Summary Report
Report submitted: January 2020
Summary Report for the High Level Meeting and Workshop on Snakebite in Nepal: The Challenges and the Needs 2-3 August 2019, Kathmandu, NEPAL
Name of High Level Meeting and Workshop on Snakebite in Nepal: conference The Challenges and the Needs
Theme Preparing for a Nepal where no one dies from snakebite
Dates 2-3 August, 2019
Location, The inaugural ceremony was held at the Nepal Presidential Palace, venue Shital Niwas, Maharajgunj, Kathmandu, NEPAL on 2 August. The conference proper was held at the Hotel de l’Annapurna, Durbar Marg, Kathmandu, 2-3 August.
Motivation This high-level meeting and workshop was a needs-driven first attempt to bring together all of the relevant players both from the global stage as well as from Nepal’s health community and ministries in the Government of Nepal. The purpose was to bring awareness among medical practitioners, policy makers, and the media to address the challenges of treatment and prevention of envenoming by snakes. The first day was a high-level consultative meeting and the second day workshop was dedicated to presentations and discussion.
This conference gave a much-needed voice to those in danger of snakebite in Nepal and also reflected a global trend supported by the 71st World Health Assembly. In May 2018, the Assembly adopted a resolution formally providing the World Health Organization with a strong mandate to develop a comprehensive plan to support countries in implementing measures for access to effective treatment for those who get bitten by venomous snakes.
Organizers Society of Internal Medicine of Nepal (SIMON), Snakebite Research Centre of the BP Koirala Institute of Health Sciences (Dharan), the Government of Nepal, Ministry of Health and Population the Epidemiology and Disease Control Division (EDCD).
Conference Dr. Sanjib Kumar Sharma, Professor and Head of Internal Medicine, BP Koirala convener Institute of Health Sciences Dharan, Nepal, WHO Snakebite Envenoming Working Group; Board of Directors, Global Snakebite Initiative; Head of the Snakebite Research Centre BPKIHS, Dharan
Conference Dr Isabella C Bassignana Khadka PhD, Rotary Club of Kathmandu Mid-Town, Coordinator Kathmandu, Nepal.
Conference See this website for full conference details: http://snakebitenepal.org/ Web page The conference was also present on Facebook at: https://www.facebook.com/Snake-Bite-Nepal-2334263546811297/
Media Several Kathmandu-based media organizations covered the event. In addition to Coverage social media (Annex 1) and print media (Annex 2) Dr Sanjib Kumar Sharma was also interviewed by Dr Sameer Mani Dixit for the popular TV Talk show Good Morning Nepal and is available on Utube (https://www.youtube.com/watch?v=PiTB333ZaSo) with a recent total of 3.39K views.
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About the The inaugural ceremony was graciously hosted by Hon’ble President of Nepal, inaugural Bidhya Devi Bhandari, at the Presidential Palace, Rastrapati Bhawan. Over 250 ceremony people attended the event; the hall was filled to capacity with standing room only. At the event, short speeches conveyed the main messages. See Annex 3. All major stakeholders attended the event. The audience consisted of: members of the diplomatic core (including Swiss Ambassador HE Ms Elizabeth von Capeller, Australian Ambassador HE Mr Peter Budd, the German Deputy Chief of Mission, among others); the Head of the WHO Nepal (Dr Jos Vandelaer); guest and international speakers as well as many regional experts from India; Ministry of Health and Population officials (about 20-25% of the audience) including the Health Minister Province Two, the Rotary District Governor and other District Officials as well as members of the Rotary Club of Kathmandu Mid-Town); environmental groups, wildlife and snake enthusiasts; representatives from the Nepal Army (including Gen. Sunil Kumar Singh and others); the Red Cross; medical doctors from Kathmandu, and the 45 young medical professionals Travel Grant recipients.
Photo taken at the Inaugural Event. Front row (left to right): SIMON President Dr. Mahesh Raj Sigdel; Hon’ble Mohammad Lalbabu Raut, Chief Minister Province Two; Hon’ble President of Nepal Bidhya Devi Bhandari; and, Conference Convener Dr Sanjib Kumar Sharma. Back row: international and regional invited guests and speakers.
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Who See Annex 7 for a full list of the conference participants. participated in the Some 20 international and regional experts on snakebite including: renowned conference? expert Prof. David Warrell (Oxford, UK), Prof David Williams (WHO Snakebite Roadmap and Chairman and Chief Executive Officer of the Global Snakebite Initiative), experts from India, Bangladesh, Germany, WHO, and many more. See profiles of invited speakers in Annex 5.
173 Nepali participants registered, consisting of: Nepal government officials: many policy makers from the Ministry of Health and other government agencies. Representatives from the Nepal Army, the Nepal Red Cross, and the Nepal Office of the World Health Organization. Representatives from several animal and wildlife organizations. 45 young medical doctors and paramedics from the Terai region. These are the hard working first responders, our front-line workers, who deal with the consequences of snakebite on a daily basis. Medical doctors and medical students from Kathmandu area who have an interest in expanding their understanding of the different aspects of the snakebite problem.
This photo shows Prof David Warrell giving the conference keynote address at the Hotel de l’Annapurna.
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Travel grants The conference was able to fund 45 modest travel grants (25,000 Npr) for young for young medical officers from the snakebite-prone areas in the south to allow them to medical travel to Kathmandu to attend the conference. The Travel Grants were funded officers in-part by members of the Rotary Club of Kathmandu Mid-Town, by the Rotary Club of Higashi-Osaka Nishi (Japan) and by Gov. of Australia through the Embassy in Kathmandu. The young recipients were especially interested and grateful to have been included. See Annex 7 for full list of names.
Photo of Travel Grant recipients with international speakers and conference organizers.
What In an innovative approach to medical education, the organizers were able to additional arrange that the medical students who participated could be awarded 9.33 CPD benefit did points by the Nepal Medical Council. This is a new approach to enhancing and these young enriching the breadth of medical education in Nepal. doctors receive?
Certificate of participation
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Who helped to Civil society and international goodwill rallied for this occasion. Many groups fund the expressed their goodwill and concern for the poorest people of Nepal by meeting? generously donating to help run the conference, these included the following: Government of Australia: For the past three years the Government of Australia (through Direct Aid Program) has partnered with the BP Koirala Institute of Health Sciences (Dharan) to train doctors and paramedics in snakebite treatment and they have also contributed significantly to this conference. Travel for two Australian scientists (Prof David Williams and Ms Diana Barr from the Univ. of Melbourne) was sponsored through the Australian Public Diplomacy fund and they also contributed to supporting some Travel Grants. The Swiss Agency for Development and Cooperation (SDC) has had a long-standing interest in helping to eradicate the problem of snakebite in Kathmandu. A few years ago they funded the first publication on identifying poisonous snakes in Nepal and they again contributed generously to this meeting. The Grande City Hospital (through generous contribution by Founder Dr. Roop Jyoti) has been a partner and notable donor since the early days of planning for this meeting; they are committed to help solve the problem of snakebite in Nepal. The Rotary Club of Kathmandu Mid-Town and the Rotary Club of Higashiosaka Nishi (Japan) have contributed to funding travel grants for young Terai-based doctors and paramedics. Similarly, the BP Koirala Foundation (Government of India) sponsored two India-based researchers to attend. Many more assisted through corporate social responsibility, such as VINS Bioproducts, Hotel Annapurna, Osho Travel and Tours to name a few.
A copy of the poster on display at the Hotel de l’Annapurna during the conference Aug. 2-3, 2019
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Scientific The conference format consisted of both traditional lectures (followed by program questions) as well as ‘workshop’ sessions in which questions/comments and interactive dialog between the invited speakers and the participants was encouraged. Please see Annex 4 for the detailed program, Annex 5 for profile of invited speakers, and Annex 6 for the submitted abstracts.
Conference Throughout the two days of the conference several themes recurred in the summary: presentations of the speakers and in the questions that the participants posed recurring both after the talks and during the workshop. The main points are summarized themes here below:
Awareness of first aid and treatment of snakebite among the general population A country-specific strategy for prevention and awareness in Nepal’s snakebite-prone areas is lacking. Awareness of the dangers of snakebite, identification of snakes, prevention, and basic first aid is not taught in Terai-area schools. Since the victims of snakebite are commonly among the poorest of the poor they often lack both information on basic first aid as well as the means to procure either transportation to a hospital or hospital care. As a result, primary intervention is commonly sought from well-meaning but often inept local healers. However, as the general educational level of the population increases, and as they are lifted out of abject poverty, there are reassuring signs that rural folks are willing to lessen their dependence on this type of intervention. Clinicians reported that cases of snakebite that were referred to care facilities invariably presented with the affected limb treated using some form of home-made remedy and tourniquet. The participants discussed the merits of pressure bandages versus availability and practicality (availability, cost, and expertise needed to apply it). They also discussed the harmful effects of tourniquet and means to discourage it. In places where there has been instruction, people now know to request local volunteers to act as ‘motorcycle ambulances’. With some minimum instruction on basic safety this method is both cost-effective and safe. Indian colleagues shared information on how they were conducting mass awareness campaigns in their areas. They also reported having good success in using social media to help disseminate information.
Medical education and snakebite statistics As a consequence of the fact that there is no system for reporting snakebite, and of the fact that there is poor infrastructure for overall record keeping in rural/remote areas where snakebite is common, the burden of snakebite is grossly underreported. This poses a difficulty when trying to assess the extent of the problem in Nepal but, on the other hand, there was a recognition that this is problem also elsewhere in the region. There was a general consensus that snakebite should be made a notifiable disease in order to help generate data to guide interventions. In the discussions that followed several presentations it came to light that in the standard MBBS course for the training of doctors in Nepal there is no instruction on the care and treatment of snakebite victims. Similarly, the standard education for nurses and paramedics also does not include any training on snakebites cases. Nevertheless, some hospitals in the Terai have taken it upon themselves to give this training.
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(Aside – following on the above point. The fact that treatment of snakebite cases is not part of the MBBS curriculum raises serious concerns for the dissemination of WHO guidelines. When these become available, how will they be disseminated?) There was a general consensus that primary health care workers should be trained to identify and manage snakebite envenoming. Many voiced the opinion that until quality antivenom is generally available (at primary care centres) medical staff should be encouraged to refer patients to better-equipped secondary and tertiary care facilities. However, others cautioned that any delay in treatment during transportation/referral could lead to lead to fatality. In summary, all agreed that the best option would be for quality antivenom to be available at all primary care centres in snakebite prone areas and that the local staff have the needed expertise to administer it. The primary health care centers were singled out since these are commonly the first point of contact point for snakebite victims. In the discussions, it came to light that for the most part private medical hospitals do not treat snakebite victims.
Airways management Participants conversant in the treatment of snakebite cases were of the opinion that even in cases where antivenom is not available, that patients could have a better outcome if they could be ventilated. Full ICU ventilator support is only available in a few places in the Terai. In places where full ICU support is not available, the snakebite victim can still be ventilated manually. However, most of the time even manual ventilation equipment (such as Ambubag and endotracheal tubes) is not available. Moreover, airways management training is not given in the instruction to paramedics in Nepal.
Antivenom The topic of antivenom came up several times both in the presentations by the speakers and the points was raised by the participants in the discussion. In particular, the following points were raised several times: Antivenom is not always available where needed and not all outposts treating snakebite are equipped with antivenom at all times. Many cited the crisis in 2011-12 when there was a critical shortage in Nepal. The antivenom which is available in Nepal can be impure and can even pose risks to patients. This threat was reported by numerous speakers. The polyvalent antivenom which is available in Nepal does not cover all of the snakes species and subspecies encountered in Nepal. This is important since there is evidence that snakes of slightly different subspecies or even of the same species can show considerable variation in their venom depending on the local habitat and conditions. This observation has serious implications for the efficacy of antivenom obtained from abroad and for the use of antivenom produced from the same snakes reared in different habitats under different conditions. Nepal does not presently have the capability to produce antivenom – the limitations to producing antivenom are not only technical but also financial and legislative. A few years ago the Ministry of Health and Population investigated the matter and documented at length the challenges involved in producing antivenom in Nepal. Clinical practitioners and others in the audience were of the opinion that there was interest in having Nepal produce its own antivenom. Many pointed out that the production of antivenom in Nepal could have a
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number of beneficial spin-offs such as developing in-house expertise for the production of vaccines and other medicines which require similar preparations; these can include ERIG (equine rabies immunoglobulin), Td (tetanus and diphtheria) and the like.
Miscellaneous Prof Ulrich Kuch (Goethe University Frankfurt am Main, Germany) one of the world’s foremost herpetologists, pointed out that the existing ‘Photographic Guide to the Venomous Snakes of Nepal’, which he helped to write a few years ago, contains a few factual inaccuracies. At present, this publication is presently the most authoritative guide generally available in the country, he suggested that this volume could benefit from a revision and reprinted as a ‘second’ edition.
