Folie 1

1
Snake bite in Bangladesh
Professor M A Faiz
Director General of Health Services Bangladesh
2
Dr Aniruddha Ghose
Chittagong Medical College Hospital Bangladesh
3
Scenario of snake bite management in Bangladesh

• Traditional concept of treatment
• Ozha Traditional healers
• Rituals
• Incision
• Tourniquet
• Application of diverse materials

4
(No Transcript)
5
Traditional "treatment" and results
Multiple superficial incisions
Ischaemic contracture following tourniquet use
6
Permanent disability after tourniquet use
7
Scenario of snake bite management in Bangladesh

• Traditional concept of treatment
• People unaware of scientific treatment
• No set-up in academic hospital
• Not emphasized in course curriculum
• Never thought to be a public health problem

8
Cases from the countryside

• July 2008
• Girl, 14, cried out during sleep
• Taken to district hospital, declared dead
• Villagers prevented cremation

9
Modern practice of ancient myths
10
Epidemiology of snake bite in Bangladesh (1)

• Hospital-based survey 1988 1989
• Covering about 10 of national territory
• 764 snake bite cases
• 168 fatalities
• Case fatality 22

Huq et al. 1995. Bangladesh J Zool 23 6164
11
Epidemiology of snake bites in Bangladesh (2)

• Postal survey 1995 1996
• 21 of 64 districts
• Annual incidence estimated 4.3 per 100,000
• Barisal and Chittagong Divisions 7 per 100,000
• Case fatality estimated 20

Sarkar et al. 1999. Report submitted to the
Ministry of Science and Technology, Government of
the People's Republic of Bangladesh
12
Epidemiology of snake bites in Bangladesh
(3)comparison with Nepal
Postal survey, Bangladesh 4.3 snake bites per
100,000 per year Community-based survey in
southeastern Nepal 1,162 snake bites per
100,000 per year Sharma et al. 2004. Am J
Trop Med Hyg 71 234238 ? very similar venomous
snake fauna ? similar exposition of population
13
Snake bite envenoming an occupational disease
14
Snake bite envenoming is an occupational disease
in Bangladesh

• Young, male, rural poor people most affected
• Most bitten while engaged in physical work
• 7088 of snake bites outdoors
• 66 of snake bites during daytime
• Usually on lower and upper limbs (hands, feet)
• Most common from May to October
• Children at particularly high risk of dying

15
Snake bite a disaster related health risk

• Second highest mortality after drowning
• 99 registered fatal snake bites in 2004 flood
• 119 fatalities (39 ) among 307 cases in 2007
  flood
• ? Increased exposition on reduced dry land
  surface
• ? Victims often outdoors at night
• ? During peak activity period
• ? Difficulty reaching hospitals

16
Causes of death after snake bites in Bangladesh

• Neurotoxic envenoming
• Cobras (Naja kaouthia, Naja naja)
• Kraits (Bungarus species)
• Many die on the way to hospital
• ? 27 bite victims admitted dead (red dots) at
  CMCH
• Population density shaded (highest
  violet)

17
Venomous snakes of Bangladeshunderestimated
biodiversity

• Historically undercollected and understudied
  fauna
• Species diversity, distribution virtually unknown
  
• Literature review 18522008 4050 species
• 25 species of sea snakes
• 2 species of cobra
• 5 species of krait
• 1 species of king cobra
• 4 species of coral snake ?
• 5 species of green pit viper
• 1 species of true viper
• records of 45 more pit vipers ?

Elapidae
Viperidae
18
Envenoming by green pit vipers in Bangladesh

• Pain, swelling, blistering
• Coagulopathy

19
Russell's Viper envenoming in Bangladesh

• No recent proven cases
• Very few specimens in collections
• Anecdotal cases from the 1920s
• Western part
• Apparently a rare species today?

20
Envenoming after Monocellate Cobra (Naja
kaouthia) bites in Bangladesh

• Local swelling neurotoxic
• signs in 80 of proven bites

• Local necrosis in gt50 of antivenom-treated bites

21
4-7 years after antivenom-treated Naja kaouthia
envenoming
22
Wall's Krait Common Krait
Bungarus walli Bungarus
caeruleus
23
Severe neurotoxic envenoming by Wall's Krait
24
Fatal neurotoxic and myotoxic envenoming after
black krait bite
Bungarus niger
25
Situation analysis

• Study in 16 subdistricts of SE Bangladesh
  12 months (1999 2000)
• ? rural people do not attend primary health care
  centres for snake bite
• ? 4 of 16 primary health care centres had no case

26
Public awareness programme

• In 2 subdistricts (SE Bangladesh)
• Before intervention 2 cases admitted per year
• After intervention 45 cases admitted in 1 year
• including 12 envenoming bites

