Snakebite As a Neglected Tropical Diseases in Indonesia: a Review Dewi Yuniasih, Ario Tejosukmono, Junaidy Heriyanto

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INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 9, ISSUE 03, MARCH 2020 ISSN 2277-8616 Snakebite as a Neglected Tropical Diseases in Indonesia: A Review Dewi Yuniasih, Ario Tejosukmono, Junaidy Heriyanto

Abstract— Despite its promising economic growths, there are group of neglected tropical diseases (NTDs) still existing in Indonesia. Since these neglected tropical diseases cause severe disability, therefore they may thwart future national growth and recent gains. The aim of this paper presents an epidemiology perspective to describe the health system situation in Indonesia and highlights the problems beneath NTDs. The epidemiology approach is provided as basis for policy decision making in reducing the threat of NTDs and improving country’s health indicators levels. Earlier, the global NTDs according to the causative agents referring to WHO classifications will be discussed and the cases of NTDs in Indonesia will be detailed. It is worthy to mention that snake bite is one of the major causes of mortality and morbidity in many areas, particularly in the rural tropics such as Indonesia. However, a study case of snake bites in Indonesia do not appear that can be evidenced by the difficulty of obtaining data or information about the number of cases in all regions in Indonesia. Therefore, it is difficult to deal with a comprehensive prevention programs and health policy intervention towards minimizing the threat of this disease.

Index Terms: Epidemiology, health system, neglected tropical disease, prevention programs, snake bite.

