Burden of snakebite and the knowledge of health professionals toward envenomation management in Hamer wereda, South Omo, Ethiopia

Introduction

Snakebites are neglected tropical diseases that impose a significant public health burden on poor rural communities in many tropical and subtropical countries. Although the world is home to over 3,000 snake species, the World Health Organization (WHO) classifies around 250 as medically significant due to the harmful effects of their venom. These medically important venomous snakes are present in 160 countries. Globally, snakebites affect an estimated 5.4 million people annually, resulting in 1.8 to 2.7 million cases of envenomation. Of these, approximately 81,000 to 138,000 deaths occur each year, with the vast majority reported in developing countries across Africa, Asia, and Latin America (1, 2). Owing to this substantial burden and historical neglect, the WHO has classified snakebite as a high-priority neglected tropical disease and set a target to halve global morbidity and mortality by 2030. The poorer a country, the more common snakebite poisoning tends to be (3, 4). In low and middle income countries, snakebites disproportionately harm women, children, and farmers living in poor rural communities (5).

Africa has over 130 venomous snake species, responsible for 435,000 to 580,000 human envenomations and around 30,000 deaths annually. Nevertheless, these figures are likely underreported as many victims never visit health facilities, and reliable epidemiological data remain scarce across the continent (6). In Ethiopia, diverse geographic, climatic, and ecological conditions create a favorable environment for numerous medically important snake species. The country is home to an estimated 10–12 venomous species, including cobras, vipers, and puff adders, widely distributed across lowland and savanna regions (7). Human activities such as resettlement, military campaigns, sheep herding, firewood collection, sugarcane cutting, honey collection, and timber work frequently disturb snake habitats and precipitate snakebite incidents. However, epidemiological data on snakebite incidence, mortality, and socioeconomic impact remain severely limited. The true burden of snakebite disease in Ethiopia lacks resolution and completeness, largely due to underreporting, as many victims seek traditional treatments either inadequate or inaccessible medical care (8, 9).

Hamer wereda, located in the South Omo Zone of the South Ethiopia Regional State, represents a particularly high-risk and understudied setting for snakebite envenomation. The wereda is characterized by arid and semi-arid lowland topography, hot climatic conditions, and sparse vegetation that support a high density of venomous snakes. The local economy is predominantly agro-pastoral, with most of the population engaged in cattle herding, goat rearing, and subsistence farming. These livelihood activities, combined with traditional housing structures that offer limited protection against snake entry, place community members at elevated risk of bites. Furthermore, Hamer wereda is geographically remote, with limited road infrastructure and long distances to health facilities. Unreliable reports and routine facility records suggest substantial underreporting, inconsistent case documentation, and potential gaps in health professionals’ readiness to manage snakebites is enhanced by adequate knowledge of envenomation and treatment protocol (10).

The seasonal patterns, case fatality rates, and proportion of victims who do not seek care remain unknown. Similarly, the readiness of health facilities specifically, health professionals’ capability to recognize snake species, administer antivenom appropriately, manage complications, and monitor patients has never been assessed. Snakebites can cause severe organ system damage, including paralysis, tissue necrosis, muscle breakdown, kidney failure, and hypovolemic shock, necessitating prompt medical emergencies and precise diagnosis (11, 12). Antivenom neutralizes only accessible venom components; it cannot repair damaged organs or tissues. Once some toxins are sequestered inside cells, they become inaccessible to antivenom immunoglobulins, making immediate treatment crucial (13, 14). A snakebite envenomation harms not only the bitten individual but also the entire family’s finances, emotions, and future life. In many cases, snakebites make poor people even poorer, forcing them to pay expensive treatment fees and borrow money to survive (15, 16). A lack of community awareness about the severity of snakebite envenomation, along with insufficient training for health professionals to improve their knowledge, attitudes, and practices remains a cause of disease related loss (17, 18).

This study provides the first baseline data on snakebite burden in Hamer wereda, by generating primary epidemiological evidence on snakebite frequency and seasonal distribution, producing actionable findings to inform targeted training. Additionally, this study contribute to improve case management for health professionals; and supporting evidence based resource allocation, antivenom supply planning, and priority setting for local health authorities and policy makers. Therefore, this study aimed to assess the facility based burden of snakebite disease in this mobile population and the readiness of health professionals to manage snakebite cases in Hamer wereda, South Omo Zone, South Ethiopia Regional State.

Methodology

Study design and setting

A facility-based cross-sectional study design was employed to assess the relevant study variables over a data collection period from April 12, 2025, to August 15, 2025. The study was conducted in Hamer wereda, which is located in the South Omo Zone of the South Ethiopia Regional State. The setting covered all public health facilities within the wereda, including Dimaka, Erbore, Kara Dusa, Shanqo, and Turmi health centers (Figure 1).

