Snakebite In India Research Articles

Role of Plant-derived Bioactive Compounds in Potential Snakebite Envenoming: A Review

: The issue of snakebite continues to be a distinctive matter of public health in various regions across the globe, with a particular emphasis on India, where the ailment is widely prevalent. Snakebites in the country disproportionately affect rural and indigenous populations, resulting in some of the highest morbidity and mortality rates worldwide. Regrettably, in numerous tropical nations, the accessibility of antivenom is frequently postponed or restricted, thereby rendering antiserum the only targeted therapeutic alternative. Nevertheless, administering antiserum in isolation does not provide adequate safeguard against the adverse effects of venomtriggered hypersensitivity complications, which may be grave. Hence, this study aims to review the plant-derived bioactive compounds used to treat snakebites in India. This review compiles a list of medicinal plants and plant-derived bioactive compounds used in treating snakebites in India, which were reviewed from the available literature in public databases (PubMed, Science Direct, Springer, and Scopus). Search words used were 'bioactive compounds,' 'treatment for a snakebite,' 'antivenom and snakebite,' 'Medicinal plants for snakebite, and 'composition of snake venom'. : A list of 200 medicinal plants traditionally used in several countries for treating snake bites was obtained. Based on scientific data, we reviewed only 83 medicinal plant extracts and bioactive compounds obtained from various families, tested under in-vivo and in-vitro conditions to determine their neutralization potency of snakebite envenomation. In this article, we have presented a comprehensive review, judgmentally analyzed medicinal plants and their bioactive compounds for their therapeutic potential against snake envenomation, and offer a thorough discourse on diverse herbal plants employed globally for managing snakebites.

National task force study on ‘the incidence, mortality, morbidity and economic burden of snakebite in India’

National task force study on ‘the incidence, mortality, morbidity and economic burden of snakebite in India’

Snakebites in Three Districts of Rural Areas of Western India during Winter

Abstract Introduction: Snakebite is more of a seasonal problem in the state of Rajasthan, as is so in India. The peak incidence of snakebite occurs in the monsoons, with high frequency also reported during the harvest season. The estimated incidence of snakebite in India is 2–3 million, annually leading to 58,000 deaths. Rajasthan is the largest state by area in India and is one of the states that report a high incidence of death due to venomous snakebite in the One-million Death Study. Since snakebite is largely seen as a seasonal problem mainly concentrated in the rainy and summer seasons, the aim of the study was to assess the incidence and mortality of snakebites in winter. Materials and Methods: A telephonic survey of the snakebites in the rural areas of three selected districts of Rajasthan, Western India, chosen based on climatic and geographic conditions. Calls were made to medical officers/in-charge of different primary care centers (PHC)/community health centers (CHC) to report snakebites in the winter season. Medical officers in PHCs/CHCs were asked to report the number of cases reported, deaths, anti-snake venom (ASV) administration, and serious adverse reactions related to ASV administration. The medical officers were further asked if they were confident while administering ASV or not. Results: A total of two deaths were reported out of 39 snakebites (5.1%). ASV was administered to the majority of them (94.8%) with two of them showing adverse reactions to ASV (5.1%). Majority of the bites were reported from primary health centers. Conclusions: The present study suggests that snakebite is not a seasonal problem with significant cases occurring even during the winter months. The study highlights the need for creating awareness and taking adequate precautions among vulnerable population, even in the winter season. In addition, sentinel surveillance for snakebites could be strengthened at the district level.

An efficient densenet-based deep learning model for Big-4 snake species classification

Snakebite poses a significant health threat in numerous tropical and subtropical nations, with around 5.4 million cases reported annually, which results in 1.8–2.7 million instances of envenomation, underscoring its critical impact on public health. The 'BIG FOUR' group comprises the primary committers responsible for most snake bites in India. Effective management of snakebite victims is essential for prognosis, emphasizing the need for preventive measures to limit snakebite-related deaths.The proposed initiative seeks to develop a transfer learning-based image classification algorithm using DenseNet to identify venomous and non-venomous snakes automatically. The study comprehensively evaluates the image classification results, employing accuracy, F1-score, Recall, and Precision metrics. DenseNet emerges as a potent tool for multiclass snake image classification, achieving a notable accuracy rate of 86%. The proposed algorithm intends to be incorporated into an AI-based snake-trapping device with artificial prey made with tungsten wire and vibration motors to mimic heat and vibration signatures, enhancing its appeal to snakes.The proposed algorithm in this research holds promise as a primary tool for preventing snake bites globally, offering a path toward automated snake capture without human intervention. These findings are significant in preventing snake bites and advancing snakebite mitigation strategies.

