improve the skills of the professional teams responsible for victim care.

ACKNOWLEDGEMENTS TheauthorsthankDr.AntonioJoaquimWerneck de Castro and Luis Eduardo Ribeiro da Cunha of Vital Brazil Institute for providing the necessary facilities, and are also grateful to post-graduation program in Information and Communication in Health (PPGICS) of Fiocruz.

COPYRIGHT © CEVAP 2012

SUBMISSION STATUS Received: December 15, 2011. Accepted: March 5, 2012. Abstract published online: March 6, 2012. Full paper published online: May 31, 2012.

CONFLICTS OF INTEREST The authors declare no conflicts of interest.

ETHICS COMMITTEE APPROVAL ThisstudywasapprovedbytheEthicsCommittee on Human Research, Joaquim Venancio Polytechnic Health School, Fiocruz (protocol number 2011/0128).

CORRESPONDENCETO Claudio Machado, Instituto Vital Brasil, Rua Maestro José Botelho, 64, Niterói, RJ, 24230-410, Brazil. Phone: +55 21 2711 9223 or +55 21 2711 9254. Email: [email protected].

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Machado C, et al. Epidemiological profile of snakebites in Rio de Janeiro, Brazil, 2001-2006 REFERENCES

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