(II) -VSofI- "The Big Four": The North South division

The term "Big Four" term is used in reference to 4 widespread and lethal snakes of India: 

They are very popular and there is plenty of literature on them so you can find plenty of information about them. 

Here I would like to center on an excellent recent article:
What the authors did was to review the literature on snakebites and found a clear pattern of snakes distribution, mainly neurotoxic envenomations are found in the North regions while hematotoxic envenomations are prevalent in the South of India. The authors propose some measures to increase awareness as well as treatment effectiveness between sanitary personnel and lay population.

This is a selection of what are for me the most relevant points. Please refer always to the original article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5113082/

The North-South divide in snake bite envenomation in India
Vivek Chauhan, Sumar Thakur
Dr. RPGMC, Kangra, Tanda, Himachal Pradesh, India
J. Emerg. Trauma Shock. 2016 Oct-Dec; 9(4): 151-154
(This is an open access article). 
Cursive are mine.

ABSTRACT:

Snake bite envenomations are common in rural areas and the incidence peaks during monsoons in India. Prominent venomous species have been traditionally labeled as the "big four" that includes Cobra, Krait, Russel's viper and Saw scaled viper. Systematic attempts for identification and classification of prevalent snakes in various states of India are missing till now and there is no concrete data on this aspect. The published literature however shows that some species of snakes are more prevalent in a particular region that the other parts of India e.g. Saw scaled vipers in Rajasthan. 
We reviewed the published literature from various parts of India and found that there is a North-South divide in the snake bite profile from India.
Neurotoxic envenomations are significantly higher in North India compared to South India, where Hematotoxic envenomations are prevalent.
Russel's viper causes local necrosis, gangrene and compartment syndrome. These manifestations have never been reported in North Indian snake bite profile in the published literature. Early morning neuroparalysis caused by Krait is a common problem in North India leading to high mortality after snake bite.
This review presents supporting evidence for the North-South divide and proposes a way forward in formulation and revision of guidelines for snake bite in India.


INTRODUCTION:

On review of literature available for India, we saw a North-South divide in the presentation of venomous snake bites in India that has not been discussed till now by researchers, and the guidelines are also silent about it. 

Russell's viper is the most poisonous snake among "the big four" and is ubiquitous in South India (S-I), but is missing completely from all of North India (N-I) reports.

N-I snakes predominantly cause neurotoxicity in 70.95% of cases (877 envenomations). 

S-I snakes predominantly cause hemotoxicity or nephrotoxicity in 83.59% (1965 envenomations). This trend becomes apparent as we move Southward from Delhi early as Maharashtra, which has thus been included by us in S-I region.

• The North Indian profile is neurotoxicity predominant (Krait)
• The South India profile is hemo/nephrotoxicity predominant (Russell's and saw-scaled vipers).

Up to 30% of snake bites in NI are also cause by vipers, mostly saw-scaled or Himalayan pit vipers that cause mild hemotoxicity and in some cases mild nephropathy but ralely requiring dialysis. 

We need separate means and resources to tackle with two totally different profiles. All health-care personnel irrespective of their place of work must be trained in the airway and ventilation management. This alone can save many lives. 

DEADLY RUSSELL'S VIPER IN SOUTH:

The Russell's viper is the one that can cause severe local necrosis, gangrene and compartment syndrome, which has rarely been reported from N-I. 

Physicians in S-I have a nightmare treating the complicated Russell's viper envenomation that can cause severe local necrosis, nephrotoxicity, hemotoxiity and neurotoxicity, all four in the same patient!!! Such presentation in unheard in the North. 

The policymakers need to be aware of this fact so that they can establish more Intensive Care Unit and hemodialysis facilities for the management of complicated Russell's viper envenomations.

A maximum of 30 vials of anti-snake venom (ASV) is recommended for Russell's viper envenomation. Ten vials repeated 6 hourly till 30 vials total if whole blood clotting time remains >20 min. The symptoms usually reverse within few hours of ASV. Some patients develop severe nephrotoxicity despite early ASV. The neuroparalysis due to pre-synaptic toxin is unresponsive to ASV or neostigmine, and it takes 2-4 days for the reversal of paralysis. 

The patients need ventilatory support to survive. 

Russell's viper bites cause severe local necrosis, swelling, bleb formation, and even compartment syndrome. Good wound care and monitoring are required for compartment syndrome, and the surgical opening of fascial planes for pressure release may be needed in some cases. 

Cardiotoxicity, arrhytmias and autonomic dysfunction can also occur with Russell's viper bites. 

Health-care personnel and lay persons need to be educated through mass communication media regarding the prevalent medically important snakes in their area and their early manifestations so that they can seek timely treatment. 

NOTORIOUS KRAIT IN NORTH:

Neurotoxicity in N-I is caused mainly by Krait that bites indoors during night and mostly while the victim is asleep. The bite is painless, so the patient usually does not awake at the time of bite. In the morning, many of the victims are found dead, and others are paralyzed. 

In the absence of the snake sighting or fang marks over the body, the diagnosis of snake bite is missed until the patients reaches a competent doctor who has knowledge of the early morning neuroparalysis caused by krait bite. 

Ninety five percent of the Krait bites are documented within June to August months (Monsoon season). 

People die of respiratory paralysis. 

Laryngeal mask airway

There is a need for mass awareness specifically for early morning neuroparalysis (even abdominal pain as seen many time on Krait bites) specially during the monsoon months. 

