Tuesday, 23 May 2017

Alcohol, Selfies and Lethal Kisses

I was convinced that most of the snake bites were accidental until I saw on YouTube an interview to a casualty doctor on snake bites, first aid and treatment. I assumed this was from a USA / Australia hospital as I've been looking again for the video but could not found it anymore!. What she said was that most of the bites they were seeing were alcohol related. People drink, maybe they have the snake at home or I do not know how but a snake appears on the scene, they try to handle it and... ups!!!
Things can be even worse. They are drunk, any common sense or feeling of embarrassment has already abandoned them, the snake appears and they try to take a selfie shot kissing it... and Oh God, you are lucky if end up on a hospital ICU!!!.
From immortality to mortality on a click.
Online newspapers, YouTubes are full of this stuff. Worldwide. Let us have a look.


ALCOHOL
Here I would like to distinguish between industrialized western countries, were snakes can be kept at home as exotic pets and those rural areas in countries were snakes are basically wild free and in occasional contact with humans.

56% of snakebite is alcohol associated. Snake bites in Wyoming.
Dr. Scott Whitlow, Director Emergency medicine, KDMC


























WFLA Web staff and NBC News. Published May 17, 2017.
"Rescue crews say a Putnam County man is in critical condition after he was bitten in the face by a rattlesnake. Rescue crews were called to Bostwick Tuesday afternoon after the man was bitten in the tongue by an eastern diamondback. The victim's friend said it happened when the man was holding the snake and went to kiss it.
The friend said the man was drinking a little bit at the time.

This is just a sample from last weeks. There is no much to say.

Found another paper from year 2012, South Carolina. According to Steve Bennet with the Department of Natural Resources, 70 to 75 percent of snake bites account for by people trying to catch or kill a venomous snake.
"Right off the bat if you stop and you leave that snake alone you are going to eliminate 70 to 75 percent of the bites, now 60 percent of those involved alcohol, so there you go"

In India, differences aside, the panorama is quite similar.
I remember one episode narrated by Dr. Kuruvilla that looks quite funny (if your are not the main character on the movie): It is about a patient quite drunk that saw on the roadside what seemed to him a nice leather belt and tried to wear it. In fact it was a snake and he got a nice bite.  Those and other things we do when we are drunk!

Same message:
Many accidents could be avoided just if people leave snakes alone. A high percent of people trying to catch, kill or play with a snake are under the influence of alcohol and end up with a bite. Just blame yourself. 

Alcohol and snake rescuers / handlers:
A special chapter here should be mentioned when the person that takes the alcohol is a snake rescuer. One of the Real Stories that appear in SHE-India is about an expert snake rescuer that was called at night. He had been drinking. Anyhow he decided to go to rescue the snake. He did some mistakes that cost his life and probably would had never done in a sober state. He left a family behind... and he is not the only one.
Snake rescuers get bitten also when smartphones, a camera or curious and noise people get involved on the play, as for just the fraction of a second his attention diverts from the snake.


SELFIES
India has the world record of selfies that resulted on death.
Me, Myself and My Killfie: Characterizing and Preventing Selfie Deaths.  
According to this study published by US-based Carnegie Mellon University and Indraprastha Institute of Information Technology Delhi, the numbers of deaths due to selfies are increasing with India on the top rank.  You can read full text here: https://arxiv.org/pdf/1611.01911.pdf
Russian government has published a guide on prevention

To me the title of the article means almost all. Me, Myself and My Killfie. Time is gone when the typical holidays picture was taken with the family and the pet dog. Now selfies reflect an individual society that looks for the short compensation of taking a few seconds of attention on the social media. 
Dangers of the selfie: The number of likes, comments and shares people get for their selfies are the social currency. The desire of getting more of this social currency prompts youth to extreme lengths
Selfie deaths characterization: The authors define a selfie-related casualty as a death of an individual or a group of people that could have been avoided had the individual(s) not been taking a selfie. This may involve the unfortunate death of other people who died while saving or being present with people who were clicking a selfie in a dangerous manner.
127 worldwide selfie related deaths in two years, 76 happened in India.

Selfies only make sense if there is other people looking at them. That's why I did not want to upload any of them here.

Other interesting news:
A man had to pay Rs 25,000 for posting a selfie with a cobra
that he put previously on a plastic bottle. He was selling on FB the cobra for Rs1,000. The picture went viral through Whatsapp and grabbed the attention of a wildlife activist who reported the Forest Department.

There are many news too about young and not so young people being bitten by a snake while trying to take a selfie... some with the result of death, but not all.

"Rattlesnake selfie" results in a $153K medical bill. CBS News. San Diego. USA
Mr. T.F. was bitten while trying to pose for a selfie with a snake. He needed many doses of antivenom. In addition, this snake bite required emergency treatment, a few days in the hospital intensive care unit and therapy to recover function of the damaged body part.






LETHAL KISSES

abcNEWS.com April 2016
A Florida man was bitten in the face by a venomous snake after trying to kiss it. A.H., 18, of Wimauma, told his friends he took a liking to the snake and decided to keep it as a pet. It was a cottonmouth snake, 4 foot. He was on a critical condition. Family members reportedly killed the reptile and brought it to the hospital.
A.H. Before and after...
Phillip, who is a professional herpetologist, said about 3,500 people in the United States are bitten each year by venomous snakes, leading to as many as four fatalities. About 70% of the victims are men between ages of 16 and 25 and alcohol is usually involved, he said.
The Florida Fish and Wildlife Conservation Commission is investigating the incident because H. allegedly did not have a permit to have the snake. He faces possible charges, according to WFTS.
Florida requires 1,000 hours of training under the guidance of a licensed expert in order to obtain a permit to handle poisonous snakes.
Somebody has to protect snakes from this kind of behavior!



ALCOHOL, SELFIES AND LETHAL KISSES WALK HAND BY HAND MANY TIMES. 
There are plenty of YouTubes, pictures, posts, on often young people dying from snake bites. Some of them are called "rescuers". They approach the snakes bare hand and are very amateurs. They do not have any specific training at all. Some will get the odd fame of appear on social media after dying of a bite. I do not want to post any of them here. 
No more publicity of it. 

