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.

Fig 1. Internal structure of the health system and factors affecting therapeutic itineraries.

Adapted from Kleinman [22]. ^#Definitions of the five dimmensions of healthcare are presented and discussed by Penchansky and Thomas [27]. ^¶Self-care practices, representations and transactions with professional and folk sectors are detailed in Menéndez [23].

Fig 2. Municipalities of origin of the study participants, with distance from the referral hospital.

1) Manaus, 2) Iranduba (34 km), 3) Careiro da Várzea (37 km), 4) Autazes (232 km), 5) Careiro Castanho (132 km), 6) Nova Olinda do Norte (247 km), 7) Itacoatiara (269 km), 8) Novo Airão (192 km), 9) Manacapuru (97 km), 10) Maués (397 km), and 11) Novo Aripuanã (1378 km). The base used to create the maps is from the Brazilian Institute of Geography and Statistics, (https://portaldemapas.ibge.gov.br/portal.php#homepage).

Fig 3. Itineraries of the study participants expressed graphically from the time from the bite to hospital admission.

The different colors of the fragments of each itinerary represent the participant’s stay at home after the trip, the means of transport employed, and the waiting times for transport that occurred along the route.

Fig 4. Spatial visualization of the physical itineraries of three of the study participants.

A) Snakebite on a farm in the municipality of Autazes. The patient sought medical assistance shortly after the bite and had to travel in part by motorcycle to the nearest community. From there, the patient was transported by ambulance to the hospital in the city of Autazes, where he had to use four more means of transport to finally reach the referral hospital (Manaus) about 13 hours after the bite. B) Snakebite in the rural area of the municipality of Manaus. The patient sought medical assistance after 28 hours of the bite. Thinking that it was not serious, he did not inform his family regarding the envenomation. After significant worsening of local pain and edema of the left foot, which prevented him from walking, he was transported by speedboat to the urban area of Manaus and then transferred to the referral hospital approximately 29 hours after the bite. C) Snakebite in the rural area of the municipality of Manacapuru. The patient was hunting near a river when he was bitten and had to row to his house in a canoe to then get a motorboat up the river to reach the urban area of Manacapuru, where he had to wait 9 hours for an ambulance to bring him to the reference hospital in Manaus. He arrived 15 hours after the bite.

Fig 5. Frequency of variables that emerged from the interviews or from the analysis of the physical itinerary according to late medical assistance.

5A) Set of variables acting to format the final TI, pushing more or less towards a delay in treatment for a particular individual; 5B) Variables’ frequencies between patients who arrived late to the hospital and those who had early medical assistance; 5C) Synthetic representation of frequencies between patients according to time to medical assistance. Dictionary of variables: 1. Feeling of safety at home and work places; 2. Absence of help from other people, means of transport or communication; 3. Feeling of isolation in the place of residence or work; 4. Lack of knowledge of the route to take to reach the hospital; 5. Use of traditional treatments; 6. Exposure to snakebite in daily activities; 7. Perception of the seriousness of the situation experienced; 8. Timely identification of warning signs/symptoms; 9. ≥200 km to reach hospital; 10. Previous experience with snakebites; 11. ≥3 means of transport needed; 12. River transport needed; 13. Waiting for transportation ≥1 hour over the itinerary. Variables numbered 1 to 8 emerged from the interviews’ statements and variables numbered 9 to 13 derived from the physical itinerary analysis. Medical care was late if the patient was treated ≥6 hours after the bite.