bioRxiv preprint doi: https://doi.org/10.1101/543009; this version posted February 6, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 Epidemiology, ecology and human perceptions of snakebites in a savanna 2 community of northern Ghana 3 4 Yahaya Musah 1, Evans P.K. Ameade 1,2, Daniel K. Attuquayefio1, Lars H. Holbech1,* 5 6 1 Department of Animal Biology and Conservation Science, University of Ghana, P.O. Box LG 7 67, Legon, Accra, Ghana. 8 2 Department of Pharmacology, University for Development Studies, P.O. Box TL 1350, 9 Tamale, Ghana. 10 * Corresponding author’s email: [email protected] 11 12 13 Word Count (Abstract with references, figures and tables): 7,659 14 Abstract: 344 15 Author Summary: 196 16 Figures: 3 17 Tables: 6 18 References: 59 1 bioRxiv preprint doi: https://doi.org/10.1101/543009; this version posted February 6, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 20 ABSTRACT 21 Background 22 Worldwide, snakebite envenomations total ~2.7 million reported cases annually with ~100,000 23 fatalities. Since 2009, snakebite envenomation has been classified as a very important ‘neglected 24 tropical disease’ by the World Health Organisation. Despite this emerging awareness, limited efforts 25 have been geared towards addressing the serious public health implications of snakebites, 26 particularly in sub-Saharan Africa, where baseline epidemiological data remain incomplete. Due to 27 poverty as well as limited infrastructure and public health facilities, people in rural Africa, including 28 Ghana, often have no other choice than to seek treatment from traditional medical practitioners 29 (TMP). The African ‘snakebite crisis’ is highlighted here using extensive complementary data from 30 a community-based epidemiological study conducted by snake ecologists in the savanna zone of 31 northern Ghana. 32 33 Methodology and findings 34 Our cross-sectional study included 1,000 residents and 24 TMPs in the Savelugu-Nanton District in 35 northern Ghana between December 2008 and May 2009, and a 10-year (1999-2008) retrospective 36 snakebite data from the district hospital. Variables tested included demography, human activity 37 patterns, seasonality, snake ecology and clinical reports. Complementary data showed higher 38 snakebite prevalence during the rainy season, and a hump-shaped correlation between rainfall 39 intensity and snakebite incidences. Almost 6% of respondents had experienced a personal snakebite, 40 whereas ~60% of respondents had witnessed a total of 799 snakebite cases. Out of a total of 857 41 reported snakebite cases, 24 (~2.8%) died. Highest snakebite prevalence was recorded for males in 42 the age group 15-44 years during farming activities, with most bites occurring in the leg/foot region. 2 bioRxiv preprint doi: https://doi.org/10.1101/543009; this version posted February 6, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 43 Highest snakebite rate was within farmlands, most frequently caused by the Carpet viper (Echis 44 ocellatus). 45 46 Conclusion 47 The relatively high community-based prevalence rate of ~6%, and fatality rate of ~3%, indicate that 48 snakebites represent an important public health risk in northern Ghana. Based on the high number of 49 respondents and long recording period, we believe these data truly reflect the general situation in 50 rural Ghana and West Africa at large. We recommend increased efforts from both local and 51 international health authorities to address the current snakebite health crisis generally compromising 52 livelihoods and productivity of rural farming communities in West Africa. 53 Keywords: Serpentes, envenomation incidence, demography, Guinea savannah, West Africa 54 55 AUTHOR SUMMARY 56 Snakebite envenomations cause tens of thousands of deaths and hundred thousands of injuries in 57 many developing tropical countries each year, and sub-Saharan Africa represents an epitome of this 58 ‘neglected tropical disease’. We present data spanning 10 years (1999-2008) which was collected 59 over a six-month period, by applying different methodologies across a typical rural savanna 60 community of northern Ghana. Our data corroborate previous findings from the region that 61 snakebites constitute a serious public health threat, and that young and active farmers are 62 particularly at risk, hence compromising both livelihoods and economic wealth of the people. We 63 highlight that many interrelated factors involving both snake ecology and human behaviour in 64 particular, are responsible for the high snakebite prevalence recorded. We conclude that our findings 65 support increased and concerted efforts by both local authorities and state institutions to address the 66 ongoing African snakebite crisis. Such interventions require the generation of more general baseline 3 bioRxiv preprint doi: https://doi.org/10.1101/543009; this version posted February 6, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 67 data on snake ecology and human behaviour, combined with education and information through 68 public awareness campaigns. To achieve this, we recommend community-based stakeholder 69 meetings involving the local people, traditional authorities, and public institutions working to 70 address the persistent snakebite menace in this part of the world. 71 72 INTRODUCTION 73 Snakebite envenomations constitute one of the most important human-wildlife conflicts, causing 74 considerable yet largely insufficiently known magnitudes of socio-economical losses, morbidity and 75 death [1]. Globally, out of >3,500 snake species, ~600 are venomous, and ~280 are considered 76 medically important, causing a conservatively estimated >1.2 million snakebite envenomations 77 causing ~100.000 deaths and >400,000 cases of morbidity annually [1, 2, 3, 4]. Prevailing 78 conservative estimates of the global burden of snakebite envenomations and fatalities are probably 79 highly underrated as majority are based on conventional health facility reports, largely neglecting 80 cases treated by local traditional medical practitioners (TMPs) [1, 5, 6]. Perhaps more realistic 81 annual estimates indicate between 4.5-5.4 million snakebites, 1.8-2.7 million envenomations and up 82 to 138,000 deaths [6, 7]. Snakebite envenomation is largely a disease of poverty, with developing 83 countries in the tropics recording the highest rates of incidence, morbidity and mortality [4, 8, 9]. 84 People engaged in farming, hunting, fishing and other rural activities are at highest risk, mostly 85 bitten on their limbs during work [9, 10]. In many parts of sub-Saharan Africa, the high mortality 86 and morbidity rates are attributed to increased vulnerability caused by both high work risk and 87 exposure to diverse snake habitats, as well as poor infrastructure and limited access to appropriate 88 medical treatment and health facilities [1, 4, 6]. Currently, an estimated ~100 million people, 89 particularly in southeast Asia and Africa, live in vulnerable areas with very high exposure to snake 90 envenomation and lack of effective antivenom therapy [4]. The current ‘global snakebite crisis’ as a 4 bioRxiv preprint doi: https://doi.org/10.1101/543009; this version posted February 6, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 91 disease of poverty, has been termed misunderstood, underrated, ignored or neglected as a public 92 health issue [5, 8, 11, 12], and has lately gained prominence as one of the most important ‘neglected 93 tropical diseases’ [7]. 94 95 In order to mitigate the inadequate health care and treatment of victims of snakebite envenomations, 96 concerted international effort is essential to gather steady and inclusive data on the epidemiological 97 nature of snakebites with socio-demographic and geographic dimensions as well as aspects of snake 98 biology and ecology [4, 5, 12, 13]. Mapping of comprehensive datasets is imperative for 99 understanding the dynamics of human-wildlife conflict such as snakebite vulnerability, and 100 constitute the baseline information needed to provide adequate health facilities and supply of 101 antivenom and other therapeutical innovations [1, 2, 6, 14]. However, inclusive community-based 102 information is currently limited from many high-risk areas particularly in sub-Saharan Africa [15, 103 16]. There is therefore the need for detailed information from studies combining both field and 104 hospital data [4, 6, 9]. Here, we present a comprehensive and complementary epidemiological 105 dataset of snakebite envenomations from northern Ghana, comprising both household and TMP 106 surveys as well as retrospective