We need an ETHICAL CODE IN THE MEDIA RELATED TO SNAKE BITES. No more pictures of children handling snakes, no more pictures of people kissing snakes, being bitten and dying in front of the cameras... WE ALL (HUMANS AND SNAKES) DESERVE MORE RESPECT.



ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful


(IV) On how snake bites will change your life: SHE-India.org



Last year, after been reading on snake venom for several weeks, I came upon this website:
SHE-India (Snake Healing and Education Society)
http://www.she-india.org
I was very grateful to see the "human side" of the snakes bites and... I was shocked too. Till then I was not really conscious of the dimension of snakebite (even not now at all!, just scratching on the surface!) For many religious, cultural, socio-economical, even geographical reasons, in India this is a particularly complex topic not to mention snakes by themselves.

The founder of SHE-India is Priyanka Kadam, and she dedicates all her available free time to snake bites and snake bitten people.

"The impact of the problem is more evident and severe in the rural parts of India, where farm laborers come in contact with snakes and medical facilities are limited.Local hospitals, clinics and care centers find anti-snake venom (ASV) difficult to procure. Limited supply of ASV adds to the demand and the distributors sell this life saving drug at an inflated price. Other significant challenges include a lack of specialized training and community outreach programs to educate the population.

Snakebite Healing and Education Society (SHE) has been founded to address all the above mentioned concerns by engaging experts from different fields. Snakebite expert doctors, Human Rights activists, Scientists, Herpetologists, Lawyers, NGO partners and administrators all form a part of the advisory board and shall help spur this issue into a movement with a unified voice"

SHE is presently working with grass root level people in West Bengal, Maharashtra, Gujarat, Chhattisgarh and Uttar Pradesh and eventually intends to cover Uttarakhand, Rajasthan, Andhra Pradesh and Bihar.
The site has several sections: Home, About us, About Snakes, Real Stories, Snakebite First Aid, Snakebite Treatment Protocol and Mouthpiece.


REAL STORIES:
I will start with what is to me the most interesting thing about this website. There are many pages on snakes, plenty of research literature but very, very few resources, are dedicated to the bitten people, mostly poor farmers. SHE-India is about them. How it happened, their living conditions, what they had to go through to get a treatment (to finally don't get it), the local healers...
I would like to highlight another important thing and it is that the written and image treatment of the person, his/her story, the pictures taken... all of them a very respectful. And we need to show respect on people and on the snakes too.
I do have permission from Priyanka to show the content of the web. There are 29 stories most of them directly written by her, with direct interviews on the field to the victim on the snakebite accident or sometimes their relatives as the person died. They are narrating how the snakebite changed their lives: Many things to be learn from that on how all this suffering could be avoided. The stablished relationship and involvement is very personal. Some of the victims are related to the St. Francis Anjali Health Center, in Phitora Chhattisgarh, an example of integration and good work. A short reference already here but that deserves a whole post by itself. 
http://onpeopleandsnakes.blogspot.in/2017/01/the-india-snake-bite-initiative.html


This is just a summary. You will find full text and more images on the site.

Ranadevi and her daughte
When Snakebite Seals a Toddler’s Future!
http://www.she-india.org/when-snakebite-seals-a-toddlers-future/
"Ranadevi's husband was working on the fields when he was bitten by a Russell's Viper. First the family resorted to faith healing. As his condition was deteriorating very fast he visited a first hospital, was referred to a second hospital and from it referred finally to a government hospital were he died on the 8th day of the bite.
This case ended in tragedy only because there was no tertiary level hospital close to the victim's village equipped for snakebite management."
(A would say that even not a tertiary level hospital is needed. A small medium clinic will do if they are resolved to give ASV treatment, and the first hours of the bite are crucial).


The Story of a Paralyzed Woman!
Viviyana Chauranth
http://www.she-india.org/the-story-of-a-paralyzed-woman/
Pradeep, a 40-year old farmer and his wife Viviyana were returning back home by bicycle. There were no street lights but as they were locals they knew the way home even in the dark. They didn't see an adult Russell'd viper crossing the road. The snake got entangled in the bicycle. Pradeep was bitten near the ankle area. First they consulted a local healer and later on did a 3 h ours journey to a hospital. Pradeep died seven days later. Not clear what was the treatment there. He left a wife and seven children. After Pradeep's death, his wife started drinking. As a result of the addiction to country liquor she developed a paralysis. Snake bite is not just a medical condition. It has a socio-economic effect on the victim's family. Pradeep unfortunate death has left his family struggling for even basis sustenance. Some of this children are school dropouts and daily wage workers to support their large family.

Kaluram's family

When Snakebite struck three generations – 
A story from Rajasthan
http://www.she-india.org/when-snakebite-struck-three-generations-a-story-from-rajasthan/
This is the story of Kaluram's family which lost 3 generations of women due to snakebite.
The first death by snakebite was in 2001. Kaluram's mother was bitten by a cobra resting behind an onion bunch hanging on a corner inside the house. She had to walk 1.5 Km to town and then in a tractor was sent to a local Hanuman Temple, She died on the way and was 35 year old. The family believes that Myth: if she had reached the temple on time she would have survived. Second death was Karula's 6 year old sister, Manchalti. She was bitten around 3 a.m. while sleeping. The family again started for the Balaji temple. She died on the way around 7 a.m. Myth: The family believes that Manchalti died as she was brought outside the house. The villagers believe that venom potency gets higher when one crosses the threshold of the main door.
In August 2012 Maluram's grandmother died indoors. She was found around 8 p.m. with dark bite mark on the side of her torso. Her pace was bluish.
India is steeped in beliefs and myths on snakebites and faith healers. Since most bites are from non-venomous species, the victims survive and the faith in religious practices deepens.

I was going to randomly select three stories but finally I just took the first three because as you can see, so many topics are there to work on!. Seems there is a long way ahead, but as the saying goes, a long journey starts with a small step.