We need to provide an early airway and breathing support for these people. 

All health-care staff needs to be trained in the use of laryngeal airway devices and the use of AMBU to ventilate a paralyzed victim till he can be shifted to the hospital. Laryngeal airway can be put blindly to secure the airway by staff nurses, health workers and technicians after a hands-on training of few hours.

The cost of laryngeal airway device is less than a single vial of ASV. Still, nowhere in N-I, we will find trained health staff and availability of laryngeal airway in the subcenters, primary health centers, and even in community health-care centers where it is badly needed. 

The use of laryngeal airways or AMBU will save more lives than any amount of ASV pumped into the system. 

Krait venom is not reversible with the use of neostigmine and takes 2-4 days to reverse. The patient needs ventilatory support for 2-4 days and most patients die due to the lack of ventilatory facilities even after reaching hospitals. 

Even the ASV does not reverse the neuroparalysis, which is due to presynaptic failure and it takes 2-4 days to regenerate presynaptic apparatus. 

ASV should be given to all neurotoxic envenomations in doses up to 20 vials maximum. The first dose for Krait bite is 10 vials and repeat doses are given if the symptoms are progressive after 1-2h. This regimen is as per the national snakebite management protocol.


COBRA BITES ARE INFREQUENT THROUGHOUT INDIA: 

Cobra is present all over India, and we found that of all venomous bites, cobra is responsible for only 5-10% all over India. This tells us that encounter with cobra is infrequent, and it does not stay as close to humans as Russell's viper and Krait. 
The differentiating feature of cobra from krait is the local pain, necrosis and swelling at the site of bite which is seen in cobra and never in krait bites. 
Neostigmine is another way of differentiating as cobra venom is post-synaptic and can be reversed using 1.5-2mg of neostigmine given intramuscular (IM) with 0.6 mg of atropine IM. The reversal is seen within minutes, and it can be repeated 0.5 mg of neostigmine IM every 30 min. for up to 8h. with 0.6 mg atropine by infusion. 
If the patient shows signs of bleeding or nephrotoxicity, we should discard a Russell's viper envenomation. Russell's venom is unresponsive to neostigmine, and it should no be repeated if there is no improvement in ptosis after the first dose within an hour. 
Cobra bite releases high volumes of venom, so ASV required is up to 20 vials. The first dose given is 10 vials and repeated after 1-2h for up to 20 vials maximum if the symptoms are showing a progression over time. 


SAW-SCALED VIPER:

It is prevalent all over India. 
The saw-scaled viper bites are more common culprits in hemo-nephrotoxic envenomations in North India than is South. Of all envenomations in North, 30% are hemotoxic. These bites are mostly caused by the saw-scaled viper. 
The patients presents with local swelling and mild bleeding manifestations. The whole blood clotting time is >20 min and the patient may be in hypotension. 
These patients develop mild acute kidney injury in most cases, rarely requiring dialysis. 
Mortality due to saw-scaled viper is rare and complications are acute kidney injury requiring hemodialysis. The ASV is effective against most of the cases in North India. 

Green pit viper and Hump-nosed pit viper:
The first has been described as hemotoxic in North-areas while the second is reported and hemo and nephrotoxic in south.


THE CURRENT GUIDELINES AND THE WAY FORWARD:
The National Snakebite Management Protocol was released by the Director General of Health Services, Ministry of Health and Family Welfare, India, in 2009. 
The World Health Organization regional office for South East Asia also released guidelines for the management of snake bites in 2010. 
These are the latest updated resources* for the identification and management of snake bites in India. 

The ASV available in India is raised in horses against "the big four" only. However, there are other medically important species naw being frequently reported from various parts on India and unresponsive to this polyvalent ASV:
Hypnale Hypnale (hump-nosed pit viper)
Echis carinatus sochureki (saw-scaled viper, Rajasthan)
Trimeresurus malabaricus (Malabar pit viper, Karnataka). 
Green pit viper (Himachal Pradesh
between others.

Seems as the authors consider Cobra and Krait as a whole. ASV is prepared specifically from Naja Naja (spectacle Cobra) and Bungarus Caeruleus (Common Krait) species. Other species of these families that are also common in some territories, like Naja Kaouthia (monocle Cobra) in Norht-East are not fully responsive to the ASV. 

This review brings into focus the updated situation of variable venomous snake bite profile in various parts of India based on the published literature.
There may be other species causing medically important envenomations but due to the lack of evidence, they have not been included.

• We suggest a nationwide registry of snakebites involving medical colleges so that we know the profile of medically important species and their variations from North to South and East to West. 
• And effort should be made to differentiate the type of viper involved when hemonephrotoxic manifestation is seen.
• Mass awareness of locally prevalent snakes, their manifestations, first aid do's and don'ts and the centers with the availability of ASV is very important in dealing effectively with the menace of snake bites in India. 
• We may find poor response to ASV against even "the big four" due to regional variability in species (and even same specie) which needs to be taken care of.
• The current ASB is produced from snakes found in a very small area in South India, and these may not be very effective against snakes found in other regions. 
• All Asha workers and ambulance technicians should be trained in first aid and early management of snake bite. They should become the rescue agents in the place of the tantriks and mantriks who delay the treatment by fostering a false belied in the minds of the people that they can do miracles. 