Study population and sample size

The study population comprised all health professionals working in the public health facilities of Hamer wereda. Since the total number of target population in these facilities was manageable and feasible for a complete enumeration no sample size was calculated, and a census approach employed. Accordingly, all health professionals who met the inclusion criteria were recruited into the study.

Inclusion and exclusion criteria

Health professionals were eligible for inclusion in the study if they had been working in public health facilities within Hamer wereda for at least six months prior to data collection. Professionals were excluded from the study if they were on annual leave, sick leave, or any other form of authorized absence during the data collection period. Additionally, those who did not provide voluntary informed consent to participate were excluded. Any medical record of a snakebite case that contained incomplete information or recorded before five years were excluded at the time of data extraction. A total of 78 health professionals were eligible for the study, of whom 75 enrolled and participated, yielding a 96.1%participation rate.

Data collection procedure

Structured questionnaires were developed based on the concept of neglected tropical diseases and a review of the literature on snakebite management (19–22). The questionnaires were prepared in English and subsequently translated into local languages to ensure participants had a comprehensive understanding of the content. Face to face interview were conducted by trained data collectors who had experience in qualitative research methods. Interviews were scheduled at a convenient time and location for each participant, typically at their workplace. To ensure privacy and confidentiality, no external individuals were present during the interviews. Field notes were taken during and after each interview to capture observations and reflections of the respondents (23, 24). All snakebite cases recorded in outpatient and inpatient medical registers between September 2021 and July 2025 representing a five-year period were reviewed across all health facilities in the wereda. For each identified snakebite case, data were extracted on sex, age, date of visit, number of days spent in the health facility, and treatment outcome (25). Data on snakebite cases and deaths were extracted from the study sites health facilities. The population at risk was estimated using annual projections from the Ethiopian Statistical Service (ESA). The burden of snakebite was quantified using standard metrics: Incidence rate, Case fatality rate, Years of Life Lost (YLL), Years Lived with Disability (YLD), and Disability-Adjusted Life Year (DALY) (26, 27).

Data analysis

Trained data clerks entered the data into a Microsoft Excel spreadsheet and subsequently exported it to SPSS version 27 for data cleaning, validation, and statistical analysis. Descriptive statistics (frequencies, and percentages) were computed to summarize the characteristics of health professionals and frequency documented snakebite case.

Variables: The dependent variables were health professionals’ readiness to manage snakebite and the annual snakebite case reported. The independent variables included sociodemographic characteristics including age, sex, professional category, years of experience, prior training on snakebite management and availability of antivenom in health facilities.

Analytical steps: First, we computed frequencies and proportions for snakebite burden indicators including seasonal distribution, snakebite related mortality and complications from retrospective facilities records. Next, we assessed health professionals’ readiness by calculating proportion of correct responses on antivenom administration, and appropriate first aid practices. Statistical significance was set at p < 0.05, and 95% confidence intervals were reported.

Data quality control

Quality control measures were implemented to ensure data accuracy and reliability. The questionnaire was pretested on five health professionals working in non-study health facilities to assess its clarity, comprehension, relevance, sensitivity, flow, length, and completion time, with subsequent refinements made accordingly. Data collectors and supervisors received standardized training, and daily supervision was provided throughout the fieldwork period. Completed questionnaires were checked daily for completeness and consistency by field supervisors. Regular team meetings were conducted to review progress, discuss inconsistencies, and ensure uniform application of inclusion criteria and data collection procedures. To minimize data entry errors, two independent operators performed double data entry. Additionally, a random sample of 10% of records was rechecked against the original questionnaires to verify entry accuracy.

Results

Sociodemographic characteristics of the participants

Young adults made up the majority of participants (Table 1), with the largest age group being 21--27 years (50.7%). Males constituted the majority of the study participants (57.3%), and nurses accounted for the largest professional cohort (37.3%), followed by health officers (21.3%). The smallest study participants were anesthetists (1.3%) and medical doctors (4.0%). With only 5.3% reporting more than ten years of work experience and 69.3% having fewer than five, the participants were primarily early-career professionals. Critically, the majority (97.3%) had never received any official snakebite management training.

Table 1. Background information of the study participants (n=75).