Ways forward Throughout the conference there was a general consensus among international and regional experts that snakebite is a ‘tool-ready’ tropical disease: the tools needed to help reduce mortality and morbidity from snakebite in Nepal can readily be made available. Below is a list of tools and tasks that the conference speakers and participants suggested can help to reduce and prevent snakebite deaths in Nepal.
All agreed that Nepal’s snakebite prone Terai region would benefit from a public awareness campaign on prevention and first aid. The WHO is already working with the Ministry of Health and Population on guidelines for ‘snakebite roadmap’. Once these guidelines are approved by WHO global they can be presented to the MoHP, who can assemble a task force to take on the work. (Note added in proof: the WHO guidelines on treating snakebite were available by end 2019). The medical curriculum at the MBBS level can be requested to include treatment of snakebite cases. A field manual for paramedics and doctors, based on the trainings that have been conducted for several years is needed. This needs to be translated and distributed (possibly before the next snakebite season). There are discussions underway with the Global Snakebite Initiative for greater involvement in Nepal and possibly for the establishment of a local chapter that could deal with all snakebite related issues. The ‘Global Snakebite Initiative Nepal’ chapter could be the local body pushing forward many of the suggested initiatives. The Rotary Club of Nepal has indicated some interest in helping to conduct a national awareness and prevention campaign. This could include a media awareness campaign on both radio and television in snakebite prone areas as well as pamphlets and posters in the schools. The production of antivenom can be undertaken in Nepal. There seems to be an interest in this in the private sector. In order for this to go forward a few legislative and legal changes need to be enacted. The ‘Photographic Guide to the Venomous Snakes of Nepal’ should be updated. A revised 2nd edition should be issued in both English and Nepali. Given the now widespread use of ‘smart’ mobile phones, Nepal could benefit from snakebite prevention and first aid information disseminated through a dedicated app and social media.
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List of Annexes
Annex 1 TV Good Morning Nepal (Utube) Coverage of the Meeting, and Facebook Social Media
Annex 2 Print Media Coverage of the Meeting
Annex 3 Text of Talks Presented at the Inaugural Event
Annex 4 Conference Programme
Annex 5 Short Profiles of Invited Speakers
Annex 6 Submitted Abstracts
Annex 7 List of Participants
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Annex 1 TV Good Morning Nepal (Utube) Coverage of the Meeting, and Facebook Social Media
Dr. Sanjib Kumar Sharma | Prof. BPKIHS, Dharan | Good Morning Nepal - 31 July 2019 Watch (24:08); Uploaded by: Kantipur TV HD, Jul 30, 2019 3.39K Views·94 Likes
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Annex 2 Print Media Coverage of the Meeting
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See also: https://www.publichealthupdate.com/national-guideline-for-snake-bite-management-in-nepal- 2019/ https://www.nepalitimes.com/banner/hisss/ https://www.publichealthupdate.com/high-level-meeting-and-workshop-on-snakebite-in- nepal/ https://www.nepalitimes.com/here-now/snakebite-is-treatable-no-one-need-die-from-it/ https://www.nepalitimes.com/banner/hisss/ https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world- health/ https://www.publichealthupdate.com/high-level-meeting-and-workshop-on-snakebite-in- nepal/ https://thehimalayantimes.com/opinion/snake-bites-in-nepal/
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Annex 3 Text of Talks Presented at the Inaugural Event
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“Welcome Note” by Conference Coordinator, Dr Isabella Bassignana Khadka
To everyone - A Hearty Welcome
I am the conference coordinator, Dr Isabella Bassignana Khadka, and I would like to welcome you all to this inaugural of the first ever international conference on snakebite to be held in Nepal. This meeting has been more than two years in the making and along the way there have been many twists and turns. But, the story of how we came to this point starts long before that. The story began some 20 years ago when a young medical doctor in Dharan met an even younger Swiss researcher and started plying him with stories of the ravages of snakebite in rural communities. Nothing doing. That young Swiss man was just not interested – he had no capacity and even less interest in pursuing the problems of snakebite in Nepal. And so it went for several more years: with the young doctor requesting, and the young Swiss researcher resisting. Needless to say that in the end, a young Dr Sanjib Sharma finally prevailed upon the young Philippe Chappuis and the result was the first ever Photographic Guide to the Venomous Snakes of Nepal. This volume is still in print and freely available on the internet – it continues to be the most comprehensive and authoritative guide to the venomous snakes of Nepal.
The story continues. In the intervening 20 years, climate change, insurgency, other pressures related to shifting and increasing populations, the problem of snakebite became even more acute. During all of this time the Nepal Army, the Ministry of Health and Population through EDCD, the BP Koirala Institute of Health Sciences Dharan, the Nepal Red Cross -- all of these groups has done much! under difficult conditions and with limited resources. But still too many die.
The story continues. Another chance encounter some five years ago. At the Rotary Club of Kathmandu Mid-Town, Dr Sanjib Sharma, by that time Nepal’s recognized authority on snakebite, presented the scenario to some 50 caring Rotarians. His message so touched them that their Board decided to take up snakebite as a priority needs-driven issue. BUT good wishes alone are not enough, the hunt was on to look for funding. Then, a story of two ladies, fast friends, and shopping buddies and a chance conversation with then Australian Ambassador Glen White who encouraged them to apply for DAP funding from the Government of Australia. The result was a collaboration with the hospital in Dharan that trained paramedics and doctors throughout the East, West, and Central Terai on the treatment of snakebite victims and the proper use of antivenom. Within the past three years more than 114 doctors and more than 308 paramedics have now received training and countless lives have been saved.
But still too many die. Training doctors and paramedics is not enough. Greater structural change is needed. That brings us to the present day and to the hope for this conference. The Chinese proverb says, “When you drink the water, remember who dug the well”. This meeting is made possible through the good wishes of so many --- First a hearty thanks to our international speakers who are among the world’s foremost experts in the field, they join us today from: the UK, from Australia, from India, from Bangladesh, from Switzerland, from Germany, and by video link even from Costa Rica. Thanks for having made such a genuine effort to join us here in Kathmandu.
Civil society has shown a groundswell of positive support – a big thanks also goes to our supporters and promoters. First to the good graces of Dr Roop Jyoti and the Grande City Hospital of Kathmandu, who was the first to give us encouragement and tangible support. Summary Report for the High Level Meeting and Workshop on Page 16 of 49 Snakebite in Nepal: The Challenges and the Needs 2-3 August, Kathmandu, NEPAL
And to the Government of Switzerland who had originally contributed to that first volume on snakes and who through the Embassy here in Kathmandu has expressed their willingness to continue to be involved and showed that willingness by supporting this conference in a meaningful way. With these two pillars we had the impetus to go ahead. As the conference coordination began in earnest we received much appreciated additional support from: The Gov of Australia, the BP Koirala India-Nepal Foundation, the Global Snakebite Initiative, VINS Bioproducts, the Rotary Club of Kathmandu Mid-Town, the Rotary Club of Higashiosaka Nishi Japan, Osho World Travel, and the Hotel de l’Annapurna. And with apologies to anyone who we may have inadvertently forgotten.
Travel Grants Not only has this financial support allowed us to organize this meeting but it has also allowed us to give modest travel grants to 45 young doctors and paramedics from the Terai to come to Kathmandu to attend this meeting. These brave young first responders are the frontline workers, the interface to the people who are the victims – the poorest of the poor who are vulnerable because of their perilous living conditions. To these young medical workers – we welcome you and we salute you for your good work. We would also like to acknowledge our partners in organizing this conference: the Gov of Nepal Ministry of Health and Population who are our full partners in this conference. To the BPKIHS in Dharan who are at the forefront in the effort to disseminate training to doctors and paramedics in the Terai. And to SIMON the Society of Internal Medicine of Nepal– who have been our organizational supporters here in Kathmandu.
This conference is the culmination of our efforts to date – it will hopefully give a platform to those groups in Nepal who are already working in the area of snakebite to make contacts nationally, regionally, and globally. But it is only the first step in a dedicated campaign: Many more activities are already under discussion – without stealing the thunder of the speakers to follow – I can briefly tell you that: -The WHO is already working with the GoN Ministry of Health on guidelines for ‘snakebite roadmap’. -A field manual for paramedics and doctors, based on the trainings that have been conducted for several years is in preparation -There are discussions with Global Snakebite Initiative for greater involvement in Nepal; and -The Rotary Club of Nepal has indicated some interest in helping to conduct a national awareness and prevention campaign. To conclude – a hearty thanks to everyone who has been involved – enjoy the inaugural and the meeting. We look forward to continuing to work together to prepare for a Nepal where no one dies from snakebite. Thank you.
Note: The organizers regret that it was not possible to obtain a copy of the speech given by Hon’ble Mohammad Lalbabu Raut, Chief Minister Province Two
“The State of Snakebite in the World” by Keynote Speaker, Prof David Warrell
Right Honourable Madam President, Excellences, very distinguished ladies and gentlemen and fellow snake-bite enthusiasts, it is a great honour and privilege to have this opportunity to discuss “The state of snake-bite in the world”, in your company, and in a country that has contributed so much to our knowledge of snake-bite through its community-based research studies • As a physician and clinical researcher, I have been striving for almost 50 years to raise awareness of the public health importance of snake-bite. Until very recently there seemed to be no progress • The reluctance of the global health community to accept snake-bite as a major public
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health challenge has been very frustrating! It was due largely to our lack of reliable information on the numbers of deaths and disabled survivors. However, two national surveys, in India and Bangladesh, published in 2010 and 2011, have riveted global attention on this “Most neglected of all the neglected tropical diseases”. • In rural Bangladesh, there are 590,000 bites and 6,000 deaths from snake-bite every year, and, in India, 46,000 deaths annually • We lack such reliable data from most other countries in the world, but current estimates suggest global totals of up to 138,000 deaths, among the more-than-5-million people bitten by snakes every year • Publication of these devastating data has raised dramatically the international medico- political profile of snake-bite. • So many deaths, many of them in young children, are tragic enough in themselves, but there is an increasing realisation that many of the lucky survivors spend the rest of their lives enduring physical and mental consequences of their snake bite. Disfiguring effects of the venom can result in social stigmatisation, making them social outcasts, or unmarriageable, and preventing their return to productive work. • Looking around the world, which continents have the greatest numbers of snake-bite fatalities? • Asia seems to be the worst affected with up to 100,000 deaths annually. • Africa and the Middle East are next with up to 32,000 deaths, but this is certainly an under-estimate due to incomplete reporting • Latin America has up to 5,000 deaths and Oceania up to 500 deaths, mainly in the island of New Guinea, while Europe and North America together have fewer than 150 deaths each year • Who is most affected? Agricultural workers and hunter-gatherers have the highest occupational and environmental risk. • Children are especially vulnerable to snake-bite. In India, 3% of all deaths among 5-14 year-olds are caused by snake-bites. In general, snake-bite victims come from the poorest communities and lack political influence • Snake-bite is an ancient scourge of mankind, but its importance has been denied, neglected or rejected for centuries, right up until very recent times • Very fortunately, things are changing at last! There is a new mood of optimism based on enlightenment, enthusiasm, activism and access to funding • Over the last 2½ years, the World Health Organization has raised the profile of snake-bite by recognising it as a top-priority Neglected Tropical Disease, and, supported by a powerful World Health Assembly Resolution has launched its strategy for prevention and control • Already this has resulted in the support of the Kofi Annan Foundation and generous funding by The Wellcome Trust, UK Government, and some private charities. • Now, today, is a highly opportune moment to discuss Nepal’s national control programme and to celebrate the fine research that has been carried out in your country • Thank you again Right Honourable Madam President for receiving us in your palace and for listening to our advocacy of snake-bite - truly the most neglected of all the neglected tropical diseases!