* This article was accepted for publication in August 2016. Later on, by the end of 2016 a new Guidelines for the management of snakebites were published. 

This is the link:

http://apps.searo.who.int/PDS_DOCS/B5255.pdf

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

(I) Venomous snakes of India (VSofI): WHO categories

To clarify concepts: 

Venom is something that goes directly into your bloodstream, as a result of a wound, punction, bite...

Poison is something you take, eat or drink. 

That is the reason why we should use "SNAKEBITE ENVENOMATION" and not poisoning, even if this term is quite popular.


CLASSIFICATION OF VENOMOUS SNAKES:
There are three families of venomous snakes in South-East Asia,

• Elapidae, 
• Viperidae and 
• Colubridae. 

ELAPIDAE
This family includes:

• Cobras, king cobra, 
• Kraits, 
• Sea snakes. 

Elapidae are relatively long, thin, uniformly-coloured snakes with large smooth symmetrical scales (plates) on the top (dorsum) of the head. There is no loreal scale between the preocular and nasal scales. Some, notably cobras, raise the front part of their body off the ground and spread and flatten the neck to form a hood. Several species of cobra can spit their venom for one meter or more towards the eyes of perceived enemies. Venomous sea snakes have flattened paddle-like tails and their ventral scales are greatly reduced in size or lost. Envenomation by an elapide snake is typically neurotoxic. Sea snakes produce myonecrosis (muscle destruction).

VIPERIDAE 
Viperidae have relatively long fangs (solenoglyph) which are normally folded flat against the upper jaw but, when the snake strikes, they are erected.
There are two subfamilies:

• Typical vipers (Viperinae) and 
  
• Pit vipers (Crotalinae). 

The Crotalinae have a special sense organ, the loreal pit organ, to detect their warm-blooded prey. This is situated between the nostril and the eye.

Viperidae are relatively short, thick-bodied snakes with many small rough scales on the top (dorsum) of the head and characteristic patterns of colored markings on the dorsal surface of the body.
Envenomation by a viperide snake is typically hemotoxic


COLUBRIDAE
This snakes are mildly or non-venomous and usually are not considered as medically important snakes but, some of the can be easily confused with venomous snakes.

MEDICALLY IMPORTANT VENOMOUS SNAKES IN SOUTH-EAST ASIA REGION 

(WHO 2010)

India has around 275 species of snakes, out of which fifty are venomous plus another forty five mildly venomous. Of this fifty, not all are lethal, and some of them are distributed in very restricted areas.Based on current herpetological and medical literature, it is possible to partially prioritize the species of snakes that are of greatest medical importance in different regions.

Detailed statistics on the species of snakes responsible for envenoming and fatalities throughout the world are lacking, except for a few epidemiological studies which include rigorous identification of the biting snake in a few scattered localities.

Venomous snakes of highest medical importance can be classified into two categories according to the following criteria:

Definitions of Category 1 and Category 2 are:

Russell's viper fangs

CATEGORY 1: Highest medical importance
Definition: Highly venomous snakes which are common or widespread and cause numerous snakebites, resulting in high levels of morbidity, disability or mortality.

CATEGORY 2: Secondary medical importance
Definition: Highly venomous snakes capable of causing morbidity, disability or death, for which exact epidemiological or clinical data may be lacking; and/or which are less frequently implicated (due to their activity cycles, behavior, habitat preferences or occurrence in areas remote to large human populations).


Category 1: The venoms of these species should be considered a starting point for establishing the most important targets for anti-venom production

• Elapidae: 
• Common Krati (Bungarus caeruleus)
• Monocled Cobra (Naja kaouthia) (east)
• Spectacled Cobra (Naja naja) (throughout)

• Viperidae: 
• Russell's Viper (Daboia russelii) 
• Saw Scaled Viper (Echis carinatus)
• Hump Nose Pit Viper (Hypnale hypnale) (south-west) 

Category 2: 

In many countries, territories and other areas there are species of snakes that rarely bite humans but are capable of causing severe or fatal envenoming. Their medical importance may not justify inclusion of their venoms in the immunizing mixture for production of poly-specific anti-venoms but the need to make anti-venoms against these species needs to be carefully analyzed. 

• Elapidae: 
• Northeastern hill krait (Bungarus bungaroides) 
• Banded Krait (Bungarus fasciatus)
• Lesser black Krait (Bungarus lividus) 
• Black Krait (Bungarus niger)
• Sind Krait (Bungarus sindanus)
• Wall's sind Krait (Bungarus walli)
• Caspian Cobra (Naja oxiana) (northwest), 
• Andaman Cobra (Naja sagittifera) (Andaman Islands); 
• King Cobra (Ophiophagus hannah) (south, north-east, Andaman Islands); 

• Viperidae: 
• White lipped pit viper (Cryptelytrops albolabris) 
• Red tail pit viper (Cryptelytrops erythrurus)
• Northern white lipped pit viper (Cryptelytrops septentrionalis)
• Himalayan pit viper (Gloydius himalayanus)
• Jerdon's pit viper (Protobothrops jerdonii)
• Kaulback's lance-head pit viper (Protobothrops kaulbackii)
• Brown spotted pit viper (Protobothrops mucrosquamatus)
• Bamboo pit viper (Trimeresurus gramineus) (south India), 
• Malalbar pit viper (Trimeresurus malabaricus) (south-west),

