1. Third International Conference on Neglected Tropical Diseases ( NTDs)

2. Topic: Challenges of Management of Snake bite Speaker: Dr. Ratindra Nath Mondal MBBS, FCPS (Medicine) Assistant Professor Department of Medicine Rangpur Community Medical College

3. Background Snake bite is a neglected public health problem in the world and one of the major causes of mortality and morbidity in many areas, particularly in the rural tropics. It also poses substantial economic burdens on the snake bite victims due to treatment related expenditure and loss of productivity. 1

4. Background (contd.) Worldwide - Venomous snakes cause 5.4 million bites -About 2.5 million envenoming and -Over 125,000 deaths annually, 2

5. Background (contd.) Most snake envenomings and fatalities occur in - South Asia - Southeast Asia and - Sub-saharan Africa with India reporting the most snakebite deaths of any country. 3

6. Background (contd.) Recently, well-designed, nationally representative surveys showed - 46,000 deaths in India - 6000 deaths in Bangladesh. 4,5

7. Snake bite status of Bangladesh

8. Snake bite in Bangladesh World Health Organisation-funded study estimated - about 8,000 cases of snakebite -over 20% mortality in Bangladesh annually. 6

9. Snake bite in Bangladesh (contd.) The incidence of snake bite episode was -623.4 bites per 100,000 persons per year The highest incidence was found in -Barisal division (2667.7) and The lowest incidence in -Sylhet division (321.6). 7

10. Snake bite in Chittagong

11. In between May 1999 and October 2002 -884 patients admitted in CMCH -350 were systemically envenomed 8 Distribution of poisonous cases of snake bite revealed - Cobra bite in 15 -Green snake bite 14 -Suspected krait bite in 2 and -3 were unidentifiable fatal poisonous snake bite.

12. Snake bite in Dhaka Medical College Hospital

13. Snake bite at Dhaka Medical College Hospital In between July 2005 to December 2006 - 50 patients admitted in DMCH -Neurotoxicity was present in 12 patients -6 had local features of envenomation. 9

14. Snake bite in Rajshahi Medical College Hospital

15. Snake bite at Rajshahi Medical College Hospital Between January 1999 to December 1999 -68 patients admitted in RMCH -27 venomous bite -7 (26%) died. 10

16. Snake bite in Rangpur Medical College Hospital

17. Snake bite at Rangpur Medical College Hospital In between 01/06/2010 – 28/02/11 -111 patients admitted in RpMCH - 69(62.16%) were male - 89 (80.18)% were from rural areas. 11 Available at : http://rcmchbd.com

18. Table: Distribution of the patient by occupation 11 N= 111 Occupation Number/ percentage Farmer 35 (31.53%) House wife 35 (31.53%) Student 32 (28.82%) Teacher 04 (3.60%) Shop keeper 04 (3.60%) Snake charmer 01 (0.90%) Available at : http://rcmchbd.com

19. Table: Distribution of victim’s activities during biting, 11 N=111 Activities during bitingNumber/ percentage Working in the field 47 (42.34%) House hold activities 43 (38.74%) Sleeping 09 (8.10%) Walking along road 12 (10.81%) Available at : http://rcmchbd.com

20. Snake bite at Rangpur Medical College Hospital -Envenomation 9.91% -Mortality 54.55% 11 Available at : http://rcmchbd.com

21. Snake bite at Rangpur Medical College Hospital (contd.) In between 01/06/2010 – 31/07/12 -28 snake bite patients who have envenomated systemically or locally. -The mean time to hospital admission to snake bite was 6.30 hours -Most of the snake bite was by krait -13 (46.42%) patient died. 12

22. Table: Distribution of the patient by ‘ interval between biting and hospital admission ’ Time in Hours Number of patient Outcome SurvivedDeath ≤5147 (50%)7.(50%) 6-1011 6 (54.54%) 5 (45.46%) >1032 (66.67%) 1 (33.33%)

23. Intubate the pt. Figure: courtesy by Dept. of Medicine RpMCH Management of respiratory failure

24. Figure: courtesy by Dept. of Medicine RpMCH

25. Some special cases observed in RpMCH

26. Wall’s krait bite patient (Bangarus walli) Some special cases observed in RpMCH

27. Myotoxicity with AKI (possible Banded krait bite) Some special cases observed in RpMCH

28. Some special cases observed in last year Photo: Consecutive bite on two people by single snake

29. Impact of Snake bite

30. Macro-economic impact WHO estimate expenditures for health care -About 40% of a household’s income after basic subsistence. 4 Illness and health-care costs as major contributors to poverty have been increasingly recognized in recent years. 13-15

