Snake bite: prevention and management in rural Indian settings

Abstract

Although it could be said to be too late, given that snakebite poisonings are century-old, time-sensitive, life-threatening accidents, we welcome WHO's first strategy for the prevention and control of snakebite envenoming.1Minghui R Malecela MN Cooke E Abela-Ridder B WHO Snakebite Envenoming Strategy for prevention and control.Lancet Glob Health. 2019; 7: e837-e838Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Since 1976, we have been studying the clinical effects, management, and prevention of envenoming by the “big four” (cobra, krait, Russell's viper, and Echis carinatus) in rural Maharashtra, India. With early diagnosis and proper management, including administration of the appropriate dose of antisnake venom (ASV) and adjuvant treatment with neostigmine, atropine, and ventilation, we have seen the case fatality rate drop from 24% during 1998–2004 to less than 5% during 2013–18.2Bawaskar HS Bawaskar PB Snake bite envenoming.Lancet. 2019; 393: 131Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar In India, more than 2·8 million snakebites are reported in the country each year and it is estimated that more than 50 000 people die from them.3Mohapatra B Warrell DA Suraweena W et al.Snakebite mortality in India: a nationally representative mortality survey.PLoS Negl Trop Dis. 2011; 5e1018Crossref PubMed Scopus (313) Google Scholar Prevention of this acute, life-threatening medical emergency is the mother of cure. At the household level, measures include eradication of rats; avoiding having rubble, firewood, and cattle sheds in residential areas; wearing of high-sided footwear; use of a torch and stick while walking during darkness on farms and in high-grown grass; sleeping on a bamboo cot with the edges of a mosquito net properly tucked under the bed; and strict prohibition of open toileting. Villagers need to be trained to identify venomous snakes and on how to prevent bites. Additionally, strict police action should be taken against mantriks and ojhas (village healers). After a snake bite, rather than wasting time by attending a mantrik or using herbal remedies, patients with a bitten part below the heart level should be immediately transferred to a primary health centre within 8–10 miles by bicycle or whatever vehicle is available.4Bawaska HS Bawaskar PH Punde DP Inamdar MK Dongare RB Bhoite RR Profile of snakebite envenoming in rural Maharashtra, India.JAPI. 2008; 56: 88-95Google Scholar Governments should make it compulsory that two medical officers be posted at primary health centres, with good living conditions and payment, so that a medical officer can be available during the night hours. They should be given proper training on the identification of venomous snakes (should patients bring the killed specimen), on early diagnosis of clinical manifestations, and on the correct dose of ASV.5Directorate General of Family Health ServicesMinistry of Health and Family WelfareStandard treatment guidelines: snakebite.164.100.130.11:8091/nationalsnakebitemanagementprotocol.pdfDate: June 2016Date accessed: July 18, 2019Google Scholar No patient with symptoms of a venomous bite should be transferred to a higher-level facility (usually a district or rural hospital) without administration of the full dose of ASV. We have known of patients who died on the way to hospital because the medical officer did not recognise the symptoms of a snakebite. Additionally, many medical officers are afraid of anaphylactic reactions to ASV. Anaphylaxis can be prevented by administering subcutaneous epinephrine before ASV, or easily reversed by intramuscular epinephrine, intravenous fluids, steroids, antihistamines, oxygen, and temporary termination of the ASV drip (all readily available at primary health centres). The production of ASV requires milking of venom and use of horses for antivenin. Moves to protect animal rights in India mean that chemical antidotes to snake venom fractions should be sought, as we sought out prazosin to counter scorpion venom. The time is right to alleviate snakebite mortality and morbidity due to snakebite envenoming in south Asia. We declare no competing interests. Download .pdf (.14 MB) Help with pdf files Supplementary appendix WHO's Snakebite Envenoming Strategy for prevention and controlTo some, the prospect of getting bitten by a venomous snake might seem extremely remote, but most of the world's population—5·8 billion people—is at risk of encountering a venomous snake. Every day, 7400 people are bitten by snakes, and 81 000–138 000 die as a result every year.1 Currently, around 400 000 people who have been bitten have permanent physical or psychological disabilities including blindness, amputation, and post-traumatic stress disorder.1 Full-Text PDF Open Access