Snakebite should be a notifiable disease In India : VV Pillay

Dr. V.V.Pillay MD, DCL
Chief, Poison Control Centre
Head, Dept of Analytical Toxicology
Professor, Forensic Medicine & Medical Toxicology
Amrita Institute of Medical Sciences & Research
Cochin, Kerala 682041

The Registrar General of India’s ‘Million Death Study’ has, for the first time, provided a direct estimate of mortality due to snake bite, nationally and in each state. Verbal autopsy was used to identify the causes of all deaths in 6671 randomly chosen sample areas, each covering about 1000 people. In 2005, 46000 people died of snake bite, approximately 1 for every 2 HIV/AIDS deaths. It must be noted that the total number of deaths due to snake bite may be even higher since some victims of nocturnal krait envenoming do not realize that they have been bitten and present with mysterious ‘early morning paralysis’ or seizures. Snake bite accounts for 3% of all deaths in children of the age of 5–14 years. Uttar Pradesh had the highest number of deaths (8700/year) and Andhra Pradesh the highest incidence of mortality due to snake bite (6.2/100 000 population/year).( Natl Med J India 2011; 24(6): 321-324. )

Snake_charmer_in_Sri_LankaNinety seven per cent of the victims of snake bite die in rural areas, 77% of them outside health facilities, presumably because they choose traditional healers. The reason is probably because most bitten people hail from uneducated strata and have more faith in traditional systems of medicine than allopathy. The problem can be addressed by increasing awareness about the dangers of such alternative therapies and the uitility of allopathic remedies, especially anti-snake venom. There are a few Govt-aided programs to tackle this issue, as well as some initiatives by a few NGOs. But they are not enough.
It is important to get snakebite included as a “notifiable disease”, which will make it mandatory for all snakebites to be reported to the public health authorities by doctors and hospitals across India involved in admitting snakebite cases. This will help us get exact figures of incidence of bites and mortality.

Use of snake anti-venom (SAV) in the healthcare system
The Indian Society of Toxicology had come out with a National Snakebite Management Protocol in 2006, based on the proceedings of a national conference in Cochin, Kerala. But the protocol has not received wide publicity or acceptance. As there are no nationally accepted guidelines for the management of snakebite in India, individual doctors and hospitals follow their own regimens. Some doctors claim that they have achieved very good results without employing SAVs, but these claims have not been subjected to peer scrutiny. SAVs are available erratically in the primary healthcare scenario. Sometimes there is adequate supply, and at other times there are no stocks.
SAVs are generally effective in the management of many snakebite cases, but contain antivenoms effective against only the 4 major venomous snakes: Common cobra, Common krait, Russells viper and Saw-scaled viper. Dialysis is often needed in viper envenomations where the patient was taken late to a hospital, or SAV therapy was inadequate or ineffective.
The focus of research in India is on diseases such as hypertension, diabetes, AIDS, etc. As a result, research in the field of snakebite has suffered. A lot needs to be done.

Snakebite neglected, forgotten and victims abandoned: David A Warrell

Prof David A Warrell , Emeritus Professor of Tropical Medicine at University of Oxford and Senior Editor of the Oxford textbook of Medicine and OTM: Infection  in an  interview with Dr. Soumyadeep B discusses various aspects of snakebite. Prof Warrell is a pioneer in research on the incidence, morbidity and mortality of snake bites as well as the clinical presentation, pathophysiology, treatment and prevention of envenoming by snakes and other venomous animals. In the interview he discusses various aspects of snakebite as a public health problem , issues with snake anti-venom and why more research is needed in this field .  

 Dr. Soumyadeep B: There is controversy over the incidence of snake bite and more so its mortality and morbidity. What your opinion on this issue?  How important is snake bite as a clinical condition in India? In terms of public health how important is it? 

Prof. Warrell : There is controversy because, until recently, there were no reliable data. Hospital returns to the Government of India in 2011 reported only 1440 snake-bites, while a much quoted WHO-sponsored study estimated between 11,000 and 15,000 deaths per year by extrapolating from hospital data. Because most snake-bite victims die outside hospital, and even hospital reporting is imperfect, these figures are bound to be underestimates. However, the Registrar General of India’s “Million Death Study” (MDS) has, for the first time, provided nationwide community-based data using “verbal autopsy” to identify snake-bite deaths (a structured interview of the relatives or close associates of the deceased by non-medical staff with central medical coding by at least two doctors). This technique is reliable for snake-bite because the event is distinctive, dramatic and therefore memorable. The result was that, in 2005, 46 000 people (99% CI 41 000–51 000) died of snake-bite in India, approximately 1 for every 2 HIV/AIDS deaths. Assuming that there are 100 non-fatal bites for each fatal bite (from results of a community-based study in Bangladesh) there could be as many as 4.6 million snake-bites in India each year. The MDS results indicate which states of India are worst affected:  the highest numbers of deaths were in Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500). This is clearly a disease of major public health importance, affecting rural people predominantly (agricultural workers and their families including young children). Its clinical importance will become more obvious as villagers are educated to seek medical rather than traditional, ayurvedic treatment.