ABOUT US:
You may read the founder's message, Mission and Vision as well as a useful Advisory Board on doctors, herpetologist, lawyers, educators committed with snakebite mitigation. A short biography and sometimes contact phones or mails are given.
Main focus is to create awareness and improve the treatment and life conditions of people affected by snakebite,  to most rural areas of India.

ABOUT SNAKES:
Here you will find some educational material on snakes, basically the Big 4. There is a link to a wonderful, wonderful movie on Prevention of the 4 Deadliest Snakes: A survival guide by Romulus Whitaker.

SNAKEBITE FIRST AID:
Basic DO's and DONT's on SnakeBite first Aid as well as some draws about the proper limb immobilization as well as different was for patient transportation.
Links to the information translated to HINDI, MARATHI, GUJARATI, BENGALI, KANNADA AND MALAYALAM.


SNAKEBITE TREATMENT PROTOCOL:

Dr Joseph K Joseph & Dr Manoj P Jose Little Flower Hospital, Angamaly 
http://www.she-india.org/wp-content/uploads/2015/04/SNAKEBITE-TREATMENT-PROTOCOL.pdf


MOUTHPIECE:
News and opinion articles on snakebites:
Snake Temple in Rajastan 

.- Fieldwork in Ranthambore, Rajastan
.- One Million Snake Bites written by Janaki Lenin
.- Loss of life can never be compensated!
.- Effective Snakebite Management in Himachal Pradesh
.- The Rescue Paradox by Kedar Bhide
.- Dark fairy tale stories by Ashok Captain
.- "Halla Bol" penned by Priyanka Kadam
.- Snakebite interest Group on WhatsApp by Dr. Dayal Bandhu Majumdar

OTHERS...
QUICK LINKS
REFERENCE PAPERS:
Guidelines for Management of Snakebites David Warrell Click here
Improve Antivenom for Treatment of Snakebite in India Click here
Snakebite in India Current Reality Click here
Snakebite Mortality Survey by Mohapatra (2011) Click here
Warrell Etal Antivenom Improvement Click here
Who Article on Snakebites as a Neglected Disease Click here
Williams 2011 Ending the Antivenom Brought Click here
Currsci Venoms Antivenoms and Snakes of Med Imp RWSW Click here
Analysis of Snakebite Data Calicut Medical Journal 2006 4 Click here
Gutierrez et al 2014 Availability of Antivenom BullWHO Click here
Notes on Indian Venomous Snakes and First Aid  Click here
Transporting Snake Bite Victims (Himachal Pradesh)  Click here


Please take time to read each of the real stories portrayed. It is worth it. The perspective point from which we look at the world is what really gives direction to our lives. It is my opinion the scientist community should try include and give voice to the most unprivileged sectors of society for the best of humankind. Science devoid of heart is like "eating rocks" for the soul.



ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful


Tuesday, 16 May 2017

(III) On how snakebites change your life: Post-Traumatic Stress Disorder

Snakebites change your life. Emotionally, many people say they will not be the same again...

Snakes bite, which is the most normal thing if, by accident, you put your bare foot on top of them but, the calvary many patients / families have to go through to get (and often don't get) a treatment may be much more painful than the bite itself. 

I've started a search on what has been published in India since some years ago. Scientific articles etc and I'm looking at the news too. Just started. 

I'm linking you to the address of the site I've found a few hours ago, move forward as it is not the first new, keep scrolling till you reach it: 
Apathy. After the serpent's sting. By Suhit Kelkar
And this is not isolated, it is common to South Asia, Africa, some countries of South America...

Here is a study done in Sri Lanka on the impact of snakebites as depression and / PTSD.

Delayed Psychological Morbidity Associated with Snakebite Envenoming

Shehan S. Williams1*, Chamara A. Wijesinghe1, Shaluka F. Jayamanne2, Nicholas A. Buckley3,4, Andrew H.
Dawson3,4, David G. Lalloo5, H. Janaka de Silva2
1 Department of Psychiatry, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka, 2 Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka, 3 South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka, 4 Prince of Wales Clinical School, University of New South Wales, Sydney, Australia, 5 Liverpool School of Tropical Medicine, Liverpool, United Kingdom 


August 2011 I Volume 5 I Issue 8 I e1255
This is an Open Access article. Please refer always to the original as this is a summary. 

ABSTRACT
Introduction
The psychological impact of snakebite on its victims, especially possible late effects, has not been systematically studied.
Objectives: 
To assess delayed somatic symptoms, depressive disorder, post-traumatic stress disorder (PTSD), and impairment in functioning, among snakebite victims.

Methods:
The study has qualitative and quantitative arms. 
In the quantitative arm, 88 persons who had systemic envenoming following snakebite from the North Central Province of Sri Lanka were randomly identified from an established research database and interviewed 12 to 48 months (mean 30) after the incident. Persons with no history of snakebite, matched for age, sex, geographical location and occupation, acted as controls. A modified version of the Beck Depression Inventory, Post-Traumatic Stress Symptom Scale, Hopkins Somatic Symptoms Checklist, Sheehan Disability Inventory and a structured questionnaire were administered. 
In the qualitative arm, focus group discussions among snakebite victims explored common somtic symptoms attributed to envenoming. 
Results:
Previous snakebite victims (cases) had more symptoms than controls as measured by the modified Beck Depression Scale (mean 19.1 vs 14.4, p<0.001) and Hopkins Symptoms Checklist (38.9 vs 28.2, p<0.001). 48 (54%) cases met criteria for depressive disorder compared to 13 (15%) controls. 19 (21.6%) cases also met criteria for PTSD. 24 (27%) claimed that the snakebite caused a negative change in their employment; nine (10.2%) had stopped working and 15 (17%) claimed residual physical disability. 
The themes identified in the qualitative arm included blindness, tooth decay, body aches, headaches, tiredness and weakness.
Conclusions:
Snakebite causes significant ongoing psychological morbidity, a complication not previously documented. The economical and social impacts of this problem need further investigation.