Systematic review and meta-analysis on the efficacy of Indian polyvalent antivenom against the Indian snakes of clinical significance.

Snakebite in India is a severe problem as it causes a mortality rate of 58,000 and a disability rate of 140,000 every year which is the highest among any other country. Antivenom is the primary therapy for snakebite, and its manufacturing techniques have essentially stayed unaltered for over a century. Indian polyvalent antivenom, a scientifically validated medicine for treating the toxic effects of snakebites, is available against the venom of the so-called Big Four snakes namely Spectacled cobra (Naja naja), Saw-scaled viper (Echis carinatus), Russell's viper (Daboia russelli) and the Common krait (Bungarus caeruleus), responsible for majority of the deaths in India. India hosts many other species of snakes, including cobras, kraits, saw-scaled vipers, sea snakes, and pit vipers, responsible for clinically severe envenomation. Neutralization strategy has been applied to access the efficacy of antivenoms, crucial for reducing snake bite deaths and disabilities. This review aims to conduct a systematic review and meta-analysis on the neutralization efficiency of the Polyvalent Antivenom (PAV) and focus on the factors that may contribute to the poor recognition of the antivenom towards the venom toxins. Reports focusing on the investigation of antivenom efficacy were searched and collected from several databases. Preclinical studies that reported the neutralization efficacy of the commercial antivenom against the medically important snakes of India were included. The articles were screened based on the inclusion criteria and 8 studies were shortlisted for meta-analysis. Pooled proportion was calculated for the antivenom efficacy reported by the studies and was found to be statistically significant with a 95% confidence interval. The heterogenicity in the venom toxicity and neutralization potency of the antivenom was evident in the overall estimate (proportion) and individual data. We provide comprehensive evidence on antivenom efficacy against medically important snakes from various parts of India which may aid in identifying the gaps in snake envenomation therapy and the need for novel potentially improved treatment of snakebites.

Identifying key factors contributing to treatment costs for snakebite envenoming in private tertiary healthcare settings in Tamil Nadu, India.

India suffers ~58,000 annual deaths due to snakebites. The 'Big Four' snakes (Russell's viper, Indian cobra, common krait, and saw-scaled viper) that are responsible for most bites cause diverse clinical effects. Delayed treatment increases the risk of serious complications and treatment costs. Although government hospitals offer free treatment for snakebites in India, most patients opt for private healthcare, which is an out-of-pocket expense as they often lack health insurance coverage. This study aims to analyse snakebite treatment costs in private tertiary care hospitals in Tamil Nadu, India and identifies the key factors contributing to treatment costs. The treatment cost details for 913 snakebite victims were collected from 10 private tertiary care hospitals across Tamil Nadu. The data were classified into hospital, pharmacy, investigation, and laboratory costs, and analysed to determine various factors that contribute to the costs. The results demonstrate that the average treatment costs vary widely for different snakes. The hospital and pharmacy costs are higher than investigation and laboratory costs for all snakebites. Notably, Russell's viper bites cost significantly more than the bites from other snakes. Overall, the type of snake, nature of complications, specialist treatments required, and arrival time to hospitals were identified as some of the key factors for higher treatment costs. These data demonstrate that ~80% of snakebite patients can be treated with INR 100,000 (~GBP 1000 or USD 1200) or less. This study emphasises the urgent need to improve rural medical care by providing appropriate training for healthcare professionals and essential resources to facilitate early assessment of patients, administer the initial dose of antivenom and refer the patients to tertiary care only when needed. Moreover, the outcome of this study forms a basis for developing appropriate policies to regulate snakebite treatment costs and provide affordable medical insurance for vulnerable communities.

Russell Viper Venom: A Journey from the Bedside to the Bench and Back to the Bedside.

