Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: 'Every Life Has Equal Value'

Abstract

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.

Keywords: antivenom; health decentralization; health service; indigenous groups; snakebite.

Figure 1

The Legal Amazon within the Brazilian territory (A) and location of indigenous health districts in Brazil in the Brazilian Amazon (B).

Figure 2

Structure of the indigenous health districts (A) and flow of care for envenomations (B). Removing the patient from the reservation territory is considered a critical event and can cause anxiety for these people, especially when they need complex health care procedures. For some communities, surgical procedures are considered an aggression that will trigger an illness. The Sanumá-Yanomami shamans, for example, regard surgical cuts as a possibility of poison being inoculated into their tribesman’s blood, which generates “old blood” and is capable of causing harm to the patient or a bad omen [19]. Furthermore, removing the patient to the city requires special protection with charms, spells and food. They believe that foods produced in different environments and by other people can cause their transformation into other beings or hinder health recovery [20,21].

Figure 3

Frequency of under-reporting and antivenom treatment in indigenous groups living in six different DSEIs in the state of Amazonas (A), and comparison between temporal trends (B), age pyramids (C), frequencies of late medical assistance and antivenom underdosage, and lethality and severity rates (D) between nonindigenous populations, indigenous populations living in DSEIs (villagers) and indigenous nonvillagers, bitten by Bothrops snakes, in the state of Amazonas, Western Brazilian Amazon.

Figure 4

(A) A 19-year-old male patient from the Mura tribe who suffered a pit viper bite in the rural area of the municipality of Careiro da Várzea. Specialized care at a tertiary health unit in Manaus was only possible 10 h after the bite. During his 38-day stay at the hospital, the patient received 10 vials of antivenom. A diagnosis of compartment syndrome led to fasciotomy. The patient developed necrosis on the dorsum of the foot as seen in the image recorded on day 15 after the bite. (B) Patient from the Kubeo tribe; a 12-year-old male who suffered a snakebite at the age of five years while accompanying a family member to carry out agricultural activities in the municipality of São Gabriel da Cachoeira. Treated with traditional medicine as the first choice, he sought specialized care 15 h after the bite. He suffered great tissue loss, and as he grew, major motor deficits occurred. Currently, he suffers from the development of scoliosis and posture deviation. (C) Scars from fasciotomy on a 40-year-old male Tikuna patient, living in the rural area of Tabatinga. He was bitten by a pit viper during agricultural activities one year before the picture was taken. He received antivenom 6 h after the bite and developed compartment syndrome. Currently, the patient has difficulty walking.