Snakebite In India: A Clearer Picture Of The Problem

 

Snakebite deaths and envenomation are largely neglected topics in global health. However, bites by venomous snakes can cause acute medical emergencies involving shock, paralysis, hemorrhage, acute kidney injury and severe local tissue destruction that can prove fatal or lead to permanent disability if left untreated.

The World Health Organization (WHO) estimates that 81,000–138,000 people die each year from snakebites worldwide. Because of such staggering numbers, the global health agency in 2017 recognised snakebite as one of the neglected diseases that require more policy initiatives, funding and research and last year launched a global initiative to halve the number of deaths and disabilities it causes by 2030.

India is among the countries most dramatically affected by snakebite and accounts for almost half the total number of annual deaths in the world. A study estimates more than one million Indians died from snakebite envenoming over the past two decades.

According to the Indian Council of Medical Research (ICMR), snakes kill more than 45,000 people in India every year, but only 30% of the victims reach hospitals to seek medical attention. They published a study on the incidence, mortality, morbidity, and socioeconomic burden of snakebite in the nation. This figure is probably underestimated because most patients in rural India attend village healers and so their cases go unreported (Source: Hindustan Times).

The study titled - 'ICMR Task Force Project- A Survey of the Incidence, Mortality, Morbidity and Socioeconomic Burden of Snakebite in India: A study Protocol' was conducted across five zones and 13 states and of the country including Uttarakhand, Himachal Pradesh, Rajasthan, Maharashtra, Kerala, Tamil Nadu, Andhra Pradesh, Odisha, West Bengal, Meghalaya, Arunachal Pradesh, Mizoram and Tripura.

At the same time, A July 2020 study titled ‘Trends in snakebite mortality in India from 2000 to 2019 in a nationally representative mortality' study estimated, that India had 1.2 million snakebite deaths (representing an average of 58,000 per year) from 2000 to 2019 with nearly half of the victims aged 30-69 and over a quarter being children under 15. This means a person dies every 12 minutes in the country due to snakebite.

A July 2020 study also showed that, 70 per cent of the snakebite deaths occurred in eight states — Bihar, Jharkhand, Madhya Pradesh, Odisha, Uttar Pradesh, Andhra Pradesh (which includes Telangana, a recently defined state), Rajasthan and Gujarat. Uttar Pradesh tops the list with 8,700 deaths a year followed by Andhra Pradesh (5,200) and Bihar (4,500).

Up to 94 per cent of the snakebite deaths in the country are from rural India. Communities most affected by snake bite are farmers, rubber tappers, tea/coffee estate pickers, brick kiln workers, and plywood industry workers. Half of all snakebite deaths occur during the southwest monsoon seasons from June to September, when encounters between snakes and humans are more frequent at home and outdoors.

A clearer picture of the problem,

The actual number of snakebite-related fatalities is debatable as it is a data that is generally underreported. First, because most people are worried about going to hospitals and the cost associated with it. Second, these cases are not recorded or reported, as snakebite is not a notifiable disease in India.

The ICMR's study protocol for snakebite incidence and burden mentions that the hospital-based data on snakebite admissions and use of anti-snake venom are gross underestimates as most snakebite victims in rural India depend more on alternative treatment methods which do not get represented in national registries.

India is home to 100,000 poisonous snake bite-related deaths annually, amounting to 50 percent of all such deaths worldwide. The RGI-MDS research (Registrar General of India- 1 Million Death Study) and another study on mortality from the state of Bihar provide the only representative data on snakebites available from India.

The one Million Death study an initiative by the Registrar General of India and the Centre for Global Health Research at St. Michael’s Hospital and the University of Toronto, India reports approximately 58,000 deaths per year. According to the Ministry of Health & Family welfare statistics, the number of deaths due to venomous snakebite in 2016 was 13009 deaths.

"The mental, financial and socio-economic impact that snakebite has on lakhs of families in India is potentially monumental and unaccounted for,” says Sumanth Bindumadhav, acting country director at the Humane Society International/India who has been actively working on management of human-snake conflict in India for over a decade.