Russell Viper Venom (RVV) is widely used as a diagnostic test for antiphospholipid syndrome (APS). But the history of how this venom came to be discovered is well known. Dr Patrick Russell is responsible for the identification of the venom during his work on snake bites in India while Dr Robert Macfarlane used it to staunch bleeding in persons with haemophilia. The ability to directly activate factor X led RVV to the laboratory diagnosis of APS. More recently, it has come back to clinical world with a potential for an engineered factor X activator from RVV to be used in the treatment of haemophilia.

Fangs in the Ghats: Preclinical Insights into the Medical Importance of Pit Vipers from the Western Ghats.

The socioeconomic impact of snakebites in India is largely attributed to a subset of snake species commonly known as the 'big four'. However, envenoming by a range of other clinically important yet neglected snakes, a.k.a. the 'neglected many', also adds to this burden. The current approach of treating bites from these snakes with the 'big four' polyvalent antivenom is ineffective. While the medical significance of various species of cobras, saw-scaled vipers, and kraits is well-established, the clinical impact of pit vipers from regions such as the Western Ghats, northeastern India, and the Andaman and Nicobar Islands remains poorly understood. Amongst the many species of snakes found in the Western Ghats, the hump-nosed (Hypnale hypnale), Malabar (Craspedocephalus malabaricus), and bamboo (Craspedocephalus gramineus) pit vipers can potentially inflict severe envenoming. To evaluate the severity of toxicity inflicted by these snakes, we characterised their venom composition, biochemical and pharmacological activities, and toxicity- and morbidity-inducing potentials, including their ability to damage kidneys. Our findings highlight the therapeutic inadequacies of the Indian and Sri Lankan polyvalent antivenoms in neutralising the local and systemic toxicity resulting from pit viper envenomings.

National programme for prevention & control of snakebite in India: Key challenges & recommendations.

National programme for prevention & control of snakebite in India: Key challenges & recommendations.

ICMR task force project- survey of the incidence, mortality, morbidity and socio-economic burden of snakebite in India: A study protocol

Snakebite is possibly the most neglected of the NTDs (Neglected Tropical Diseases). Half of the global deaths due to venomous snakebites, estimated at 100,000 per year, occur in India. The only representative data on snakebite available from India is the mortality data from the RGI-MDS study (Registrar General of India- 1 Million Death Study) and another study on mortality from the state of Bihar. Incidence data on snakebite is available for 2 districts of the state of West Bengal only. Hospital-based data on snakebite admissions and use of ASV are gross underestimates as most snakebite victims in rural India depend more on alternate treatment methods which do not get represented in National registries. The proposed study is a multi-centric study to determine the incidence, morbidity, mortality and economic burden of snakebites in India covering all 5 geographical zones of the country. A community level surveillance for snakebite covering 31 districts in 13 states of India in order to obtain annual incidence of snakebites from the community. Frontline health workers will be trained to gather information on new cases of snakebite over the study period of 1-year, from "wards "(smallest administrative subunit of a village or town) that they represent in the study districts. Dedicated field officers would collect data on snakebites, victim characteristics, outcomes, utilization of health facilities on a questionnaire sheet designed for this purpose. The study duration is for 18 months from April 2022 to October 2023. The study would be the first of its kind in India looking prospectively at the incidence of snakebite covering 13 states in 5 zones of India and a population of 84 million. Our study covers 6.12% of the total population of the country as compared to the incidence study conducted in Sri Lanka which covered 1% of the total population.

Herbs as Antidote for Snake Bite Treatment- Traditional Practices and Its Future Prospects- A Review

Snake bite is a life-threatening neglected tropical infection reporting high mortality across the world including India. Out of the available yearly statistics of this occupational hazard caused 4.5-5.4 million people and nearly 1,38,000 fatalities were reported globally. Several factors such as the low availability of antivenom, inadequate health centres in rural areas, poor transportation facilities affected the higher number of morbidity and mortality cases of snake bite. The prognostic and diagnostic approach towards the snake bite infection is difficult due to its complexity in venom. The conventional therapy is polyvalent antivenom derived from horses or sheep, with its limitations. The traditional physicians use plants and other herbs as its sustainable remedy for snake bite treatment. Nearly, 523 plant species from 122 families reported their neutralizing property against toxic venom. The secondary metabolites extracted from plants, are capable of reducing the toxic effects of the venom. Many research works has been reported the inhibitory potential of the plant compounds against the snake venom enzymes. Therefore, there is a necessity for increasing therapeutic studies on plant metabolites and the development of an antidote for the better treatment of snakebite. This review article discusses various herbal plant used for snake bite in India.