INTRODUCTION:
In Sri Lanka, about 40,000 persons are treated for snakebite in government hospitals each year. The actual number of bites is likely to exceed this number, as many of the victims seek traditional forms of treatment. Only six of the 92 snake species in Sri Lanka are medically important. These are the Russell's viper, cobra, the two kraits (common and Sri Lankan), saw scaled viper and hump nosed viper. Russell's viper, cobra and kraits account for most of the morbidity and mortality.
There are very little data on the long term physical and psychological consequences experienced by victims of snakebite. This is unfortunate, as most snakebite victims are in the economically productive age group, and the economic impact of any disability is likely to be high. 
Snakebites are sudden and unexpected, and the element of surprise and the associated threat to life may cause extreme stress and anxiety in the victim.
The objective of our study was to assess stress and anxiety: particularly symptoms of anxiety and depression, post-traumatic stress disorder*, somatisation and impairment in functioning, at least 12 months following snakebite envenoming.

PTSD DEFINITION: Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better. If the symptoms get worse, last for months or even years, and interfere with your day-to-day functioning, you may have PTSD. Souce: Mayo Clinic

For the study, the Polonnnaruwa district of the North Central Province of Sri Lanka was selected. It is a dry zone, with predominantly rural agricultural population. The highest numbers of snakebite envenoming in Sri Lanka are reported from this region. Mental health services in this area are pooly developed. 

DESIGN:
Quantitative arm: n= 200 persons (cases) over 18 years of age, with history of snakebite envenoming treatment at least 12 months previously. 
Letters (in Sinhala, vernacular language used in the district) were sent out to those selected inviting them to participate in the study.
Structured questionnaire: Demographic characteristics, circumstances of the bite, hospital stay, perceived severity of the bite, return to work and functioning. Physical examination and psychological scales (modified Sinhala version of the Beck depression inventory, Post-traumatic Stress Symptoms Scale-Self Report, Hopkins symptoms checklist and Sheehan Disability inventory) were administered by experienced psychiatrists on these tools.
Hospital attendees Control group matching age, sex, geographical location and occupation without history of SB.

Qualitative branch: 5 focus group discussions consisting of 6-10 snake bite victims.

RESULTS:
Of the 200 snakebite victims to whom the letters of invitation were sent, 88 (74 males and 14 females) responded and participated in the study. No significant differences between responders and non-responders were found. 
Results are best seen on table 2

A negative effect on their subsequent employment resulting in less skilled or fewer hours of work was claimed by 24 (27%) of victims; nine (10%) had stopped working after the incident. 

Qualitative findings
Various physical symptoms were attributed to the snake envenoming. Five main themes were identified: Poor vision, tooth decay, body aches, headaches, weakness and tiredness of the body. Poor vision, body aches and tiredness were the most frequently occurring observations.
(If you remember the article on socio-economic impact in Tamil Nadu, patients complaints are the same! tiredness, loose of vision and watery eyes...)

DISCUSSION:
The findings show significant psychological morbidity one to four years after snakebite envenoming. This study demonstrate depressive symptoms in more than 50% of snake bite victims who had been treated for serious envenoming, more than 1 year after the index episode (control group 15%).  There are almost no studies on the consequences of animal bites in children or adults published on literature worldwide.
The population of the study was composed by young adults (mean age 41), with young families, living in poverty (daily income less than US$ 7.5) and often working under difficult conditions in farms and rice fields.

COMPARISON WITH PSYCHOLOGICAL MORBIDITY AFTER OTHER TRAUMA:
This association is very creative! It's  a great idea that helps a lot to understand!
Naga Raksha (Cobra Mask). Sri Lanka Jorge Láscar Wiki Commons

Following the tsunami that affected Sri Lanka in 2001, PTSD and depression rates were 21% and 16% respectively. In a study at car crashes, 23% of the hospitalized passengers and 11% of the drivers had significant levels os stress 18 months after the accident. Following war trauma in a civilian population in Lanka, 27% reported PTSD, 25% major depression, 41% somatization and 26% anxiety disorders. 
PTSD prevalence in the snakebite victims of the study is comparable to the rates seen following the tsunami and car crashes, and lower than that reported following war trauma in Sri Lanka. 

Like in many parts of South Asia, in Sri Lanka too snakes are revered, and particularly the cobra is considered sacred. Stories of protection as well as vengeful attacks by snakes for past atrocities even in a previous birth, based on a belief of re-birth as animals, abound. 

Further exploration of the overall impact of snake bite in the rural tropics and the direct and indirect cost associated with the psychological sequelae and loss of employment is warranted.


ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful


Friday, 12 May 2017

(II) On how snakebites will change your life: Defining catastrophic Health Expenditures.

Few days back I was reading the article that will be posted here today. It is also a socio-economic study on the impact of snakebites on Bangladesh. It is a short study, one of the few done on this particular topic and almost at the end introduces the concept of: CATASTROPHIC HEALTH EXPENDITURES.
Any health expenditure that threatens a household's financial capacity to maintain its subsistence needs is termed as catastrophic
First I will summarize the article and then we can go further to explore this concept.
Please refer alway to the full article.


The impact of snake bite on household economy in Bangladesh
A. Basher et al. Dpt. of Medicine, Sir Salimullah Medical College, Dhaka, Bangladesh.
TROPICAL DOCTOR 2012: 1-3
DOI: 10.1258/td.2011.110137

The present study aims to assess the different types of costs for treatment of snakebite patients, to quantify household economic impact and to understand the coping mechanisms required to cover the cost for snakebite patients in Bangladesh. 
The patients admitted to four tertiary level hospitals were interviewed using structured questionnaires including health-care-related expenditures and the way in which the expenditures were covered.

Introduction:
In rural Bangladesh snake bite is an acute medical emergency. There are approximately 4.3 bites / 100,000 people with around 2000 deaths annually.
Delays in diagnosis and treatment are common and result in part from the burden of payment for the service providers and drug therapy. When indicated snake anti-venom is given(ASV). The ASV is not manufactured in Bangladesh and supplies to government hospitals are irregular.