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“The work of World Health Organization and Global Snakebite Initiative” by Prof David Williams
Greeting… Every year snakebite claims up to 138,000 lives worldwide, and leaves 400,000 more permanently disabled. Conservatively, at least 60,000 deaths occur in South Asia alone. Most are poor, disadvantaged men, women and children from the world’s most impoverished communities. They are people just you and me. They have hopes, dreams and aspirations. They are parents who make sacrifices every day to help their children have better futures. Children with untold potential… … Future farmers, home-makers, teachers, doctors, world leaders … the possibilities are endless because history teaches us time and again that the greatest among us often come from the most humble of beginnings. Yet every 4 minutes, somewhere around the world, another person dies after a bite from venomous snake. And indeed for decades, the plight of snakebite victims has failed to attract the attention of public health authorities in the same way that the suffering of those affected by other diseases has. As past UN Secretary-General, the late Kofi Annan said “snakebite is the biggest public health crisis you’ve never heard of” But in the last four years the tide has finally begun to turn. Advocacy and political engagement by the Global Snakebite Initiative, Médecins sans Frontières, Mr Annan and others led to recognition, in 2017, by the World Health Organization that snakebite envenoming is a neglected tropical disease. More recently our efforts in highlighting the devastating impact of snakebites, and mobilising governments to work together, resulted in the adoption of a robust resolution directing comprehensive measures to address the problem, by the 71st World Health Assembly in May 2018. This strong mandate to WHO delivered the political support for action that until now had been lacking. In his capacity as a board member of the Global Snakebite Initiative, Professor Sanjib Sharma, who will be speaking to you soon, played a substantial role in achieving this important outcome for the victims of snake bites, around the world, and here in Nepal. Along with myself, Professor Warrell and other experts, Professor Sharma was an important senior member of the WHO’s Snakebite Envenoming Working Group. We were all very pleased, when at the 72nd World Health Assembly in Geneva this year, the WHO launched its own global strategy for the prevention and control of snakebite envenoming. This comprehensive road map takes a strong holistic approach to reducing the burden of injury. Indeed it aims to use community engagement, improvements to health systems, access to safe, effective treatments and broad collaboration and partnership to cut deaths and disabilities by 50% by 2030. It is a pragmatic and practical plan with realistic expectations and wide support. At the centre is the aim of integrating improved management of snakebite within national health plans, and into the overall effort to achieve universal health coverage and meet the sustainable development goals. It is a plan that focuses on building local capacity and building local and regional cooperation to create sustained solutions. It leverages technical support and global coordination from WHO and calls on all stakeholders to collaborate and cooperate to deliver and implement sustainable solutions. And the reality is that snakebite is an eminently treatable disease… But it is multi-faceted and requires a coordinated, multi-disciplinary and multi-factorial
Summary Report for the High Level Meeting and Workshop on Page 19 of 49 Snakebite in Nepal: The Challenges and the Needs 2-3 August, Kathmandu, NEPAL response, driven by clear leadership and commitment from government, and supported robustly through broad engagement with stakeholders.
At a minimum…We must improve epidemiological surveillance. Snakebite should be a notifiable disease and reporting systems should be standardized and interlinked within countries, regions and globally. Access to safe, effective and affordable treatment must be guaranteed. Antivenoms manufactured according to internationally accepted standards of Good Manufacturing Practice, and designed appropriately so as to be fit-for-use can save many lives. The control and regulation of antivenoms must be strengthened. Manufacturers and scientists must collaborate to improve the design, quality, safety and effectiveness of current products. The days of accepting that products with 50 to 80% adverse reaction rates should remain licensed must end. The industry must clean up its act. And thankfully some manufacturers are already taking important steps in the right direct, and more will follow. But at the same time manufacturers will not take the risk of improving these products without the surety that governments and procurement agencies will pay a fair price and ensure a sustained market. Health systems must be strengthened. Medical personnel must be trained. Resources for diagnosis, acute and ongoing care must be available. For victims rehabilitation and return to productive living must be assured. No person should be discriminated against because of disability, and no person should be condemned to a life of poverty through snakebite envenoming. And we must ensure that all victims of snakebite have access to effective treatment without being plunged in the spiral of debt and destitution that has befallen so many of them in the past. Lastly, prevention is always better than cure. We must educate communities and devise, design and deploy tools to reduce contact with venomous snakes, and to avoid envenoming in the first place. We must engage effectively to promote the right treatment-seeking behaviours and the ensure that first responders are able to support life until medical care is available. I am honoured and proud to have been invited to attend this ground-breaking high level meeting on snakebite in Nepal. Your country has long been a leader in innovative approaches to this important problem: • Your use of motorcycle ambulances to carry snakebite victims to hospital have been adopted in several other countries. • Likewise the community survey techniques pioneered here by Professor Sharma and his colleagues are now being replicated as far afield as Cameroon, Senegal and Papua New Guinea. • And evidence of the effectiveness of sleeping under well-tucked in mosquito nets on raised sleeping platforms in preventing nocturnal krait bites in the Terai, has even led African malaria experts to use this data to persuade families to make use of bed nets in areas where nocturnal cobra bites are a common problem On behalf of the Global Snakebite Initiative, of which Dr Sharma is a key member, I congratulate you all for your enthusiasm and commitment to tackling this public health tragedy. We would be honoured to assist and support Nepal in any way we can. I look forward to two days of productive and proactive discussion and hope to have time to speak with as many of you individually as possible. And I hope that recommendations to come from this meeting will result in Nepal taking up the WHO’s new snakebite envenoming strategy and becoming the first country in the region to use this road map as a blueprint for implementing its own snakebite prevention and control programme.
Summary Report for the High Level Meeting and Workshop on Page 20 of 49 Snakebite in Nepal: The Challenges and the Needs 2-3 August, Kathmandu, NEPAL
“The State of Snakebite in Nepal” by Conference Convener Prof Sanjib Kumar Sharma
स"माननीय रा)*प,तज्यू , माननीय स्वास्थ्य तथा जनसंख्या राज्यम ीज्यू, Sachibjiu डेि भड वारेल and David Willium jiu ज्यू ििितथगण, sanchar karmi mitraharu सपर्दंश क्षेत्रमा ि क्रयाशील स्वास्थ्यकमी셍ह셂 भद्र िम셍ला तथा सज्जनबृन्द सवर्प्हथम, 셍ाम्रो ि नम्तोलाई स्वीकारेर र्देश ि वर्देशबाट पा쥍नु भएका सम्पूणर् ििितथ म셍ानुभाव셍셂लाई "नेपालमा सपर्दंश क्षेत्रमा उत्पन्न िकठनाई एवं आवश्यकता셍셂 छलफल गनर् आयोि जत यो उच्चस्तरीय बैठक तथा सम्मेलन" मा 셍ाि र्दकह स्वागत गनर् चा셍ꅍछु । सपर्दंश एक उिपेक्षत तर िजटल जनस्वास्थ्य समस्या र셍ेको छ । सपर्दंश उष्णर्प्र्देशीय क्षेत्रको ग्रामीण र ि वपन्न समुर्दायमा ने तर त्यित वास्ता निगरएको एउटा स्वास्थ्य सङ्कट समेत 셍ो । नेपाल, ज셍ााँको झण्डै २६ वटा ि जल्ला, ि वशषेतः तराई क्षेत्रका सपर्दंशबाट र्प्भाि वत छन् । तसथर् सपकर् ो डसाई 셍ाम्रो मुलकुमा सधैाँ नै जनस्वास्थ्य सम्बन्धी चासोको ि वषय र셍ने गरेको छ तथा य셍ी सपर्दंशका कारण र्प्िके वषर् कय ाँ त्यिक्त셍셂को िकालमा मृिु ने गरेको छ । त镍ांक िनुसार, विषेनह ि वश्विभर ५० लाख माि नस셍셂 सपर्दंशले र्प्भाि वत ꅍछन् भने िसमध्ये ८१००० र्देि ख १३८००० जनाको य셍ी ाँ कारणले मृिु ने गरकेो छ । ४ लाखभन्दा बढीमा सपको टोकाइको िसरले 셍ातखुट्टा काट्नुपनेर् तथा िपाङ्ग नुपनेर् जस्ता िजटलता र्देि खꅍछन् । ि वषालु सपर्दंशबाट र्प्ताि डत सबैभन्दा बढी जनसंख्या िर्दक्षण िएसयामै र셍ेको छ । 셍ालसालै भएको िध्ययन िनुसार नेपालमा विषेनह िकरब ४०,००० माि नस셍셂 सपर्दंशले पीि डत नु र ती मध्ये १००० जनाले मृिुवरण गरेको त镍ांक आफैमा र्दुःखर्दायी छ । Bharat ko yek िध्ययनले र्देखाए िनुसार एचआईभी/एड्सका कारण ने २ जनाको मृिु◌ ु सपर्दंशले गनेर् एक मिृ ु बराबर ꅍछ भने िकोतहफर् नेपालको ग्रामीण ठाउाँमा ८०% ि वषालु सपर्दंशबाट पीि डत त्यिक्त셍셂को िस्पताल पुग्नु ििघ नै मृिु◌ ु ने गरेको छ । 셍ाम्रो र्देशमा ि वषालु सपर्दंशबाट जनजीवनमा पनेर् समस्या र जोि खम ि वकराल छ भने स्रोतसाधनको सीि मतताले यसलाई िझै भयाभय बनाएको छ । २०१८ मे मा भएको ि वश्व स्वास्थ्य संगठनको ७१ ि◌ ◌ ाँ भलेाले ि वषालु सपले ने मृिु रोक्नका लाि ग र स्वास्थ्यमा पाँच बढाउनका लाि ग सपर्दंशबाट र्प्भाि वत र्देश셍셂लाई िलक्षत गरी ठोस ि नणयह ि लन तथा कायक्रहम तजुमाह गनर् ि नर्देशहन ि र्दएको िवथा छ । सपर्दंश सम्बन्धी उच्चस्तरीय बैठक तथा सम्मेलन गनुर् यो भन्दा उपयुक्त िवसर सायर्द ि셂 ाँर्दैन镍ो hola। नेपाल, ज셍ााँ र्प्ािथमक उपचार लगायत सामान्य उपचारीय ि िवध एवं उपकरण셍셂 ग्रामीण र्दूरर्दराजमा पुर्याउन 셍म्मे셍म्मे पछर्, िस िवथामा सपर्दंशबाट जनसमुर्दायलाई जोगाउनु तथा ि वषालु सपको डसाईबाट पीि डत त्यिक्तको ज्यान बचाउनु 셍ाम्रा लाि ग ठूलो चुन तीको ि वषय 셍ो, तर िसम्भव भने 셍ोइन । माि नस셍셂मा सपर्दंश सम्बन्धी जनचेतना फैलाउने र्देि ख ि लएर स्वास्थ्य संथामा सफल 셂पमा उपचार गनेर् वातावरण बनाउनु िि셍लेको ि नतान्त आवश्यकता 셍ो । ि वश्व स्वास्थ्य संगठनले सपर्दंशद्वारा ने मृिु र िपाङ्गता सन् २०३० सम्म ५०% ले घटाउनका लाि ग ४ वटा रणनीि त셍셂 ििघ सारकेो छ । जसिनुसार समुर्दायको सशक्तीकरण र संलग्नता, सुररक्षत र र्प्भावकारी उपचार, स्वास्थ्य र्प्णालीको सु◌ ु饃ढीकरण, र साझेर्दारी समन्वय तथा स्रोत셍셂को ििभवृि द्ध गनेर् िठोट ि लएको छ । ि वश्व स्वास्थ्य संगठनले य셍ी रणनीि तको कायान्वहयनका लाि ग सु셁वातमा १० र्देि ख १२ र्देश셍셂लाई संलग्न गनेर् योजना राखकेो छ । सु셁वातमै नेपाल िपन यी र्देश셍셂 मध्ये एक न सके नेपालमा सपर्दंशको रोकथाम एवं उपचारका लाि ग कोशेढुङ्गा साि बत ने कुरामा र्दुई मत छैन । यसका लाि ग नेपाल सरकारकै िगुवाइ तथा ि वश्व स्वास्थ्य संगठनको र्प्ाि िवधक स셍योगमा सरोकारवाला셍셂, यस क्षेत्रका र्प्ाज्ञ, स셍योगी ि नकाय셍셂, र्प्ाि ज्ञक िर्प्तष्ठान, नािगरक समाज लगायतको स셍भाि गतामा सपर्दंशको िउचत िवथापन गनर् 셍ालेमालो गनर् ज셁री र्देि खꅍछ । नेपालमा सपर्दंशको रोकथामका ि िनम्त के셍ी र्प्यास नै नभएका भने 셍ोइनन् । सपर्दंश सम्बन्धी ि िवभन्न ठूलाठूला िध्ययन셍셂 नेपालमै भएका छन् । 셍ामीले सु셁 गरेको मोटरसाइकल स्वयंसेवक ििभयानको र्प्भावकाि रताले गर्दार् यो ि िवभन्न र्देशमा समेत िनकुरण िगरएको छ । िस्तै कुन ि िकसमको सपले टोकेको भनेर रगत जााँच गरेरै था셍ा पाउन िसकने गरी Rapid Diagnostic Kit को ि वकासमा र्प्यत्नरत छ ाँ । नेपाल सरकार, स्वास्थ्य तथा जनसंख्या म ालयले िइपडेि मयोलोजी तथा रोग ि नय ण म셍ाशाखा माफतह सपर्दंशको र्प्कोपलाई न्यूनीकरण गनर् सपको ि वषका ि व셁द्ध तयार िगरएको िर्प्ितवष ि◌ षधी िथातह