The forgotten Sea snakes!!!
"Although venomous marine sea snakes have not been included in the tables of medically important venomous snakes, it should be recognized that there are a number of species of marine snakes with potent venoms that can cause illness or death"

SOURCE: WHO guidelines for the production, control and regulation of Snake Anti-venom Immunoglobulins 2010 

http://www.who.int/bloodproducts/snake_antivenoms/snakeantivenomguideline.pdf




THE ANTI-VENOM

Nowadays, the only anti-venom available in India is a polyvalent anti-venom against four out of the six snakes listed in the category 1:

• Common krait (Bungarus caeruleus)
• Spectacled Cobra (Naja naja)
• Viper Russell's (Daboia russelii)
• Saw scaled viper (Echis carinatus)  

There is NO anti-venom for:

•  any of the two left snakes in category 
• Monocled Cobra (Naja kaoutia)
• Hump Nose pit viper (Hypnale Hypnale)
• or any of the snakes listed in category 2 and we should have in mind that 
• sea snakes also are not included in any list or category.

Furthermore, anti-venom activity has a high geographical variability.
Ideally, anti-venom should be produced from the same snakes common in a particular geographical area otherwise, less activity, waste of vials, increase of secondary effects include anaphylaxis are the consequence. We will see that in another post.
Next post about "the Big Four and much more".

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

Indian Snakebite Panorama: The Mohapatra study

Snakebite Mortality in India: A Nationally Representative Mortality Survey

Citation: Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, et al. (2011) Snakebite Mortality in India: A Nationally Representative Mortality Survey. 

PLoS Negl Trop Dis 5(4): e1018. doi:10.1371/journal.pntd.0001018 

Published April 12, 2011 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075236/pdf/pntd.0001018.pdf

This is an Open Access article.

This study changed the face, created a kind of "new paradigm" on the believes about snakebite related deaths in India.  It is a very rigorous study on snakebite mortality. 

Abstract Background: India has long been thought to have more snakebites than any other country. However, inadequate hospital based reporting has resulted in estimates of total annual snakebite mortality ranging widely from about 1,300 to 50,000. We calculated direct estimates of snakebite mortality from a national mortality survey. 

Methods and Findings: We conducted a nationally representative study of 123,000 deaths from 6,671 randomly selected areas in 2001–03. Full-time, non-medical field workers interviewed living respondents about all deaths. The underlying causes were independently coded by two of 130 trained physicians. Discrepancies were resolved by anonymous reconciliation or, failing that, by adjudication. A total of 562 deaths (0.47% of total deaths) were assigned to snakebites. 

Snakebite deaths:

• occurred mostly in rural areas (97%), 
• were more common in males (59%) than females (41%), and 
• peaked at ages 15–29 years (25%) 
• and during the monsoon months of June to September. 

This proportion represents about 45,900 annual snakebite deaths nationally (99% CI 40,900 to 50,900) or an annual age-standardised rate of 4.1/100,000 (99% CI 3.6– 4.5), with higher rates in rural areas (5.4/100,000; 99% CI 4.8–6.0), and with the highest state rate in Andhra Pradesh (6.2).

Annual snakebite deaths were greatest in the states of Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500). 

Conclusions: Snakebite remains an underestimated cause of accidental death in modern India. Because a large proportion of global totals of snakebites arise from India, global snakebite totals might also be underestimated. Community education, appropriate training of medical staff and better distribution of anti-venom, especially to the 13 states with the highest prevalence, could reduce snakebite deaths in India. 

The Registrar General of India (RGI) organizes the Sample Registration System (SRS), which monitors all births and deaths in a nationally representative selection of 1.1 million homes throughout all 28 states and seven union territories of India. The number or births and deaths are registered every six months but not the cause of death. What the author's did was to train 800 people that visited each SRS area every six months and recorded a written narrative (in the local language) for each death from families or other reliable informants as well as standard questions about the death. These field reports, or ‘verbal autopsies’, were emailed randomly (based on the language of the narrative) to at least two of 130 collaborating physicians trained in disease coding. 

The data were statistically analyzed and undergone several quality control procedures. 

The data obtained between 2001 and 2003 were applied to the population estimates of the United Nation for India for 2005. According to the author's it doesn't introduce a significant bias to the results. 

RESULTS

DEMOGRAPHICAL DATA

• A total of 562 of the 122,848 deaths from the 1.1 million homes national survey( 0.47% weighted by sampling probability or 0.46% unweighted) were from snakebites. 
• Almost all snakebite deaths (544 or 97%) were in rural areas
• More men (330, 59%) than women (232, 41%) died from snakebites (overall ratio of 1.4 to 1).
• The proportion of all deaths from snakebites was highest at ages 5–14 years
• Only 23% (127/562) of the deaths occurred in a hospital or other healthcare facility. 
• Expressed as national totals, snakebites caused 45,900 deaths in India in 2005 (99% CI 40,900 to 50,900).
• The age-standardised death rate per 100,000 population per year was 4.1 (99% CI 3.6– 4.5) nationally and was 5.4 (99% CI 4.8–6.0) in rural areas.