Burden of snakebites, clinical profiles of cases and complications

As detailed in Table 2, snakebites represent a regular clinical burden, with 48.0% of health professionals managing 5–20 cases annually. Seasonal variation was noted, with the highest incidence reported during the rainy season (40.8%). The demographic profile of typical victims identified productive aged adults (15–60 years) as the most affected group, accounting for 74.7% of the cases. This corresponds with occupational data, which identified farmers (51.3%) and herders (40.8%) as the highest-risk groups, underscoring that snakebites in this region function predominantly as occupational threats for rural, agricultural workers. The clinical manifestations of cases were distributed almost evenly among neurotoxic (30.3%), hemotoxic (30.3%), and local tissue damaging (38.2%) envenomation.

Table 2. Snakebite management and case profiles reported by the study participants (n=75).

* Multiple responses and percentages are not mutually exclusive.

A lack of antivenom (65.3%) and delayed medical presentation (61.3%) were the greatest reported challenges. High mortality (66.7%) had reported in health facilities from snakebites in the last five years. Most of the reasons for death were distance and lack of transportation (44%) and prolonged visits to traditional healers (32%). Frequently reported complications were systemic reactions such as shaking chills, fever, and vasodilation (37.3%). However, disability was reported in 9.3% of the patients.

The majority of snakebite victims recorded at the study health facilities (58.9%) were males (Table 3). A significant association was found between sex and age distribution (p<0.001), with the largest proportion of cases (48.2%) reported in individuals over 32 years. The most frequently affected age group was the 10–19 years age group, accounting for 33.9% of all cases, followed by the 20–29 years age group (29.5%). Collectively, these two groups represented nearly 63.4% of the total snakebite cases. The overall health outcomes following snakebites were severe. Nine deaths (8.0%) and two permanent disability cases (1.8%) were recorded. A statistically significant association was observed between sex and health status (p<0.001). While the number of deaths was male (n=4) and female (n=5), both recorded cases of disability occurred in female patients. The vast majority of male patients (93.9%) recovered to a normal status, whereas 84.8% of female patients did. Delays in seeking health professionals an essential finding. Over half of the victims (51.8%) presented to a health facility 48 hours or more after the snakebite, with a significant association with sex (p<0.001). Males constituted the majority (62.1%) of those in this delayed presentation group. Conversely, the length of stay in the health facility after admission was also significantly associated with sex (p<0.001), with most patients (54.5%) staying between 7 and 10 hours. A greater proportion of female patients (28.3%) presented within the critical first 6 hours than did male patients (19.7%).

Table 3. Snakebite related mortality and complications in the last five years (n=112).

Over the five-year period, a total of 112 snakebite cases were recorded in Hamer Wereda, with nine deaths reported (Table 4). The average annual incidence rate was 26.15 per 100,000 population. The incidence fluctuated during the study period, peaking in 2024 at 36.42 per 100,000 and reaching its lowest point in 2025 at 20.76 per 100,000. The average case fatality rate was 7.85% (9 deaths per 112 cases), with annual rates varying significantly from a high of 10.53% in 2022 to a low of 4.76% in 2021. The total disease burden for the period was 551.22 DALYs. YLL accounted for the vast majority of this burden (547.38 DALYs), while YLD contributed only 3.84 DALYs, reflecting a high fatality to morbidity ratio from the envenoming.

Table 4. Burden of Snakebite in Hamer Wereda (2021–2025).

IR, Incidence rate (per 100,000); CFR, Case fatality rate; YLL, Years of Life Lost; YLD, Years Lived with Disability; DALY, Disability-Adjusted Life Year; Disability Weight: 0.163.

Population (Hamer wereda) for each year’s taken from Ethiopian Central Statistical service (ESA). The Life Expectancy at age of death = 60.82 years (based on worldometer data for Ethiopia, the mean age of snakebite victim 7.33 years with remaining life expectancy of 60.82 years).

Challenges in snakebite management

The majority of health professionals (81.7%) reported having antivenom in their facilities (Table 5). The primary source of this antivenom was the donor (74.7%), with only a limited number of facilities (25.3%) reporting that it was obtained from the Ethiopian pharmaceutical supply service (EPSS). Furthermore, all health facilities reported using a polyvalent antivenom type. However, a significant majority of facilities (81.7%) reported that they did not receive a sufficient quantity of antivenom to meet their requests. Regarding the cost to the patient, the price for a full dose of antivenom varied, with the most common price range being 2,501-3,500 birr. Most facilities (89.3%) reported not encountering any antivenom related complications during patient treatment. The financial burden on patients is considerable, with nearly 70% of facilities reporting a full dose cost exceeding 2,500 birr and over 20% reporting costs above 3,500. This high cost, coupled with potential supply insufficiency, can create terrible expenditures for affected families and act as a barrier to accessing life-saving treatment.

Table 5. Antivenom availability, sourcing and types (N = 75).