31. Macro-economic impact (contd.) The economic burden caused by snake bite is more devastating for venomous snake bite as generally it is the poor population that is affected. 16

32. Macro-economic impact (contd.) Median household income of - US$50 per month - Few had income that provided more than a subsistence. 16

33. Macro-economic impact (contd.) 75% of the patient were between 6-40 years. 12 Average age of the victims were 31.77 years (8-55) Male: Female 4.55:1 Farmer 56% 9 Rural area 80.18% 12

34. Macro-economic impact (contd.) Some of the victim were the only earning member of the family. The loss of income due to the morbidity and mortality suffered as a result of snake bite can impact on a family’s economy. 12

35. Macro-economic impact (contd.) The expenditure ranged from -Venomous snake bite US$13.43 to US$2294.03 (mean US$231.03) and -Non-venomous US$3.61 to US$134.33 (mean US$ 33.58). 16

36. Macro-economic impact (contd.) The daily wage loss varied from - US$ 0 to US$ 895.52 (venomous snake bite) -US$ 0 to US$ 11.94 (non-venomous snake bite) 16

37. Difficulties of management of snake bite

38. Difficulties of management of snake bite (contd.) Difficulties in service provider 1. Lack of trained staff (Doctor, nurse) 2.Country-wide training programme for health-care service providers. 3.Lack of separate snake bite management unit 4.Lack of ICU 5.Lack of awareness generating programmes 6.Lack of anisnake venom

39. Lack of ICU 7 patients presented with respiratory failure, all died within 2 hours due to lack of ICU Respiratory failure was managed with endotracheal intubation and AMBU bag respiration. 12

40. AMBU bag respiration

41. Lack of antisnake venom The anti-snake venom (ASV) is not manufactured in Bangladesh ASV are manufactured in India, are given to government hospitals. The supply of ASV in public hospitals is irregular It is not available to private hospitals or the private market. Even when it is available, it is often too expensive for the patients. 16 6 patients did not get antivenom due to unavailability 12

42. Difficulties of management of snake bite (contd.) Difficulties in service receivers: 1.Lack of awareness 2.False believe

43. Lack of awareness 54.2% patients went to traditional healers (ohza) 7.2% to unqualified doctors (quack doctors) 3.6% to a private clinic 2.4% to a registered doctor 33.7% to government hospitals for their treatment Some patients went to more than one ohza. 16

44. Lack of awareness about first aids Ligature had been applied in almost all the cases (96.43%) No patient presented with immobilization of the limb and In one patient fasciotomy had to do due to tight ligature. 11

45. Lack of awareness about first aids Incision In a study done in RpMCH 5.40% patient presented with multiple incision. 11 Photo: Effect of incision at bite site

46. Lack of awareness The mean time to hospital admission to snake bite was 6.30 hours. 12 In a study of RMCH The mean time to hospital admission to snake bite was 8.73 hours. 10 Most of the time spent due to seeking non-scientific treatment (Jar-fuk) by the ojhas.

47. False believe of the patient and relatives 1. Poisonous snake bite should be managed by Ojhas.

48. What are the difficulties of Management of snake bite in our country

49. 1. In Service Providers Physician crisis in Bangladesh 1 – Per 10,000 peoples1.1in rural – Per 10,000 peoples18.2in urban Lack of skill of physicians Ref. 1. Human Resource for Health; 2011.

50. 2. Poor Health Status Population 15,85,70,535 Per capita income$ 700 Population growth rate 1.566% Birth rate 22.98 Death rate 5.75 Hospital bed density4/10,000 peoples. Physician density 2.95/10,000 peoples Health expenditures3.4% of GDP. Source: CIA World Fact book, July 12, 2011

51. Antisnake venom is not available 16 Lack of snake specific antivenom- which is effective against systemic envenoming by cobra, krait, Russell’s viper and saw scaled viper only Lack of ICU and skilled person to manage respiratory failure at Upazilla and sometimes district levels. Lack of update of guideline -updated on 2000. Scarcity in management

52. 3. Difficulties in Service receiver 1.Lack of awareness 2.Illiteracy 3.Poor economic condition. 4.Wrong belief and perception.

53. 3.4 Poor Economic Condition. Bangladesh is a least developing country. 20-40% of population in rural area leads poor lifestyle. High cost of antisnake venom in respect to income.