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1 INTRODUCTION environmental degradation has decreased drastically in Indonesia. In this case, some aspects such as population growth, ith a population of more than 250 million people, W the emergence of sudden disease outbreaks, natural disasters Indonesia has promising economic potentials where a large and cases of pollution and environmental damage due to fast market and a dynamic and competitive market exist. With an growing industrialization could threat public health. Therefore, area of some 1.9 million km² scattered in more than 17,000 at attempting to boost national economic growth of Indonesian islands, in addition, Indonesia’s nature is home to some of government, unpredicted exposure of NTD cases could thwart highest level of biological diversity in the world. However, as country's development targets. As a logical consequent, the with most other tropical countries, the country is not free from focus of research on the epidemiology of NTD must be the threat of spread tropical diseases worldwide which their strengthened [4]. incidences are disregarded, a group of disease known by the Therefore, this paper presents an epidemiology view of World Health Organization (WHO) as neglected tropical NTD in Indonesia. Two sections shall discuss in general diseases (NTD) [1]. magnitude NTD in Indonesia and the health and environmental The term of NTD referred to a group of disease caused factors affecting public health. As a case study, snakebite will be by a variety of pathogens such as viruses, bacteria, protozoa shown as one example of NTD cases that rarely receive any and helminths and based on the fact that these tropical diseases publicity and lack of data epidemiology. are not being considered as important diseases. They affect more than billion people in tropical and subtropical countries. 2. LITERATURE REVIEW Moreover, NTD leads to long life’s deformities and handicaps, decrease productivity and economic status as well as many 2.1. Neglected Tropical Diseases in Indonesia social burden and stigmatization [2]. Despite NTD has been already introduced several years by In line with Indonesian national economic targets, there are WHO there are very few studies reported concerning NTD 11% people living below national poverty line in 2014 [3]. your incidences in Indonesia and epidemiology data in Indonesia is paper.Rural residences are living poorer than urban residence minimal. As a consequence, risk factors, prevention and control where 13.8% of them are living below rural poverty line [3]. In programs were poorly understood in most of national and addition, there are rapid changes in socio-economy and regional health services in Indonesia. Table 1 represents the NTD cases specified by WHO and its ———————————————— magnitude in Indonesia. Wibawa and Satoto [5] reported that  Dewi Yuniasih is currently a lecturer at Faculty of Medicine of Ahmad by the end of 2015 NTD is still problematic in Indonesia. Even Dahlan University Yogyakarta, Indonesia, PH-087832155004. E-mail: though the Ministry of Health of Indonesia reported only five [email protected]  Ario Tejosukmono and Junaidy Heriyanto are lecturer as well at the NTD that can be found in Indonesia, namely leprosy, filariasis, Faculty of Medicine of Ahmad Dahlan University,Yogyakarta, Indonesia. schistosomiasis, soil-transmitted helminth, and yaws, however, ———————————————— the magnitude of problems of other three diseases shall be 6180 IJSTR©2020 www.ijstr.org INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 9, ISSUE 03, MARCH 2020 ISSN 2277-8616 addressed and considered since NTD are closely related with morbidity and mortality are not available. Moreover, in many local vector and intermediate host distribution which are developing countries the records of a large number of cases do specifically associated with geographic region. not appear in official statistics since people often seek traditional methods of treatment. Indeed, it would appear that delayed presentation to hospitals frequently contributes to TABEL 1. increased morbidity and mortality from snake bites. RESUME OF THE MAJOR REPORTED NEGLECTED TROPICAL DISEASES Despite being included in the 2009 WHO list of NTDs, IN INDONESIA (SUMMARIZED FROM: [4],[5]) snakebite has not been incorporated into the globally coordinated efforts to reduce the impact of the NTDs [7]. The Highest prevalence Diseases Reported cases reason of this negligence is probably based upon the perception regions that, because snakebite is not an infectious disease, therefore the Prevalence fluctuated strategies for its alleviation do not fit within the strategies used between 0.3% and between 0.3% and 4.8% in Napu Valley 4.8% in Napu Valley to combat the ―typical‖ NTDs [7]. Schistosomiasis and between 0.8% and and between 0.8% and 3.6% in Lindu Valley 3.6% in Lindu Valley 2.3. Snakebite in Indonesia during 2008-2011 Maluku, Papua, West Indonesia is harbor of approximately 450 species of snakes. Lymphatic 11,914 chronic cases in Irian Jaya, East Nusa Four of those indigenous species commonly found in rural area, Filariasis 2000-2009 Tenggara and North namely Russell's viper, saw scaled viper, cobra and Krait, are Maluku thought to be venomous snakes. Bites from these snakes can be Fourteen provinces important cause of mortality [8]. However, there is no 5.29 new cases and 160 districts, information available on the magnitude of snakebite incidences Leprosy detection rate in 2013 which mostly are in Indonesia. located in Java island In Kasturiatne report [9] , Indonesia was identified as a Spread in 18 provinces country where venomous snakebites do not occur, since there 5,319 cases in 2011 and of Indonesia, mostly in are no reports regarding estimation of incidence rate and the Yaws 3,476 cases in 2012 eastern part of number of snakebites envenoming in recent peer reviewed Indonesia publication. 35–40 incidences per Spread across the Dengue The fact that most effective treatment for snakebite based on 100,000 people in 2013 country the recommendations of WHO is the administration of 6 districts in Indonesia Chikungunya monospecific antivenin [10],[11],[12]. However, such 3,529 cases in 2008, (Tangerang, and Japanese monospecific antivenin therapy is not always available to 83,756 cases in 2009 Karanganyar, Ngawi, encephalitis snakebite victims because of its high cost, frequent lack of Jembrana, Mataram) availability, lack of technology and the difficulty in identifying Soil 400,000 individuals the snake correctly [13]. transmitted (mostly children) in Spread in 33 provinces Although there are various locally venomous snakes in helminthes elementary schools Indonesia that demands specific antivenin, but in fact until now (STH) a common antivenin used in Indonesia is polyvalent antivenin. 206 cases in 2010 and Table 2 shows the specifications of standard polyvalent 119 cases in 2013. The antivenin used in all hospitals and community health centers in number of humans 24 provinces, Bali is Rabies Indonesia [14],[15]. bitten by dog still enigma

estimated over 4,000 per month Since the public health burden of snake bite is very substantial and similar to other more widely recognized NTDs, therefore efforts and attention to commensurate with its burden should be made available for the report and control of snakebite 2.2. Snakebite as a neglected disease incidences.

Snakebite is an important and serious public health problem in many parts of tropical countries [6]. The World Health Organization estimates place the number of snake bites to be 421,000 envenoming and 20,000 deaths occur worldwide from snake bite each year, but warn that these figures may be as high as 1,841,000 envenoming and 94,000 deaths per annum [6] Due to poor reporting system, the incidences are commonly not well documented and thus reliable data for levels of 6181 IJSTR©2020 www.ijstr.org INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 9, ISSUE 03, MARCH 2020 ISSN 2277-8616

4. RESULTS TABLE 2 DESCRIPTION OF COMMON ANTIVENIN IN INDONESIA. We have three articles that provide some epidemiological Name, Biosave®, Biofarma information such as morbidity and mortality and also producer incidence of snakebite in Indonesia (Table 3.).