Knowledge of snakebite management and practices

The knowledge of snakebite envenomation signs and antivenom administration criteria for health professionals reveals critical gaps (Table 6). The identification of local signs such as swelling (58.7%) and painful lymph nodes (46.7%) was relatively common. Recognition of systemic and critical laboratory signs was very low. Local swelling (58.7%) in the form of snakebite envenomation was the most common criterion to allow antivenom for victims. Wound management and secondary infection were more consistent, with a majority reporting immediate first aid (72.0%) and antibiotic prophylaxis (64.0%). However, adherence to tetanus prevention (42.7%) was inadequate, suggesting a need to reinforce comprehensive wound care protocols.

Table 6. Health professionals knowledge and practices regarding the clinical decisions of snakebite cases (n=75).

Health professionals relied mainly on the clinical signs of victims, with severe local swelling (50.7%) and systemic symptoms such as difficulty of breathing (44.0%) and nausea/vomiting (41.3%) being key identifiers of venomous snakebites. Reliance on puncture wound patterns is less common, which is clinically appropriate for confirming the bite of venomous snakes. A significant deficit in knowledge was evident in the area of snake species identification, with 78.7% of the respondents being unable to identify venomous snakes common in their area. A major finding of concern is that tourniquet application is the most common method (54.7%) used to control swelling. This practice is medically discouraged, as it can concentrate venom and lead to ischemia and increased tissue damage. Limb immobilization practices were reported by only 44.0% of the respondents, indicating that harmful first aid practices were prevalent. The root cause of these knowledge gaps is the severe lack of formal training (85.3%) for healthcare workers reporting no prior training in snakebite management. The possible solutions reported preventive measures (61.3%), enhancing healthcare access (54.7%), and community engagement (53.3%) as the most effective ways to reduce the snakebite burden.

Community awareness and barriers to prevention measures

A majority of the respondents (61.3%) reported that the community lacked awareness of snakebites (Table 7). Most respondents (69.3%) indicated that their health facility does not provide health education on snakebite prevention, control, and acute management.

Table 7. Community awareness, and health facility practices related to snakebites (n=75).

The data reveal a critical delay in patients seeking medical care following a snakebite. The majority of respondents (86.7%) reported that snakebite victims do not visit health facilities immediately.

For those who did not seek immediate care, the respondents identified several key barriers. The most frequently cited reason was transportation problems (56.0%), followed closely by traditional healers (53.3%). The inadequate supply of antivenom at the health facility was also a significant (40.0%) barrier.

Discussion

This study highlights the perceptions of health professionals regarding snakebite management in Hamer Wereda. The findings show a significant burden of envenomation, characterized by systemic challenges in prevention, substantial delays in treatment, and difficulties in clinical management. The demographic profile of health professionals indicates that most are young and less experienced, with a severe scarcity (97.3%) of formal snakebite management training. This knowledge gap is troubling, as it means that the majority of victims face inadequate care, and a lack of knowledge in treating cases is a key challenge (19). The limited training for health professionals in snakebite management in this study is greater than that in other hotspot areas (26). Although most professionals reported the availability of antivenoms in their facilities, dependency on donors creates severe vulnerability in the supply chain. This dependence contributes to the widespread insufficiency of antivenom, with over 80% of health facilities not receiving the requested quantities, potentially leading to shortages and poor treatment for snakebite victims. The use of polyvalent antivenom in all facilities suggests a lack of species-specific treatment options, which may influence efficacy. This predominant use of polyvalent antivenom and donor dependency has also been reported in different parts of Ethiopia (28).

Clinical management practices involve diverse adherence to standard guidelines. Local swelling (58.7%) and systemic symptoms are common principles for initiating antivenom therapy, and the use of the twenty minute whole blood clotting test a key diagnostic tool for coagulopathy was reported by only 10.7% of the respondents. Even though the common snake species responsible for envenomations were ambiguous in the study area, local swelling has also been reported as a clinical characteristic of puff adder envenomation (29, 30). More than half (54.7%) of health care providers still consider tourniquet application to be an appropriate method for controlling swelling, a practice discouraged by the WHO due to potential harm (26, 31). This reflects persistent gaps between evidence-based guidelines and on-ground practice. Remarkably, community awareness appears to be very low and lacks snakebite knowledge, and most health facilities do not offer associated health education. This prevention gap, together with access barriers, underscores the intricate nature of the snakebite burden.

