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Darshani S, Gnanathasan A, Arambepola C, Chang T. Knowledge on prevention, diagnosis and treatment of snakebite envenoming among doctors in snakebite-dense regions in Sri Lanka. Trans R Soc Trop Med Hyg 2021; 115:984-991. [PMID: 34323280 DOI: 10.1093/trstmh/trab112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sri Lanka is one of the highest envenoming reporting countries globally with >80 000 snakebites per year. Among other factors, knowledge of snakebite among doctors predominantly determines patient outcomes. METHODS Using a pretested 72-item self-administered questionnaire, we assessed knowledge on identifying common snake species, signs of envenoming and management of venomous snakebites among 280 doctors working in eight state hospitals in regions where snakebite prevalence is highest in Sri Lanka. RESULTS Visually, 92.1% correctly identified a cobra and 74.3% identified a Russell's viper, but only 30% could identify a hump-nosed viper (HNV). Syndromic identification of snakes was best for the krait (71.8%) followed by the cobra (59.6%), but poor for the HNV (30%). The median knowledge scores of pictorial and syndromic snake identification, indoor preventive measures and indications of antivenom were <75% of the maximum score. Apart from 62.5% who expected the victim to bring the snake along to the hospital, most doctors selected the correct options of pre-hospital care. The duration of work experience did not influence the competency of syndromic identification. Utilisation of local guidelines was associated with better knowledge in antivenom usage (odds ratio 2.22 [95% confidence interval 1.04 to 5.36]; p=0.03). CONCLUSIONS Specific deficiencies of core knowledge in snakebite management exist among doctors working in snakebite prevalent regions.
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Affiliation(s)
| | | | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, 25, Kynsey Road, Colombo 00800, Sri Lanka
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Mukherjee AK, Mackessy SP. Prevention and improvement of clinical management of snakebite in Southern Asian countries: A proposed road map. Toxicon 2021; 200:140-152. [PMID: 34280412 DOI: 10.1016/j.toxicon.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
In the Southern Asian countries, snakebite takes a substantial toll in terms of human life, inflicts acute morbidity and long term disability both physical and psychological, and therefore represents a neglected socio-economic problem and severe health issue that requires immediate medical attention. The 'Big Four' venomous snakes, viz. Daboia russelii, Naja naja, Bungarus caeruleus and Echis carinatus, are prominent, medically important species and are the most dangerous snakes of this region; therefore, the commercial polyvalent antivenom (PAV) contains antibodies against the venoms of these snakes. However, envenomations by species other than the 'Big Four' snakes are grossly neglected, and PAV is only partially effective in neutralizing the venom of these snakes. Many issues confounding effective treatment of snakebite are discussed in this review, and these hurdles preventing successful treatment of snakebite must be addressed. However, in South Asian countries, the pre-hospital treatment and appropriate first aid are equally important to mitigate the problem of snakebite and therefore, these issues are also highlighted here. Further, this review suggests a roadmap and guidelines for the prevention of snakebite and improvement of hospital management of snakebite in these Southern Asian countries.
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Affiliation(s)
- Ashis K Mukherjee
- Division of Life Sciences, Institute of Advanced Study in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, 781035, Assam, India; Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur, 78028, Assam, India; School of Biological Sciences, University of Northern Colorado, Greeley, CO, 80639-0017, USA.
| | - Stephen P Mackessy
- School of Biological Sciences, University of Northern Colorado, Greeley, CO, 80639-0017, USA
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Hannan Wan Ibadullah WA, Azmi MF, Abas MI, Syed Abdul Rahim SS, Jeffree MS, Azhar ZI, Hayati F, Hassan MR. Determinants of snakebite mortality in Asia: A systematic review. Ann Med Surg (Lond) 2021; 62:16-20. [PMID: 33489110 PMCID: PMC7809159 DOI: 10.1016/j.amsu.2020.12.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This systemic review summarizes the evidence exploring the determinants of mortality due to snakebite envenomation in Asia. MATERIALS AND METHODS The database PubMed, Web of Science and Science Direct were searched to identify the relevant literatures concerning mortality due to snakebites mortality in Asia. All the articles chosen were critically appraised for its quality using a mixed-method assessment tool by two independent reviewers with discrepancies sorted by a third person. RESULTS A total of 7 studies were included in the final analysis which was 3 cross-sectional studies, 2 case reports, 1 observation prospective study and 1 randomized control trial study. Two studies were conducted in India and two studies in Sri Lanka while one study was conducted in Taiwan, Vietnam and Nepal respectively. The cases of snakebite victims were retrieved from the year of 1987 until 2017. In total, there were 762 cases of snakebite victims recorded, with 61 of those victims succumbed to death. From the final total of 7 studies, 4 of the studies showed snakebites mortality were related to delayed treatment access and 3 studies due to suboptimal care. CONCLUSION Mortality and morbidity can be reduced if there is a quick access for victims to emergency medical care, rapid transfer time to hospital and receiving immediate optimal medical treatment from trained medical staff once in the hospital or dispensary.