RISK FACTORS AND SEASONALITY

• Per religion, the risks of snakebite deaths were significantly increased among Hindus.
• Farmers/laborers were the most affected. 
• Deaths occurring outside home
• The monsoon months of June to September show a high number of deaths. 
• Gender and education were not significantly associated with risk of snakebite death

STATE MORTALITY PATTERNS

Annual age-standardised mortality rates per 100,000 from snakebite varied between states, from 3.0 (Maharashtra) to 6.2 (Andhra Pradesh) in the 13 states with highest prevalence (average 4.5) compared to 1.8 in the rest of the country. 

Total deaths were highest in Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500). The age and gender of snakebite deaths also varied by region, although these differences were not significant due to the small numbers of snakebite deaths in each state. Deaths at ages 5–14 years were prominent in the states of Jharkhand and Orissa, whereas deaths at older ages were prominent in Andhra Pradesh, Bihar, Madhya Pradesh, and Uttar Pradesh (data not shown). In Bihar, Madhya Pradesh, Maharashtra and Uttar Pradesh, female deaths exceeded male deaths

Colors represent prevalence SB deaths/100.000 habitants.
Bars represent the estimated total number of deaths in
thousands. States with SB death below 3/100.000 or with
population less than 10 millions are not shown.

DISCUSSION (I've selected some of the paragraphs):

Snakebite remains an important cause of accidental death in modern India, and its public health importance has been systematically underestimated. The estimated total of 45,900 (95% CI 40,900–50,900) national snakebite deaths in 2005 constitutes about 5% of all injury deaths and nearly 0.5% of all deaths in India. 

It is more than 30-fold higher than the number declared from official hospital returns. 

The underreporting of snake bite deaths has a number of possible causes. 

• Most importantly, it is well known that many patients are treated and die outside health facilities – especially in rural areas. Thus rural diseases, be they acute fever deaths from malaria and other infections or bites from snakes or mammals (rabies), are underestimated by routine hospital data. 
• The true burden of mortality from snakebite revealed by our study is similar in magnitude to that of some higher profile infectious diseases; for example, there is one snakebite death for every two AIDS deaths in India. 
• Very crudely, even if we halve the fatal/nonfatal bite ratio to 32, this would suggest at least 1.4 million non-fatal bites corresponding to the 45,000 fatal bites. The actual number of non-fatal bites in India may well be far higher
• Our study has limitations; notably the misclassification of snakebite deaths. However, snakebites are dramatic, distinctive and memorable events for the victim’s family and neighbors, making them more easily recognizable by verbal autopsy. We observed a reasonably high sensitivity and specificity when compared to re-sampled deaths. Confusion with arthropod bites and stings is unlikely because of the different circumstances, size and behavior of the causative animal and the course of envenoming. 
• Kraits (important agents of snakebite death in South Asia) may unobtrusively envenom sleeping victims, who may die after developing severe abdominal pain, descending paralysis, respiratory failure and convulsions. Such deaths might not be associated with snakebite at all.
• The marked geographic variation across states in our study is similar to that in a country-wide survey conducted during the period 1941–45, which identified Bengal, Bihar, Tamil Nadu, Uttar Pradesh, Madhya Pradesh, Maharashtra and Orissa as having the highest death rates from snakebite. Moreover, despite the obvious underestimates in hospitalized data, their geographical distribution of bites and deaths were similar to what we observed from household reports of deaths. The marked differences in snakebite mortality between states of India may be attributable to variations in human, snake and prey populations, and in local attitudes and health services. 
• The 13 states with the highest snakebite mortality are inhabited by the four most common deadly venomous snakes: Naja naja, Bungarus caeruleus, Echis carinatus and Daboia russelii. With the exception of E. carinatus, which favors open wasteland, these are widely distributed species of the plains and low hills where most Indians live. 
•  As found in an earlier study [33], the peak age group of snakebite deaths is 15–29 years (25% or 142/562). However, the relative risk of dying from snakebite versus another cause was greater at ages 5–14 years. The peak age range and gender associated with snakebite mortality varied between states, perhaps reflecting differences in the relative numbers of children and women involved in agricultural work. 
• The slight excess among Hindus may reflect more tolerance of snakes and greater use of traditional treatments. 
• Snakebites and snakebite fatalities peak during the monsoon season in India and worldwide , probably reflecting agricultural activity, flooding, increased snake activity, and abundance of their natural prey. 
• Only 23% of the snakebite deaths identified in our survey occurred in hospital, consistent with an earlier study from five states. This emphasizes three points: 

1. Hospital-based data reflect poorly the national burden of fatal snakebites; 
2. Inadequacy of current treatment of snakebite in India; and 
3. Vulnerability of snakebite victims outside hospital. 

PRACTICABLE SOLUTIONS INCLUDE:

• Strengthening surveillance to allow a more accurate perception of the magnitude of the problem, 
• Improving community education to reduce the incidence of snakebites and 
• Speed up the transfer of bitten patients to medical care, 
• Improving the training of medical staff at all levels of the health service (including implementation of the new WHO guidelines), and 
• Deployment of appropriate antivenoms and other interventional tools where they are needed in rural health facilities to decrease case fatality. In addition, 
• Phylogenetic and venom studies are needed to ensure appropriate design of antivenoms to cover the species responsible for serious envenoming

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

First Aid Snakebite Video for Students. Ramathibodi Hospital. A Thailand Initiative.

There are quite a lot of videos on Snake Bite first aid for the general population. I will go through them on the time. Some are good, some are not that good, some are still giving wrong or misleading indications about what to do o not to do.