27
Provision of treatment and awareness programmes
increase hospital admissions

• Chittagong Medical College Hospital
• 1993/94 44 cases
• 1999 307 cases
• Mortality of hospitalized snake bite patients at
  Chittagong, Dhaka, Rajshahi, Khulna Medical
  Colleges lt 2

28
Ward model conception

• One ward for management of all snake bite cases
  admitted to Chittagong Medical College Hospital
• Documentation
• Research
• Training
• Skill development
• National guidelines outreach materials

29
National Guidelines and training materials

Two editions 2000 2008
30
BCC material
Outreach materials

• Poster
• Leaflet

Leaflet
Newspaper ad
Poster
31
Current activities (1)

• Training

• Epidemiology of snake bite in Bangladesh
• WHO funded nation-wide community survey
• Randomized selection of communities
• 6 divisions gt 4 districts/div gt 2
  subdistricts/dist gt 2 unions/subdistricts gt 1
  block/union
• Target population 21,000
• Start January 2009

32
Current activities (2)

• Integrating Ozhas in early management of snake
  bite

Goal Convert "ozhas" into first line of defence
against snake bite morbidity and mortality in
Bangladesh
33
Current activities (3)Improving the referral
system
Present scenario 1 A journey through the system
ozha 1
ozha 2
Thana Health Complex
District Hospital
Medical College Hospital
Private Hospital
34
Current activities (3)Improving the referral
system
Present scenario 2 Bypassing the system
ozha 1
ozha 2
Union Health Complex
Thana Health Complex
District Hospital
Medical College Hospital
Private Hospital
"From ozha to tertiary care"
35
Current activities (3)Improving the referral
system
Preliminary target Early referral to health care
facility
ozha 1
Thana Health Complex
District Hospital
Victim
Medical College Hospital
Private Hospital
36
Current activities (3)Improving the referral
system
Goal Effective primary care referral system
ozha 1
Thana Health Complex
District Hospital
Victim

• Strengthening primary health care
• basic facilities for treatment of snake bites
• training of primary care physicians, especially
  in
• use and application of antivenom
• intubation and manual ventilation (e.g., by Ambu
  bag)

Medical College Hospital
Private Hospital
37
Current activities (4)Improving health care
facilities

• Training of trainers
• Professors of medical colleges (2007, N30)
• Next series starts December 2008
• Target 500 participants over 6 months
• Procurement of essential medicines equipments
• Antivenom 10,000 vials Dec 2008
• 14 ventilators designated for snake bite victims

38
Current activities (5) Study of voucher
specimens

• 10 of snake bite victims in Bangladesh bring
  the snake to hospital
• Preservation of whole snake and tissue samples
• Morphlogical and genetic analysis

39
Current activities (6) Molecular diagnosis
project
Identification by PCR-based analysis of snake
DNA from bite site
40
Current activities (6) Molecular diagnosis
project
PCR test of bite-site swab samples from clinical
cases
Lycodon aulicus
Lycodon aulicus
Lycodon aulicus
Bungarus sp. 1
Bungarus sp. 1
Bungarus caeruleus
Snake-specific primers for mitochondrial
cytochrome b gene primers blocking binding
sites in the human gene
41
Snake species causing highest mortality in
Bangladesh
Naja kaouthia Monocellate Cobra Naja
naja Spectacled Cobra Bungarus caeruleus
Common Krait Bungarus niger Greater Black
Krait Bungarus walli Wall's Krait
Species in red are not included in Indian
polyvalent antivenom production
42
Antivenom problems in Bangladesh

• Polyvalent antivenom imported from India
• Used when available not when needed
• Demand greatly exceeds short supply
• Lack of antivenom loss of public confidence
• High rate of adverse reactions
• Doubtful efficacy against some species
• Attempt in 1990s to locally produce antivenom

43
Antivenom priorities for Bangladesh

• Local breeding of snakes and venom production
• Regional centres with expertise to produce
  specific antivenoms for individual countries
• Local production of antivenoms

44
Acknowledgements

• Professor DA Warrell
• The Institute of Neurosciences, University of
  Newcastle upon Tyne, United Kingdom
• University of Oxford, Nuffield Department of
  Clinical Medicine, United Kingdom
• Biodiversity and Climate Research Centre,
  Frankfurt am Main, Germany
• Liverpool School of Tropical Medicine, United
  Kingdom
• Department of Zoology, University of Chittagong,
  Bangladesh

45

• Thank You

46
(No Transcript)
47
(No Transcript)
48
Cases from the countryside (2)

• Monsoon season of 2005
• A mother heard her 9-yr-old son crying at night
• Found black snake having swallowed one of the
  boy's fingers up to the base
• The snake regurgitated the finger and escaped
• The boy died 2-3 hr later while preparations to
  bring him to hospital were still being made