A Way to Solve Snakebite Problem in Odisha and India

Odisha Review April - May - 2014

Dr. Indramani Jena

Odisha is one among the snakebite prevalent states of India : total 600,000 to 1600, 000 cases of with large number of fatalities. Here, not only the bite and 11,000 to 25, 000 deaths due to snakes. rural and agricultural preponderance contribute This is due to tropical climate, agricultural and to high mortality, but the lack of prompt forest based profession and many social factors. ambulance service and loss of golden period of The American Society of Tropical Medicine and treatment is spoiled by resorting to traditional Hygiene are quoting still very high figures from methods. Technically, major burden of the India: 46,000 people dieing every year from problem can be solved by 108 ambulance services snakebites against the official figure of only 2,000.3 for transport and Anti Snake Venom used Lack of direct statistics of snakebite is due to judiciously in time, but inherent delay in multitude of factors like biting snakes, transporting the victim due to prevalent predominance of night time bites, hesitation of sociological milieu is a hurdle in this direction. people to notify a bite. There is necessity of motivation in snakebite But it is a fact that snakes and snakebites prevalent areas through health education by regular are reducing in number due to pesticide use, health workers, PRI representatives and voluntary urbanization and deforestation. Evidences of agencies. Time, transport and therapy will snakebite attendance in medical centres at present remarkably reduce the alarming incidence of and revealed figures given by newspapers now a snakebite in the tropical environment. day are definitely reduced to some extent Let us examine the feasibility of this idea compared to figures of a decade back. The faster from technical angle. urbanization and deforestation is a way definitely to reduce snakebite substantially, yet total Introduction: reduction cannot be thought of in such a tropical climate. Exact figures of snakebite and snakebite deaths are not known in Odisha and India. It is Certain Issues estimated that 2500 to 6000 cases of snakebite HIGH INCIDENCE: occurs in Odisha and out of them, 400 to 900 cases die (around 1000 snakebite deaths per Snake scare stalls Odisha Assembly. 4 annum in Odisha)1,2 . Similar figure is seen in whole Peculiarly, the Odisha Legislative Assembly came

60 April-May - 2014 Odisha Review to the horror of harbouring a snake, when it was with another species of cobra, called Monocled suspended for some days and started functioning Cobra (Tampa Sapa in Odia). These are very under vigilance of Snake Help Line, Bhubaneswar dangerous snakes as they have a habit of residing and with presence of an emergency physician with around human habitations, paddy fields, bushy enough stock of antivenom. The appearance of forests both in rural and even urbanized areas of snakes has recurred time and again in Odisha Odisha. Legislative Assembly even in present year. Every monsoon turns Bhubaneswar into a ‘city of The pathetic story of cobra is its venom snakes’ and large population of cobras (Naga capacity and killing capacity. A single bite of cobra Sap) exist in surrounding areas of residences in contains venom capable of killing 15 to 20 the capital city. 5 Raj Bhavan officials were on their persons. When 13 mg of venom is fatal for an toes, when a rat snake was found in the VVIP average weight man, it can inject 12 to 20 times suite which was to be occupied by President such dose and that is why serious cobra bite cases Pranab Mukherjee during his second visit to may not reach hospital within one hour. But luckily Odisha on September 6. 6 such cases are very few and may be 2-3 %. Krait bites often outnumber cobra bites and krait can Capital Hospital in Odisha is a figurative inject larger than fatal dose in successful bites. hospital like S.C.B. Medical College for good Banded Krait (Rana Sap in Odia) bites rarely and catchment of snakebite case. There are 4-5 it is to be noted that Indian antivenom has no snakebite predominant coastal districts. Presently neutralizing effect in this snakebite. Large number Capital Hospital7 records a number of snakebite of Russell’s Viper (Chandan Boda Sap in Odia) cases. bite cases come with severe local pain at site of BITING VENOMOUS SNAKES OF bite with bleeding from the site, with bleeding from ODISHA1: gum margins. Sometimes the non-poisonous snakebite (Pond snake and Rat snake bites) Common Indian Cobra (Naga Sapa in causes alarm reactions in a patient like palpitation, Odia) is found in large numbers in Odisha along restlessness and fear, but this is of no significance on mortality point of view.

