A 12-year-old girl gets bitten in the remote village of Kharang at 5:30pm while playing in the orchard near her house. She complains of severe pain on the bitten hand, which starts swelling in no time. Her mother rushes her to the nearby primary health centre, where there is no ASV (anti-snake venom) available, so the little girl was referred to a higher centre at Shillong.
Her desperate mother, acting on a suggestion by neighbours and villagers, takes her to a traditional healer nearby, who incises the wound with a used blade in spite of the excruciating pain the girl is in and then applies a snake stone, which the healer believes sucks the venom out of the system. The girl slowly starts becoming unresponsive, showing signs of respiratory distress, and is then hurried to Sohra community health centre at a distance of 48km (2 hours by road) but reaches the CHC unresponsive and is declared dead on arrival.
Snakebite envenoming (SBE) was added to the list of Neglected Tropical Diseases (NTDs) in 2017 by the World Health Organisation (WHO). The WHO also estimates that there are 4.5-5.4 million snakebites worldwide resulting in 1.8-2.7 million envenoming, 81,000-1,38,000 deaths and permanent disabilities in 4,00,000 annually.
India has the dubious distinction of accounting for half the number of bites, approximately 20 lakh and 58,000 deaths annually. Over 70 percent of SBE occur in males, typically in the productive ages of between 20 and 60 years of age and therefore having a tremendous socio-economic impact, especially in case of death of the sole earning member of the family.
The reasons for the neglect are many, including general lack of awareness with regards to snakebite among health care workers, community etc; the available polyvalent ASV not having the neutralising effect against snake species of the North East; victims in remote villages depend on traditional healers for treatment; absence of a national protocol for treatment; questions with regards to the efficacy of the polyvalent ASV; reluctance of health staff to infuse ASV in rural PHCs fearing allergic reactions; lack of awareness of dosing of ASV; non-availability of ASV especially in the monsoon months when shortages are reported; most PHCs in remote rural areas lacking in-patient facilities; poor rural infrastructure of roads, lights and toilets leading to increased incidence etc.
All these factors alongside the general apathy shown towards SBE by health policy makers, pharmaceutical industry, funding agencies and the health system in general, in spite of the considerable social ramifications is contributory. The issues highlighted are more pronounced in the North East as snake species here differ considerably from the rest of India and the effect of ASV against the common envenoming species like Naja kouthia (monocellate cobra) and pit viper species is doubtful.
SBE is an eminently treatable disease, if treated early and well with the only scientifically proven treatment, ASV, the victim improves within hours to a day or two without any significant complications resulting from bites in the majority. Delay in first-aid measures and in starting treatment is what leads to complications. As close to 80 percent of snakebites are non-venomous or dry hence, traditional healers succeed in treatment as there is no venom injected. In the 20 percent cases of envenoming ASV is mandatory and it is imperative that the victim be shifted to hospital.
In order to be able to prevent death and complications awareness needs to be created in the community about snakebite, how it could be prevented, the first-aid measures and the value of ASV as the only available treatment for envenoming. The awareness campaign needs to percolate down into the community through schoolchildren, ASHA workers etc. Doctors in PHCs and CHCs need to be trained on the immediate first-aid measures, signs and symptoms of envenoming, dosage of ASV and the pre-medications, and complications.
Doctors working in areas where neurotoxic bites predominate need to be trained in basic-life-support skills and airway management. Availability of ASV needs to be ensured especially during the rainy season when snakebites peak. Proper mapping of the venomous species in the North East, study of characteristics of venom from different species and production of ASV specific to the North East as the steps forward to make the ASV more effective and specific.
In order to address this neglect and inequity the ICMR constituted a National Task Force for the study of incidence, morbidity, mortality and the socio-economic burden of snakebite in India. The PI of the project Dr Jaideep C Menon (Cardiologist, Amrita Institute of Medical Sciences, Kochi), the Co-PI Dr Omesh K Bharti (State Epidemiological Officer, Himachal Pradesh) and Dr Santanu K Sharma (Scientist G and Lead PI, Coordinating centre RMRC- Dibrugarh) are currently conducting field trips for situational analysis of snake bites and its management in the four North East states of Arunachal Pradesh, Meghalaya, Mizoram and Tripura.
Health authorities and policy makers for the North East need to take cognisance of these facts such that stories similar to the girl from Kharang are not repeated. The United States and Australia have equally venomous snakes but lose only about 10-12 victims to SBE annually through early diagnosis and proper treatment with appropriate ASV which neutralizes the maximum circulating venom before it is fixed in the tissue thereby preventing many deaths which could occur due to SBE.
