Comparing community and hospital data of snakebite in North Bihar: a community incidence survey and a parallel hospital-based clinical study

Clinico-Epidemiological Profile, Trends, and Health-Related Outcomes of Snakebite Victims: A One-Year Prospective Study from Eastern India

INTRODUCTION

Snakebite envenomation is a significant life-threatening public health problem in Southeast Asia (SEA). In this region, India reported the largest number of snakebite deaths from 2000 to 2019 (1.2 million), with an average of 58,000 deaths yearly.

METHODS

This prospective observational study was carried out among snakebite victims at the emergency department (ED) of a tertiary care public sector hospital in eastern India.

RESULTS

A total of 145 cases of venomous snakebite were investigated. More than half (n = 81, 56%) of the snakebite victims were between 17 to 45 years. Most of the snakebite victims were male (68%) and were farmers (53%) by occupation. The majority of snakebites occurred during the daytime (76%) and while outdoors (67%). Most victims sustained a bite on the lower extremity (71%). The peak incidence of snakebites occurred from June to September (69%). Three-quarters of all patients were unaware of the required first aid measures following a snakebite. Among the 145 venomous snakebites, 48 were presumptively identified as the Indian cobra, 32 by the Indian krait, 56 by the Russel's viper, and 9 by saw-scaled viper. The mean duration from the snakebite to the onset of systemic effects in the Indian cobra was 52 ± 14.28 min, 66 ± 18.35 min in the Indian krait, 42 ± 13.47 min in Russel's viper, and 48 ± 16.38 min in saw-scaled viper. Respiratory failure was the commonly observed complication following an elapid envenomation. The mortality rate was 2.1% among the patients treated with antivenom.

CONCLUSIONS

Snakebite is considered an occupational hazard in India, commonly affecting the young population in their productive period. The peak incidence was during monsoon season, and the majority had neurotoxic envenomation following an elapid bite (55%) that contributed to the increased mortality and morbidity among young adults. Of the 145 patients, the majority (84%) recovered fully with treatment; 16% of the victims developed morbidity viz cellulitis, respiratory failure, acute renal failure, compartment syndrome, local tissue necrosis, intracerebral hemorrhage, and disseminated intravascular coagulation. Appropriate first aid measures and timely medical intervention can significantly improve the treatment outcome following snakebites.

Revolutionizing snakebite care with novel antivenoms: Breakthroughs and barriers

Snakebite envenoming (SBE) is a global public health concern, primarily due to the lack of effective antivenom for treating snakebites inflicted by medically significant venomous snakes prevalent across various geographic locations. The rising demand for safe, cost-effective, and potent snakebite treatments highlights the urgent need to develop alternative therapeutics targeting relevant toxins. This development could provide promising discoveries to create novel recombinant solutions, leveraging human monoclonal antibodies, synthetic peptides and nanobodies. Such technologies as recombinant DNA, peptide and epitope mapping phage display etc) have the potential to exceed the traditional use of equine polyclonal antibodies, which have long been used in antivenom production. Recombinant antivenom can be engineered to target certain toxins that play a critical role in snakebite pathology. This approach has the potential to produce antivenom with improved efficacy and safety profiles. However, there are limitations and challenges associated with these emerging technologies. Therefore, identifying the limitations is critical for overcoming the associated challenges and optimizing the development of recombinant antivenoms. This review is aimed at presenting a thorough overview of diverse technologies used in the development of recombinant antivenom, emphasizing their limitations and offering insights into prospects for advancing recombinant antivenoms.

Conducting epidemiological studies on snakebite in nomadic populations: A methodological paper

INTRODUCTION

Research on snakebite has mostly been conducted on settled populations and current risk factors and potential interventions are therefore most suited for these populations. There is limited epidemiological data on mobile and nomadic populations, who may have a higher risk of snakebite.

METHODS AND RESULTS

We conducted a scoping review to gather evidence on survey methods used in nomadic populations and compared them with contemporary survey methods used for snakebite research. Only 16 (10.5%) of 154 articles reportedly conducted on pastoralist nomadic populations actually involved mobile pastoralists. All articles describing snakebite surveys (n = 18) used multistage cluster designs on population census sampling frames, which would not be appropriate for nomadic populations. We used geospatial techniques and open-source high-resolution satellite images to create a digital sampling frame of 50,707 households and used a multistage sampling strategy to survey nomadic and semi-nomadic populations in Samburu County, Kenya. From a sample of 900 geo-located households, we correctly identified and collected data from 573 (65.4%) households, of which 409 were in their original locations and 164 had moved within 5km of their original locations. We randomly sampled 302 (34.6%) households to replace completely abandoned and untraceable households.

CONCLUSION

Highly mobile populations require specific considerations in selecting or creating sampling frames and sampling units for epidemiological research. Snakebite risk has a strong spatial component and using census-based sampling frames would be inappropriate in nomadic populations. We propose using open-source satellite imaging and geographic information systems to improve the conduct of epidemiological research in these populations.