Table showing details of Biting Snakes in Odisha1 Snake Fatal Dose Venom Symptoms and Later Complications Deaths Variety of venom store time sequence (mg) (mg) Cobra 15 150-300 Small local swelling Local necrosis and 50 % [Naga at site of bite; within sloughing of skin SapTampa two hours drooping taking months to heal Sap] of eyelids, salivation, air hunger, confusion, delirium and respiratory failure

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Common 10 5-20 Negligible local Negligible 40 % Indian mark; develops Krait[Chiti drooping of eyelids, Sapa] salivation and air hunger; terminally respiratory failure Banded 10 35-50 As Common Indian Negligible ~ Krait[Rana Krait Sap] Russell’s 42 120-250 Local swelling and Prominent local 3-% Viper bleeding, Bleeding swelling and usually [Chandan gum, blood in sputum it heals after one Boda Sap] and urine; kidney is or two weeks; affected and urination rarely local sloughing stopped. seen Rat 0 0 Scratch only Nil 0 % Snakebite [Dhamana Sap] Pond 0 0 Scratch and local Nil 0 % Snakebite injury only [Dhanda Sap] The following are snakes of medical importance in Odisha, 95 % of deaths due to snakebite are due to these species1.

Spectacled Cobra (Naga) Monocled Cobra (Tampa)

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Common Krait (Chitti) Banded Krait (Rana)

Russell’s Viper (Chandan Boda) Russell’s Viper (Chandan Boda)

Pond Snake (Dhanda, not poisonous) Rat Snake (Dhamana, not poisonous)

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FATAL COBRAS: TIME RESTRAINT : Fatality in cobra bites is astonishing. Time is a great factor in the cure of Cobras abound in rural as well as urban areas. In snakebite. The largest venom dose of any snake the city of Bhubaneswar, this species is can be neutralized by antivenom. Simply to encountered frequently. Severely envenomed illustrate, it can be said that injection of a mix of cases are few among such bites, very short time this venom and equivalent antivenom has no effect at hand due to very quick spread of venom in on experimental animals. Then, where is the human system and affecting nerve mechanism of difficulty in curing a cobra bite? respiration and rapid onset of death debars cases People spoil time in reaching the hospital. in receiving treatment. Cases with moderate and They spend minutes in ignoring the gravity of mild envenomation can avail benefits of therapy. snakebite, search a local traditional healer; even The author has encountered at least 10 cases of today, rural people carry the victim to Lord Siva’s cobra bite, where the patient succumbed within temple to pour water on the head. 45 minutes of bite where reaching at nearest hospital was not possible after known cobra bite. All methods of first aid have been proved Few cases, which were alert from the moment of to be ineffective in snakebite except cobra bite, could be saved with right treatment in immobilization of the victim, i.e. minimum time. movement of the bitten part so that venom will be confined to the local site of bite longer than if the FATAL KRAIT : part is moved or patient walks or runs when blood Krait bite is frequent in villages and danger circulation will hasten venom entry to blood and for residents of thatched houses. Common Indian brain. Krait (Chiti Saap) lives very close to human FALSE BELIEF THAT A SNAKEBITE habitation and beyond our imagination the CASE DIES DUE TO FEAR : innocent looking krait of the day becomes active, agile and aggressive bites viciously in winter nights. Snakebite is quite alarming, never kills a The bite is small, a man in sleep cannot trace and person due to fear. This blind belief often reduces signs of fatality appear when the person awakes. the gravity of poisonous bite and allows undue delay in deciding whether to rush to hospital or SERIOUS RUSSELL’S VIPERS : make dilly dally by consulting a local traditional Typical Russell’s viper bite occurs by healer. walking over the snake and this poisoning is CULTURAL PRACTICES IN RURAL associated with bleeding and thinning of blood ODISHA : resulting in bleeding disorder. Occasionally the snake spontaneously bites without provocation. Number of cultural practices enhance This snakebite is easy to grade, follow up and snakebite mortality. Any movement or exercise cure compared with treacherous krait bite and of the victim after the bite is very harmful. I am dangerous cobra bites due to slower process of shocked to say that some snakebite victims are envenomation. Blood can be tested in simple forced to swim, if they are capable, to cure manner hourly. Venom that enters slowly from snakebite. This is extremely dangerous and will site of bite to circulation and consumes clotting land in fatality quite early. Any delay in reporting elements can be neutralized by antivenom. at treatment centre is a technical crime. Worship,

