The snake in the room: snakebite’s huge death toll demands a global responseBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2449 (Published 05 June 2018) Cite this as: BMJ 2018;361:k2449
Thirteen years ago, Jose Louies, then a snake rescuer, got a routine call from police. A cobra had slithered into a New Delhi slum dwelling. Louies rushed to the location and rescued the snake.
Curiosity also led him to the makeshift chamber of a faith healer who was treating a 3 year old girl who had been bitten by the cobra. After a scuffle with her parents, Louies took the child to the nearest hospital. But she died in his arms on the way.
Now a prominent wildlife conservationist, Louies remembers this as a life changing moment: when the enormity of India’s snakebite problem dawned on him.
Global estimates of deaths from snakebite are around 138 000 a year.1 Three times that number are permanently disabled by venom.
Last year, the World Health Organization finally added snakebite to its list of neglected tropical diseases. It was first added to the list in 2009 but later removed without explanation. In December last year, WHO appointed the Snakebite Envenoming Working Group to develop treatment and prevention strategies for snakebite.
WHO’s decision to declare snakebite a neglected disease, and campaigning from civil society organisations, has put pressure on countries to act, says Julien Potet, policy adviser on neglected tropical diseases for Médecins Sans Frontières. For example, the Kenyan government developed its own snakebite management protocol after the WHO decision.
Moreover, the World Health Assembly, at the end of May, passed a resolution urging member states to step up their efforts by increasing research on anti-venom and training healthcare providers.2
The world’s most snakebite deaths
India reports the most snakebites of all countries worldwide. A government funded study estimated 46 000 annual deaths.3 For cultural and financial reasons many patients do not attend hospital, and many deaths go uncounted.
“Snakebite is not considered a medical emergency in many places,” says Louies. “People go to local healers.” If the snake’s not venomous they might be lucky; if not, many die.
Given the mortality rates, awareness is surprisingly lacking among the public and politicians. India’s health ministry did not respond to The BMJ’s questions about its inaction on snakebite.
“Unfortunately, snakebite happens largely to people who are from rural India and don’t have a political voice,” says Louies. “It doesn’t make headlines because snakebites don’t affect the urban classes.”
The BMJ spoke to Sarveshwar Bhure, who oversees the National Health Mission in Chhattisgarh, a state run programme that provides affordable healthcare, especially in rural areas. Chattisgarh is a highly forested state. “It is difficult to avoid conflict between humans and snakes, as people keep going into forests,” he says. But he said that Chattisgarh’s efforts to build public awareness through village community meetings may have reduced the number of people going to faith healers after being bitten.
India’s public health infrastructure is weak, especially in rural areas. Public hospitals are chronically understaffed, and doctors often don’t know how to treat patients who have been bitten.
“Snakebite management is grossly neglected in undergraduate medicine,” says Dayal Bandhu Majumdar, a doctor from the team that prepared snakebite treatment guidelines for West Bengal. “Even though it’s part of the curriculum, teachers at medical colleges are only interested in teaching about big diseases.” Majumdar is training rural doctors in snakebite management in a local project.
India produces most of the world’s anti-venom
Given the scale of the problem, it’s not surprising that India is the largest producer of snake anti-venom in the world.4 Six companies produce two million vials of the drug, which they also export to other south Asian and African countries. Media reports have suggested that public hospitals often run out.4
Louies says there’s enough snake anti-venom produced in India, but the problem is in its distribution and injudicious use. “Doctors sometimes can’t distinguish between a venomous and non-venomous snakebite and administer anti-venom when it’s not needed,” says Louies. Rural health centres may not have a freezer to keep the liquid properly. Some hospitals are in remote locations, making deliveries a challenge.
Indian anti-venoms are polyvalent: they can help patients bitten by at least one of the “big four” snakes: the Indian cobra, the common krait, Russell’s viper, and the saw scaled viper. More than 90% of deaths are caused by these four, but there are many other snakes whose bites can lead to death.5
In a 2015 commentary in Neurology India, the herpetologist Romulus Whitaker suggested that current Indian anti-venoms may be less robust that those made 70 years ago. Louies suspects that government price caps have driven down quality.5
Anti-venoms are manufactured by injecting a horse (or other mammal) with snake venom and extracting the antibodies that the animal produces.
Most of India’s anti-venom is manufactured from snake venom collected by a tribe in Tamil Nadu. But venom of snakes of the same species varies by location—and so does the efficacy of anti-venom.
“Climate and the age of the snake affect venom quality,” says Soumyadeep Bhaumik, a research fellow at the Georgia Institute for Global Health, India. “Depending on whether snakes of the same species bite in a hilly area or in Rajasthan’s deserts, they have different toxicity levels.”
A global problem
India’s neglect of snakebite is representative of the global situation. “It is very much neglected in Africa as well,” says Potet. “There’s not much debate and not much political will to tackle the problem.”
Although WHO declaring snakebite a neglected disease has raised its profile on the global agenda, the organisation’s own treatment guidelines, which inform many countries’ protocols, including India’s, were found by a recent study to be substandard.6
Bhaumik, one of the authors of the study, says the guidelines are insufficiently evidence based, do not take into account the views of patients and care givers, and the authors had conflicts of interest. “Anti-venom manufacturers were part of the guideline preparation process,” he says.
India’s national snakebite management protocol for healthcare providers is not enough, says Louies, because it isn’t a legal commitment to provide staff and funding.7 “We need a national response—a full blown programme for snakebite management,” he argues.
Louies runs the Indian Snakebite Initiative, a pan-India effort to map sightings of the big four snakes. Snake rescuers use an app to submit images of rescued snakes. Louies says that similar technology could be used by rural doctors to seek help from experts for treatment.
Majumdar wants regional collection centres of snake venom. Meanwhile, Bhaumik says India should take the lead in producing diagnostics and more robust anti-venom. “We can’t rely on western countries and big pharma,” he says. “It’s not their problem.”
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.