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.

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants’ demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2–49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4–39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed.

Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

Snakebites are a major public health problem in the Brazilian Amazon and may lead to local complications and physical deficiencies. Access to antivenom treatment is poorer in indigenous populations compared to other populations. In this study, we report three cases of long-term severe disabilities as a result of Bothrops atrox snakebites in indigenous children, according to the narratives of the parents. The three cases evolved to compartment syndrome, secondary bacterial infection and extensive necrosis. The cases are associated with delayed antivenom treatment due to very fragmented therapeutic itineraries, which are marked by several changes in means of transport along the route. The loss of autonomy at such an early stage of life due to a disability caused by a snakebite, as observed in this study, may deprive children of sensory and social experiences and of learning their future roles in the community. In common to all cases, there was precarious access to rehabilitation services, which are generally centralized in the state capital, and which leads to a prolonged hospitalization of patients with severe snakebite, and distances them from their territory and family and community ties. Prospective studies should be conducted in the Amazon that estimate the burden of disabilities from snakebites in order to formulate public policies for the treatment and rehabilitation of patients through culturally tailored interventions.

RESUMOObjetivo: relatar a experiência da educação em saúde sobre a biossegurança realizada aos acompanhantes de pacientes portadores de doenças infectocontagiosas internados em um hospital de referência em infectologia no Amazonas. Método: estudo descritivo, tipo relato de experiência, realizado com acompanhantes de pacientes portadores de doenças infectocontagiosas em uma unidade de referência em infectologia. Resultados: foram realizados 49 encontros com um registro de participação de 488 ouvintes. Quase a totalidade (89,6% dos acompanhantes entrevistados) informou nunca ter tido a oportunidade de participar de um programa de educação em saúde em outros hospitais. A dúvida mais frequente dos ouvintes, antes dos ensinamentos de biossegurança, foi de não saberem quais medidas realizar para não levar microrganismos existentes no ambiente hospitalar para dentro de suas residências. Conclusão: os dados confirmam a importância de disponibilizar, aos acompanhantes, os cuidados de biossegurança, a partir de uma linguagem simples e didática, para que o conhecimento se torne acessível e entendível, assim, promovendo mudanças de hábitos positivos no ambiente hospitalar. Descritores: Educação em Saúde; Promoção da Saúde; Familiar Cuidador; Doença Infectocontagiosa; Segurança do Paciente; Serviço Hospitalar de Educação.ABSTRACT Objective: to report the experience of health education on the biosafety carried out to the companions of patients with infectious diseases hospitalized in a hospital of reference in infectology in the Amazon. Method: descriptive study, related experience type, carried out with caregivers of patients with infectious diseases at a reference unit in infectology. Results: 49 meetings were held with a participation register of 488 listeners. Almost all (89.6% of those interviewed) reported that they had never had the opportunity to participate in a health education program in other hospitals. The most frequent doubt of the listeners, before the biosafety teachings, was, not knowing what measures to take to avoid carrying microorganisms, existing in the hospital environment, into their homes. Conclusion: the data confirms the importance of providing biosecurity care to the caregivers, based on a simple and didactic language, so that knowledge becomes accessible and understandable, thus promoting positive habit changes in the hospital environment. Descriptors: Health Education; Health Promotion; Caregivers; Communicable Diseases; Patient Safety; Education Department, Hospital.RESUMEN Objetivo: relatar la experiencia de la educación en salud sobre la bioseguridad realizada a los acompañantes de pacientes portadores de enfermedades infectocontagiosas internados en un hospital de referencia en infectología en Amazonas. Método: estudio descriptivo, tipo relato de experiencia, realizados con acompañantes de pacientes portadores de enfermedades infectocontagiosas en una unidad de referencia en infectología. Resultados: fueron realizados 49 encuentros con un registro de participación de 488 oyentes. Casi la totalidad, el (89.6% de los acompañantes entrevistados) informó que nunca haber tenido la oportunidad de participar en un programa de educación en salud en otros hospitales. La duda más frecuente de los oyentes, antes de las enseñanzas de bioseguridad, fue de no saber cuales medidas realizar para no llevar microorganismos existentes en el ambiente hospitalario dentro de sus residencias. Conclusión: los datos confirman la importancia de ofrecer, a los acompañantes, los cuidados de bioseguridad, a partir de un lenguaje sencillo y didáctico, para que el conocimiento se haga accesible y entendible, así promoviendo cambios de hábitos positivos en el ambiente hospitalario. Descriptores: Educación en Salud; Promoción de la Salud; Cuidadores; Enfermedades Transmisibles; Seguridad del Paciente; Servicio de Educación en Hospital.