Summary Report for the High Level Meeting and Workshop on Page 21 of 49 Snakebite in Nepal: The Challenges and the Needs 2-3 August, Kathmandu, NEPAL
Anti Venom लाई ि िवभन्न िस्पताल एवं सपर्दंश उपचार केन्द्र셍셂मा ि नःशुल्क ि वतरण गनेर् तथा स्वास्थ्यकमी셍ह셂को लाि ग ताि लम आयोजना गरी उपचारमा िद्यािवधक गर्दैर् एक셂पता कायम गनर् स셍योग गर्दैर् आइर셍ेको छ । साथै ि वश्व स्वास्थ्य संगठनको र्प्ाि िवधक स셍योगमा नेपाल सरकारले सपर्दंश उपचार एवं िवथापनका ि िनम्त नयााँ ि नर्देर्ि शका जारी गनेर् क्रममा छ । यसले सपर्दंशको उपचारमा एक셂पमा ल्याउने ि वश्वास छ । सामुर्दाि यक सपर्दंश उपचार केन्द्र셍셂 कतै समुर्दायको स셍भाि गताले त कतै नेपाली सनेा र गाउाँपाि लका वा थानीय जनतासाँगको स셍कायमाह खु쥍नु आफैाँ मा एकर्दमै र्प्शंसनीय कुरा 셍ो । नेपालमा सपर्दंशको ि◌ षधी िथातह िर्प्ितवष ि◌ षधी (Antivenom) उत्पार्दन नने ाँर्दा 셍रेक वषर् भारतबाट त्यखरर्द गनुपहरेको बाध्यता छ । यसले गर्दार् नेपालका िस्पताल셍셂मा र्प्ायः ि◌ षधी िपुग ने सम्भावना िपन रर셍आएको छ । नेपालमै र्प्शस्त मात्रामा ि◌ षधी उत्पार्दन गनर् सके र समयमै ि बरामीलाई िस्पताल पुर्याउन सके िपन सपर्दंशबाट धेरैले ज्यान गुमाउनु पर्दैनह镍ो । यो कायक्रहम सु셁वात 셍ो, ि 셍ोइन । र्दूरर्दराजमा काम गर्दैर् गरेका स्वास्थ्यकमी셍ह셂ले सपर्दंशको उपचारमा भोग्दै आएका समस्या셍셂लाई छलफलका माध्यमबाट िप셍चान र न्यूनीकरण गर्दैर् उ셍ााँ셍셂मा सचेतना फैलाउनु तथा िद्यािवधक सपर्दंश उपचार ि नर्देर्ि शकाका बारेमा जानकारी गराउनु नै यस कायक्रहमको मुख्य उद्दश्ये 셍ो । 셍ामी 셍ाम्रो उद्देश्य पूरा गनर् सक्षम नेछ ाँ भन्ने आशा ि लएक ो छु र सबैको तफबाहट स셍योगको 셍ाि र्दकह िपेक्षा गर्दछुह । स्वास्थ्य िवथाका कमीकमजोरी셍셂 िप셍ल्याउन, भएका सीपमा भएका िपुग पाटो셍셂 था셍ा पाई िसमा सधुार गनर् समते यो कायक्रहमले टेवा पुर्याउने छ भन्ने ि वश्वास 셍ामीलाई छ । नेपाल सरकारका सामु सपर्दंशको ि वषय एउटा ठूलो चुन ती मात्र नभएर िवसरको 셂पमा िपन आएको मलाई ला嵍छ । यो िवसरलाई सकारात्मक मानेर सपर्दंश क्षेत्रमा प셍लकर्दमी ि लने 셍ो भने सपर्दंशको कारणले कुनै िपन नेपालीले कुनै िपन र्प्कारको र्दुघटहना सायर्द ि셍ोनुर् पर्दैनह镍ो र यो नै 셍ाम्रा लाि ग ठूलो उपिलब्ध ने ि थयो ।
िन्ततः यो कायक्रहमको आयोजना गनर् स셍योग पुर्याउन ने सम्पूणमाह 셍ाि र्दकह धन्यवार्द ज्ञापन गर्दछुह । आशा र ि वश्वास छ, जनसमुर्दायको ि वकराल समस्याको ि वषयमा आयोजना िगरएको यो कायक्रहम सबैका ि िनम्त लाभर्दायी नेछ । धन्यवार्द ।
Address by the Right Hon’ble President of Nepal, Bidhya Devi Bhandari
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Annex 4 Conference Programme
Day One Friday August 2, 2019
Inaugural Event (Text of the following five talks are available in Annex 3) “Welcome Note” Dr Isabella Bassignana Khadka Conference Coordinator
“The Challenge of Snakebite in Nepal” Hon’ble Mohammad Lalbabu Raut, Chief Minister Province Two
“The State of Snakebite in the World” Prof David Warrell Emeritus Professor of Tropical Medicine, Nuffield Department of Clinical Medicine; Honorary Consultant Physician, Oxford; University Hospitals Trust; Honorary Fellow, St. Cross College, UK
“The work of World Health Organization and Global Snakebite Initiative” Prof David Williams Head of the Australian Venom Research Unit (AVRU) in the Department of Pharmacology and Therapeutics at the University of Melbourne; Chair and Chief Executive Officer CEO of Global Snakebite Initiative; and, WHO Snakebite Roadmap
“The State of Snakebite in Nepal” Prof Sanjib Kumar Sharma Professor and Head of Internal Medicine, BP Koirala Institute of Health Sciences Dharan, Nepal, WHO Snakebite Envenoming Working Group; Board of Directors, Global Snakebite Initiative; Head of the Snakebite Research Centre BPKIHS, Dharan
Address by the President Hon’ble President of Nepal, Bidhya Devi Bhandari
KEYNOTE ADDRESS Snakebite: Why to invest in snakebite? By Prof David Warrell LUNCH
SESSION ONE Burden of Snakebite: The community based studies in India, Nepal, and Bangladesh What we have learned from community studies Dr Lois Amstrong – India
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Prof Mohammad Abul Faiz – Bangladesh Dr. Rafael Ruiz de Castañeda - Nepal
SESSION TWO Strategic interventions to reduce snakebite incidence and increase access to effective health care Snake Conservation and Snakebite Mitigation – a common goal common agenda by Mr. Ajay Kartik Challenges of producing snake venoms for antivenom production: is it possible to achieve GMP standards? – by Dr Diana Barr International Collaboration for Global Change: Opportunities to Improve Snakebite Outcomes through research and Innovation By Dr. Rafael Ruiz de Castañeda
SESSION THREE Clinical management of snakebite Clinical management and complications of snakebite Prof. David Warrell Snakebite and Acute Kidney Injury Prof Sandeep Mahajan Management of Snakebite – when to expect the unexpected by Prof Mohammad Abul Faiz VICC, thrombotic microangiopathy and antivenom ineffectiveness in hemotoxic snake envenomation in South India by Prof. Anand Zachariah Zero Snake Bite Death Project by Dr Sadanand Dagadu Raut
Day TWO Saturday, August 3, 2019
SESSION FOUR Panel Discussion Scientific innovation in the diagnosis and treatment of snakebite Scientific innovation in the diagnosis and treatment of snakebite by Prof. Ulrich Kuch Sharing the study findings of Thailand visit to explore the possibility of Snake Anti-Venom Production In Nepal by Dr. Guna Nidhi Sharma
SESSION FIVE Panel Discussion How to reduce the snakebite in Nepal and South East Asia Panel Discussion Moderator: Prof David Warrell Prof Mohammad Abul Faiz, WHO SEARO Representative, Director EDCD (Focal point of snakebite), Dr Dilip Punde, Dr Anup Bastola, and Dr Guna Nidhi Sharma
SESSION SIX Implementation of WHO Strategy to implement snakebite prevention and management WHO Strategy for Prevention and Control of Snakebite Envenoming – An opportunity for Nepal to be a regional leader Dr. David Williams Reducing the incidence and sequalae of snakebite – What Nepal has done? by Prof Sanjib
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Kumar Sharma Snake-Byte project: geospatial methodology and the accessibility to better snakebite health care by Dr. Carlos Ochoa
SESSION SEVEN Awareness and success stories Prevention of snakebite by raising awareness VIDEO Priyanka Kadam Confronting snakebite envenoming in Costa Rica: an integrated approach of several decades WEB-VIDEO. Prof José María Gutiérrez, University of Costa Rica
WORKSHOP ONE Research to improve diagnosis, syndromic approach Aim of session: To review current technical approaches to developing improved snakebite diagnostic and approach
WORKSHOP TWO Antivenom use and reaction, management of clinical complication of neurotoxic envenoming, management of pit viper envenoming, and surgical management Moderator: Prof David Warrell Experts: Prof Anand Zakharia, Dr Anup Bastola, Dianna Bar (on antivenom), Lois J Amstrong, and Dr Chhabilal Thapa Aim of session: To review current clinical and surgical management of snakebite, identify gaps in our knowledge and systems to overcome the identified clinical needs.
CLOSING CEREMONY SIMON President and Organizing Chair
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Annex 5 Short Profiles of Invited Speakers
Dr. Sanjib Kumar Sharma, CONFERENCE CONVENER
Professor and Head of Internal Medicine, BPKIHS, Dharan Member, WHO Snakebite Envenoming Working Group Board of Directors, Global Snakebite Initiative Chief Researcher at Snakebite Research Centre BPKIHS, Dharan Sanjib Kumar Sharma (MBBS, MD, DM, FISN, FESC, FACC) is Professor and head of internal medicine at BP Koirala Institute of Health Sciences Dharan, Nepal. Prof. Sharma received his MD (Medicine) degree from Dibrugarh, India. He went to Mario Negri Institute of Pharmacological research, Bergamo, Italy for Fellow of International Society of Nephrology (Italy); Fellow ISPD (Dialysis) (London, UK); Fellow JSN (Mie University, Japan) and DM (Cardiology) from Kathmandu University, Nepal. He has been widely recognized for his medical work and research in snakebite, cardiovascular disease and Kidney disease. His areas of interest and research are snakebite and its prevention; the prevention of kidney and heart disease through community involvement; and the management of chronic disease in resource poor setting. Dr. Sharma is has been invited speaker at a number of national and international congresses. He has published more than 120 papers in national and international journals and written book chapters in related areas; he has also written informative booklets on Snakebite, diabetes, kidney disease and high blood pressure for public awareness. Sharma is involved in several local and international research projects, collaborations and partnerships including international registries, epidemiological studies, diagnostic studies, health system research and clinical trials e.g. ‘0by25’AKI initiative, INVICTUS studies, KHDC-Nepal program, SnakebYte study, national survey on CKD etc. He also plays active role in various national and international technical and scientific bodies. He is also commissioner of Nepal NCDI and poverty commission. He serves as a member of WHO Snakebite envenoming working group, SRC Committee of ISN, International Advisory Committee of AFCKDI, Board of directors of Global Snakebite Initiative, among others.
Dr Isabella C Bassignana Khadka PhD, CONFERENCE COORDINATOR
Rotary Club of Kathmandu Mid-Town, Kathmandu, Nepal., “Welcome Note” Dr Bassignana Khadka is a retired scientist who has an interest in promoting prevention and awareness of snakebite in Nepal. She holds a PhD in chemical physics from the University of California Los Angeles, and worked in the area of material science for over 20 years. This research included two years as an Alexander von Humboldt Scholar (with Nobel Prize laureate Prof G Ertl in Germany) and over 15 years as a research scientist at Nortel Networks (Ottawa, Canada) where she worked on dynamical x-ray diffraction for the study of advanced materials used in fibre optic systems and high speed electronics. She authored or co-authored over four dozen scientific publications in peer-reviewed journals in related disciplines in her scientific work. For the past 20 years she has been resident in Nepal where she has worked with Summary Report for the High Level Meeting and Workshop on Page 27 of 49 Snakebite in Nepal: The Challenges and the Needs 2-3 August, Kathmandu, NEPAL
INGOs (such as the World Bank, ICIMOD, UNICEF, and the like) on a wide variety of topics ranging from climate change to gender, cast and social equity, knowledge management, and so on where she was substantive editor/consultant in several dozen development-related publications. Over the recent decade she has been an active fundraiser with the Rotary Club of Kathmandu Mid-Town where she has raised considerable funds for a variety of worthy causes in Nepal; most notably for Nepalese victims of the 2015 earthquake and for the training of paramedics and doctors on the prevention and treatment of snakebite. She is committed to ‘A Nepal where no one dies from snakebite’.