Type Polyvalent antivenom TABLE 3 Dose 5 ml each vial SNAKEBITE’S PUBLICATION IN INDONESIA 2015-2017 Administration For the first dose: 2 vials were diluted with No Title Author Relevancy normal saline to achieve concentration of 1 Guidelines for the WHO Regional Morbidity 2%, followed by infusion with a rate of 40- management of Office of South- Snakebite’s 80 drops per minute. Another dose can be Snakebites, 2nd Edition East Asia cases, given after 6 hours. If the envenoming [10] symptoms still persist, antivenom can be 2 Where did Venomous Farid Rifaie, Tri Morbidity given with the maximal dose of 80-100 ml Snakes Strike? A Spatial Maharani, Amir Snakebite’s every 24 hours. Statistical Analysis of Hamidy cases Source Biofarma [14] Snakebite Cases in Bondowoso Regency, Indonesia [16] 3 Severe coagulopathy Nelwan EJ, Morbidity and transient Adiwinata R, Snakebite’s 3. METHODOLOGY hypertension following a Handayani S, cases We searched two main electronic databases namely Rhabdophis subminiatus Rinaldi I MEDLINE (via Pubmed) and Google Scholar. The search was bite: a case report [17] conducted within 3 year, from January 1, 2015 to December 31, 2017 of all publication with the following key words written in English and Indonesia : ―snakebite‖, ―snake envenomation‖, The estimation of snakebite which was obtained from direct ―snake envenoming‖ cross-referenced with the word personal contact Maharani with the hospital in some area, are ―Indonesia‖ to obtain the maximum possible number of studies reported at WHO South-East Asia Region Office (SEARO) [10]. addressing the burden of snakebite (prevalence, incidence, morbidity, and mortality). We scanned the reference lists of TABLE 4 articles yielded by the electronic search in order to retrieve THE ESTIMATION OF SNAKEBITE CASES IN INDONESIA additional relevant studies. We exclude the article which are not No City Cases No City Cases relevant for epidemiology of snakebite in Indonesia. /week /week The flow of study selection is shown on the figure 1. 1 Semarang 1-3 6 Bondowoso 148

2 Jogjakarta 5-8 7 Bengkulu 2-4 3 Madiun 1-3 8 Palu 1-2 4 Surabaya 2-5 9 Timika 1-3

5 Sidoarjo 2-5 Source: WHO SEARO 2016 [10].

There is an estimation of snakebite cases in 5 islands in

Indonesia. The most cases of snake bites are in eastern Java.

Bondowoso alone occurred 148 cases during March 2015 to May

2016 [10].