Methods:
The study includes 83 patients admitted suffering from snakebites from June to October 2006. Adult members of the households involved were interviewed using structured questionnaires documenting history, clinical features, treatment-seeking behavior, health-care-related expenditures and the way in which these expenditures were covered.
Direct treatment cost as well as indirect cost (transport, attendant cost...) and opportunity cost (lost of wages) were also recorded. The authors conducted a survey on private pharmacy shops close to hospital in order to document market prices, availability of ASV.

Results:
Total of patients included in the study: 83. Around 70% male. The occupations were widely distributed, only 18% agricultural labour. Others were house wife (17%), businessman (16%)... even student 11%.
Almost 60% were living in katcha house (constructed from mud, stone and wooden beams). 65% had electricity, 30% radio, 42% tv, 68% used a sanitary latrine and most 95% were drinking water from a tube well.
The monthly income ranged from US$4.48 to US$1,194. Mean of US$ 44.7

Treatment-seeking behavior before hospital admission:
54% of patients went to traditional healers (ohza); 7% to unqualified doctors (quack doctors); others to private clinics, or registered doctors and 34% to government hospitals. 

Treatment offered by traditional healers (ohza) includes cutting, biting, sucking, burns on or around snakebite site or induced vomiting.

Hospital Treatment
From those 83 snakebite patients, 38 were suffering from venomous snakebite. 35 recieved the ASV. 7 required artificial respiratory support and 13.2% died. 

Expenditure: (here the variation is very high between groups)
Household expenditure:
US$ 13.43 to 2,294 for venomous snakes
US$   3.61 to    134 for non-venomous snakes

ASV cost:
From US$ 8.21 to US$ 13.43 per vial.

Coping mechanism:
Among the households, 74% spent from their savings and 61% borrowed money to cope with the cost.
Spend savings (73%) , loans (61%) , sell livestock (3.6%) and others like sell ornament, sell business and even land mortgage 

DISCUSSION:
The importance of illness and health-care cost as major contributors to poverty have been increasingly recognized in recent years.
Health economist at the WHO have defined "catastrophic health expenditures" as expenditures for health care totaling 40% of a household income after basic subsistence.

In the study, the population had a median household income of US$ 50 per month.

The authors stress the need for the following in order to improve the care of snakebite cases:
1) The initiation of a country-wide training program for health-care service providers.
2) A mass awareness development program about first aid treatment of snakebite patients
3) The provision of a smooth supply of anti-snake venom to public hospitals.
4) The supply of logistics to enable proper diagnosis, especially in endemic zones
5) The setting up of proper ICU facilities, initially in all medical college hospitals and subsequently in major district hospitals.

I like the introduction of the concept of catastrophic health expenditures as it is something recognized internationally and a very graphic way to express it and also it allows us to quantify it. This is one of the very few studies that really measures some of those economic factors. The study is based on those patients reaching a tertiary level hospital in Dhaka the capital of Bangladesh. Rural population of the sample is only a 18% of a population sample that seems must include many inhabitants from the suburbia around the city. 








CATASTROPHIC HOUSEHOLD EXPENDITURE FOR HEALTH

Any health expenditure that threatens a household's financial capacity to maintain its subsistence needs is termed as catastrophic. 

It does not necessarily equate to high health-care cost. Even relatively small expenditures on health can be financially disastrous for poor households. These is because almost all their available resources are used for basic needs and they are thus less able to cope with even very low health expenditures compared to richer households.
WHO estimates that families who spend 50% or more of their non-food expenditure on health care are likely to be impoverished. However, there is no consensus on the catastrophic threshold and cut-off values ranging from 5-20% of the total household income have been reported in the literature.
Health expenditure has been also defined as catastrophic if a household's health expenditure exceeds 40% of income remaining after subsistence needs have been met. 
In developing countries, high out-of-pocket payments, an absence of risk-pooling mechanisms in health financing systems and high levels of poverty can result in catastrophic health care expenditure. Other factors contributing are households headed by an elderly or disabled person, families with a low income and those who have a member with chronic disease. 











Understanding household Catastrophic Health Expenditures: a Multi-country analysis
Ke Xu, David B. Evans, Kei Kawabata, Riadh Zeramdini, Jan Klavus, Christopher J.L. Murray 
Health Systems Performance Assessment: debates, methods and empiricism.
World Health Organization, 2003, Chapter 42

Catastrophic health expenditure is defined in relation to a household's capacity to pay. In this study health expenditure is defined as catastrophic when a household's out-of-pocket payments are greater or equal to 40% of its capacity to pay.
Household capacity to pay is defined as effective income remaining after basic subsistence needs have been met. 
The poorer the household, the higher the shares of total income or consumption devoted to food.
Health expenditures requiring out-of-pocket payments include all categories of health-related expenses. Typically these include consultation fees, purchases of medication and hospital bills. 
59 countries were analyzed with a wide range of results. (India in not included in the study!)

The triad of 
  1. poverty, 
  2. health service utilization
  3. absence of risk pooling mechanism
account for most of the variation across the countries.

Catastrophic payments are the biggest problem when all three of these factors are strong. In other words, we would expect to see high rates of catastrophic spending in countries with high rates of poverty, groups excluded from financial risk protection mechanisms such as social insurance, and moderate to high levels of health care physical access and utilization. 

At this point, snakebite accidents fit perfectly on: Affect mostly small agricultural, rural villages with  low incomes, they do not have any type of financial risk protection and the accident demands the access and utilization of high level and costly health services (many times private health facilities), sometimes far from were the accidents took place. 

It is important to recognize that the impact of out-of-pocket (OOP) payments is not fully captured by examining catastrophic spending. Many poor households will choose not to seek care rather than become impoverished. Making the users of health services pay OOP for the services they receive has a potential dual effect at the population level: impoverishing some households that choose to seek services and excluding other individuals from seeking health care. 

These is also quite clear on snakebites. When asked, patients would choose to go directly to a hospital if treatment is free or much cheaper as first option instead of local healers. 


Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges

Michael Kent Ranson, Health Policy Unit, London School of Hygiene and Tropical Medicine. UK.
Bulletin of the WHO 2002; 80: 613-621

Material wealth, health and the ability to cope with adverse health events are intimately related. 
Community-based health insurance schemes allow many people's resources to be pooled to cover the costs of unpredictable health-related events. They protect individuals and households from the risk of catastrophic medical expenses in exchange for regular payments of premiums. 
Prepayment (even in the absence of pooling) can facilitate access to expensive medical care, because it spreads cost over time and prevents people having to pay at the time of treatment. 
Community-based health insurance allows pooling in settings where institutional capacity is too weak to organize nationwide risk-pooling, especially in low-income countries. 

The Self Employed Women's Association was started by Ela Bhatt in Ahmedabad in 1972. "It is an organization of poor, self-employed women workers. There are women who earn a living through their own labor or small businesses. They do not obtain regular salaried employment with welfare benefits like workers in the organized sector. They are the unprotected labor force of India". (Would say the same for farmers!!!)

The Self Employed Women's Association's Integrated Social Security Scheme was set up in 1992. From an annual premium of 72.5 Rs, 30 Rs were dedicated to medical insurance. Women who pay this premium are covered to a maximum of 1200 Rs per year n case of hospitalization. 
It is a reimbursement system. The SEWA ass. directly provides preventive and curative services through 95 health centers which are open to its members as well as non-members. 
The author analyzes the changes occurred over from 1992 to 2002.

The aim of the study is to assess the impact of a community-based health insurance scheme on the medical indebtedness or impoverishment of their members.  

For Materials, methods, statistical analysis etc. please refer to the original as it is quite extensive. 

Results:
Between 1 July 1994 and 30 June 2000, 1930 claims for hospitalization were made. Mean age was 41 years. The leading causes for hospitalization were injuries, malaria, acute gastroenteritis and hysterectomy. Mean duration was 6.1 days (median=4days). Private-for-profit, government and private-non-profit hospitals cared for patients in 63.9%, 28.6% and 7.5% of claims, respectively.
Claims were rejected in 215 (11%) of 1927 cases.
The women who made claims were much poorer that the general population. The mean self-reported annual household income was 24,723 Rs (67.7 Rs/day), median 19,797 (54.2 Rs/day). 502 (27%) of claimants for whom income information was available fell below the poverty line. This value is within the wide range of estimates of the percentage of Gujarati households that are below the poverty line*.

*The poverty line values correspond to a total household expenditure estimated as enough to provide 2400 calories daily in rural areas and 2100 calories daily in urban areas, plus some basic non-food items. The poverty line in 1999-2000 was an income of 254 rupees per person per month's income. The author considered a household to be below the poverty line if its reported yearly income was below 13, 716 Rs (254 Rs per person per month x 12 months x 4,5 household members).

The median spent on the 1712 hospitalizations for which the cost was reimbursed was 1387 rupees and the median amount reimbursed was 1200 rupees.
47% of the claims were reimbursed full.

Expenditures on hospitalizations meant that an additional of 107 (6.6%) households fell below the poverty line. Reimbursement by the SEWA prevented 56 of this households (3.4% of 1632 claimants who were reimbursed) from falling below the poverty line (paired t-statistic=7.6, p<0.001), i.e. the fund significantly reduced the percentage of hospitalizations that would have resulted in impoverishment by 52%.

On average, claimants received reimbursement almost four months after hospital discharge, the lag time appeared to be longer for claimants who lived in rural areas and significantly for those who worked as farmers or agricultural laborers. This figures were substantially reduced on the last two years of the study: the 98 days between discharge and reimbursement broke down to 55 days.


Discussion
The SEWA Medical insurance Fund successfully included the poor. This reflects the commitment of the SEWA to target self-employed, poor women. This is probably due to the fact that it charges a flat-rate premium that is fairly low (currently 72.5 Rs, a 0,4% of median annual household income among claimants in this study). Studies of community-based health insurance have found that the cost of membership is an important determinant of participation.

This is challenging as low premiums that target a population for which the frequency of illness, and thus hospitalization, may be relatively high. A community-based health scheme that aims to strictly target the poor could improve equity and financial viability by seeking subsides from government or donor agencies. Subsides may, however, not be sufficiently reliable or sustainable. Alternatively, a socially oriented community-based health scheme could seed to broaden membership to include wealthier populations, but would ensure equity by indexing premiums to income and enabling equal (or better) access to care among the poor. For voluntary community-based health insurance schemes, this would require a high degree of social solidarity among members.


Even after claimants received reimbursement, cost relating to hospitalization were still catastrophic for some members. Some women may have paid the uncovered balance out of their savings, many undoubtedly had to borrow, sell capital, work more or forego spending.

The lag time between discharge and reimbursement was much higher than the SEWA stated goal of 30 days, at is was certainly too long for women who had to borrow at high rates of interest to pay for their hospitalization. Some proposals to remedy that as well as to help women to submit the claims. 

CONCLUSIONS:
This study is one of the few that have investigated the impact of a community-based health insurance scheme on use of health care and the financial burden of medical expenses.
In India, spending related to hospitalization is often catastrophic for household finances. The study shows that community-based health insurance schemes can effectively protect poor households from the uncertain risk of medical expenses, and they can be implemented in areas where institutional capacity is too weak to organize mandatory, nationwide risk-pooling. 


We need studies on the impact of the snakebite accident on the life / economy of the victims, particularly in India. Maybe we should start thinking on ways to help coping with this stressful situation through a kind of risk pooling for rural population. Need to investigate what has been done till now. Many more patients will go to hospitals if they could afford it, at the same time we need to guarantee good services able to deal properly with snakebites.
ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful



Wednesday, 10 May 2017

(I) On how a snakebite will change your life...

One of the things that are difficult to find related to snakebites is papers on how they affect the life of people. How this stressful situation is reflected, mostly at psychological and economical level. Some studies say that many patients suffer from Post Traumatic Stress disorder or depression after a snakebite. 