64 April-May - 2014 Odisha Review making a phone call to somebody who will pray of ambulance is a great asset to think of god, pouring water over head of the victim in front transporting a victim to treatment centre in time. of Lord Siva, taking a herbal medicine (Gada) or Odisha State is one among other states to applying utensil (Dishes to draw out venom) and introduce the 108 ambulance services for hundreds of other manoeuvres are time killing and emergency. detrimental. It is termed like ‘The Golden Hour’ and Certain Trends in the way of solving the the ‘Platinum Ten Minutes’ that imply the Snakebite Mortality : importance of Emergency Medical Services Snakebite Protocol of India, 20078 - Ideal (EMS) all over the world. It is a well-accepted Treatment and Establishment of Well fact that a patient who receives basic care from Equipped Treatment Centres: Snakebite has trained professionals and is transported to the created an alarm all over the world and World nearest healthcare facility becomes more safe. The Health Organization9 has issued some guidelines average response time of 20 minutes for urban, in snake bite with display of venomous snakes of 25 minutes for semi-urban and 35 minutes for the medical importance for different regions. Nations rural areas has been kept as performance with high snakebite fatality like India, Pakistan have parameter for the service provider. formulated national protocols of snakebite for Again, the team of technical experts can their areas. Indian national protocol has be trained to give life support to a victim and to formulated the method of treating different types start the process of evaluating and testing or of bite and has outlined treatment (with clinical administering antivenom to a serious victim of use of antivenom, with all precautions of hazards snakebite. With available ambubags and of such therapy) on basis of evidence. It critically antivenom, life saving adrenaline at hand, the views first aid methods and recommends that only sensitivity test of antivenom can be started within immobilization of the snakebite victim (least the transit, which takes 15 minutes in hospital movement and not walk or run). Apart from before starting intravenous push. treating a victim, it also has recommended maintenance of well equipped centres with Odisha Emergency Ambulance Service: The required antivenom stock in snakebites abundant Odisha Government decided to set up a areas. It is mandatory to observe a case for 24 comprehensive pre-hospital emergency medical hours before discharging as a case of non- service with introduction of a fleet of ambulances poisonous or non-envenomated. to cover the entire state in a phased manner. This initiative will facilitate an integrated and Role of Prompt Ambulance: Beyond the comprehensive health care management in the spectrum of protocol of snakebite, there should state providing high-end ambulance transport shine popular alertness and very prompt system from the doorstep of the patient to the ambulance facilities if we have attempts to reduce appropriate care in a hospital. The 108 ambulance snakebite mortality. It must be multiple approaches is available for all emergencies like road accident, like managing infant mortality rate in Odisha. In natural disasters, emergency health care, spite of the protocol confined to the limits of hospital, snakebite mortality will run unabatedly pregnancy and delivery. Special 102 Ambulance in our country. service is meant for antenatal cases and Odisha Health Help line is available at 104. Thus 104 Emerging Ambulance Facilities - 108 Help Line and 108 ambulances can be very well Ambulance10 Promises: Present day innovations taken care of for snakebite victims.

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Highlighting Gravity of Snakebite -Posing The Protocol should specify the nearest Snakebite as a Challenge for cure: Local Snakebite Treatment Centre (at CHC or PHC alertness in snakebite can be sponsored by local or Sub Divisional Hospital etc.). Transport, Health health workers, Panchayati Raj representatives Education and involvement of multiple and workers, village youth and local NGOs. Such organizations for catchment of cases in time should a discussion must come in the spectrum of their be elaborative. work to run to the victim and help the victim to Snakebite treatment centres must have avail the first aid outlined below and call for 108 capacity to handle any sort of snakebite and must instantly before first aid. have required beds for observation. Short supply SIMPLE FIRST AID IN SNAKEBITE: As of Anti Snake Venom in such centre is awesome; all old methods of first aid advised to public on hence good management of pharmacy must be the event of snakebite have been obsolete or done. Hopefully, high speed communication of proved harmful, the only first aid is ‘NO today with mobile phones can make people alert MOVEMENT OF SNAKEBITE VICTIM and informative on these aspects. AND VERY LITTLE MANIPULATION OF Conclusion: BITING LIMB’. This advice rather advises one not to put ligatures, ice, bandages etc. Ambulance service and sensitization of community are as important factors for combating PRI participatory revolution and way of snakebite cases as the modality of prompt therapy motivation of saving time of snakebite victim: for cure in hospital. 108 Ambulance services With today’s Panchayati Raj activities and rising definitely promise to transport a snakebite victim Grama Sabha participation, awareness generation at treatment centre within time. Any delay in and sensitization of people and volunteers can be searching an ambulance by the family member of done for the simple work of motivating and snakebite victim or searching for local remedy transporting a case. It will be credit of a local should be overcome by arrival of local volunteers representative to see that a snakebite victim in his of locality and calling 108 and lifting the victim to / her area is carried instantaneously and does not the van. The Snakebite treatment centres are to die untreated without right treatment. administer justified treatment as per Protocol. The As the snakebite case will be observed Snakebite which had long been a fatal unsolved for 24 hours in treatment centres, it must be problem on transportation grounds will have full mandatory to transport such cases instantly from scope of cure. the first attendant of the victim and these gold References: words of transport at first hand and ring up to 1. Jena, I., Sarangi, A. Snakes of Medical Importance 108. Ambulances at hand quicker than 108 are and Snakebite Treatment, Ashish Publishing always welcome. House, New Delhi, 1993; Behuria, B., Odishare Saap (in Odia); and Venomous Snakes of Odisha Some Limitations 2. Mohapatra, B.N. “Snakebite in Coastal Odisha” Few cobra bites may be too poisoned to in the Souvenir named Treatment of Snakebite: A take advantage of 40 minutes, but majority can Resume. be saved. The provisions of National Snakebite 3. Times of India, 6 December, 2011. Protocol are not conclusive on treatment of such 4. Sandeep Mishra, Times of India, Jul 23, 2009. cases. 5. The Times of India, 25 June, 2012.