I would like to start this video that is an initiative of the Department of Emergency and Accidental Center, Ramathibodi Hospital (Faculty of Medicine Ramathibodi Hospital), Mahidol University, Thailand.

Please watch it. It is aimed to create AWARENESS among students and can be applied to any situation. 

Bravo for the initiative!


The story:

A student is at the campus enjoying a sunny day, she is bitten by a cobra. We will see, on a funny way, what their classmates try to do for help, many times more harmful than anything!

Through that, we will learn the more correct way to first aid snake bites.

There english subtitles, white color and small size not easy to read. I'm transcribing the text that is significant for fist-aid. 

Who said that create awareness is a boring thing? sure they had a great time doing this video!!!

Those are the transcriptions of some of the scenes:

2:31 At the park, after applying a tourniquet...

- Classmate (C): Let's get her to the hospital

- Sport students (SS): Shouldn't we try to catch the snake?

- C: What for? we don't have time for that. 

3:09 At the Hospital

- Doctor (D): Who told you to apply a tourniquet? - That's a common misconception 

- C: What misconception?

- D: A tourniquet is the wrong first-aid procedure for a snake bite. It could be harmful and it is the wrong way to help.

- All: What? the wrong way to help?

- C: What I hear is that when a snake bites, you should apply a tourniquet to slow down the venom.

- D: That's a misconception. A tourniquet can obstruct the blood flow to the bitten site which can result in an amputation. 

- Patient (P): What? an amputation? You should have known better!!!

- D: Calm down, hold still. Especially around the bitten area. Try not to move. But you can breathe and move a little. 

- C: What is the right procedure? What should we do?

- D: Well, the right procedure is to (to the patient) keep still as much as you can, then find and elastic bandage to tie above the bound.

4:48 At the park.

C: Please get me some ice and bandage. 

P: It hurts!!!

.../...

P: What are you doing?

C: Covering the wound.

P: Covering to where?

C: To the level of your heart. 

P: My heart? Why?

C: To slow down the venom.

5:35 At the Hospital.

D: Who told you to mummify her like this? and who told you to apply the ice? Don't you know the everything you did was the wrong way to help?

All: What? the wrong way to help?

D: To cover the wound just tie the bandage above the wound or the whole leg, but make sure it is not too tight so the blood can still circulate. Squeeze the toe, if it is still red its fine. 

eh! don't try to catch the snake! just notice its appearance or the color or take a picture of it. 

6:28 At the park

They try several methods like apply a flame - electric shock, apply herbs on the wound or make several cuts around the wound and try to suck the venom... All they are wrong!

... / ...

P: What are you doing?

C: Take off your shoes, also need to remove all your jewelry. 

P: What are you doing?

C: Covering the wound. Then squeezing the tip of the toe to see if blood flow is correct. 

8:17 At the Hospital

D: What have you done to her?

C: So we when back, she was worse so we burned the wound but it didn't help, (D looks quite astonished) then we tried a different method and we used herb to cover the wound, it also didn't help, then we cut the wound open and then sucked the venom out, also didn't help!!!
D: Why didn't you just electroshock her?
C: I tried, but we didn't have the apparatus!
D: I was being sarcastic! do you realize that all you did was the wrong way to do it?
All: What? The wrong way?
D: That's right. Listen: burning the wound or electroshocking her doesn't help at all, if anything, it'll make it worse. Covering the wound with herb can also lead to an infection. Cutting the wound open risks slashing the main arteries. Huge complications, you know? Also, who is it that told you to suck the venom? You are watching too much movie! it doesn't help one bit, and the person who does it might receive the venom herself.
C: So, what is the best way to perform first-aid in this case?
D: Here is how to do it. For a snake bite you would see the fang marks, right?

1. the first step is to calm down the patient
2. then you should position the wound below the patient's heart level
3. and if there is any jewelry or constricting items: remove them, because the venom may cause swelling at the site of the bite. 
4. (patient) stay as still as you can 
5. then cover the wound with some gauze or cloth. Use a elastic bandage to cover over the wound or the whole leg. Tie like you would do with a patient with a broken leg. The way you did is actually correct. If you can find a stick you can create a splint by using the other leg instead, just like this. But the thing is make sure it is not too tight so the blood can still circulate. 
6. One more thing, if the patient is loosing conscience, don't pour whiskey in her mouth to wake her up, she might choke.
7. Also notice the patient's vital signs, if she stops breathing perform CRP immediately
8. Most important of all, you must to stay calm yourself. 

C: That's a lot! won't the patient be death before reaching the hospital?
D: I don't think so. If we treat her correctly the venom will not spread quickly. Most snakes that bite are just frightened. In some cases, the snakes didn't even release the venom.
P: Why didn't you learn all these before?
C: I don't know
D: I've got a simple solution for you, just dial 1669, it is a 24h. emergency hotline. They've got trained professionals and vehicles with qualified staff that are ready to mobilize and assist the patient at the scene...

Final everybody dancing!!!

FIRST AID SNAKEBITE DOs and DON'Ts

DO calm the patient down
DO ensure that the wound is below the patient's heart level
DO remove all the jewelry, tight-fitting clothes
DO cover with bandage or make a loose splint
DO bring the patient to the hospital ASAP, perform CPR if necessary

DON'T apply a tourniquet
DON'T burn the wound
DON'T cover the wound with herb
DON'T cut the wound open and suck the venom out
DON'T electroshock the wound
DON'T pour whiskey into the mouth of the patient who's unconscious.