Whereas Rifai et al found the characteristic of snakebite’s

patients (table 5) that more than 38% the victims of snakebite

are farmers. The most biting’s area are hands (52%) and the

most responsible snake for the cause of snakebite in Bondowoso is Trimesurus albolabris (31%)[16]. The third article is from Nelwan et al reported a snakebite case of disseminated intravascular coagulation with enhanced fibrinolysis following a Rhabdophis bite [17]. The patient Figure 1. Flow diagram of study selection received two vials (10mL) of polyvalent antivenom (Biosave) were diluted in 500mL of normal saline solution on the 7th, 8th and 9th days after bite. Although the antivenin from Biofarma 6182 IJSTR©2020 www.ijstr.org INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 9, ISSUE 03, MARCH 2020 ISSN 2277-8616 indicated for the treatment of Naja sputatrix, Bungarus resources. In terms of socio-economic factors, many studies fasciatus, and Agkistrodon rhodostoma envenomation however pointed that the victims of NTDs are more in rural area than in Nelwan et al reported the improvements in the patient's urban area. hemostatic parameters suggesting a potential for cross- Some explanations underlying this reason is that rural neutralization after administration that antivenin [17] people are living mostly from the extraction of natural resources, such as fisheries, agriculture and plantation sectors, TABLE 5. in close contact with infectious vectors and domestic animals CHARACTERISTIC OF SNAKEBITE’S PATIENTS and livestock. In addition, barrier factors such as limited access No Characteristic n % of communications, poor transportation infrastructure, 1 Occupation restricted health care services and inadequate quality of Farmers 23 38 sanitation pattern also corroborate risk factors for disease Others 8 13 occurrence in the community. In general, rural residence can be No Information 30 49 a marker for poverty, thus vulnerability to NTD as well. 2 Area of biting One of main barrier to effective care for rural residence is Hands 32 52 cost. In a region where a farmer earns Rp.200,000 (around $14) Legs 15 25 monthly from their agricultural activities, antivenin product is Heads 2 3 estimated simply too expensive. As comparison to other No information 12 20 countries, many cases of snake bite mortality are strongly 3 Responsible Snake associated with poverty and poor investment in health by Trimesurus albolabris 19 31 national governments. The victims did not want to search for Naja sputatrix 4 6,6 hospital treatment just simply because they could not afford the Bungarus candidus 1 1,4 antivenin and the whole treatment [25][26]. Therefore, an No information 37 61 adequate health insurance system may support in increasing Source [16] probability of snake bite victims for adequate quality of treatment and hospitalization hence preventing mortality due to snake bite. DISCUSSIONS Comparing to other studies in terms of the number of Many people in the rural village thought that snake bite is a snakebite victims in a particular period of time [18],[19],[20], harmless incident and the treatment is absent from national and [21], the finding in Bondowoso [10], even only in a district level regional health system. Many of them looked for the emergency shows a relatively high prevalence of snakebite incidences. In treatment by means of prepared herbal from traditional healers. addition, comparing to other common neglected diseases in Moreover, people activities in Indonesia with the clearest Indonesia as presented in table 1, snake bite prevalence in seasonality pattern were farming, which represents the Indonesia is comparably high. This study provides evidence economic base of Indonesia. The activities traditionally include that snake bite is a common problem in Indonesia, especially in land clearing, preparation, planting, weeding, tending and rural areas. Therefore, a high attention must be paid to prevent harvesting as well as post-harvest handling, processing and the people from such public health threats from snakebite. storage. Though the data from the reporting from Maharani [10], [15] In order snake bite patients to be treated with adequate might not represent the whole populations, the highest antivenin, the antivenin supply plays an important role in terms incidence in east of Java can be explained by their large of need (amount and type), logistic, antivenin storage, experts’ population and better reporting of cases due to better patients, room during hospitalization and in the end the cost management of the health system. Since there is not a allocated annually from the government can be estimated. As systematic organization to record all aspects of snakebite in the suggested in other research [27], it is important to note here that whole country, therefore the snakebite incidences may be the only manifestation of venomous snakebite is the timely higher than the documented records in this study. administration of antivenin. Snakebites were predominant in rural areas, which suggest Learning from the scarcity of antivenin in Africa [13],[27], that the risk of bites may be higher because of more intense stakeholders such as governments and private employers, agricultural activities nowadays [15],[16]. This observation especially agricultural firms, health insurance providers, etc. corroborates previous studies [21],[22],[23],[24]. In other hand, need to overcome the scarcity caused by inadequate product people in rural area suffer the medical burden of the neglected distribution, deficit of adequate training for medical staffs and tropical diseases. funding limitation. Since the snake bite victims affected mainly This observation corresponds to WHO study that the NTDs people in rural areas with from low-income people and less are characterized by their specificity determined by the complex financial, and constraints of access to transport therefore basis of features of environmental and social factors. Recently study still epidemiological studies that detail plays an important role in confirmed that the outspread of NTD is commonly among rural predicting accurate availability that should be there, the residence with features such as low income and limited selection of antivenin effective against local species, quite safe 6183 IJSTR©2020 www.ijstr.org INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 9, ISSUE 03, MARCH 2020 ISSN 2277-8616 for usage in underequipped facilities, reliable enough for feedback on the first draft of this manuscript. shipping and storage on local weather in Indonesia. Unfortunately, most snake bite cases in Indonesia were REFERENCES treated with polyvalent antivenin. Since the most effective [1] World Health Organization, Neglected tropical diseases, hidden successes, treatment for snakebite based on the recommendations of WHO emerging opportunities. 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