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ZERO SNAKE BITE DEATHS :: IMPOSSIBLE TO POSSIBLE.

India is World’s ‘Snakebite Capital’ with 2.8 million bites a year with 35,000–50,000 people dying per year according to World Health Organization (WHO) [1,2]. Lack of a coordinated comprehensive care in snake bite management is the key factor of highest numbers of deaths and morbidity in India.India and our state, Assam too lacks comprehensive care model in snake bite management.However we ,Assam has no robust data about snake bite related deaths.

We received phone calls from Digboi on 11/06/2022,patient was bitten by a snake ,they went to faith healer/tantra and mantra and died.They did not reported hospital.How many deaths are happening like this without notification to health centre,we donot have data.

There is no LINK between snake bite and hospital care.Therefore we tried our best to create and sustain this link. 

Till 11th June of 2022,we have received reports of 3 deaths from various parts of Assam. Two were from Digboi and one was from Dhuburi.Unfortunately all these deaths could have been prevented if both public and health care workers were aware of venomous snake bite symptoms.

For successful care of snake bite victims,we have to formulate comprehensive care to such victims,so that they shouldnot dissatisfied from our care.We also have to remember that snake bite is a poor men’s acute emergency.Therefore,we must try our best not to give economic burden to these poor patients in this snake bite crisis time.

Therefore Comprehensive care is a planned coordinated preventive,promotive,curative,mental & socioeconomic care to snake bite victims. India lacks the coordinated movement of snake bite victims from field to hospital.Demow Model hospital cum CHC,tried their best to provide Comprehensive care to these victims since 2018.

Why India need comprehensive care?

1.Lack of awareness amongst public.

2.Majority attended faith healers [3,4].

3.Poorly trained health care workers (HCW) in rural districts [5,6]. Fear of HCW to administer ASV (Anti snake Venom).

4.Poor transportation system to hospital.

5.Delayed ASV administration [7,8]

6.Nonavailability of ASV

7.No support to victim’s family due to huge financial burden [9], if treatment is prolonged.

8.No address to mental issues post snake bite [10]

9.It is not approached as acute emergency.

10.Myth that snake bite cases can be treated only in tertiary center.

India and Assam have huge gaps from prehospital, point of source hospital, secondary care hospital to Government level. For effective treatment of snake bite victims, we should have an organized care system.

Prehospital management: Venom Response Team (VRT)

Prehospital management is greatly neglected in India due to lack of education of our society. After snake bite our public completely lost and often misleaded. We started to train and educate public since 2008(Fig A). A VRT can be constructed to guide snake bite victims in each gram panchayat level comprising gram Sevak, local organizations & ASHA workers. They can be trained so that they can activate, communicate HCW & can transfer victims safely to nearest hospital. It is the need of the hour. Our model focused to educate, empower, and train public. These trained/educated public are called VRT.We have done till now 150 numbers of community awareness programme in and around Demow and Sibsagar district.We have also collaborated with APADA MITRA project of central Government under District Disaster Managaemner Society(FigB).Our plan is to create train and educate health volunteers under APADA Mitra  Project,which are now officially called VRT.We have formed a whats app group with Public of different communities along with trained APADA MITRA health volunteers.These VRT will notify us as well as safe and scientifically transfer snake bite victims to nearby hospital.

Figure: A: Community Awareness programme

Our effort towards comprehensive care in snake bite in Upper Assam

It is true that public and society have to rush to hospital once there is any snake bite. If they don’t rush to hospital immediately, morbidity and mortality couldn’t be prevented at all. So, our model starts from public/society and ends in Hospital.

  1. Public awareness & Education is the key. How we did it?

We have to take help of 3Ps.Public, Press & Politician. Now a days, digital platform is the best to reach out many within short span of time. We have to publish our own successful stories in our own local language in various digital formats. Facebook and what’s app are the most popular digital media in various nook and corners of India, we should post our success stories of venomous snake bite treatments with photographs and address of the victim (with their written informed consent) . Let public know that snake bite means hospital admission. Make them believe that there is a full proof medical management of venomous/nonvenomous snake bite in India. We have also participated in Television talk show  and Radio talk  show campaigning for hospital admission immediately after snake bite.

We have formed a what’s app group with our trained and educated general public. The name of our group is SNAKE: Public awareness group. It works like VRT. Every small community should have such group. We are readily accessible, and we come to know any snake bite incident in our local area, who are immediately transferred to nearby hospital.  \ On 29th September 2019, we have conducted a scientific CME(Continuing Medical Education) about snake bite with our local public and General Practitioners. We have trained general public along with doctors, paramedical staff & ASHA workers.

  1. Strengthening the health care system

We have interviewed 100 victims of snake bite all over from Assam. We found all had full faith in local healers and they believed there is no medical treatment for snake bite. Few of them reached nearest hospital at the earliest but soon referred from one hospital to other and died in the ambulance itself. Many hospitals had ASV but did not administered by health care workers for possibilities of litigation and fear. Few had expired ASV, and many hospitals did not have the ASV at all. We have also witnessed nearby hospitals were 100-200 km apart and, in some places, transportation was also not feasible.

We have to strengthen our rural primary (PHC) and community health Centre (CHC). It is true that bites from Cobra we may not get time. From 0hrs-3hrs, patient may develop fast neurotoxic symptoms. People staying in remotest village and transfer such victims to district hospitals may kill these groups of patients. Point of source identification (at PHC and CHC level) of venomous snake bite symptoms and administration of ASV (and neostigmine in neurotoxic) will definitely prevents many deaths in India. Even if patients come late to hospital with full blown neurotoxic symptoms to a PHC, our HCW should be educated and trained enough for simple maneuver like bag and mask ventilation and transfer with ASV.Our health care workers can identify the early danger symptoms and signs and can administer ASV or neostigmine or airway management in snake bite room. These trained health care workers are called fast response team (FRT)

Every PHC/CHC should have snake bite room and SOP of snake bite treatment. Snake bite room is an organized room where all medications including ASV are kept, so that we can readily administer if required. Big display (photos) of venomous snakes of the local area should be there, so that patients can identify the snake who bitten him

Our comprehensive model

Any snake bite incident, report to local VRT.Team will provide prehospital management and transport. Communication and activation of trained HCW in nearby hospital. Point of source HCW assesses the situation, treats there & if needed transfer to nearby ICU with bag & mask ventilation and ASV (for neurotoxic bite). Communication activation of tertiary care Centre by Primary/Secondary center. Government aids to these victims if treatment is prolonged, e.g., need of plastic surgery/amputation etc. Follow up of these victims both by physician and psychiatrist atleast for 6month.

As of now Indian clinicians are treating snake bite victims with SYNDROMIC approach. Clinicians have to wait for symptoms to develop. If our scientists can find a venom detection kits, it will be paradigm shift in future in snake bite management in India.

Depending upon the available venomous/poisionous snakes of Assam,we have modified our NHM Indian guidelines.These protocols are displayed in emergency room and snake bite room,so that not only Doctors but even nurses can treat snake bite victims effectively.

 

Fig:9 : Our modified Protocols/SOP displayed in snake bite room.

 

Fig 10:No surgeons in our hospital.Still we made it possible.

 

Fig 10B:No surgeons in our hospital.Still we made it possible.

Results of our model

Total 751 numbers of snake bite victims attended our hospital from 2018-2022.Refer to higher centre is ZERO.Death is one,who actually came to our hospital very late in moribund state,whom unfortunately we couldnot save him even after our best efforts.

Because of extensive community awareness,victims are attending hospital as early as 15minute after snake bite in 2022,in comparision to year 2018,where snake bite to hospital admission time was 184minute.

In 2021,Demow Hospital registered 464 snake bite victims with 128 numbers poisionous/venomous bites in the form of Cobra,Krait red necked keelback and pit Viper,which constituted 17.04%.In 2021,this hospital did not refered a single patient to higher centre and all team mebers celebrated ZERO death

In the year 2021(April to November) 464 snake bite victims attended our small Government rural community health Centre. Thanks to our community awareness programme and VRT.112 numbers were bitten by venomous snakes. Monocled Cobra bite 18 numbers, Krait bite 3 numbers, Green Pit Viper bite 72 numbers, Red necked keelback bite 4 numbers. Unknown bite and later developed had sign/symptoms of venomous snake bites 15 numbers. Venomous snake bite percentage was 24.13%. Refer to other health center zero. Death zero.

Conclusion

A comprehensive model for snake bite treatment in India starts from public, society, different social organizations, different electronic & print media, strengthening our health care systems & manpower from PHC level and willingness of our policy makers and Government. We all must work as a unit, then only we can prevent many preventable deaths from snake bite.

By our concept of VRT, FRT and snake bite room and forming and sustaining the chain(Fig13) starting from Community to all Government Rural Hospitals of Assam and India,We are sure we can prevent many preventable deaths as proved by our Demow model.

Dr Surajit Giri
Consultant Anaesthesiologist
National Health Mission(NHM)
Demow Rural Community Health Centre
Sivasagar, Assam

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