I would like to say: do not give any intoxicant or caffeine to a patient with snake bite as can be misleading if it has been a neurotoxic bite. Furthermore, caffeine can increase heart rate and speed the spreading of the venom.

The "India Snake Bite Initiative"

I would like continue the websites resource's list with the  Indiansnakes.org website, that includes the "India Snake Bite Initiative".

"For snakes and snake people"

The site map has been developed and is maintained by the Ramakrishna Mission, Shivanahally.

This web contains very helpful and interesting features like:

ON SNAKES

• COMPLETE DATA BASE ON INDIAN SNAKES

You can search a snake by

• Family (scientific family)
• Toxicity (Venomous, mild, non venomous)
• Region of India (the states of India)
• Type of snake (common family names)

Here is one example, 

http://indiansnakes.org/content/banded-krait

I choose one snake from the last page, in this case a banded-krait (there are more than 200 snakes listed). This is the information give: Scientific name, family, common regional names in local language, map with the geographical distribution,  venom type (neurotoxic in this case), full description with escalation for complete identification, habitat, natural history, bite symptoms, particular threats for this species. 

The Ramakrishna Mission, has developed an application for iOS and Android so you can check for any snake or related resources,  even if you are offline!

• SNAKE BITES FIRST AID, FACTS AND PREVENTION

Very good presentation. I will go into more detail into a separate post as snake bites (SB) first aid deserves several posts.

http://www.slideshare.net/JoseLouies/snake-bite-firstaid-facts-prevention?ref=http://www.indiansnakes.org/content/snakes-kanha-saving-human-and-serpent-lives-and-around-tiger-reserve

• BLOGS: As it is explained at the beginning of one of the post (Snakes of Kanha) the origin of the Indiansnakes.org was basically to build a data base on indian snakes. Slowly, the human factor grew, the fact the snakebites are a plight affecting the rural areas was the starting point for being involved in many activities to create awareness on snakebite prevention, snake preservation, snakebite treatment and even research. 

• COMMANDMENTS: Do's and Dont's of snake rescue

• FANG FACTS: Those questions you wanted to ask and their answers

• FIND A SNAKE RESCUER: Map of India where you can click to obtain name and contact phone number of a recognized well trained and "snake preservation oriented" snake rescuer. Avoid fame thirsty "media star " snake rescuers (this is a personal advice).

• "THE INDIA SNAKE BITE INITIATIVE": PROJECT PITHORA 

The Anjali Health Centre is located in Lahrod Village, Pithora block under Mahasamund District of Chhattisgarh. It is 100kms from Raipur which is the capital of Chhattisgarh. Anjali Health Centre has basic health care facility managed by a group of missionary nuns belonging to the Third Order of St. Francis. The congregation has health care units in Chhattisgarh, Madhya Pradesh, Jharkhand (2) and Uttar Pradesh. All the five health care centers are located in remote areas and caters to hundreds of villages around them. Out of the five units, Anjali Health Centre is the biggest one with a capacity of 20 beds. 

Anjali Health Centre is well known for the Snake bite treatment in the region. The centre is managed by Sr. Stella, the administrator; Dr. Sr. Siji, MBBS, Sr. Arochia staff nurse and trained nurse anesthetist and three trained nurse sisters from the convent.

The hospital holds a stock of ASV (Anti Snake venom) to treat snake bite victims. There is no other medical health assistance facility in the range of 45 kms and in case of snake bite, the patient should reach a government hospital in Raipur which is about 100 kms away. Considering the logistic availability and resource constraints, it may take minimum of four to five hours for a villager to reach a victim to the hospital, which is often too late for treatments. 

"The main challenge faced is the timely arrival of the patients to the hospital, the availability of anti-venom in enough quantity and a ventilator as the most wanted life supporting system".

I will dedicate a full post to this initiative and the reasons why it works and the people behind it. 

• SNAKES CHECK LIST: there is a list with photo and scientific name of 208 (that is what I counted, hope it is correct) snakes, from non-venomous to lethal. Brings you to same page as the indian snakes database. 

• CONTACT US: Info on the aim of the website, goals and team. 

"This website is a collective effort of various people who contributed their expertise voluntarily towards creating awareness about snakes and snake conservation across the country. The team consists of professionals from the field of Wildlife Conservation, Software Industry, Photography & Management. All of us work together as a group with specific roles to play and tasks to complete."

Vision: “Co-existence of serpents and people across the world “

Mission: “Conserve snakes in their natural habitat and reduce human mortality from snake bites through research, education & outreach activities “

Our Five year goals ( 2010 : 2015 )

• 1. Create an online database of Snakes of India.
• 2. Conduct / facilitate awareness workshops on snakes and snake bites.
• 3. Promote ethical and legal rescue and handling of snakes & an online database of snake rescuers across the country.
• 4. Build a network of snake bite treatment experts across the country.
• 5. Provide email / on phone assistance to people on various snake related issues.
• 6. Provide a platform for students, researchers and naturalists to collect scientific data and facilitate study of different species of snakes.

Our final goal is to have a global website and information management tool (mobile apps which can be used as ready reference even when one is offline) for the snakes of the world which will be maintained by a global network of experts. 