Prof. David Warrell, KEYNOTE SPEAKER
Emeritus Professor of Tropical Medicine, Nuffield Department of Clinical Medicine;Honorary Consultant Physician, Oxford University Hospitals Trust; Honorary Fellow, St. Cross College Professor David Warrell is one of the world's leading figures in tropical medicine, and is the founding director of the Centre for Tropical Medicine and Wellcome Trust-Mahidol University Oxford Tropical Medicine Research Programme, Thailand. He has advised, among others, the British Army, the Foreign Office, the Royal Geographic Society and the World Health Organisation, on tropical medicine. His most recent research focuses on the incidence, morbidity and mortality of snake bites in Africa, Asia, Oceania and Latin America; and on the clinical presentation, pathophysiology, treatment and prevention of envenoming by snakes and other venomous animals. The key component of snake bite treatment is provision of specific antivenom. New antivenoms for treatment of saw-scaled viper bites in Nigeria and of taipan bites in Papua New Guinea have been developed and have or are being clinically tested. Recent findings in India give support to the belief that snake bite is the most neglected of all neglected tropical diseases and deserves reprioritisation. This programme is aimed at producing evidence relevant to establishing the true status of snake bite as a public health problem. David Warrell is co-editor of the Oxford Textbook of Medicine (1983, 1987, 1996, 2003, 2010); Concise Oxford Textbook of Medicine (2000); Essential Malariology (1993, 2002); Expedition Medicine (1998, 2002); and the Oxford Handbook of Expedition and Wilderness Medicine(2008, 2015)
Prof. David Williams, INVITED SPEAKER
BSc, GDipResMeth, PhD, Chairman and Chief Executive Officer of the Global Snakebite Initiative since 2012 David Williams is a University of Melbourne clinical toxinologist and herpetologist working on improving the treatment of snakebite in Papua New Guinea (PNG). He conducted clinical studies of the management of snakebite in PNG as a PNG Department of Health/University of PNG affiliated researcher while undertaking his PhD with the assistance of a Nossal Institute for Global Health/Australian Venom Research Unit scholarship. He is the Head of the Australian Venom Research Unit (AVRU) in the Department of Pharmacology and Therapeutics at the University of Melbourne, and also heads the Charles Campbell Toxinology Centre (CCTC) at the University of Papua New Guinea. David has worked on snakebite projects for the World Health Organization in Cambodia and in Geneva, including the drafting of WHO’s Guidelines for the Production, Control and
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Regulation of Snake Antivenom Immunoglobulins, and the production of the WHO’s venomous snake distribution and antivenoms database. Most recently he oversaw the revision of the WHO Guidelinesdocument and the redrafting of its second edition. In Cambodia he conducted an evaluation of snakebite management issues for the WHO’s Western Pacific Regional Office and the Cambodian Ministry of Health. Together with Dr Simon Jensen, he has developed practical snakebite management training courses for doctors and healthworkers in Papua New Guinea and Cambodia. David was the senior editor and an author of PNG’s first textbook on envenoming, Venomous bites and stings in Papua New Guinea, published in 2005. He collaborates with a number of international colleagues on issues relating to improving snakebite treatment, venomous snake systematics, venom proteomics and antivenom development.
Diana Barr, INVITED SPEAKER
Australian Venom Research Unit; University of Melbourne and Global Snakebite Initiative. Email: [email protected] Diana Barr is working to reduce snakebite deaths and disability around the world, puts her in very close contact with the most venomous snakes in the world. Her areas of expertise are the safe extraction of venom from snakes for research on anti-venom production and the handling of snakes with the aim of maximising safety for both the handlers and the snakes. Her most recent work was in India where she worked on improving venom production for use in anti-venom serum production and also training snake handlers in new techniques that can improve the quality and volume of venom from each snake. Brought up in a small village in Yorkshire, northern England, she was drawn to snakes like a moth to light. She says she could not resist the unblinking eyes, flicking tongue and incredible speed and agility. “Snakes are shrouded in superstition, legend and myth and I was fascinated by this. I was equally in awe of their ability to kill a person with a single bite,” she says. While in her 20s, she backpacked around Australia for a year, living with Aborigines, learning about the wild animals on the continent including snakes. She met the herpetologist and toxinologist David Williams, an international snakebite expert. Within a few weeks, she was handling some of Australia’s most venomous snakes and performing venom extractions under his expert training. “Working with large powerful venomous snakes can be exhausting but you must remain 100 per cent focused and have lightning fast reflexes,” she says. “Some snakes will fling themselves around, snapping at your hands, legs, body, face, sometimes in rapid succession. Working with large snakes requires a good deal of upper body strength, stamina and dexterity.”
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Prof. Ulrich Kuch, INVITED SPEAKER
Goethe-Universität Frankfurt am Main · Institute of Occupational Medicine, Social Medicine and Environmental Medicine. Email: [email protected] Prof Kuch is a researcher at the interface of biodiversity, health, and occupational, environmental and social medicine, my interest focuses on the positive and negative roles that biodiversity plays for health, the effects that global change has on health, and the nexus between these especially where disease prevention, control and integrated primary healthcare development are concerned. The team he direct consists of emerging public health and research leaders whose backgrounds include degrees as medical doctors, biologists, or environmental scientists with specializations in environmental health, epidemiology, public health, medical entomology, parasitology, ecology, genetics, and zoology. Common denominators are our focus on poverty-related emerging and neglected tropical diseases, R&D for the primary level of healthcare, and commitment to dialogue with academic, government and non-government partners including industry. Geographically, his team’s emphasis is on the WHO SEARO region of South and Southeast Asia and the CAN (Andean Community) region in Latin America with an increasing engagement in West and western Central Africa. In Germany and abroad, Prof Kuch’s unit integrated medical biodiversity research across political, linguistic and disciplinary borders and served as the interface between public health authorities, climate impact research, healthcare providers, and the media. It has also been a focal point for interaction with federal and state ministries and agencies, members of parliament, government health authorities, NGOs and SMEs. The ultimate goal of Prof Kuch’s work is to support increasing the access to quality health services by generating and translating new fundamental, applied and operational research results to decision-makers and lead users, and by introducing evidence-based clinical medicine and public health interventions into our dialogues with community-based and intermediary organizations, service providers and regulatory authorities.
Priyanka Kadam, INVITED SPEAKER
President and Founder of Snakebite Healing and Education Society (She-India.org). Email: [email protected] Ms Kadam spends her time working with individuals and NGOs working in the area of snakebite management. Her expertise is Human Right Issues, Community Engagement &Advocacy. She has brought together talents from varied backgrounds to work on the grossly neglected health issues related to snakebites in India. Snakebites are estimated to kill more than 50,000 people annually in India and the morbidity that accompanies a venomous snakebite is 5 times more than human fatalities. Ms Kadam has been actively working with various grass root level groups in Chhattisgarh,
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Uttar Pradesh, West Bengal, Jharkhand, Maharashtra, Gujarat, Rajasthan and Karnataka to mitigate snakebite incidences and spread awareness in rural India. She has been driving projects at the community level with a special focus on capacity building of missionary hospitals & awareness through panchayats across Indian states. Ms Kadam has more than 27 years of corporate experience. She holds a BA in Economics, M.A. in Sociology and a PG Diploma in Human Rights. She is also CAMS (Certified Anti-Money laundering Specialist) certified and remains an active member of India's evolving AML & Regulatory Compliance Fraternity. Ms Kadam has recently quit her full-time corporate role to work on snakebite mitigation full-time. She is the Former Member of WHO's Global Snakebite Envenoming Group and helped author WHO's Snakebite Strategy and Road map published in May 2019. Ms Kadam considers snakebite incidents as a human right issue and focuses to create awareness around this challenge through advocacy and community engagement. In the last five years, Ms Kadam has presented in various snakebite & toxicology symposiums in India, Netherlands and USA to create awareness on this socio-economic impact on people’s lives. Ms Kadam is an animal lover with a keen interest in bird watching. When not on the field, she can be found in and around Mumbai, Maharashtra.
Prof José María Gutiérrez, INVITED WEB SPEAKER
University of Costa Rica. Email: [email protected] J.M. Gutiérrez’s main research interests focus on the biochemical and toxicological characterization of snake venoms, the mechanism of action of myotoxic phospholipases A2 and metalloproteinases from snake venoms, technological development of antivenoms, and public health aspects of snakebite envenomings. Dr Gutiérrez has worked on the isolation and characterization of the toxins responsible for these effects and studied their mechanisms of action, using electron microscopy as well as a variety of in vitro systems for the analysis of muscle and membrane damage caused by the venoms. Haemorrhagic effects of the venom toxins have also been studied, and this part of the research has contributed to an increased knowledge about local lesions caused by snake venoms. The antivenom developed by Dr Gutiérrez has proved to be effective against other snake species found throughout Latin America. The IFS Board of Trustees, says, "The results of Dr Gutiérrez' IFS-supported research are not only of high scientific quality, they have also found practical use in improving the treatment of victims of snake bites, which constitute a serious health problem in Central America. Dr Gutiérrez, as Director of the Instituto Clodomiro Picado, has developed the institute into an internationally well-known and scientifically respected institute with a considerable amount of top-quality research in the area of toxinology."
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Dr. Dileep Pandurangrao Punde, INVITED PANELIST
Punde Hospital Mukhed, Dist.Nanded, Maharashtra, India. E-Mail: [email protected] Dr Punde, has an M.D. (General Medicine) and has worked as a Medical Officer at Rural Hospital, Mukhed since 1988 to 1997. He has been working in own set-up at “Punde Hospital Mukhed” since 1997. He has extensive experience in treating snakebite an has managed over 6200(six thousand two hundred) bite cases till today. He has spoken on the management of snake bite as a faculty in various regional, state and national and international conferences. He has held free camps for mass awareness and education programmes for the society at large about on snake bite which are regularly organized by Punde Hospital, Mukhed in neighbouring villages. To date he has shared prevention and awareness information with over 5,00,000 people. He has published many papers including a landmark publication: “Management of snake bite in rural Maharashtra: A 10 years experience” published in The National Medical Journal of India. His work on snake bite has been noted, recorded, and telecast by Discovery, Care TV, and E-tv Marathi, ABP Maza. He has trained 100 Doctors on snakebite management at the Punde Hospital. He has published numerous papers and presented his work at international fora; his work is highly quoted.
Ajay Kartik, INVITED SPEAKER
is the Assistant Curator and the Snakebite Mitigation project coordinator of the Madras Crocodile Bank Trust/Centre for Herpetology, Mamallapuram, Tamil Nadu, India. Email: [email protected] A reptile lover since childhood, Ajay has been with MCBT/CFH since 2011 and is a part of the team that manages the 2000+ captive reptiles at the croccodile bank. In addition, Ajay works on MCBT/CFH’s snakebite mitigation project which works on multiple fronts to deliver outreach programs, interface with government bodies, create educational material and films and study geographic variation in venoms/antivenom efficacy against venom from different species and regions of India.
Prof Sandeep Mahajan, INVITED SPEAKER MD, DM, FISN, FICP, MNAMS, FASN is currently in the Department of Nephrology at the All India Institute of Medical Sciences in New Delhi, India. Prof Mahajan is ISN Education Ambassador and ISPD Fellow. His research interests include: peritoneal dialysis, prediction equation for GFR estimation in Indians; screening for CKD, non- traditional risk factors for cardiovascular mortality in CKD and renal transplant patients; he also has an interest in the study of infections in post-renal transplant and peritoneal dialysis patients. Prof Mahajan has authored over 90 research publications. He has also authored 10 book chapters in related areas. Anand Zachariah, INVITED GUEST
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Professor of Medicine at Christian Medical College Medicine Unit 1 Christian Medical College, Vellore, Tamil Nadu Prof Zacharia has special interests in Medical education, Clinical toxicology, Snake envenomation and medical humanities. His areas of interest in medical toxicology include organophosphate poisoning and plant poisonings. His areas of work in snake envenomation include syndrome species correlation, variable effectiveness of antivenom, pathogenesis of Russell’s viper envenomation and bedside clotting tests in snake bite. He is working towards antivenom trials in snake bite. See: https://www.youtube.com/watch?v=I79VQZCY3DM
Dr. Guna Nidhi Sharma, INVITED SPEAKER
Tribhuvan University, Institute of Medicine, Maharajgunj Campus. Dr Sharma (MPH, Virije University, Amsterdam, the Netherlands, and MBBS) is a senior health administrator at Nepal’s Ministry of Health and Population. He is policy and planning section chief at Policy, Planning and Monitoring Division. He has been intensively engaged in formulation of National Health Policy 2075, National Migration Health Policy 2075, 15th Periodic Plan 2019-2023 and Health Financing Strategy. He has almost 14 years' of work experience; worked with different national and international organizations; predominantly worked in Nepal, also have international experience. He has experienced in policy and planning, public health emergency and disaster management, tuberculosis, neglected tropical diseases migration health, health financing and international health regulations. In 2016, he led a team to Thailand in order to study the possibility of Snake Anti-venom production in Nepal.
Prof. Mohammad Abul Faiz, INVITED SPEAKER , Professor of Medicine (Retired), Former Principal Dhaka Medical College,Former Director General of Health Services (Govt. of Bangladesh, President, Toxicological Society of Bangladesh Prof. Faiz has been Professor of Medicine, (Chittagong, Dhaka & SSMC Medical College, Dhaka) as well as Technical Chief of Ministry of Health and Family Welfare, and Director General, Directorate General of Health Services. He has also been Principal of the Dhaka Medical College, and Dean of the Faculty of Medicine, University of Dhaka and Administrative Chief of the Largest and oldest Medical College of Bangladesh. He has had a long and distinguished career in Tropical Medicine, which included research on: Malaria, Organophosphorus Compound Poisoning, Snake Bite, Nipah Infection, Kala Azar, and Tuberculosis. He has more than 259 publications of which 59 are on the topic of snakebite. More recently he is interested in: artesunate suppository severe malaria cohort (SBASSMC); PRactice of VENTilation in critically ill patients in Middle–
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Income Countries (PRoVENT–iMIC) – an international multicenter service review focusing on ICUs in Asia.