Snakebite epidemiology, outcomes and multi-cluster risk modelling in Eswatini

BACKGROUND

Halving snakebite morbidity and mortality by 2030 requires countries to develop both prevention and treatment strategies. The paucity of data on the global incidence and severity of snakebite envenoming causes challenges in prioritizing and mobilising resources for snakebite prevention and treatment. In line with the World Health Organisation's 2019 Snakebite Strategy, this study sought to investigate Eswatini's snakebite epidemiology and outcomes, and identify the socio-geographical factors associated with snakebite risk.

METHODOLOGY

Programmatic data from the Ministry of Health, Government of Eswatini 2019-2021, was used to assess the epidemiology and outcomes of snakebite in Eswatini. We developed a snake species richness map from the occurrence data of all venomous snakes of medical importance in Eswatini that was subjected to niche modelling. We formulated four risk indices using snake species richness, various geospatial datasets and reported snakebites. A multivariate cluster modelling approach using these indices was developed to estimate risk of snakebite and the outcomes of snakebite in Eswatini.

PRINCIPAL FINDINGS

An average of 466 snakebites was recorded annually in Eswatini. Bites were recorded across the entire country and peaked in the evening during summer months. Two cluster risk maps indicated areas of the country with a high probability of snakebite and a high probability of poor snakebite outcomes. The areas with the highest rate of snakebite risk were primarily in the rural and agricultural regions of the country.

SIGNIFICANCE

These models can be used to inform better snakebite prevention and treatment measures to enable Eswatini to meet the global goal of reducing snakebite morbidity and mortality by 50% by 2030. The supply chain challenges of antivenom affecting southern Africa and the high rates of snakebite identified in our study highlight the need for improved snakebite prevention and treatment tools that can be employed by health care workers stationed at rural, community clinics.

Analysis of News Media-Reported Snakebite Envenoming in Nepal during 2010-2022

BACKGROUND

Snakebite envenoming is a well-known medical emergency in the Terai of Nepal in particular. However, there is an epidemiological knowledge gap. The news media data available online provide substantial information on envenomings. Assessing this information can be a pristine approach for understanding snakebite epidemiology and conducting knowledge-based interventions. We firstly analyzed news media-reported quantitative information on conditions under which bites occur, treatment-seeking behavior of victims, and outcomes of snakebite envenomings in Nepal.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed 308 Nepalese snakebite envenomed cases reported in 199 news media articles published between 2010 and 2022 using descriptive statistics, Wilcoxon, and Chi-square tests to know why and how victims were bitten, their treatment-seeking behavior, and the outcomes. These envenomated cases known with substantial information represented 48 districts (mostly located in the Terai region) of Nepal. These envenomings mostly occurred in residential areas affecting children. Generally, envenomings among males and females were not significantly different. But, in residential areas, females were more envenomed than males. Further, victims' extremities were often exposed to venomous snakebites while their active status and these episodes often occurred at night while victims were passive during snakebites indoors and immediate surroundings of houses. Snakebite deaths were less among referred than non-referred cases, males than females, and while active than passive conditions of victims.

CONCLUSION/SIGNIFICANCE

The most of reported envenomed patients were children, and most envenomings were due to cobra bites. Consultation with traditional healers complicated snakebite management. In most cases, deaths that occur without medical interventions are a severe snakebite consequence in Nepal. Further, several deaths in urban areas and mountains and higher hills of Nepal suggest immediate need of snakebite management interventions in the most affected districts. Therefore, there is an urgent need to immediately admit Nepalese snakebite victims to nearby snakebite treatment centers without adopting non-recommended prehospital interventions. The strategies for preventing snakebite and controlling venom effects should also include hilly and mountain districts where snakebite-associated deaths are reported.

Attitudes, knowledge and practices of traditional snakebite healers in Nepal: implications for prevention and control of snakebite

BACKGROUND

Traditional healers are a valuable source of information about community-level treatment of snakebite. Snakebite victims in Nepal depend on traditional healers for treatment, but their practices have not been well-documented.

METHODS

This was a cross-sectional study of 50 traditional snakebite healers (TSHs) who were selected using a snowball sampling method representing eight districts and four provinces of Nepal. Data were collected using face-to-face-interviews and semi-structured questionnaires.

RESULTS

About half of the respondents liked to gain knowledge on modern care for snakebite management and nearly all respondents (94%) wished to cooperate closely with the local healthcare system to support snakebite management. People's ingrained faith in traditional healing of snakebite (84%), unaffordable modern care of snakebite (60%) and wishes for early treatment of snakebites (44-48%) were the main causes of their dependency on TSHs. Rauvolfia serpentina, Piper nigrum, Momordica charantia and Tinospora cordifolia were commonly used plants in traditional treatment of snakebite.