54. High Cost in respect to income Antivenom: US$70 (4900 tk) to US$120 (8400tk) for one dose of anti-snake venom. 16 Travelling: Ambulance cost minimum 1000 Tk Hospital stay: Food cost of the attendant ICU cost: If require 25000tk per day Total: huge cost than income NB. Per capita income $700 in Bangladesh.

55. 3.5 Wrong belief and perception. Most of the patients depend on ojhas for management of snake bite. 55

56. How to Overcome the Situation

57. 1.Increased number of physicians. 2.Skillness of the service providers should be improved and updated by regular training programs. 3.Regular update of guideline for management of snakebite.

58. How to Overcome the Situation (contd.) 4. Improvement of rapid transport facility 5. Increment of literacy rate. 6. Improvement of awareness by -Mass communication -Health education 7. Implementation of population based heath policy.

59. How to Overcome the Situation (contd.) 8. Antisnake venom should be manufactured in our country according to our snake epidemiology. 9. Antisnakevenom should be ensured in district and upazilla level hospital.

60. References 1.Faiz MA, Hossain MR, Younus A, Das EB, Karim JC, et al. A hospital based survey of snake bite in Chittagong Medical College. Journal of Bangladesh College of Physicians and Surgeons. 1995;13:3–8. 2.Chippaux JP (1998) Snake-bites: appraisal of the global situation. Bull World Health Organ 76: 515–524. 3."The Global Burden of Snakebite: A Literature Analysis and Modelling Based on Regional Estimates of Envenoming and Deaths“."The Global Burden of Snakebite: A Literature Analysis and Modelling Based on Regional Estimates of Envenoming and Deaths“ 4.Mohapatra B, Warrell DA, Suraweera W, et al. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis 2011;5(4):e1018. 5.Rahman R, Faiz MA, Selim S, et al. Annual incidence of snake bite in rural Bangladesh. PLoS Negl Trop Dis 2010;4(10):e860. 6.Huq F,Islam M A, Sarker M H, Chowdhury B, Ali M W, Kabir M M (1995). Epidemiology of snake bite in Bangladesh. Bangladesh J Zool. 23 (1): 61-64. 7.Ridwanur Rahman, M. Abul Faiz, Shahjada Selim, et al. Annual Incidence of Snake Bite in Rural Bangladesh, PLoS Negl Trop Dis. 2010 October; 4(10): e860. 8.John B. Harris, Md. Abul Faiz, M. Ridwanur Rahman, David A. Warrell,, Ulrich Kuch. Snake bite in Chittagong Division, Bangladesh: a study of bitten patients who developed no signs of systemic envenoming. Transactions of the Royal Society of Tropical Medicine and Hygiene 104 (2010) 320–327. 9.Chakraborty P, Bashar A, Arif SM, Faiz MA. Clinical study of snake bite cases admitted in Dhaka medical college hospital. available from:http://www.asiatox.org/6th%20APAMT%20pdf/Clinical%20study%20of%20snake%20bite%20cases%20admitted%20in%20Dhaka% 20medical%20college%20hospital. 10.Q T Islam, MA Faiz, M A Azhar, A R M S Ekram, M T Alam, Snake bite in the northern Bangladesh: a hospital based study of 68 cases, TAJ (1999); 12, 135-138 11.Dr. Ratindra Nath Mondal, Dr. Moni Rani, Dr. Nurmohammad3 et al; Pattern of poisonous snake bite in Rangpur Medical College hospital; RCMCJ 2011; 1(1): 13-18. 12.Ratindra Nath Mondal, Moni Rani, Nurmohammad et al; study of envenomated patient in Rangpur Medical College hospital, (unpublished). 13.Kawabata K, Xu K, Carrin G. Preventing impoverishment through protection against catastrophic health expenditure. Bull WHO 2002;80:612 14.Van Damme W, Van Leemput L, Por I, Hardeman W, Meessen B. Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia. Trop Med Int Health 2004;9: 273–80 15.Meessen B, Zhenzhong Z, Van Damme W, Devadasan N, Criel B, Bloom G. Iatrogenic poverty. Trop Med Int Health 2003;8: 581–4 16.S M K Hasan, A Basher, AAMolla, N K Sultana, MAFaiz, The impact of snake bite on household economy in Bangladesh; TROPICAL DOCTOR 2012: 1–3, DOI: 10.1258/td.2011.110137