Carlos Ochoa, INVITED Research and teaching assistant, and PhD candidate at the Institute of Global Health, GeoHealth group, University of Geneva, Switzerland. Carlos Ochoa is a Colombian and Swiss biologist, ecologist and biostatistician, who is doing his PhD in Global Health in the frame of the international and multidisciplinary SNAKE-BYTE project (Switzerland – Nepal – Cameroon). He works under the supervision of Dr. Nicolas Ray and Prof François Chappuis in the fields of spatial global health and geo-epidemiology of snakebite. His areas of interest are GIS, One-Health, biostatistics and ecology.
Dr Rafael Ruiz de Castaneda, INVITED Leads the Precision One Health Unit at the Institute of Global Health of the Faculty of Medicine of the University of Geneva (Switzerland). Dr. Rafael Ruiz de Castaneda, he is widely interested complex public and global health problems at the human- animal-ecosystem interface (i.e. One Health approach) and snakebite has become a central area of his research in recent years. His research and education activity is strongly connected with so called “International Geneva”, including major players in global health such as the World Health Organization or Doctors Without Borders. His research approach is highly interdisciplinary and based on the use of digital innovation, including, for example, novel applications of crowdsourcing and computer vision to snake identification and snakebite epidemiology and clinical management.
Lois J Armstrong, BSc MPHTM Lois worked in South India, firstly, as a school nurse in an international boarding school and then as a research project manager for tuberculosis research projects at CMC Vellore. After this she moved to North India where she worked for Emmanuel Hospital Association at Duncan Hospital, Bihar, building research capacity in local health care workers. During this time, she developed an interest in the area of snakebite due to the large number of cases seen in the area. She is especially keen to understand more about the social, spiritual and community issues connected to snakes and snakebite, to enable snakebite prevention and improved access to treatment.
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Annex 6 Submitted Abstracts
Molecular and functional venom variation in geographically distinct populations of Saw-scaled viper Echis carinatus Siddharth Bhatia1, Karthikeyan Vasudevan2 1. Ph.D. Student, Centre for cellular and molecular biology, Hyderabad, India 2. Principal Scientist, Centre for cellular and molecular biology, Hyderabad, India Abstract Snakebite in India claims around 50000 lives annually and several victims are left with physical disability. This alarming mortality can be attributed to lack of infrastructure in PHCs, people resorting to faith healer, Antivenom ineffectiveness, etc. There are several reports showing inability of Indian polyvalent antivenom (ASV) to neutralize the snake venom. We hypothesize that the ineffectiveness of ASV could be due to the geographical venom variation. Since ASV is made from venom sourced majorly from Irula coop based in Chennai, ASV might not be effective in neutralizing snake venom from other regions. To test the hypothesis, we collected saw-scaled viper venom from Tamil Nadu, Goa and Rajasthan and perform detailed compositional analysis using RP-HPLC, SDS-PAGE and Mass Spectrometry. Our study found toxins belonging to 10-12 toxin families which differ in its composition among venom collected from these locations. We analyzed the antivenom- venom immune complex formation for different venoms using size-exclusion chromatography. The dose dependent parameters estimated showed variation in binding of ASV to venoms from different locations. We conclude that there is geographical venom variation in saw-scaled viper, causing differential binding of ASV. This makes the commercially available polyvalent ASV inefficient for treatment of snakebite victims.
Role of Snake Conservation Society (SCS) in the research and conservation of snakes in Nepal Mahendra Prasad Katila, President, Snake Conservation Society (SCS) Nepal Pokhara-01, Simpani, Kaski, Nepal; Email: [email protected]; Mob: 9851173425; www.scsnepal.org
Founded in 2016 by the dedicated wildlife biologists and citizen scientists, Snake Conservation Society (SCS) Nepal has been devoted for the research and conservation of snakes in Nepal. Since 2016, we have rescued >1,000 snakes of different species including King cobra and other deadly venomous snakes from personal houses, hotels and settlements and safely released them in the natural forests. We have also trained >250 people including students, teachers, security personnel and medical professionals in snake handling. More than 100 thousand people have been educated during several awareness campaign. Community outreach materials such as brochure and posters were published and distributed to the local people, students and medical professional for the rapid relay of snake conservation message to the society. Besides, training, rescue and awareness campaign; we have been also surveying the snakes in different parts of the country. To date, we have surveyed snakes in more than 10 districts focusing on King cobra and we recorded King cobra in Kaski, Tanahu, Lamjung, Parbat, Myagdi and Syangja district. We recommend that series of conservation education, community outreach, snake identification trainings and in-depth surveys are required for the conservation of snakes in Nepal.
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Snakebite prevalence and practices at a rural municipality level of eastern Nepal
Poster presentation
Dr. Surya B. Parajuli Assistant Professor, Department of Community Medicine Birat Medical College & Teaching Hospital, Tankisinuwari, Morang, Nepal Email: [email protected] Mobile: 9841794785 ORCID: https://orcid.org/0000-0003-0386-9273
Introduction: Pre hospital care is vital for a good outcome on snakebite. Many traditional practices on snakebite still exist.
Objective: To assess the prevalence and practices of snakebite in rural communities of Budhiganga rural municipality of eastern Nepal.
Methodology: A community based cross sectional study was conducted between April-June 2019 among 245 household of 3 communities of Budhiganga rural municipality.
Results: We found 13.06% prevalence of snakebite and majority of snakes were unidentified. Among them, 70% followed traditional healers. Majority were below poverty level (75.1%) and having non concrete house (57.14%). Regarding snake identification, 25% had false believe that banded krait is not poisonous while rat snake (50%) and water snake (30%) are poisonous. The wrong practices were use of tourniquet (81%), belief on traditional healer (80%), wash bite site (53.47%), cut bite site (52%), suck by mouth (34%), the use of traditional plant Jharmauro (14.29%), ice cubes at bite site (9%), drinking alcohol (4%) and use of electric sparks (1%). The wrong beliefs were snake drinks milk (85.31%), give water after snake bite (47%), give chilly after snake bite (41.63%), snake bite poisoning transfer to another if consumed the food taken by victim (33.47%), no poisoning if taken nim patta for many years (31.84%), no toxicity if snake bite during alcohol intake (14.29%), honey will cure snake bite (11.84%) and eating earthworm will cure the snake bite (4.08%). Around 30% were not aware on Snakebite treatment place. Almost half don’t know about Anti Snake Venom (ASV). No previous snakebite awareness program reported.
Conclusion: Many traditional snakebite practices exist which are harmful and increase the mortality due to snakebite.
Keywords: First aid, Nepal, Rural Communities, Snakebite
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Crusade Against Snake Bite
Dileep P Punde1, Gaurav D Punde2
1. Senior Consultant Physician and Head, Punde Hospital Mukhed, Nanded, Maharashtra, India 2.Resident Doctor in cardiology department, Global Hospital Hyderabad, Telangana, India Key Words – Big four, syndromic approach, Respiratory paralysis, ARF, Antivenom, Mass awareness
Cobra, common krait, Russell’s viper and Saw scaled viper are the venomous snakes flourished all over Maharashtra, India. This is a clinical study of 2535 bite cases treated at Punde Hospital Mukhed Dist Nanded, a remote rural part of Maharashtra with restricted resources from 2002 to 2015. This study includes venomous snake bites 1104 (89.25%), Non venomous 133 (10.75%), Not identified 1211 and scorpion sting 87. Out of 1104 venomous snake bites cobra 332 (30.07%), Krait 97 (8.78%), Russell Viper 420 (38.04%), Saw scaled viper 158 (14.31%) and vasculotoxic not identified 97 (8.78%). Incidence of ASV anaphylaxis 187 (16.95%) and mortality 20 (1.81%). Geographically occurrence of big four, poverty leading to poor living conditions and farming as a main occupation are the main risk factors. Incidence of snake bite was more in males, age group 21 to 40 years and in June to October months (P<0.05). Diagnosis of snake bite was done by proper history, Local and systemic signs and examination of killed snakes if brought by the patient or bystander and showing preserved specimen or photographs and syndromic approach. Local oedema, rapid descending paralysis and respiratory paralysis is the common presentation of cobra bite. Early morning abdominal pain, slow neuroparesis, minimal or no local signs is hallmark of krait bite. Rapid progressive oedema, pain, lymphadenopathy, shock, bleeding diathesis and acute renal failure are the common features of Russell’s viper bite. Local oedema and rarely bleeding is observed after echis bite in this area. At rural level CBC, WBCT, Urine exam, RFT and LFT are enough for diagnosis and management. 20 WBCT test is valid for readministraion of ASV and not helpful always for early envenoming which is diagnosed clinically. In cobra bite respiratory paralysis was found in 121 (36.4 %) cases, morbidity in 29 (9.93%) cases and mortality 4 (1.20%), in krait bite respiratory paralysis 36 (37.11%) and mortality 1 (1.03%), In Russell viper bite acute renal failure 54 (12.85%), shock 30 (7.14%), Capillary leak syndrome 06 (1.42%) mortality 14 (3.33%). In saw scaled viper ARF 3 (1.89%) and mortality 1 (0.63%) and in vasculotoxic not identified ARF 5 (5.15%) mortality 0 (0.00%). Mean dose of ASV used for cobra was 160.22 ml, krait 160.87 ml, R-viper 210 ml, saw scaled viper 68.30 ml and vasculotoxic not identified 134.81 ml. Refractory shock, capillary leak syndrome, sepsis, intracranial bleed ARDS and cerebral anoxia are the bad prognostic signs. Rational use of antivenom, timely ventilation, maintains of nutrition, electrolytes and extensive training of peripheral doctors and public awareness are the main weapons in crusade against snake bite. All these at our rural centre revolunized the morbidity and mortality (4.7% - 1.81%). [email protected] [email protected]
Date : 10/07/2019
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Dr.Sadanand Raut consultant physician M.D Gen Medicine Vighnahar Nursing Home Narayangaon Tal Junnar Pune Mah.INDIA.
Zero Snake Bite Death Project
Incidence of snake bite in western Maha is rising due to increase cultivated land due to irrigation projects. Russell’s viper & Cobra bite are more common than krait &Echis . Diagnosis of snake bite is done by proper history, Local & systemic signs, examination of killed snakes if brought by relatives, pictures etc. Rapid descending paralysis & local necrosis is the common presentation of cobra bite. Pain in abd, vomiting, slow neuroparesis, painless & non visible bite marks is common in krait bite. Atypical presentations convulsions, coma, & chest pain are seen in krait bite. Severe pain & rapid progressive edema, lymphadenopathy, shock, bleeding disorder are the common features of Russell’s viper bite. We have treated less no. of saw scaled viper bite(10 ). Local edema and rarely bleeding is observed after Echis bite. Basic investigations like CBC, BT CT Urine exam RFT and LFT, 20WBCT are done for diagnosis and management. 20 WBCT test is useful for readministration of ASV. We are not using prophylactic adrenaline to prevent anaphylaxis. Incidence of anaphylaxis is very low. 22 patients of cobra bite were brought in cardiac arrest with dilated pupils, resuscitated successfully after CPR and rapid infusion of ASVs & ventillation . 1 patient of 6ft 9”cobra bite had dry bite. As per our experience 5 -20 vials of ASV is optimum & adequate for Neurotoxic bites & 2-4 vials for Echis, 20-45 vials for Russell’s viper bite. 3% patients of R-viper bite had ARF. We had 7 patients with pregnancy & venomous snake bite, there is no foetal & maternal loss. 0% fatality in last 5 years. Early administration of ASVs prevents respiratory paralysis in elapid snake bite. Patients with respiratory insufficiency after neurotoxic snake bite require immediate endotracheal intubation & ventilatory support. Anticholiestrase may help to reverse neuromuscular dysfunction. 10 RV bite patients had S/S of neurotoxicity ptosis & flaccid paralysis ,only one of this required NIV & took long time for recovery . We have started zero snake bite death project in our region. Training for Doctors, massive Community awareness programs, availability of effective treatment locally helped to achieve 100% survival. Email:[email protected] , 'Zero Snake Bite Death Project'
Nepal Toxinology Association Establishment in Nepal
Dr. Chhabilal Thapa Magar, President, Nepal Toxinology Association, Member, International Society of Toxinology (IST 0845), Medical Director Kaligandaki Hospital, Kawasoti, Nawalpur. Email: [email protected] Abstract: Nepal Toxinology Association (Reg, No 2198 NTA) is a non-profitable non-governmental organization. It has been established in 02 February 2017 to make Nepalese aware in conservation of all creatures venomous including snakes, effects of animal and plant origin toxins on mankind, medicines required to treat their effects, and support Nepal government in policy making via conducting research and developmental activities associated to all creatures venomous and their uses for human welfare. NTA promotes and advance the study knowledge of toxinology in all aspects also aims to conduct programs empowering people for save the snakes. Management of snakebites and cooperate with national and international organizations achieving the goals. Key words: Toxinology, Venomous, save the snakes, snakebites management. ======
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Report of Bungarus bungaroides (CANTOR, 1839) from Dhankuta, Nepal Authors: 1. Kul Prasad Limbu. Associate Professor, Department of Zoology, Post Graduate Campus, Tribhuvan University, Biratnagar, Nepal 2. Jawan Tumbahangfe, Ph.D. scholar, Central Department of Zoology, Tribhuvan University, Kirtipur, Kathmandu Abstract:
One killed snake specimen was examined and confirmed as Bungarus bungaroides (CANTOR, 1839). WHO identified B. bungaroides as medically significant venomous species. Pholidosis, morphometry, and distribution of the specimen were presented. The distribution of the little-known species is now extended to Dhankuta, Nepal.