CONCLUSIONS

Easily accessible and affordable healthcare facilities provided by TSHs, public beliefs in traditional healing and inadequate knowledge of antivenom therapy caused dependency on TSHs. The introduction of snakebite treatment centres in snakebite-prone regions and educational interventions are essential to minimize this kind of dependency and associated deaths and disabilities.

Uniting behind a common goal: Collaboration between traditional healers and allopathic health care workers to improve rural snakebite care

Snakebite envenoming is an acute medical emergency which affects hundreds of thousands of people worldwide, primarily in remote rural areas of low-and middle income countries in the Global South. A considerable proportion of snakebite patients turn to traditional healers (THs) for help, driven by a number of push and pull factors. These include socio-cultural factors, geographical proximity, and the absence or inaccessibility of overstretched and often costly allopathic healthcare services. Although traditional healers and allopathic healthcare staff share a common focus -the recovery and well-being of their patients- both systems operate largely in parallel to each other with collaborations being an exception rather than the rule. This is to the detriment of snakebite patients, who frequently find themselves being caught-up in the dualism between the two separate systems. Given the right circumstances, snakebite patients could benefit from elements of care from both modalities. Here, we have reviewed the role of THs in snakebite care and explored how their integration into the formal healthcare system could improve the implementation and outcome of care. The effective recruitment of THs to aid in disease control and treatment efforts in diseases other than snakebite underscores the potential benefits of this strategy. Carefully devised proof of concept studies are needed to test our hypothesis that collaborations between the formal healthcare sector and THs are feasible and improve outcomes in snakebite care.

Perceptions, awareness on snakebite envenoming among the tribal community and health care providers of Dahanu block, Palghar District in Maharashtra, India

INTRODUCTION

India has remarkably the highest number of snakebite cases contributing to nearly 50% of the global snakebite deaths. Despite this fact, there is limited knowledge and awareness regarding the management practices for snakebite in the Indian population. The study aimed to explore the knowledge, awareness, and perception of snakes and snakebites, first aid, and treatment amongst the community and the frontline health workers in a tribal block of Dahanu, Maharashtra, India.

METHODS

A cross-sectional study was carried out from June 2016 to October 2018 in the Dahanu Block, Maharashtra. Perceptions, knowledge, awareness, and first-aid practices on the snakebites among the community were studied through focus group discussions (FGDs). Semi-structured questionnaires were used to assess the knowledge, awareness, and experience of the traditional faith healers, snake rescuers, frontline health workers on the snakebites and their management. A facility check survey was conducted using pre-tested questionnaires for different levels of the government health care facilities.

RESULTS

Most of the tribal community was aware of the commonly found snakes and their hiding places. However, there was inadequate knowledge on the identification and classification of venomous snakes. Belief in a snake god, the perception that snakes will not come out during thunderstorms, change in taste sensation, the ability of tamarind seeds or magnet to reduce the venom effect were some of the superstitions reported by the tribal community. The application of a harmful method (Tourniquet) as the first aid for snakebite was practiced by the tribal community. They preferred herbal medicines and visiting the traditional faith healers before shifting the patient to the government health facility. The knowledge on the ability to identify venomous snakebites and anti-venom was significantly higher amongst nurses and accredited social health activists (ASHAs) than auxiliary nurse midwives (ANMs) and multi-purpose workers (MPWs) (p < 0.05). None of the traditional faith healers; but nearly 60% of snake rescuers were aware of anti-venom. Fifty percent of the medical officers in Dahanu block did not have correct knowledge about the Krait bite symptoms, and renal complications due to the Russell viper bite.

CONCLUSIONS

Inappropriate perception, inadequate awareness, and knowledge about snakes and snakebites may predispose the tribal community to increased risks of venomous snakebites. Unproven and harmful methods for snakebite treatment practiced by the community and traditional faith healers could be dangerous leading to high mortality. Therefore, a multi-sectoral approach of community awareness, mapping of vulnerable populations, capacity building of health care facility, empowerment of health care workers (HCWs) could be useful for reducing the mortality and morbidity due to snakebite envenoming in India.

Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study

The World Health Organization call to halve global snakebite deaths by 2030 will require substantial progress in India. We analyzed 2833 snakebite deaths from 611,483 verbal autopsies in the nationally representative Indian Million Death Study from 2001 to 2014, and conducted a systematic literature review from 2000 to 2019 covering 87,590 snakebites. We estimate that India had 1.2 million snakebite deaths (average 58,000/year) from 2000 to 2019. Nearly half occurred at ages 30-69 years and over a quarter in children < 15 years. Most occurred at home in the rural areas. About 70% occurred in eight higher burden states and half during the rainy season and at low altitude. The risk of an Indian dying from snakebite before age 70 is about 1 in 250, but notably higher in some areas. More crudely, we estimate 1.11-1.77 million bites in 2015, of which 70% showed symptoms of envenomation. Prevention and treatment strategies might substantially reduce snakebite mortality in India.