Dr. Omesh Kumar Bharti & Dr. Gaje Singh Snakebite management through toll free 108 emergency ambulance service in Himachal saves lives ! Dr. Omesh Kumar Bharti & Dr. Gaje Singh

Snakebite Epidemiology In India, estimated annual snakebite deaths are 45,900 Annual age-standardized death rate is 4.1/100,000 with higher rates in rural areas (5.4), the highest rate in the state of Andhra Pradesh (6.2). Annual snakebite deaths were highest in the state of Uttar Pradesh (8,700) followed by Andhra Pradesh (5,200) and Bihar (4,500). Other Indian states with high incidence of snakebite cases are Tamil Nadu, West Bengal, Maharashtra and Kerala. Because a large proportion of global totals of snakebites arise from India, global snakebite totals might also be underestimated. (Mohapatra et al 2011)

BACKGROUND Delayed presentation to hospital frequency contributes to increase in morbidity and mortality from snakebites. The case-fatality rate of snakebite decreased from 10.5% in the pre-intervention period to 0.5% during the intervention (Rapid Transport by motorcycle, Sanjib K Sharma et al, 2013) Based on the concept that timely and free ambulance service equipped with life saving Anti Snake Venom ( ASV) can save lives and lessen morbidity and mortality due to snakebites, the emergency ambulances were loaded with ASV vials

Methods This study aims at evaluating how a free, round the clock emergency ambulance service, having facilities for Anti-Snake Venom injection, can help save lives by responding to a toll free number 108 and transporting the snakebite victims to nearest appropriate hospital within golden hour. The data was analysed for eleven months as to ASV vials used and lives saved.

Results A total of 469 patients of snake bite cases availed the free emergency ambulance service i.e. From December 25, 2010 to November 30, 2011 by dialling toll free number 108. All patients were examined for evidence of snakebite and wherever possible, the snakes were identified based on description, identification (if the snake was brought) and symptoms of envenomation. Based on signs & symptoms ASV was used inside the ambulance, whenever required. All patients were shifted within golden hour to the nearest appropriate health facility to treat snakebite patients. OMESH BHARTI

RESULTS Out of 469 cases, in 47 patients (10.02%) ASV had to be used inside the ambulances in critical condition. Only one patient had mild allergic reaction and life saved after ASV utilization was 42( 89.36%). Total life saved out of 469 cases was 451 cases i.e. 96.2% of snakebite victims as followed up to 48 hours. Highest 22.38% cases were reported in warm Kangra district just opposite to cold tribal district of Lahul and Spiti where only one case was (0.21%) reported . OMESH BHARTI

RESULTS Female to male ratio was 54:46 percent. The age group most affected was between 11- 40 years (56%) in this, highest affected age group was 21-30 year (24.9%). Most bites occurred while the person was cutting grass, working in the fields or walking in the hills (75.3%). Snake bites while sleeping were at uncommon sites (Ear and Head)

RESULTS 76% of the bites were on the feet (up to the ankle) where as 22% bites were on hand (figure & elbow) and only 1% bites were on lower back and head Seasonal variation in snakebite was seen with a peak in the months of August (27%). No bites were recorded in December, January and only one bite was recorded in February. OMESH BHARTI

CONCLUSION Snakebites occur frequently in the hills of Himachal Pradesh. The initiation of toll free and user charge 24X7 free emergency ambulance service called Atal Swasthya Sewa in PPP mode with GVK-EMRI helped snakebite victims to call the service anytime in emergency. This helped us save more than 451 precious lives in the state of Himachal within 11 months. OMESH BHARTI

Recommendation We recommend ASV equipped free emergency ambulance network to save the lives of people bitten by snakes without losing time (within golden hour). This model needs replication in Asia and Africa where death rate due to snakebite is very high in the world. Let no body die of Snakebite by 2020 ! OMESH BHARTI