Farmers who work in fields in India are especially at risk of getting bitten by snakes such as the Russell’s viper (Daboia russelii) shown here.Credit: John Benjamin Owens, MEFGL Bangor University/Captive & Field Herpetology

Factors that delay in treatment of snakebites,  

Snakebites are not a priority of our government "because it is a rural-tribal centric illness, and not an urban issue", foreign funding bodies, health care professionals and even the media also neglect snakebite as a national health issue.

The Indian Council of Medical Research – National Institute for Research in Reproductive Health and Public Health Department, Maharashtra said-"Of concern is the inappropriate perception, inadequate awareness, and knowledge about snakes and snakebites that may predispose the tribal community to increased risks of venomous snakebites."

"... If correctly diagnosed and treated the victim would return to as productive a life as before. Despite this snakebite remains neglected because it is a disease of the socio economically marginalized groups that tend not to be in the spotlight," - study published in the international research journal Plos One on August 5, 2021.

Inadequate treatment is a key factor behind such a high death toll. Snakebite management is not given enough focus in the medical curriculum and health workers in remote areas are reluctant to treat snakebite cases as they are afraid of managing anti-venom associated adverse reactions, says the report. 

According to reports, approximately only 20% to 30% of snakebite victims in rural India go to hospitals for treatment. It is challenging to comprehend the full impact of the disorder because of underreporting and a lack of statistics on incidence, death, and socioeconomic hardship, the study found.

According to a new study published in medical journal, The BMJ – ‘Poor health facilities in rural areas are a major factor due to which snakebite victims do not get adequate care. First, people don’t reach health facilities in time due to lack of transport; even if they do, healthcare personnel have inadequate knowledge of snakebite management and lack effective antivenom.’

“Most snakebite victims die before they reach a health facility because they first approach a traditional healer for treatment. The quality of available antivenom in health facilities is another problem,” pointed out Ravikar Ralph, a member of the research team from Christian Medical College Vellore.

Snakebite is preventable, however in most cases, there is a lack of initial response to snakebite that causes severe problems. The primary health centres (PHCs) of our country lack the trained human resources and health facilities to admit and treat patients with snakebite. This compels the victims to go to alternate forms (Kaviraj, Oza, Mantrik and Sarpa chikitsa) of treatment which are rampant in most parts of India. Even today, PHCs at village level are ill-equipped to respond to snakebite cases.

Secondly, India lacks a commercially available snake venom detection kit (SVDK), clinicians depend on the 'syndromic approach’ for the diagnosis of envenomation. The syndromic approach involves observing for signs and symptoms along with blood tests, of which the whole blood clotting test is most commonly employed to diagnose viperidae bites, to decide as to whether there has been envenomation.

Thirdly, India’s anti-venom is derived from the venoms of four widespread species: the Russell’s viper, the saw-scaled viper, the spectacled cobra and the common krait, together known as the ‘Big Four’. But, it is not effective against other species prevalent in different regions.

In addition, the antivenom products available vary in their neutralization, efficacy and clinical effectiveness, the study pointed out. The quality of liquid antivenom suffers due to problems in cold storage and transportation as it has to be stored at 2-8° Celsius.

Doctors at primary health centres in India are replaced every 6–12 months and have poor knowledge about, and experience in, management of snake bites. Many victims die on the journey to big, city-based hospitals. WHO's inclusion of snake-bite envenoming in the list of category A neglected tropical diseases is welcome but comes too late.

Most doctors are not updated about the latest snakebite treatment protocol published and circulated by the Government of India based on the guidelines provided by the World Health Organisation,” According to Bindumadhav, acting country director at the Humane Society International/India.

The reasons for such high mortality range from delayed or non-arrival of the victims at the health centres within six hours, shortage of anti-venom and inadequate care provided at the health centres, says a report published in The BMJ, one of the world's most prestigious medical journals. 

Many of the deaths and disabilities due to snakebites can be averted if health authorities take steps to prevent snakebites as well as improve facilities for treating those bitten by venomous snakebites.

Along with the associated morbidity and mortality, snakebite leads to a significant financial burden on the victim, both by way of hospital bills and labour hours lost. Snakebite is also a cause for considerable psychological stress among survivors. However, most snakebites are eminently treatable and curable.