A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study)

Abstract

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient’s admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment. In the Amazon Region, when individuals are bitten by a venomous snake, they are obliged to seek care in hospitals located in the urban area in order to receive adequate treatment, i.e., the use of antivenom. Despite the fact that snakebites occur mostly in rural areas and riverine and indigenous communities, antivenom is not available in the health units located in these areas. Thus, this individual may take a long time to arrive at the hospital, because in addition to the great distance he/she must travel, there may be difficulties in obtaining transportation. In addition, individuals often use home treatments, believing that they will be effective in reversing the effects of the envenomation. This study was carried out through the application of questionnaires and interviews conducted with patients victims of snakebites treated at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, which is a reference center for the treatment of tropical diseases, including snakebites, and is located in Manaus, capital of the state of Amazonas, Brazil. The patients came from 11 municipalities, and many came from very distant municipalities. The routes, in addition to being long ones, are very fragmented, and require different forms of transport in order to reach the reference hospital. In the places where they perform their daily activities, patients feel safe and do not use protective clothing. Many home treatment practices are used, including some that can be harmful, such as tourniquets. It is common for patients to seek help only when the clinical signs worsen, i.e., when severe pain, extensive edema and bleeding occurs. It is believed that if antivenoms were made available in health units closer to the patients’ place of residence, there would be a decrease in cases of delay in treatment, and thus reduce the possibility of complications.