Ophidian envenomation in Morocco: Analysis of specific hospitalization records (2012-2015)

. Snakebites are a real public health problem in Morocco, from the point of view of incidence and mortality. Inorder to contribute to the reduction of the resulting morbidity and mortality, the present work aims to describe the epidemiological profile of cases of Snakebites and to follow the spatio-temporal trends of the health indicators studied (incidence, fatality and mortality). The methodology adopted consists of a retrospective analysis of the cases collected from the Anti Poison and Pharmacovigilance Center of Morocco from specific hospitalization records. Between 2012 and 2015, the MPCC gathered 224 cases. The mean age was 26.9 ± 18.9 years with a sex ratio (M / F) of 1.4. Most of the bites occurred during hot seasons (84%) and in rural areas (95%). The time to hospitalization exceeded 24 hours in 7% of cases. Clinically, compartment syndrome was observed in 17 patients, renal failure in 13 patients and shock in 13 patients. The distribution according to clinical gradation was almost uniform. From a therapeutic standpoint, in addition to the antivenom, two types of treatment were the most recommended: symptomatic treatment based on the administration of analgesics (n = 168) and on the administration of an antitetanus serum (n = 99), and treatment involving transfusion (n = 58). Analysis of all of these files enabled us to detect parameters having a direct impact on morbidity and mortality following a bite and ophidian envenomation, on which the competent authorities should focus in order to thwart this scourge and its complications.


INTRODUCTION
Snake bite envenomation remains a serious health risk and threat throughout the world, including morocco, recording an annual incidence of about 0.5 bites per 100,000 inhabitants a fatality rate of 4% [1]. Among 3000 snake species reported worldwide, around 30% are venomous snakes [2]. In Morocco, the ophidian fauna of the country consists of twenty-eight species, eight of which are poisonous represented by two families, Elapidae (with one species) and Viperidae (with seven species) [3]. To deal with that, snake bites has been integrated into the national envenomation control strategy since May 20, 2013 [4]. The aim of this study was to describe the epidemiological characteristics of snake bites after the national envenomation strategy, Morocco over a four years period from 2012 through 2015

Structure
The Anti Poison and Pharmacovigilance Center of Morocco (MPCC) is the public utility institution mandated by the Ministry of Health, responsible for the management of poisoning at the individual and collective level in Morocco. It ensures a vigilance and health alert function, to reduce mortality, morbidity and health expenses related to poisoning and envenomation

Cases collected at the Poison Control and Pharmacovigilance
Center of Morocco (MAPPC), Through 2012 to 2015

Methods
This study is a descriptive retrospective analysis of all reported cases collected at the Poison Control and Pharmacovigilance Center of Morocco (MAPPC), Through 2012 to 2015 from hospitalization records specific to snakebites. Frequencies were calculated to describe the characteristics that were studied.  The majority of cases were men (59%), the average age of these patients was 26.9 ±18.9 years. They live mostly in rural location (95%), half of recorded bites occurs in summer, mostly with a hospital stay of less than 24 hours (93%),

Since 2012, 224 cases have been collected at the Poison Control and Pharmacovigilance Center of
The site of the bites was determined in 170 cases. The upper limb was the most affected (92 cases; 54%), especially in the right hand (38 cases). The other cases were bitten on the lower limb, namely the left foot.
Prior to admission, 76 victims used traditional practices more than once, in 10.5% of cases, and most patients used tourniquets (56 cases), incisions (15 cases) or sucking (13 cases).
The initial grade was mostly grade 0 (29 % of cases) and, grade 1 (30% of cases), the white bite represented 14% of cases. Patients' condition was worsened (upgraded to a higher grade) 25 times, from grade 1 to grade 3 in 6 patients and from grade 2 to grade 3 in 5 patients, while the condition improved in 10 patients.

Figure 1: Distribution of the gradation of snakebites
In this study, 186 victims were symptomatic cases, or 83% of the total cases studied. Most of the victims (121 cases) presented with pain. Among these victims, 125 patients presented with edema (local, regional or extensive). The table 2 shows the frequency of symptoms

DISCUSSION
In many regions of the world, snake bites are an important public health problem, as has been shown in many studies, bites occur especially in rural areas, and most victims were adults [5]. According to the results, most incidents occurred during the spring and summer months, when snakes are more active [6,7]. The warm period of the year coincides with the harvesting period: people are more active in the fields and therefore are more frequently exposed to snakes, which explains the high frequency of bites and envenomations outside the home. [8,9] The specific hospital records included new parameters specific to the bite; the site of the bite, contraindicated gesture, detailed symptomatology (biological assessment and complications), clinical gradation and recommended treatment.
According to the results of the statistical analysis, the snake bites were localized in the lower limbs and upper limbs of the victims, while in intertropical Africa the site of the bite is most often in the foot or leg [10,11].
For customary and economic reasons, several victims had committed at least one prohibited act (sussions, tourniquet, incision) following a snake bite. These behaviors delay medical treatment and jeopardize the functional prognosis of the bitten limb as well as the patient's vital prognosis [12,13].The tourniquet was the most performed. This gesture is however to be avoided; it promotes limb ischemia and retention of the poison in the tissue [14].
There is no cobraic syndrome in our study, consisting mainly of paralysis of the respiratory muscles and striated muscles, has been described. This is predictable given its threatened Mediterranean population [15].

CONCLUSION
Analysis of all of these files enabled us to detect parameters having a direct impact on morbidity and mortality following a bite and ophidian envenomation, on which the competent authorities should focus in order to thwart this scourge and its complications.