Core team@Indiansnakes:

Snake identification, photos and data management: Vivek Sharma

Site management: Raj Pawan G

Team Lead: Jose Louis

• ABOUT: 

"This is a meeting place for all those who are interested in Snakes of India. Members can share their photos, videos, rescue experiences, snakebite cases and all related matters to understand them better for their conservation and positive relations with humans. We support balance between ethical, sensitive and scientific way of treatment."

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

Part 4, Dr. Robert Harrison SB tissue necrosis

Part 4 is focused on snake bite (SB) tissue necrosis. Starting minute 30':30

SNAKE BITE TISSUE NECROSIS:

SB tissue necrosis affects three times the people that die from SB at least, so in Sub-saharan Africa is estimated that hundred thousand people that survives SB are suffering conditions like this. 

This is a nine years old girl bitten by a cobra in North-East Nigeria, the tissue was debrided,  this keloid contracture developed that has completely malformed the fingers of her hand... two weeks ago we saw a virtually identical thing in Kenya so, it is happening all over the place. Amputations are not uncommon, estimations of 8.000 amputations are performed on SB victims every year in Africa Sub-Saharan Africa. There is no medicinal treatment, IgG that is effective against the lethal effect in systemic circulation is ineffective against this. It is a too large molecule to rapidly cross from the blood where is intravenously delivered to the tissues, to negate this type of progression of tissue destruction. Surgical debridement / amputation is the only recourse to deal with this. Therefore, there is a compelling and I think really urgent need for research to do something about it, to come with an alternative, and we are following a route through camelids using their unique immunology. 

We all have, all our immunoglobulins are heavy and light chains, this are large, 150 kDa. Camels are unique in the animal kingdom, except for sharks, and that most of their IgG lacks light chains, if lacks that is a severe disease but in camels is not a problem at all. What is really interesting for us is that this moiety that binds the foreign protein, the VHH, is only 15 kDa, is one tenth the size of conventional IgG used to treat SB patients. So we figured, we considered that if we could make and AV consisting of this, then we might have something to work with. And we entered into collaboration with the Central Veterinarian Research Labs (CVRL) in Dubai, injecting animals, extracting the blood from venom immunized camels.

Don't worry about this (figures on the slide) I just wanted to emphasize that we put a lot of effort into this, it is a over of years of immunization and of the poly-specific immunized camels, I want you to focus on this, this one camel here, which is this fellow, and what we did is we extracted the IgG, the total IgG from this animal and we then purified out just the heavy chain, only IgG, and then fractionated the VHH using papain as well, and we compared this three camel IgG entities with the most effective AV in sub-saharan Africa which is the South African product, in their ability to neutralize the lethal, the hemorrhagic and the coagulopathic effects of the saw scaled viper. And bear in mind when you look at this figures that the more effective it is, the lower the amount needed. You will see that VHH gram per gram, microgram per microgram, five times more effective than total IgG and three times more effective than AV, that the best AV in Africa, due to neutralization of hemorrhage, due to neutralization of coagulopathy. 

This is by far the more affective AV ever devised because it's got ten times the binding valency than any of the other AV, because is so small, it is only 15 kDa. And we were really keen because we think that 15 kDa it will have the same tissue distribution dynamics as the venom protein but, there is always a but, we had to resolve the problem of the very low yield of VHH from IgG, it is terrific, it is not commercially viable, and so what we are going to do is clone the genes from here, take this VHH from the camel B cells and make them as recombinant proteins. 

The next thing we need to do is to make an only specific, this VHH, to those venom toxins that causes necrosis, many venom proteins don't, so we can make a toxin-specific exactly  in the same way that we are doing in the systemic approach and then finally decided upon a delivery way, it is absolutely clear that you could not deliver a 15 kDa VHH into the blood circulation and expect it to last any length of time at all, it will be cleared in 20 minutes, so we need another system for delivery, something that overcomes but delivers the VHH direct to where is needed in the tissues. 

Basically we are following a number of different routes to try and come out with better drugs 

to treat snakebite (SB) because that is what we think is needed, it will improve demand, we are calling this the next generation SB therapy because someone told us that has the right ring to it to get the Welcome Trust attention... 

Key points that I want to make here today are:

• Snakebite is an important, is a neglected disease of the rural poor in Africa and Asia

• We desperate need more accurate data on mortality, morbidity and socio-economic impact to understand the disease burden and to use that disease burden data to rise awareness amongst governments and IHAs so they actually recognize it as a deeply neglected tropical disease and is worth doing something about it. 

• We know that current AV therapy can be effective but there is lots of problems with it. In terms of improvement, we certainly need better regulatory control and until new drugs, next generation of AV drugs come around. 

• We need urgently the investment by governments and IHAs in the production and delivery of this conventional AV but in much large scales to stop the deaths. Snakebite death is completely preventable, give AV and stop those deaths. 

• We need to establish regional training centers on the clinical management of SB. That is absolutely clear from our experience in Nigeria, is very very important because SB is a very specific and very complicated thing to treat. And...

• We need governments and IHAs to support the development and delivery of effective and affordable AV and finally, just a push for the scientist, 

• We need more fundings for this new tools.

I just like to thank all the various people that had been involved in this project, within my own institute The Liverpool School of Tropical Medicine, Central Vet Labs in Dubai, the EchiTab study group in Nigeria and UK, the Kenya snakebite study group that we just started there and various fundings. Thank you very much. 

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.