The Indian cobra genome and transcriptome enables comprehensive identification of venom toxins Somasekar Seshagiri, ModMab Therapeutics, USA and SciGenom Research Foundation, India
Snakebite envenoming is a serious neglected tropical disease that kills ~100,000 people annually. High quality snake genome-enabled comprehensive characterization of venom gland toxin genes will facilitate development of effective antivenoms. We report a de novo near-chromosomal assembly of Naja naja (Indian cobra), a highly venomous, medically important snake. Our assembly has a scaffold N50 of 223.35 Mb and contains a 375 Mb scaffold that represents the entire chromosome 1. Transcriptomic data from 14 different tissues was used to identify 12,346 genes expressed in the venom gland including a minimal set of 19 venom gland-specific toxin genes that likely form the core toxic components of the venom. Overall, the Indian cobra genome will be an important resource for effective antivenom development and evolutionary studies of snakes. Overall, our high-quality genome will be an important resource for evolutionary studies of snakes and antivenom development.
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Title: Krait bite mimicking brain death Authors: Parag Vijayvergia, Saurabh Kumar, Gopal Krishna Bohra, Maya Gopalakrishnan Affiliation: Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India Introduction Snake bite envenoming is a common and serious problem in the tropics which has varying presentations depending on the type of snake. Neurotoxicity is a feature of envenoming due to elapids which can commonly present as ptosis and paralysis; however extreme clinical presentations mimicking brain death occur rarely. Case We report a case of 25 year old male who presented with unconsciousness and had absent dolls eye reflex, cough reflex and caloric stimulation test. Clinical picture was suggestive of brain death. There was no prior history to ascertain the cause of the condition. The patient was intubated and mechanical ventilated. EEG was done which was suggestive generalised brain dysfunction. On detailed examination of patient a possible bite mark was observed in the lower limb. Hence, a possibility of snake bit was considered and polyvalent anti snake venom was administered empirically (30 vials of polyvalent ASV) . On day 4 of admission patient showed mild flickering of eyelids. A neostigmine challenge was given to the patient, after which he showed significant improvement in weakness. Patient improved and was weaned off ventilator gradually. Patient was discharged on day 18 of admission with a diagnosis of possible krait bite. Conclusion This report highlights the importance of considering elpaid envenomation in unexplained neuro-paralytic syndromes even if antecedent history of snake bite is absent. Clinicians must be aware of this presentation and strongly consider empiric antisnake venom in such situations. Keywords: Snake bite, krait, Brain death, coma
Snake bite scenario of western Nepal. Snake bite has been a global issue for decades. Nepal too has been tremendously affected by this issues for a long.Eastern part of Nepal has been taken care of by prof Sanjeev Sharma sir for more than ten years. But for western Nepal, it was a phenomenon of chance that snake bite victims survive until 2015, as there was no systematic approach for the snake bite management. Only the referral center and the best center for snake bite victims was Bheri Zonal hospital and this hospital had no provision of ICU set up until 2015. After set up ICU and critical care service , snake bite mortality has been significantly lowered .
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Venom-induced consumption coagulopathy due to Echis carinatus sochurecki: A case report from Rajasthan India
Authors: Maya Gopalakrishnan, Naresh Midha, Rohit Mathur, Prakrati Yadav, Mahendra Kumar Garg Affiliation: Department of Internal Medicine. All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India Address for correspondence: Dr Maya Gopalakrishnan Assistant Professor, Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India [email protected] Tel: +919994492075.
Background: Snake bite envenoming is a serious and life threatening problem in the Indian subcontinent. Regional intraspecific variation is especially important in vipers. Echis carinatus sochurecki has been reported previously from desert regions of Rajasthan. We report a case of venom induced consumption coagulopathy (VICC) secondary to Sochurek’s viper envenoming not responding to polyvalent antivenom. Case report: A 60 year old farmer from Barmer district, Thar Desert region of Western Rajasthan, India was bitten over right foot while working at the fields. He developed swelling and bleeding at the bite site. He also complained of headache after the bite. Ten vials of Indian polyvalent antivenom (ASV) were given within 1 hour of bite at district hospital. He presented to our emergency department 6 hours after bite. As whole blood clotting time (WBCT 20) was prolonged at 6 hours, 10 vials of antivenom (Premium Serums and vaccines private limited, Nagpur, India) were given. A further 10 vials of ASV was administered as WBCT 20 was persistently incoagulable after next 6 hours. Prothrombin time and activated partial thromboplastin time (aPTT) remain unrecordable (>120s), 72 hours after the bite. Local bleeding has subsided, platelet counts and renal functions are normal. A photograph of the snake taken by the patient relatives and unresponsiveness to polyvalent antivenom strongly suggests Echis carinatus sochurecki envenoming. The patient is currently admitted and receiving supportive care. Outcome and follow up shall be reported subsequently. Conclusion: Echis carinatus sochurecki is a medically important snake in the desert regions of Western India causing significant morbidity. The usefulness of Indian polyvalent antivenom appears limited. There is an urgent need to develop region specific antivenom or monovalent antivenom for this area. Key words: Snake bite, Saw scaled viper, Echis carinatus sochurecki, Venom-induced consumption coagulopathy, Arid Desert, Rajasthan.
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Annex 7 List of Participants
INVITED SPEAKERS Name Affiliation Country
CONFERENCE CONVENER Dr. Sanjib Kumar Sharma Professor and Head of Internal Medicine, BPKIHS, Dharan NEPAL Head of the Australian Venom Research Unit (AVRU) in the Department of Pharmacology and Therapeutics Dr David William at the University of Melbourne, Australia and AUSTRALIA Technical support officer at the Australian Venom Research Unit at the University of Melbourne and Ms Diana Barr Global Snakebite Initiative AUSTRALIA David A. Warrell Emeritus Professor of Tropical Medicine, Hon Fellow St Cross College, Professor, Dr David A. Warrell University of Oxford UK Assistant Curator at Madras Crocodile Bank Mr Ajay Kartik Trust/Centre for Herpetology, Madras INDIA Christian Medical College Vellor Prof Anand Zacharia Tamil Nadu INDIA Professor, Department of Nephrology, All India Institute of Medical Sciences, Prof Sandeep Mahajan New Delhi INDIA Executive Director. Snakebite healing and Education Dr. Priyanka Kadam Center, Mumbai INDIA Professor of Medicine (Retired) Prof. Mohammad Abul Faiz President, Toxicological Society of Bangladesh (TSB) BANGLADESH Department of Tropical Medicine and Public Health, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Prof. Dr. Ulrich Kuch Frankfurt am Main, Germany. GERMANY Senior Health Administrator , Ministry of Health, Dr. Guna Nidhi Sharma Government of Nepal NEPAL Institute of Global Health, Faculty of Medicine, University of Geneva. And Institute for Environmental Mr. Carlos Ochoa Sciences, University of Geneva Geneva, Switzerland. SWITZERLAND Institute of Global Health, Faculty of Medicine, Dr. Rafael Ruiz de Castañeda University of Geneva SWITZERLAND
Duncan Hospital, Raxaul, Bihar, India Lois Armstrong (A Unit of Emmanuel Hospital Association) INDIA
SPEAKERS (invited but not supported financially) Name Affiliation Country Vighnahar Nursing Home Narayangaon Tal Junnar Dr Sadanand Dagadu Raut Pune Maharastra INDIA Dr Dilip Punde Punde Hospital Mukhed, Dist.Nanded, Maharashtra INDIA Dr Anup Bastola Sukraraj Tropical and Infectious Disease Hospital NEPAL
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COMPLEMENTARY REGISTRATION Ms Susen Mole Sheer Memorial Hospital, Banepa (RAPPORTEUR) NEPAL Mr Siddharth Dagar VINS Bioproducts INDIA Mr Ajit Nair VINS Bioproducts INDIA Dr Buddha Basnyat Nepal International Clinic NEPAL Mr Talak Hayu Embassy of Switzerland, Kathmandu NEPAL Chakra Singh Karki Gokuleshowar Hospital Darchula NEPAL Mr Krishna Karki Embassy of Australia, Kathmandu NEPAL Mr Glen White Embassy of Australia (former ambassador) AUSTRALIA Mrs Marianne White Embassy of Australia (spouse of Glen White) AUSTRALIA HE Mr Peter Graeme Budd Ambassador of Australia to Nepal AUSTRALIA Dr. Lungten Z. Wangchuk Team leader CDS WHO Nepal Dr. Usha Kiran National professional Officer -NDT WHO Nepal
Snakebite Conference Delegates List
S.N Name Contact No Institution Address Designation Remarks Abinash Prasad 1 Singh EDCD Kathmandu Regular Jhalanath Khanal Inst of 2 Achut Khanal 9851074375 Health and Science Baneshwor Regular
3 Ajit Nair VINS Bioproducts India Regular Emmanuel Hospital Junior Medical 4 Amos Dasari 8332813687 Association India Officer Regular
5 Asith Wanniarachchi 94-112719996 University of Colombo Sri Lanka Regular
6 Bhola Adhikari Regular Medical 7 Binita Panthi 9802003121 Peace Corps Nepal Kathmandu Assistant Regular Brig Dr Devendra 8 Khatri Army Regular Brig. Dr. Arun 9 Sharma Army Hospital Kathmandu Regular Gokeleshowar Hospital 10 Chakra Singh Karki 984877024 Darchula Darchula Regular Province 1 Health 11 Chandra Dev Meheta Directorate Biratnagar Regular Nepal Red Cross 12 Chandra Shah Society Lakhanpur Chairman Regular
13 Dhirubhai C. Patel India Regular Public Engagement 14 Dinesh Deokota 9851050915 Media For Development Kathmandu Officer Regular
15 Dipak Ghimire Butwal Regular Dr Ajay Raj 16 Rajbhandari Army Regular
17 Dr Alok Pradhan Regular
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18 Dr Bibek Kumar Lal EDCD Kathmandu Regular
19 Dr Bijay Bartaula Maya Metro Hospital Dhangadi Regular Sukraraj Tropical and Dr Bimal Sharma Infectious Disease 20 Chalise 9856027905 Hospital Kathmandu Regular Nepal International 21 Dr Buddha Basnyat Clinic Nepal Regular Punde Hospital 22 Dr Dileep Punde 9422874826 Mukhed,Nanded India Panelist Regular
23 Dr Elina Mulmi Regular Dr Krishna Prasad 24 Acharya Regular
25 Dr Madhav Ghimire Regular Dr Nawraj 26 Lamichhane Regular
27 Dr Nishan Bhurtyal Teaching Hospital Kathmandu Regular Madhyapur Thimi 28 Dr Pradip Adhikari 9841235239 Hospital Kathmandu Regular Province 2 Health 29 Dr Pramod Yadav Directorate Janakpur Regular
30 Dr Prateek Neupane 9845197165 Bharatpur Hospital Bharatpur Credit Quest Regular Dr Radhika 31 Thapaliya EDCD Kathmandu Regular