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6. TNN 23.08.2013. mortality as well as deaths and disabilities 7. Records of Capital Hospital, Bhubaneswar. providing medical attention within golden hour. The uninterrupted functioning of the centralized 8. Government of India: Snakebite Protocol, 2007. call centre at Bhubaneswar and overall Emergency 9. World Health Guidelines on Snakebite. Response Service ensures that no call goes 10. Emerging Ambulance Facilities - 108 Ambulance: unattended. 1.108 Ambulance Facility: 108 is a free telephone Similarly in case of Mass Causalty Incidence and number for emergency services to call in the Indian natural calamities the services of the fleet of states (Odisha, Bihar, Andhra Pradesh, Punjab, ambulances will be quite handy for the Gujarat, Uttarakhand, Goa, Rajasthan, Tamil Nadu, administration to deal with the situations. NHAI Chhattisgarh, Karnataka, Kerala, Assam, and Odisha State Disaster Management Authority Meghalaya, Himachal Pradesh, Madhya Pradesh (OSDMA) have agreed to provide their expertise and Uttar Pradesh. The 108 Emergency Response to 108 Ambulance service whenever their services Services is a free, 24/7 emergency service for are required particularly in rainy season and providing integrated medical, police and fire inclement weather. emergency services. The service is provided in The ratio of ambulances of one per one lakh Public Private Partnership between State population has been kept as per the standard of Government and Private EMS providers. WHO. The fleet will have both ‘Basic Life Support’ 11. Odisha Emergency Medical Ambulance Service: (BLS) and ‘Advanced Life Support’ (ALS) The Odisha Government decided to set up a ambulances. The mix of ALS and BLS will be at comprehensive pre-hospital emergency medical the ratio of 20:80.There shall be a total of 420 service with introduction of a fleet of ambulances ambulances under the Odisha Emergency Medical to cover the entire state in a phased manner. This Ambulance Service (OEMAS). The project will initiative will facilitate an integrated and be implemented in two phases on the basis of comprehensive health care management in the implementation feasibility, equity and need. In the state providing high-end ambulance transport first phase 280 ambulances will be launched system from the doorstep of the patient to the covering 15 districts with a focus on the trauma appropriate care in a hospital. Under OEMAS corridor in Odisha across National highways. project, this modern free emergency ambulance All the 15 districts have been covered under the service is being run on PPP mode in collaboration 1st phase of OEMAS ,with launching at Keonjhar with an eminent Mumbai based company M/s. on 17th of July 2013. The MoU for the 2 nd phase of Ziqitza Health Care Ltd. OEMAS covering the remaining 15 districts The average response time of 20 minutes for (Bargarh, Bolangir, Boudh, Deogarh, Gajapati, urban, 25 minutes for semi-urban and 35 minutes Jagatsinghpur, Jharsuguda, Kalahandi, for the rural areas has been kept as performance Kandhamal, Kendrapara, Malkanagiri, parameter for the service provider. However the Nabarangpur, Nayagarh, Nuapada and Sonepur) response time can be made more flexible depending have been signed by the Principal Secretary, upon the geographical terrain especially in the Health & Family Welfare, Govt. of Odisha with KBK region where the average time may vary from the CEO of Ziqitza Health Care Limited, on 16th 45 to 60 minutes. Mapping and defining of July 2013. The implementation of 2nd phase is strategic positioning of the ambulances with route expected to be completed soon. maps, motorable points, nearest catch points in case of inaccessible locations are the guiding factors in chalking out the operational parameters of the project. Round the clock pre hospital emergency transport Dr. Indramani Jena, M.D. (Internal Medicine), care services across the state with agreed response SAMAROH, 128, Dumuduma (A), Khandagiri, email time will help in reducing maternal and child ID: [email protected].