Profile of Snake Bite Deaths in South India: An Autopsy based Stud

Background: The burden due to the morbidity and mortality of snake bite in India is significantly higher. Itis estimated around 1.2 million snakebite deaths (average 58,000/year) has occurred in India from the year2000 to 2019. However the real burden of snake bite is unknown due to under reporting. This study aims tobring out region specific data on fatal snake bitesResults: The study was conducted at the dep of forensic medicine from 2016 to 2020. A total of 75 cases offatal snake bite cases were autopsied. The number of female cases 39 (52.3) and males were 36 (48.0). Themaximum no 52 (69.4%) cases were reported between the months of April to September. The common timefor snake bite was in the night 40 (53.3%) followed by the daytime 33 (44.0%). The place of incidence wheremost of the bites happened was in and around the homes of the victims 46 (61.3) followed by the workplaces29 (38.7%). The commonest site were the bite mark was noted in the lower limbs 33 (44%) cases. Around 22(23.9%) cases were seen in age groups of 45 to 59 years and 19 (25.3%) cases in 35 to 44 years. The speciesof snake in majority of the cases i.e., 65 (86.7%) was unknown. Around 40 (53.3%) cases of kidney samplesshowed acute tubular followed by congestion.Conclusion: The number of fatal bites were comparatively higher than that of the statistics available. Most ofthe findings of our study was consistent with the similar studies. The species of snake was largely unknownin this study because new snake species like hump nose pit viper can inflict fatal bites and are difficult toidentify. Region specific data on snake bite will reflect the exact volume of snake bites in the country andwould largely help in drafting policies to reduce mortality

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol.

Background: In India, lack of data and underreporting of cases and deaths due to snakebite makes it difficult to estimate its socio-economic burden. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: The study is a community based cross-sectional study recruiting victims of snakebite occurring over a 12 month period prior to start of the study , across Ernakulam district, Kerala state, India. For the community-derived disability weights,70 adult patients who were treated within a 3 month period prior to commencement of the study at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites in Ernakulam district.. Standard methods for analysis and reporting of mortality, morbidity, Years of Lives Lost (YLL), Years lived with disability (YLD), disability weights, and costs of treatment will be calculated. The study will be started in April 2021 and is expected to be completed by July2021.. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so. The protocol has been developed using guidelines for cross-sectional studies, cost of illness studies and international guidelines for conducting community derived disability weights. The evidence generated by this study will contribute significantly to knowledge regarding the epidemiology, economic burden and community-derived disability weights for snakebites in India and other countries where incidence of snakebite is high.

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol

Background: In India, lack of data and underreporting of cases and deaths due to snakebite makes it difficult to estimate its socio-economic burden. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: The study is a community based cross-sectional study recruiting victims of snakebite occurring over a 12 month period prior to start of the study , across Ernakulam district, Kerala state, India. For the community-derived disability weights,70 adult patients who were treated within a 3 month period prior to commencement of the study at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites in Ernakulam district.. Standard methods for analysis and reporting of mortality, morbidity, Years of Lives Lost (YLL), Years lived with disability (YLD), disability weights, and costs of treatment will be calculated. The study will be started in April 2021 and is expected to be completed by July2021.. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so. The protocol has been developed using guidelines for cross-sectional studies, cost of illness studies and international guidelines for conducting community derived disability weights. The evidence generated by this study will contribute significantly to knowledge regarding the epidemiology, economic burden and community-derived disability weights for snakebites in India and other countries where incidence of snakebite is high.