I'm starting to see snakebites as divided into three parts: 
  1. The first part is THE ACCIDENT ITSELF, and this must be approached with preventive measures basically, awareness campaigns like for car accidents or labor accidents. To be aware, do not drink alcohol, use some protection... There is no much done on job security and even car security is still very precarious. In some cases, appropriate laws and application of this legal measures eventually will be needed. Prevention is better than cure. Better safe than sorry.
  2. Second part is immediately AFTER THE ACCIDENT, and here is were all the diagnostic, therapeutic, research and others play a role.
  3. MEDIUM, LONG TERM CONSEQUENCES of the accident for the individual and the society.
There is plenty of literature on the second topic but very few on the first (awareness, prevention) and even less on the third (human impact of the bites).
Let's see what i there on the "cosmonet"!


This is a beautiful and rigorous study on the socio-economic impact of snakebites on the Rural population of Tamil Nadu, India. I will present a summary of the full article.

This is a PLOS article (open-access article). Please refer always to the original.

Snakebite and its Socio-Economic Impact on the Rural Population of Tamil Nadu, India.


Valyapuri S, Valyapuri R, Ashokan R, Ramasamy K, Nattamalsundar K et al.
University of Reading, United Kingdom / Karpagam University, Coimbatore, Tamil Nadu, India.
November 2013 / vol 8 / Issue 11 / e80090
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0080090


Abstract
Background: Snakebite represents a significant health issue worldwide, affecting several million people each year with as many as 95,000 deaths. India is considered to be the country most affected, but much remains unknown about snakebite incidence in this country, its socio-economic impact and how snakebite management could be improved.

Methods/Principal Findings: 
We conducted a study within rural villages in Tamil Nadu, India, which combines a household survey (28,494 people) of snakebite incidence with a more detailed survey of victims in order to understand the health and socio-economic effects of the bite, the treatments obtained and their views about future improvements. Our survey suggests that snakebite incidence is higher than previously reported. 3.9% of those surveyed had suffered from snakebite and the number of deaths corresponds to 0.45% of the population. The socio-economic impact of this is very considerable in terms of the treatment costs and the long-term effects on the health and ability of survivors to work. To reduce this, the victims recommended improvements to the accessibility and affordability of antivenom treatment.
Conclusions: Snakebite has a considerable and disproportionate impact on rural populations, particularly in South Asia. This study provides an incentive for researchers and the public to work together to reduce the incidence and improve the outcomes for snake bite victims and their families. 

INTRODUCTION:
The objective of this study was to obtain a more complete understanding of the incidence and effects of snakebites among the rural population of India and in particular to obtain the snakebite incidence rate in three different sizes of rural villages, prevalence rate in male and female populations and socio-economic impact of snakebites on rural population.

METHODS:
The study was conducted following ethical guidelines. Permission for the study were obtained from village and Panchayat leaders. The aims of the research were explaines to the participants in local languages and informed written consent was obtained from all study
participants. All data were anonymized prior to analysis. 

HOUSEHOLD SURVEY:

Villages were divided into three categories based on the number of households (2001 census Tamil Nadu). Type I less than 100 houses, type II between 100 and 250 and type III more than 250 houses. 
Ten villages from each of the three categories were randomly selected. The sample size is statistically meaningful and representative of the different geographical regions of Tamil Nadu. 
Village life in Tamil Nadu

Households surveys were conducted from every house in each sampled village, a total of 7,578 households representing 28,494 people. 
Every snakebite incidence that occurred in the last 10 years was registered and verified.
A detailed questionnaire (Study material S1, translated into Tamil*) was devised to ask victims about the circumstances of the snakebite, treatments and socio-economic impact direct and indirect for the victim and his/her family. The information was collected by face to face interviews. 
Answers were collected from 93 victims and 12 relatives of victims who had died following the snakebite. Between these 105 people this accounted for 129 bites. 
Exhaustive statistical analysis was done. 

RESULTS:
Household survey: A total of 7578 households representing 28,494 people were survey (621 from type I villages, 1871 from type II and 5086 from type III). 
  • 88.9% were involved in agriculture
  • Total number of snakebites 1409. 1115 people (3.9% of the sample) had been bitten by a snake and 20% of these more than once. People living in small (type I) villages were more likely to suffer from snakebites.
  • Rate higher in men than women
  • 9% (127 people) of the total bites resulted in death (0.45% of the total population surveyed).
  • The year-to-year variation correlated with the annual rainfall. More bites and deaths were recorded in years with higher rainfall. 
  • More precise data on the year the study was conducted show highest number of incidents between September and November, high incidents between April and June and low between December and March, correlating with the rainfall pattern as well as the agricultural activities. During wet months, more snakes may also enter into living areas to capture prey resulting in greater number of bites.
  • Economically active age groups (between 11 and 50) had higher number of bites with higher risk between 40 and 50).
  • In 77% of cases the snake was identified by the victim or the family. Of these, 79.4% were due to venomous snakes, all of which from the Big Four group, with Russell's viper and cobra being the most frequent cause of bites. Identification was not possible during night time.


DETAILED SURVEY OF SNAKEBITE VICTIMS
129 snakebite victims or their relatives answered a more detailed questionnaire which investigated the circumstances of the snakebite incidents, the treatments obtained, and their views about future improvement in treatment provision. In 12 of the cases the victim had died following the bite. 

  • 79% occurred when the victims were in the fields
  • 15% of the bites occurred indoors
  • 72% during working time 
  • 19% walking along main roads to villages or agricultural land
  • More frequent one peak in the morning and one late afternoon.
  • 82% on parts of the legs
  • 16% on parts of the arm. 
  • 20% the snake was killed and 14% of victims took the snake to hospital for identification.
  • Most frequent symptoms after snakebite were pain at the bite site, bleeding, giddiness, vomiting, sweating or unconsciousness and paralysis. 
  • 64,3% of the victims did not received first aid immediately after the bite. Where first aid was provided (98% by untrained individuals) the most common treatment was a tourniquet, applied with or without incision of the wound. Other measures were application of plants (Calotropis gigantea) , blood sucking, application of calcium carbonate. Some victims were advised to carry heavy weights or forced to vomit.  
  • 67% of victims went to hospital, 17% obtained traditional treatments and 10% had both. In hospital, 70% received snake antivenom (ASV)