Dr. Soumyadeep B: Most snake bite victims in India go to traditional or faith healers instead of coming to doctors .Why is it so? How can this cultural aspect be suitably modified? Any notable programs being taken by govt/NGOs/corporates (in India or abroad) towards this direction that you are aware of? What steps do you recommend as an expert?

Photo by Ayyappan Ram on

Prof Warrell  : Rural people trust herbal and other traditional forms of treatment because that is what they are brought up to believe. Traditional practitioners are readily available in the village, their services are cheap and since the overall case-fatality of snake-bites is low (~1% see above) and only about 50% of bites by venomous snakes result in envenoming (injection of sufficient venom to cause local and/or systemic effects) even useless remedies will appear effective in a proportion of cases. However, these treatments have no scientifically demonstrable effectiveness, may be harmful and will delay the patients’ arrival in hospital. Alternative therapies should therefore be discouraged or the traditional practitioners educated to refer patients with definite symptoms of envenoming. Community education is the key to reducing the risk of snake-bite. There are several successful pilot projects, for example in West Bengal and Kerala. The main elements of the programmes are to emphasise where and when the risk of snake-bite is greatest (types of terrain, times of day and times of year) and to encourage safer working and walking by using adequate footwear and other protective clothing and carrying a light after dark; and safer sleeping by using a well tucked-in mosquito net. Victims of bites are encouraged to travel to hospital without delay, not wasting time with traditional treatments. The Australia-based charity “Global Snakebite Initiative” (GSI) is committed to promoting preventive programmes for which it is actively seeking funding.

Dr. Soumyadeep B: Research in snakebite epidemiology, prevention, treatment and rehabilitation is important but neglected. Why do you think is reason behind this?

Continue reading “Snakebite neglected, forgotten and victims abandoned: David A Warrell”

Doctors in the private sector should report adverse events after immunisation to complete dataset

The Indian Academy of Pediatrics has called for doctors working in the private sector to report adverse events after immunisations to the national surveillance system to ensure more complete vaccine safety data.

In a position paper published in Indian Pediatrics, the academy said that the adverse event following immunization (AEFI) surveillance system run by the government needed to be strengthened by including reports from the private sector.1

India has one of the largest universal immunisation programmes in the world, with 26 million babies born every year. Approximately …Read the full article by Dr. Soumyadeep B at British Medical Journal 

On a National snake bite survey in India in BMJ Blogs

…Snake bites are estimated to cause more than 45,900 deaths in India, and affect millions of Indians—most of them from socially and economically disadvantaged sections of the society. Strangely however, in India the species-syndrome correlation has never been studied and the appropriate dosage requirements for treatment have not been found. As was evident from the data and protocols presented by 15 centres from across India, there are wide variations in anti-venom dosage and administrations, their indications for usage, their adverse effect profile, and even the standards of care adopted. All of the experts at the workshop, who probably represented the entire gamut of possible management procedures, wondered how in spite of managing snake bites for at least a century there is still no evidence about how best to treat them…

Read the entire blog by Dr. Soumydeep Bhaumik on the National Snake bite survey in India on BMJ Blogs here (OPEN Access)

Clinical Trial Data and the “Do no harm” principle

In an era of evidence based medicine clinical trials hold the key to validate or negate a medical intervention, whatsoever is its nature. However, clinical trials have been under increased scrutiny in the recent past due to concerns over violations of ethical concerns and research related injury. Thus it has become imperative on the part of those at the helm of affairs of clinical trials (drug makers as well as non-governmental organisations and governments which funds such studies) to make available the full and complete information of clinical trial available in public domain.

Making clinical trial data available right from the initial phase’s right till its end in the public domain not only enhances the transparency and validity of the trial it is also beneficial to those running the trial itself. It helps to improve the quality of clinical trials by making it possible to identify potential problems as well as allow health care practitioners to identify researchers related to their field.

Read Dr. Soumyadeep B’s response to the BMJ Open Data Campaign at the British Medical Journal (Open Access)