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Affiliation(s)
| | - Muhammad Fikri Azmi
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Ihsanuddin Abas
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Unit of Community Medicine, Faculty of Medicine, Universiti Sultan Zainal Abidin, Terengganu, Malaysia
| | - Syed Sharizman Syed Abdul Rahim
- Department of Community & Family Medicine, Faculty of Medicine & Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia
| | - Mohammad Saffree Jeffree
- Department of Community & Family Medicine, Faculty of Medicine & Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia
| | - Zahir Izuan Azhar
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine & Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia
| | - Mohd Rohaizat Hassan
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Suraweera W, Warrell D, Whitaker R, Menon G, Rodrigues R, Fu SH, Begum R, Sati P, Piyasena K, Bhatia M, Brown P, Jha P. Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study. eLife 2020; 9:e54076. [PMID: 32633232 PMCID: PMC7340498 DOI: 10.7554/elife.54076] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/04/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Wilson Suraweera
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - David Warrell
- Nuffield Department of Clinical Medicine, University of OxfordOxfordUnited Kingdom
| | - Romulus Whitaker
- Centre for Herpetology/Madras Crocodile Bank, Vadanemmeli VillageChennaiIndia
| | - Geetha Menon
- Indian Council of Medical Research, Ansari NagarNew DelhiIndia
| | - Rashmi Rodrigues
- Department of Community Health, St. John's Medical College, St. John's National Academy of Health SciencesBangaloreIndia
| | - Sze Hang Fu
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - Rehana Begum
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - Prabha Sati
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - Kapila Piyasena
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - Mehak Bhatia
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
| | - Patrick Brown
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
- Department of Statistical Sciences, University of TorontoTorontoCanada
| | - Prabhat Jha
- Centre for Global Health Research, Unity Health Toronto, and Dalla Lana School of Public Health, University of TorontoOntarioCanada
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Role of neostigmine and polyvalent antivenom in Indian common krait (Bungarus caeruleus) bite. J Infect Public Health 2010; 3:83-7. [PMID: 20701896 DOI: 10.1016/j.jiph.2010.01.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 01/20/2010] [Accepted: 01/29/2010] [Indexed: 11/22/2022] Open
Abstract
Bungarus caeruleus (Indian common krait) bite during monsoons is common in Northwest India. This study was undertaken to find the effectiveness of neostigmine and polyvalent antivenom in improving neuromuscular paralysis following bite. All the consecutive patients admitted between June 2007 and December 2008 with common krait bite, identified either from brought snake or circumstantial evidence were studied. Ten vials of polyvalent antivenom and three doses of 2.5 mg neostigmine at 30 min intervals after administration of 0.6 mg of atropine were administered I.V. and patients were assessed for any improvement in neuroparalysis. Seventy-two patients were admitted during the study period. All the patients except two came from rural areas and were brought between June and September. Sixty-two patients were bitten during the day while clearing bricks, cutting grass or walking. The mean time interval between bite and arrival to hospital was 4.5 h. None of the patients showed any improvement following treatment and all patients developed respiratory paralysis, requiring assisted ventilation. Seventy survived and two died. Neostigmine is ineffective in reversing or improving neuroparalytic features in patients with B. caeruleus bite even at higher dose than normally recommended.
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Abstract
Snake bite is one of the most neglected public health issues in poor rural communities living in the tropics. Because of serious misreporting, the true worldwide burden of snake bite is not known. South Asia is the world's most heavily affected region, due to its high population density, widespread agricultural activities, numerous venomous snake species and lack of functional snake bite control programs. Despite increasing knowledge of snake venoms' composition and mode of action, good understanding of clinical features of envenoming and sufficient production of antivenom by Indian manufacturers, snake bite management remains unsatisfactory in this region. Field diagnostic tests for snake species identification do not exist and treatment mainly relies on the administration of antivenoms that do not cover all of the important venomous snakes of the region. Care-givers need better training and supervision, and national guidelines should be fed by evidence-based data generated by well-designed research studies. Poorly informed rural populations often apply inappropriate first-aid measures and vital time is lost before the victim is transported to a treatment centre, where cost of treatment can constitute an additional hurdle. The deficiency of snake bite management in South Asia is multi-causal and requires joint collaborative efforts from researchers, antivenom manufacturers, policy makers, public health authorities and international funders.
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Affiliation(s)
- Emilie Alirol
- Division of International and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
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Simpson ID, Norris RL. The global snakebite crisis--a public health issue misunderstood, not neglected. Wilderness Environ Med 2009; 20:43-56. [PMID: 19364169 DOI: 10.1580/08-weme-con-263.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The global problem of venomous snakebite continues to attract attention despite it being described as a "neglected" issue. The current focus of the World Health Organization (WHO) remains anti-snake venom quality, although "availability and sustainability" of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be 'unaffordable.' The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis. This paper introduces a marketing model to examine global snakebite and to identify if the current approach is relevant and effective. The "4 Ps" model examines if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum. The resulting analysis demonstrates that the current approach is characterized by a misunderstanding of the nature of the global snakebite problem. Further, a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols, has inevitably led to a lack of improvement in the snakebite arena over the last 30 years.
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Simpson ID, Norris RL. Snake antivenom product guidelines in India: "the devil is in the details". Wilderness Environ Med 2007; 18:163-8. [PMID: 17896852 DOI: 10.1580/07-weme-ed-099r.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Venomous snakebite continues to exact a tremendous toll in human suffering and mortality in India. Contributing to this problem is the fact that all of the current Indian snake antivenom manufacturers include a great deal of misinformation in the package inserts and guidelines that accompany their products. Examples include erroneous recommendations regarding first aid, misleading information regarding the signs and symptoms to be anticipated after Indian snakebite, and misleading and ambiguous recommendations as to initial dosing and repeat dosing of antivenom. In addition, the significant problem of acute adverse reactions to Indian antivenoms is compounded by a lack of appropriate recommendations regarding prevention, diagnosis, and management of such reactions. It is the intent of this article to point out problems with the current Indian antivenom product guidelines and to encourage these manufacturers to produce new literature to accompany their products based on the best available evidence.
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