Snakebites predominantly affect adults aged 15–60 years, especially farmers and herders, who are prone to occupational exposure during (32, 33). Snakebite envenomation increases during rainy seasons when snakes become active on the ground and farmers work in the field. This finding aligns with that of Dhoble et al. (34), who reported that a majority of snakebites are produced during the rainy season. The majority of male victims, mainly in the older age group (>32 years), strongly indicated that occupational exposure is a key risk factor. This likely represents pastoralists and farmers who spend extensive time in fields and grazing lands, which are environments where human snake conflicts are more credible. In this region, snakebite incidents are more reliably reported during the rainy season, when snakes migrate toward human settlements in search of dry ground and prey.

Delayed presentation was a critical factor, as most patients arrived at health facilities ≥48 hours after exposure, often because of initial visits to traditional healers, transportation barriers or a lack of awareness. A similar study conducted in French Guiana revealed patients were bitten very late after antivenom administration, which is ≥12 hours and is linked to various socio-economic factors (35, 36). These delays, exacerbated by a lack of antivenom and poor referral systems, directly contribute to mortality and complications such as neurotoxic and hemotoxic effects (37, 38). In many cases, snakebite envenomation either receives no medical treatment or is treated only after a significant delay in antivenom administration, which may lead to several long-term complications, including acute kidney failure and necrotic tissue infections, with psychological trauma. This delay is associated with poor health outcomes, including progression to systemic envenomation, irreversible tissue damage, organ failure, and death. The higher rate of delayed presentation among male victims might be related to the nature of their remote worksites, their distance from health facilities, or greater tendency to visit traditional healers first. All disability cases in females and a greater proportion of exposed females died of envenomation, despite a slightly better rate of early presentation. The case fatality rate is too high and points to systemic failure in the chain of survival for snakebite victims (24, 39). The finding indicated that children under twelve years were more affected group that requires immediate prevention and control measures. The highest snakebite incidence in 2024 attributed to climatic factors, such as heavy rainfall flooding, that often drive human-snake encounters. A life threatening concern is the high case fatality rate and Disability-Adjusted Life Year (DALY), which is high compared to the study conducted in Burkina Faso (40).

Conclusion and recommendations

The findings of this study affirm that snakebite envenomation is a serious public health burden in the study area, with high rates of mortality and inevitable long-term morbidity. This situation is sustained by a confluence of systemic failure and access barriers. Ultimate faults within the healthcare system, including critical shortages of health professionals training and unreliable antivenom supply chains reliant on external donor sources, directly compromise clinical management. These institutional inadequacies are worsened by significant prehospital delays driven by complex cultural beliefs, economic constraints, and insufficient community awareness. There is a distinct and significant gap between internationally recognized snakebite management protocols, and real clinical practices. The simultaneous lack of vigorous, sustained preventive measures and community engagement programs also perpetuates the cycle of risk and poor snakebite outcomes. The persistent morbidity and mortality from snakebite envenomation in this region are not predictable. However, this is a direct result of identifiable and addressable failures through resilient health professionals. A meaningful reduction in the burden of this neglected tropical disease requires vital, harmonized, and targeted intervention strategies. These efforts are initiated through prioritizing the improvement of health professionals’ ability through consistent training, strengthening antivenom logistics, and supply systems, implementing effective community-based prevention and health education initiatives, and eliminating barriers to ensure timely access to proper medical care. On the basis of these findings, a series of multilevel alliances are needed to mitigate the burden of snakebite envenomation in the wereda. The implementation of relevant control and prevention measures through a coordinated one-health approach engaging community, healthcare, and policy stakeholders. The integration of extensive snakebite management into consistent hands on training for all health professionals in high-risk areas is crucial to avoid harmful first, aid practices. Health facilities must adopt and display standard treatment guidelines for snakebite management in all emergency and outpatient departments to monitor their clinical practice. To ensure effective treatment, establishing an essential medicine supply chain is crucial to confirm the consistent and affordable availability of antivenoms at health facilities. Furthermore, vibrant protocols for the transportation of severe snakebite cases and emergency referrals should be established and disseminated to strengthen the referral system. For community and public health interventions, it is essential to institutionalize constant health education programs regarding snakebites. These should include regular awareness sessions focused on snakebite prevention, the risk of treatment delay, and the critical importance of seeking immediate medical care.

Additionally, the documentation of snakebite cases in health facility registries and surveillance systems should be improved to inform future policies and strategies. These findings improve the understanding of local epidemiology and treatment outcomes. Finally, conducting ecological studies to identify the most prevalent venomous snake species in the area is necessary to guide the potential development or procurement of antivenom methods that target local venomous snakes.

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Footnotes

Edited by: Sana Tamim, National Institute of Health, Pakistan

Reviewed by: Rene Kinda, Centre National de Recherche et de Formation sur le Paludisme, Burkina Faso

Gaauri Metkar, Maharashtra Institute of Medical Education and Research (MIMER), India