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol

Background: In India, geographical variation, lack of data and underreporting on cases and deaths due to snakebite makes it difficult to estimate socio-economic burden of snakebites. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none so far in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: A cross-sectional community based study for estimating epidemiological and economic burden of snakebite, recruiting victims of snakebite occurring over a nine month period prior to start and over the three month period of the study, across Ernakulam district, Kerala state, India. For the community derived disability weights, 60 adult patients admitted and treated at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The sample size to determine the mortality rate is calculated at 108,458 persons in Ernakulam.The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites. Standard methods for analysis and reporting of mortality, morbidity, years of lives lost, years lived with disability, disability weights, and costs of treatment will be calculated and presented. The study will be started in March 2021 and is expected to be completed by June 2021. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so.The protocol has been developed using guidelines for both cross-sectional studies and for conducting community derived disability weights. The evidence generated will contribute to knowledge regarding epidemiology, economic burden and community-derived disability weights for snakebites in India and other LMICs.

A comparative study in the outcome between the two fixed doses of polyvalent anti snake venom, 10 vials versus 20 vials, with mechanical ventilation in children with severe neurotoxic snake envenomation

Background: Every year about 50,000, people die of snake bites in India. Anti-snake venom and mechanical ventilation is mainstay of treatment in cases with severe neurotoxic envenomation. ASV is costly and scarce resource. There is lack of universal consensus towards the optimal dose of ASV in management protocol for children with severe neurotoxic snake envenomation. Objective was to compare the difference in outcome between two fixed doses of ASV, 10vials versus 20 vials, in children with severe neurotoxic snake envenomationMethods: This comparative observational study was carried out for a period of 3 years in Department of Pediatrics of SVS Medical College, Mahabubnagar, Telangana, India. Children with history of snake bite and clinical evidence of neuroparalysis were included. In addition to the mechanical ventilation and other supportive measures, every alternate patient was administered with 10vials (low dose) and 20 vials (high dose) of ASV over 1 hour. Outcome was compared between the two groups.Results: Of the 62 patients, 32 were in each group. The median time to extubation was 41 hours and 39.5 hours and mean duration of the hospital stay was 4.6 days and 4.5 days among the low dose and high dose groups, respectively. There were three deaths, one from low dose group and two from high dose group.Conclusions: There was no significant difference in outcome between the 10 vials vs 20 vials of ASV in addition to mechanical ventilation in treatment of children with severe neurotoxic snake envenomation. So, 10 vials of ASV can be utilized to reduce the cost of treatment.

Burden and risk factors for snakebite in India: protocol for a systematic review.

Introduction: Snakebite is a neglected tropical disease with a high burden in South and South-East Asia and sub-Saharan Africa. In 2019, the World Health Organization (WHO) released a roadmap which aims for a 50% reduction in death and disability due to snakebite globally by 2030. It is estimated that India has the highest number of snakebite deaths in the world. Objective: To synthesize evidence on the burden (incidence/ prevalence, mortality, morbidity, health facility and economic), and risk factors for snakebite in India. Methods: We will search for peer-reviewed literature and grey literature in six electronic databases (MEDLINE, EMBASE, Global Health, PsychInfo, CENTRAL, SafetyLit) and hand-search IndMed, conference abstracts, relevant websites and citation tracking. Two reviewers will screen and extract data independently with a third reviewer acting as an arbiter for any inconsistencies. Quality of the included studies will be assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. For burden, data from facility based and community-based studies will be synthesised and reported separately, except for studies conducted concurrently. We will conduct meta-analysis for community-based studies at state-level for incidence/prevalence, mortality and morbidity , if appropriate. The PROGRESS Plus lens will be used to explore equity . Analyses for each individual risk factor-outcome pair will be conducted and reported separately. If appropriate, meta-analyses will be conducted as per JBI guidelines, assessing heterogeneity using Tau-squared, Cochran's Q test and Chi-squared (p > 0.05) tests. We plan to conduct sub-group analyses based on pre-specific parameters. A funnel plot will be generated if there are more than nine studies included in a specific meta-analysis, to assess publication bias When meta-analysis is not appropriate, structured tabulation of results across studies and/or by vote counting based on the direction of effect as per guidelines in the Cochrane Handbook.