HOW TREATMENT FOLLOWING SNAKEBITE COULD BE IMPROVED:
When the victims were asked for their views on how treatment following snakebite could be improved, most of the victims or their relatives considered that
  • Health care facilities equipped with ASV should be available in each village or, failing that, a vehicle available in each village to take snakebite victims to hospital. The primary health centers available in some of the villages did not hold any ASV.
  • Most of the victims or relative would be willing to go to hospital instead of traditional healers if hospital treatments were easily available.
  • ASV is available free of charge in government hospitals, but the majority of victims suggested that snakebite should be treated free of charge even in private hospitals. 
  • Victims also suggested that increased knowledge among the general public about the correct first aid for snakebites and how to handle bites from non-venoumous snakes would be a priority.
www.indiansnakes.org

SOCIO-ECONOMIC IMPACTS CAUSED BY SNAKEBITES
The major impact caused by snakebites was the financial burden to the family. 
The direct cost (transport and medical expenses) to the victims of treating the snakebite varied considerably, from as little as zero (16.3% of victims) to a maximum of Rs 350,000. 
The cost of treatment was increased dramatically in private hospitals due to the severity of the bites and the need for emergency medical equipment such as ventilator. 
75% of the victims that obtained hospital treatment attended only private hospitals and paid the treatment cost themselves.
Delay in treatment may be due to having first sought treatments by traditional healers, or their village primary health centre prior to referral to the nearest town hospital, and the further referred to district government hospital. In some cases they had travelled further to private hospital.

None of the 108 victims who paid for their treatment were covered by medical insurance. 
  • Over 40% of victims required to take a loan to pay for the treatment. The financial implications of snakebites were exacerbated by a lack of availability of loans for medical and associated expenses by the nationalized banks. 
  • In order to repay the loan, the families often had to sell their valuables.
  • The victims who paid for their treatment found it necessary to:
    • 17.8% sold stored crops (Rs 1000-20000)
    • 14% sold Valuable items (Rs10000-100,000)
    • 9.3% sold cattle (Rs 5000-30000)
    • 5.4% sold vehicles such as bicycles (1000-2000) and motorcycles (5000-20000)
    • A small number of people found it necessary to remove their children from education and send them to work.
    • Some had to sell family land or property (Rs 50000-400,000).
According to the Indian labour bureau, the average daily wage in India for agricultural occupations in 2007-2008 was Rs 76 for a man and Rs 54 for a woman. 
35% of the victims were admitted in hospital for more than a week for their treatment. In addition, around 50% had home rest after their treatment of between 1 month and 2 years, reducing family income. 

LONG TERM ECONOMIC AND PHYSICAL EFFECTS are associated with envenomation.
In two cases encountered in this study, the bite killed the only son within a family, leaving elderly parents with no financial support. 
Even where victims survived there were medium and long term consequences in 90% of cases.
In the long term 68% of victims experienced tiredness, which affected their ability to work. In six of these cases the victim was no longer able to work in agriculture and had to find alternative employment.
35% of victims experienced pain at the bite site or elsewhere ini the body. Other symptoms as numbness, swelling of face, hands and legs, liquid oozing from the bite site, blurred vision, eye watering, giddiness, shivering and nausea. 

DISCUSSION
This is the first large household survey of snakebite incidence. Snakebite is a significant problem within the rural population, particularly in the smallest villages. 

The distribution of bites with respect to age and gender are consistent with snakebite being an occupational health hazard affecting mostly agricultural workers. 

Bites are more common during periods of high rainfall and at harvest times. 

In most cases the species of snake could be identifies and was either one of the Big Four or a non-venomous snake.

Accepting the limitation in extrapolating these data to the whole population, if we assumed the data obtained from the 30 sampled villages as representative on entire rural Tamil Nadu, we would estimate on average that around 113,000 snakebites and 10,000 associated deaths occur annually within the rural population of Tamil Nadu. 
Mohapatra et al. estimated the annual death rate within Tamil Nadu to be 3,100. Interestingly, our data suggest that the number of bites is only 11 times the number of deaths, which is considerably lower than the ratio of 64 bites/death suggested by Mohapatra et al. based on hospital data. 


A sign hangs outside of a clinic in rural Tamil Nadu. The sign makes clear that
the clinic stocks antivenin against snake
A considerable level of migration was evident from the study villages to urban areas within the last 10 years, as members of the population seed to gain access to better employment and education. 

Immediate first aid often takes the form of traditions treatments. 

The delays in arrival at hospital, possibly linked to patients first seeking locally available traditional treatments or to the distance from health centre, caused complications. 

The socio-economic impacts that snakebites cause to victims are substantial. Beginning from the one-off direct cost to long term cost, endanger the livelihood of the family. The type of venomous snake responsible for envenomation is also a factor. For example, when Russell's or saw scaled viper bites occurred, they caused severe bleeding disorders and necrosis at the bite site, and these resulted in blood or plasma transfusion and/or skin grafts and major surgery. Elapid bites frequently cause severe respiratory distress / failure resulting in a requirement for ventilator use and multi-speciality hospitals. 


The clinicians that we interviewed in this study (data not shown) emphasized:
  • The need for reduction in the incidence of snakebite  by 
    • raising community awareness of the risks
    • prevention by wearing appropriate footwear
  • Improvements in the training of medical personnel in rural areas and in the education of medical students. 
  • Standard protocols and tools for diagnosis and treatment
  • Improvements to the currently available antivenoms either in terms of reduced side effects or improved efficacy. The available polyvalent ASV may not be effective against bites from some snakes (e.g. hump nose pit viper and Levantine viper) more recently recognized to be of medical significance. 
The victims also suggested
  • educating the community to enable them to administer first aid and making the availability of first aid kits in the rural community centres for easy and immediate access. 

The authors hope that this study will provide the incentive for researchers, the general public and clinicians to work together to achieve the key initiatives of the global snakebite initiative:
  • Improved community education
  • Improved education of medical personnel
  • Improved research on efficacy and safety on antivenom
The Study material S1 can be downloaded from the publication. 











ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful.