Right anti-venom, given on time, can reduce snakebite deaths in India

 India alone accounts for nearly half of the global annual snakebite deaths

Most snakebite deaths in India occur during the southwest monsoon season. Representative photo: iStock.

Death from snakebite is avoidable; still, millions of people across the world die every year due to it. Some 5.4 million snakebites occur globally each year, with up to 2.7 million cases of envenoming, according to the World Health Organization’s (WHO) 2021 estimates.

Envenoming results from the injection of venom, a mixture of specialised toxins of a venomous snake. Snakebite envenoming is a life-threatening event in an individual’s life, potentially leaving a huge burden of economic debt and psychological trauma to the survivor.

Read more: Snakebite: Researchers purify commercial Indian antivenoms, find them more potent 

Over 5.8 billion people, or three in four people globally, live with or in close proximity to venomous snake species. As a result, an estimated five million bites and more than 500,000 deaths, amputations, and permanent deformities occur each year.

The annual global burden of snakebites is 81,000–138,000 lives, and many more permanent limb injuries and amputations. To underscore the urgency of the global public health crisis posed by snakebite envenoming, the WHO classified snakebite envenoming as a top priority neglected tropical disease (NTD) in 2017.

In addition, in 2019, WHO launched its roadmap at the World Health Assembly, which aims to halve death and disability from snakebites by 2030.

India is the global hotspot for this NTD, with around 58,000 annual deaths and 140,000 incidents leading to various disabilities, including limb injuries and amputations. Bihar, Jharkhand, Madhya Pradesh, Odisha, Uttar Pradesh, Andhra Pradesh, Gujarat and Rajasthan carry the high burden of snakebite deaths in India.

Bites are mainly caused by the so-called ‘big four’ venomous snakes: the common krait (Bungarus caeruleus), spectacled cobra (Naja naja), Russell’s viper (Daboia russelii), and saw-scaled viper (Echis carinatus), although as many as 30 per cent of bites come from a large range of other medically important species.

Snake venom contains toxins which produce a range of effects, including neuroparalysis, coagulopathy, hemolysis, acute kidney injury, and tissue damage. A snakebite is a medical emergency requiring rapid diagnosis and treatment with an appropriate anti-snake venom.

Most snakebite deaths in India occur during the southwest monsoon season (June-September). This season is notorious for flooding in the sub-continent. A study conducted by Nibedita S Ray-Bennett in Odisha found snakes to be appearing in dry places such as roofs or doorways during flooding as the water enters snake holes. During the 2007 flooding in Bangladesh, snakebites were the second largest cause of disaster-related deaths, a study found.

Read more: Recent study on kraits shows great lacunae on snake venom research in India

Even under lower emissions scenarios, nearly all Asian countries would face an increase in the frequency of extreme river flows causing floods in the Ganga-Brahmaputra-Meghana basin, projected the World Bank Group’s Climate Risk Country Files, published in 2021.

The Ganga basin is the largest river basin in India. It constitutes about 26 per cent of the country’s land mass (861,404 square kilometres), and about 43 per cent of the population derives their livelihood from this basin, according to National Mission for Clean Ganga.

The basin covers 11 states — Uttarakhand, Uttar Pradesh, Madhya Pradesh, Rajasthan, Haryana, Himachal Pradesh, Chhattisgarh, Jharkhand, Bihar, West Bengal and Delhi. Of these, seven carry a high burden of snakebite deaths.

This means the increasing number of floods in the Ganga basin is likely to increase human-snake encounters and, in turn, snakebites, exacerbating suffering, mortality, morbidity and poverty. 

Who bears the burden?

Snakebite envenoming largely remains a public health problem with significant morbidity and mortality in developing countries.

The Indian sub-continent has the greatest burden of snakebite envenoming in the world and India alone accounts for nearly half of the global annual snakebite deaths. This burden results from a large population working in rural and agricultural settings with a high density of medically important snakes.

Snakebite deaths largely affect the poor and vulnerable in rural areas. Still, they are considered an individual risk (unlike collective risks, such as floods), implying a different risk perception compared to large-scale disasters.

Rural populations, tribal communities, farm workers, fisherfolks, herders, children, and communities with limited access to education and health care largely carry the burden of snakebite deaths and morbidity.

Children, in particular, are at high risk of encountering snakes outdoors, around homes, in village gardens and bushland because of their innate curiosity.

Read more: Half of all snakebite cases in the world from India, finds study

A staggering 1.2 million snakebite deaths occurred in India during the 20 years from 2000 to 2019, resulting in 58,000 deaths per year and an additional 140,000 disabilities per year, found a study published by Suraweera et 2020. Of these deaths, 325,000 (28 per cent) occurred in children younger than 15 years, and most occurred in rural areas, specifically agricultural or rural areas at lower altitudes.

Snakebites in children have a higher potential of harm due to their lower body weight relative to the same amount of venom injected into an adult.

Smaller body mass leads to the faster and more severe onset of envenoming syndromes, and those suffering amputations or disfigurement carry the burden of post-traumatic stress and social stigma. Together, these factors reduce the likelihood of a happy, productive and healthy adulthood for child victims of snakebites.

Existing approaches 

The use of anti-venoms is the principal intervention for victims of snakebites. This approach has several limitations — snake venom composition varies by species and region, and sourcing venom from only one small area in Tamil Nadu precludes wider efficacy. Timely administration of appropriately matched anti-venom is critical to avoiding deaths.

Snakebite is a disease of the poor in rural areas. Typical barriers to effective treatment include long distances to proper medical care, financial constraints for transport costs, and language and cultural barriers at the local level. Such health inequalities increase the risks and burden of snakebite to a segment of the population already vulnerable to livelihood, climate and economic shocks.

Several projects in India have focused on improving anti-venom production, increasing community education and awareness, mapping venomous species and identifying medical facilities with adequately trained staff and appropriate stocks of anti-venom.

The WHO has developed a snakebite envenoming strategy to reduce the number of deaths and injuries, empower and engage communities and increase partnerships, coordination and resources by 2030.

The Avoidable Deaths Network (ADN) is a global membership network dedicated to avoiding human deaths from natural and human-made disasters and aims to build on these strategies within India.

Read more: India needs specific anti-venom for snakebites in different regions

Unlike other NTDs, snakebite deaths are avoidable. Although there are many ways avoidable deaths can be reduced (a few mentioned above), the ADN advocates preventable, amenable and risk governance measures in tandem. To amplify this approach, ADN is launching a public engagement global campaign — International Awareness Day for Avoidable Deaths — on March 12.

Both amenable and preventable measures can be enhanced through robust and effective risk governance related to snakebites. 

Preventative measures include public health measures, surveillance, outreach, awareness programme in schools, colleges and universities, screening, policy development, and development of regional anti-snake venom, and stockpiling anti-venoms during monsoon season in high-risk areas. 

Amenable measures include reducing waits and sometimes harmful delays for those who receive and give care. Availability and accessibility to anti-snake venom are critical for the most venomous snakes. 

Risk governance, according to UNDP, is the way in which public authorities, civil servants, media, private sector, and civil society (aka stakeholders) cooperate to manage and reduce risks at community, national and regional levels.

Additionally, it ensures sufficient levels of capacity and resources are made available to prevent, prepare for, manage, and recover from disasters. Effective risk governance in the context of disasters has proven vital in reducing disaster deaths. To implement this approach, ADN advocates a three-phase networking model.

This model consists of state actors, non-state actors and an ’at risk’ community ( or stakeholders). Phase one consists of mapping and identifying the relevant stakeholders. Phase two consists of holding a symposium and a series of consultations with key stakeholders to assess the feasibility of a network and identify activities and actors for the network.

Phase three consists of developing a roadmap for launching a sustainable network owned by the network’s leadership. Beyond the feasibility stage, network leaders own the network and implement activities that can reduce avoidable snakebite deaths.

The network leaders also promote coordination, cooperation and communication between stakeholders for resource sharing, capacity building and initiating transformative research and innovation for death reduction.

A challenge as systemic as snakebite deaths, ADN’s ‘networking model’ is a panacea. Because it is contextual, community focus fosters diverse perspectives underpinned by systems thinking and is led by key stakeholders or the community of snakebite mitigation.

With the University of Leicester’s Institute for Advanced Studies (LIAS)’ ‘Pioneering Partnerships Fund, ’ ADN started phase one of the ‘networking model’ in January in three high-burden states of Odisha, Assam and Madhya Pradesh. ADN is identifying the key stakeholders responsible for reducing snakebites in collaboration with 22 organisations.

This includes six governmental organisations (All India Institute for Medical Sciences, Indian Council of Medical Research, Zoological Survey of India, Demow Rural Health Centre), five nonprofits, three universities, four international organisations and emerging collaborators.

Our initial consultations with different individuals and organisations indicate that the ‘community of snakebite mitigation’ are diverse and located at different levels (local, national, regional and global).

They represent multiple sectors, trans-actors, and trans-disciplines. They indicate that the international frameworks, namely, the United Nations Sustainable Development Goals, Climate Change Protocol, Sendai Framework for Disaster Risk Reduction and WHO’s Snakebite Envenoming Strategy for Prevention and Control, ought to work in interface to reduce avoidable snakebite deaths.

The stakeholders’ Symposium will be conducted in Odisha from June 20-24, 2023. The findings of these activities will lead to the development of a ‘roadmap.’ The roadmap will outline the feasibility through an operating model of a network, community roadmap, roadmap implementation project, and value proposition – among other things.

It is envisioned that national, state and local-level collaborators representing governmental and non-governmental institutions and the ’at risk’ community will provide leadership to the state, sub-district and village levels to represent different sectors, trans actors, genders and populations most at risk.

Besides shared knowledge, networking and the production of a roadmap report, we anticipate the creation of possible pathways for the Centre and WHO to envisage snakebite under the remit of disaster risk reduction and climate change so that health, education, disaster management, emergency and ambulance services can be adapted to save lives for sustainable development. 

Nibedita S Ray-Bennett is an Associate Professor in Risk Management and Founding President of Avoidable Deaths Network (ADN), University of Leicester, UK. Stephen P Samuel is a VP of Clinical Medicine at Ophirex, Inc. and ADN’s collaborator for the LIAS-funded project entitled ‘Exploring the Feasibility and Value of Pioneering Partnerships to Reduce Avoidable Snakebite Deaths in India. Tom Caley is a blog writer for ADN.

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