Burden and risk factors for snakebite in India: protocol for a systematic review

Introduction: Snakebite is a neglected tropical disease with a high burden in South and South-East Asia and sub-Saharan Africa. In 2019, the World Health Organization (WHO) released a roadmap which aims for a 50% reduction in death and disability due to snakebite globally by 2030. It is estimated that India has the highest number of snakebite deaths in the world. Objective: To synthesize evidence on the burden (incidence/ prevalence, mortality, morbidity, health facility and economic), and risk factors for snakebite in India. Methods: We will search for peer-reviewed literature and grey literature in six electronic databases (MEDLINE, EMBASE, Global Health, PsychInfo, CENTRAL, SafetyLit) and hand-search IndMed, conference abstracts, relevant websites and citation tracking. Two reviewers will screen and extract data independently with a third reviewer acting as an arbiter for any inconsistencies. Quality of the included studies will be assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. For burden, data from facility based and community-based studies will be synthesised and reported separately, except for studies conducted concurrently. We will conduct meta-analysis for community-based studies at state-level for incidence/prevalence, mortality and morbidity , if appropriate. The PROGRESS Plus lens will be used to explore equity . Analyses for each individual risk factor-outcome pair will be conducted and reported separately. If appropriate, meta-analyses will be conducted as per JBI guidelines, assessing heterogeneity using Tau-squared, Cochran’s Q test and Chi-squared (p > 0.05) tests. We plan to conduct sub-group analyses based on pre-specific parameters. A funnel plot will be generated if there are more than nine studies included in a specific meta-analysis, to assess publication bias When meta-analysis is not appropriate, structured tabulation of results across studies and/or by vote counting based on the direction of effect as per guidelines in the Cochrane Handbook.

Clustering the envenoming of snakebite in India: The district level analysis using Health Management Information System data

AimThe study aims to estimate the prevalence of snakebite and deaths due to animal bites and stings in India. MethodsThe study used Health Management Information System data of years 2017-18 and 2018-19. ResultsResults estimated that 2,00,492 and 2,30,950 persons were envenomed due to the snakebites in the respective years 2017-18 and 2018-19 in India. West Bengal (36.6 person), Tamil Nadu (36.6), Goa (34.5), Maharashtra (32.4), Andhra Pradesh (31.7), Odisha (27.1) and Karnataka (20.3) have higher prevalence of snakebites per 100,000 populations during 2017-18. In 2018-19, cases were increased for West Bengal (39.4), Odisha (37.0), Tamil Nadu (36.4), Andhra Pradesh (35.3) and Maharashtra (35.0). The results also highlighted that 9,200 (2017-18) and 8,890 (2018-19) persons are died due to the animal bites and stings in India. ConclusionOur findings significantly contributes in the policy making at the administrative level including district level, state level and eventually to the nation.

Burden and risk factors for snakebite in India: protocol for a systematic review

Introduction: Snakebites are a neglected tropical disease with a high burden in South and South-East Asia and sub-Saharan Africa. In 2019, the World Health Organization (WHO) released a roadmap which aims for a 50% reduction in death and disability due to snakebite globally by 2030. It is estimated that India has the highest number of snakebite deaths in the world. Objective: To synthesize evidence on the burden (incidence/ prevalence, mortality, morbidity, health facility and economic), and risk factors for snakebite in India. Methods: We will search for peer-reviewed literature and grey literature in six electronic databases (MEDLINE, EMBASE, Global Health, PsychInfo, CENTRAL, SafetyLit) and hand-search IndMed, conference abstracts, relevant websites and citation tracking. Two reviewers will screen and extract data independently with a third reviewer acting as an arbiter for any inconsistencies. Quality of the included studies will be assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. For burden, data from facility based and community-based studies will be synthesised and reported separately, except in the case of studies conducted concurrently. We will conduct narrative analyses with the aim of understanding patterns in data through tabulation for both burden and risk factors evidence synthesis. The PROGRESS Plus lens will be used to explore equity pertaining to burden of snakebites. Analyses for each individual risk factor-outcome pair will be conducted and reported separately. If appropriate, meta-analyses will be conducted as per JBI guidelines, assessing heterogeneity using Tau-squared, Cochran's Q test and Chi-squared (p > 0.05) tests. We plan to conduct sub-group analyses based on setting, study design, sex/gender, age-groups, tribal people and occupation. A funnel plot will be generated if there are more than nine studies included in a specific meta-analysis, to assess publication bias. Asymmetry of the funnel plot will be adjudged using the Egger, Begg and Harbord tests.