32 Dr Rajan Thapa Regular Nepal Medical College MD General 33 Dr Ritu Bajracharya 9841508378 Teaching Hospital Kathmandu Physician Regular
34 Dr Roshana Shrestha Regular
35 Dr Roshika Shrestha EDCD Kathmandu Regular Dr Samir Kumar 36 Adhikari EDCD Kathmandu Regular Dr Sarwani Adhikary 37 Khand Regular Dr Satya Narayan 38 Chaudhary Regular
39 Dr Sushil Baral 9841371800 BIR Hospital Kathmandu Regular Dr. Achyut Bhakta 40 Acharya 9856034678 BPKIHS, Dharan Dharan DM Resident Regular
41 Dr. Akshat Mishra 9865596739 BPKIHS, Dharan Dharan JR Medicine Regular
42 Dr. Anu Dahal 9867575558 Kirtipur Hospital Kathmandu Registrar Regular Sukraraj Tropical and Infectious Disease 43 Dr. Anubhav Poudel 9843298785 Hospital Kathmandu Medical Officer Regular Kist Medical College & 44 Dr. Avatar Verma 9857010617 Teaching Hospital Kathmandu Doctor Regular Medical 45 Dr. Badri Baidawar 9847324413 Bhim Hospital Bhairahawa Superitendent Regular
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Grande International 46 Dr. Binti Shah 9841346852 Hospital Kathmandu Physician Regular College of Medical 47 Dr. Bipul Bhagat 9849794986 Sciences Bharatpur Regular Kaligandaki Health 48 Dr. Chhabilal Thapa 9845069638 Foundation Kawasoti Doctor Regular Scheer Memorial 49 Dr. Dale Mole 9860655110 Adventist Hospital Banepa CEO Regular
50 Dr. Deepak K Yadav 9842056901 BPKIHS, Dharan Dharan Regular
51 Dr. Divya Dhungana 9813331215 Bardiya District Hospital Gulariya Medical Officer Regular Dr. Diwash Raj 52 Bohora 9800975199 AMDA Hospital Damak MD Medicine Regular Kantipur Dental College 53 Dr. Durga Bhandari 9851139572 Teaching Hospital Kathmandu Doctor Regular Sukraraj Tropical and Infectious Disease 54 Dr. Eliz Achhami 9846710319 Hospital Kathmandu Regular Dr. Ganga Prasad 55 Yadav 9860165713 Sirha District Hospital Sirha Physician Regular Dr. Hari Prasad 56 Panthi 9857063246 TUTH Kathmandu MD Resident Regular
57 Dr. Indira Ojha 9843031073 Bara Hospital Regular Emergency 58 Dr. Jagadish Joshi 9841943586 Seti Zonal Hospital Dhangadi Physician Regular Dr. Kamal 59 Lamichhane 9849099215 TUTH Kathmandu MD Resident Regular Dr. Krishna Psd 60 Acharya 9851145147 Bheri Hospital Nepalgunj Regular
62 Dr. Mani Gautam 9851076043 Bharatpur Hospital Chitwan Doctor Regular
63 Dr. Manoj Subedi 9846261837 BPKIHS, Dharan Dharan JR Medicine Regular Dr. Maya Gopala Assistant 64 Krishnan 919994492075 AIIMS Jodhpur India Professor Regular Vighnahar Nursing Home & Rural Critical Dr. Sadanand's 65 Dr. Mrs Pallavi Raut Care Center India wife Regular
66 Dr. Navin Chaudhary 9851145644 Nepal Police Hospital Kathmandu Doctor Regular Dr. Parag Vijay 67 Vargeiya 7014248914 AIIMS Jodhpur India JR Medicine Regular
68 Dr. Pradeep Panthi 9847245383 TUTH Kathmandu MD Resident Regular Dr. Prahalad Kumar Nepal Army Snakebite 69 Mahato 9841956080 Centre Gaighat Gaighat Army Doctor Regular Dr. Pratiksha Dental 70 Dhungana 9840254221 Manav Dental hospital Jhapa Surgeon Regular
71 Dr. Rajan Poudel 9863064864 Midpoint District Hospital Kawasoti Medical officer Regular Dr. Ram Narayan 72 Shah 9851107982 Thimi Hospital Kathmandu Physician Regular
73 Dr. S K Pahari Regular Kist Medical College & 74 Dr. Sajana K.C. 9841314790 Teaching Hospital Kathmandu Lecturer Regular
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75 Dr. Saroj Thapa 9866497804 Kirtipur Hospital Kathmandu Regular
76 Dr. Saurabh Kumar Regular
77 Dr. Seema Oli 9849233645 Bara Hospital Regular Dr. Sher Bahadur Seti Anchal Hospital, 78 Kamar 9841277823 Dhangadi Kathmandu Physician Regular Sukraraj Tropical and Dr. Shrawan Kumar Infectious Disease 79 Mandal 9841597345 Hospital Kathmandu Medical Officer Regular College of Medical 80 Dr. Shreeja Gamal 9849513035 Sciences Bharatpur Medical Officer Regular
81 Dr. Shreya Dhungana 9851212879 Kathmandu Medical officer Regular
82 Dr. Shyam Dhodary 9841316349 BPKIHS, Dharan Dharan JR Medicine Regular
83 Dr. Sudeep GC 9802003115 Peace Corps Nepal Kathmandu Medical Officer Regular Dr. Sujeeta 84 Bajracharya 9841478595 Army Hospital Kathmandu Regular World Health Zonal Organization India, Coordinator 85 Dr. Suman Saurabh 7766906623 Muzaffarpur India NTD Regular Birat Medical College & Assistant 86 Dr. Surya B. Parajuli 9841794785 Teaching Hospital Biratnagar Professor Regular
87 Dr. Swarup Shrestha 9801077217 NAMS, Bir Hospital Kathmandu Registrar Regular
88 Dr. Usha Kiran WHO Nepal Kathmandu Regular
89 Glen White Embassy of Australia Australia Regular HE Mr Peter Graeme Ambassador of Australia 90 Budd to Nepal Australia Regular
91 Heera KC Birat Medical College Regular Prathamik Swastha Public Health 92 Jagdish Mandal 9814754132 Karyalaya, Sirthauli Dhudhauli Inspector Regular John Benjamin 93 Owens C & F Herpetology, UK UK Regular Nepal Toxinology Snake 94 Kamal Devkota 9851203342 Association Butwal Conservationist Regular Keshab Prasad 95 Poudel 9861148386 Kaligandaki Hospital Kawasoti Lab Technician Regular
96 Khusbu Gupta Regular
97 Krishna Karki Embassy of Australia Nepal Regular
98 Krishna Raj Pandey Regular Post Graduate Campus, Associate 99 Kul Prasad Limbu 9852063755 TU Biratnagar Professor Regular Anti Snake Venom Serum Research & Mfg. 100 Laxmi Phuyal 9842103792 Pvt. Ltd. Itahari Businessman Regular
101 Lt. Dr. Sunil Chalise Army Regular
102 M.V. Khadilkar Regular
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Snake 103 Mahendra Katila 9804456789 Pokhara Conservationist Regular Maj Dr Rabindra Jang 104 Rayamajhi Army Regular
105 Mamata Bista 9841085959 Regular
106 Man Bdr Nepali Regular Kapilvastu Snake Bite 108 Nabin Bhandari 9857050973 Care Center Kapilvastu Manager Regular VINS Bioproducts 109 Nikhil Sharma Limited India Regular
110 P.K. Chhetri Regular Prakash Chandra 111 Ghimire EDCD Kathmandu Regular
112 Prem Bista 9842397231 Biratnagar Regular SDM College of Ayurveda and Hospital, 113 Prerok Regmi 9849374627 Udupi India PG Scholar Regular
114 Rashmi Ben Patel India Regular
115 Ravindra Yadav 9817404426 Bhim Hospital Bhairahawa Volunteer Regular Snake 116 Rohit Giri Pokhara Photographer Regular B. Pharamcy 117 Sabin Ranpal 9847176314 Lumbini Zonal Hospital Butwal Student Regular Nepal Medical College 118 Sameer Thapa 9841414170 Teaching Hospital Kathmandu Regular
119 Santosh BK BPKIHS Regular
120 Sashikant Upadhyay 9857020183 Bhim Hospital Bhairahawa AHW Regular Kapilvastu Hospital, 121 Shashi Tripathi 9805470560 Taulihawa Kapilvastu A.N.M. Regular Shenali 122 Wanniarachchi 94-112719996 University of Colombo Sri Lanka Regular Centre For Cellular And Molecular Biology, 123 Siddharth Bhatia 27192606 Hyderabad India Ph.D. Student Regular
124 Siddharth Dagar VINS Bioproducts India Regular
125 Sub Kamala Nepali Regular Sub Shraddha 126 Neupane Regular Snake 127 Sunil Sapkota 9845364525 Raise Hands Nepal Chitwan Conservationist Regular Susan Ambrose Research 128 Michael 919955873974 Duncan Hospital, Raxaul India Assistant Regular Scheer Memorial 129 Susen Mole Hospital Nepal Regular
130 Talak Hayu Embassy of Switzerland, Nepal Regular Vanmala Dileep Punde Hospital Dr Punde's 131 Punde 9422874826 Mukhed,Nanded India Wife Regular
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Simultala 132 Vishal Santra Conservationist India Regular Anti Snake Venom Yagyaprakash Serum Research & Mfg. 133 Shrestha 9851046968 Pvt. Ltd. Itahari Businessman Regular Health Travel 134 Anand Raj Joshi 9867867427 Chaurmandu Hospital Achham Assistant Grantee Western Regional Travel 135 Anju Acharya 9846156558 Hospital Pokhara Nurse Grantee Bhupendra Prasad NRCS Snakebite Snakebite Travel 136 Adhikari 9842650836 Treatment Centre Damak Paramedics Grantee Health Travel 137 Bishal Dahal 9852029228 Itahari Hospital Itahari Assistant Grantee Bishweshwar Prasad Health Travel 138 Bhatt 9848711562 Sarmoli Health Post Darchula Assistant Grantee Arghakhanchi District Travel 139 Dr. Aayusma Bhusal 9849667282 Hospital Arghakhanchi Medical Officer Grantee Travel 140 Dr. Alina Tandukar 9841525624 Mangalbare hospital Morang Medical Officer Grantee Dr. Alok Chandra Panchkhal Primary Travel 141 Mahato 9807867312 Health Care Centre Kavrepalanchok Medical Officer Grantee Bharatpur Samudiyak Travel 142 Dr. Amod Ghimire 9865005828 Hospital Chitwan Medical Officer Grantee Travel 143 Dr. Amrit Devkota 9843056359 Gorkha District Hospital Gorkha Medical Officer Grantee Travel 144 Dr. Amrit Panthi 9841363317 Rampur Hospital Palpa Medical Officer Grantee Dr. Arbinda Kumar Travel 145 Yadav 9804729428 Rangeli Hospital Biratnagar Doctor Grantee Dr. Bharosha District Hospital Travel 146 Bhattarai 9843292529 Dhankuta Dhankuta Medical Officer Grantee Dr. Bishesh Travel 147 Lamichhane 9845370198 Shishuwa Hospital Chitwan Medical Officer Grantee Travel 148 Dr. Dev Raj Ghimire 9851253653 BPKIHS, Dharan Dharan JR Emergency Grantee Travel 149 Dr. Katyayani Pandey 9849135141 Katari Hospital Udayapur Medical Officer Grantee Travel 150 Dr. Lalit Karki 9841199101 Sotang PHC Solukhumbhu Medical Officer Grantee Travel 151 Dr. Lalit Dhami 9868420967 Chaumala PHCC, Kailali Dhangadi Medical Officer Grantee Travel 152 Dr. Nabin Timilsena 9860577681 Mehalkuna Hospital Surkhet Medical Officer Grantee Travel 153 Dr. Navin Bhatt 9849286223 Bayalpata Hospital Achham Medical Officer Grantee Travel 154 Dr. Niraj Paudel 9841351858 District Hospital Syangja Pokhara Medical Officer Grantee Research Travel 155 Dr. Prajwal Gautam 9865188378 BPKIHS, Dharan Dharan Officer Grantee Travel 156 Dr. Prakash Kharel 9849060821 Parroha Health Post Rupandehi Medical Officer Grantee Travel 157 Dr. Preksha Dugar 9858030990 Yashoda Hospital Nepalgunj Medical Officer Grantee Research Travel 158 Dr. Prince Agrawal 9860604667 BPKIHS, Dharan Dharan Officer Grantee Travel 159 Dr. Sajana Poudel 9842586353 Damauli District Hospital Tanahun Medical Officer Grantee Travel 160 Dr. Samir Kshetri 9849130747 BPKIHS, Dharan Dharan JR Emergency Grantee
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Travel 161 Dr. Sandip Pokharel 9852056445 KTM Polyclinic Chitwan Medical Officer Grantee Travel 162 Dr. Sanju Bhatta 9869357428 Chitwan Medical College Bharatpur Medical Officer Grantee Travel 163 Dr. Sunil Bogati 9849453341 Kolhabi PHC Bara Medical Officer Grantee Dr. Sunil Kumar Travel 164 Chaudhary 9803953813 Rangeli Hospital Biratnagar Doctor Grantee Travel 165 Dr. Trilochan Panthee 9849673677 Bhim Hospital Bhairahawa Medical Officer Grantee Lumbini Provincial Travel 166 Dr. Yogesh Pandey 9849258220 Hospital Butwal Medical Officer Grantee Health Travel 167 Ganesh Prasad Kafle 9803673464 Bhim Hospital Bhairahawa Assistant Grantee Travel 168 Ganga lal Devkota 9844897031 Midpoint District Hospital Kawasoti AHW Grantee Khyam Chandra NRCS Snakebite Snakebite Travel 169 Adhikari 9842790119 Treatment Centre Damak Paramedics Grantee Health Travel 170 Mahananda Joshi 9848751876 Rim Health Post Baitadi Assistant Grantee Ram Kumar Health Travel
171 Biswakarma 9851185621 Itahari Hospital Itahari Assistant Grantee Biratnagar Nursing Travel 172 Sheela Thapa 9841642566 Campus Biratnagar M. Nursing Grantee Health Travel 173 Tilak Yadav 9862866403 Patheka Health Post Khotang Assistant Grantee
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