Situation of Snakebite Envenomation in Nepal

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Situation of Snakebite Envenomation in Nepal
Chhabi Lal Thapa1, Deb Prasad Pandey2 1General
Physician Toxinologist, Dumkauli Primary Health
Care Center, Ministry of Health and Population,
Nepal Gov., Kali Gandaki Hospital, Kawaswoti,
Nawalparasi 2 Lecturer, Dept. of Zoology,
Birendra M. Campus, Tribhuvan University,
Institutional Member, PARASED, Nepal, President,
ANCSU, Nepal, debpandey_at_gmail.com Corresponding
author Thapa, CL, Email paudel_dr_at_hotmail.com
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Background

• extreme geographical and ecological
  diversification and can be divided into 3 main
  ecological zones
• 26 districts of lowland are highly prone to
  snakebite
• In Nepal, about 1000 snakebite envenomations
  (excluding viperidae) bites and about 200 deaths
  occur annually
• Polyvalent ASVS-by Haffkine , VINS Bioproducts
  Bharat serum and Vaccines Ltd.,
• Since fiscal year 2056/57(1998/99) ASVS has been
  supplied free of cost to the envenomed Nepalese
  citizen.

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Introduction

• Snake bite is significant public health problem
  in many countries with large number of
  envenomings and deaths although it is difficult
  to be defined the actual number of snake bite
  victims1.

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Introduction (contd.)

• In Nepal, incidence of snake bite shows a
  distinct seasonal pattern closely related to
  rainfall and temperature, and snake bite is
  observed in all age groups, the large majorities
  (90) are in males aged 11-50 years5.One study in
  Eastern Nepal revealed 75 of the patients in the
  age group of 11- 40 yrs.6.

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Introduction (contd.)

• From the field based survey in Chitwan and
  Nawalparasi, the maximum snakebite victims (65)
  were recorded in summer and the minimum (4) in
  winter. Of totality, 42 were venomous victims of
  which 27 died 63 of the venomous victims were
  recorded from the Nawalparasi and 37 were from
  Chitwan7.
• Characterization snakebite situation in Nepal has
  been significant and essential to overcome the
  limitations and improve the quality of snakebite
  management.

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Methodology

• The retrospective study of envenomed and admitted
  snakebite victims treated with ASVS reported to
  EDCD, Kathmandu from the health institutions
  throughout Nepal during 2000 2005 was carried
  out in Jan. to June 2008. Next six month study
  will extract the information for 2006-07. The
  study will be continued till Dec 2008. Victims
  envenomed by Pit viper were not treated with
  ASVS hence, it excluded most of viperidae bites
  (except Russells viper bites).

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Methodology

• Identification of enveonomations were based on
  symptoms, history of bite, snakes carried in
  hospital.
• The information so obtained collected,
  compiled and analyzed by the application of
  Microsoft excel and illustrations.

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Limitations
Methodology

• There were no records of species of snakes
  involved in envenomation. Only group name like
  Krait bite, Cobrabite, Viperbite or Unknown was
  provided in the data sheet.
• The records provided to EDCD could not enumerate
  the entire epidemiological data of snakebite.

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hospitals in collaboration with WHO found 3189
treated victims of whom 144 victims died i.e.
CFR 4.54. In Nepal, incidence of snake bite
shows a distinct seasonal pattern closely related
to rainfall and temperature, and snake bite is
observed in all age groups, the large majorities
(90) are in males aged 11-50 years5.One study in
Eastern Nepal revealed 75 of the patients in the
age group of 11- 40 yrs.6. From the field based
survey in Chitwan and Nawalparasi, the maximum
snakebite victims (65) were recorded in summer
and the minimum (4) in winter. Of totality, 42
were venomous victims of which 27 died 63 of
the venomous victims were recorded from the
Nawalparasi and 37 were from Chitwan7.
Characterization snakebite situation in Nepal
has been significant and essential to overcome
the limitations and improve the quality of
snakebite management.  Methodology The
respective study of envenomed and admitted
snakebite victims treated with ASVS reported to
EDCD, Kathmandu from the health institutions
throughout Nepal during 2000 2007 was carried
out in Jan. to June 2008. Next six month study
will extract the information for 2006-07. The
study will be continued till Dec 2008. Victims
envenomed by Pit viper were not treated with
ASVS hence, it excludes most of viperidae bites
(except Russells viper bites). Identification
of enveonomations were based on symptoms, history
of bite, snakes carried in hospital. The
information so obtained was compiled, collated
and analyzed by the application of Microsoft
excel and illustrations.     Results

• The data includes the snakebite envenomations of
  the years 2000 to 2005.

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DISCUSSION

• Present study depicted that the mortality rate
  was decreasing that was not supported by the
  field study in Chitwan and Nawalparasi (27)7
• Greater male victims record reflected their
  greater outdoor activities. Similar results were
  extracted in field and hospital based study in
  Chitwan and Nawalparasi7,6.
• Snakebite envenomations were greater in the age
  group above 15 yrs. The findings was supported by
  the studies in Nepal5,6.

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DISCUSSION

• The bite in extremities was found significantly
  greater that was also reported from the field
  based study in Nepal7.
• Snakebite envenomations started to rise from the
  month of May (i.e. onset of summer) and peaked in
  the months of July, August and September (i.e.
  during and after monsoon). The cases slowly
  started to decline from the month of October.
  Even during other months also very few cases were
  reported. The findings was supported by the
  similar findings of the different research
  works4, 5,7 in Nepal

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Conclusion and Recommendation

• Snakebite management in Nepal is slightly
  ameliorating.
• Snakebite management and data keeping is poor for
  elaborative description of snakebite epidemiology
  in Nepal.
• People should be made aware of first aid and
  preventive measures to snakebite, habit and
  habitat of prevalent venomous snakes.
• Snakebite issue should be prioritized as
  national public health problems.

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• People should be educated for awarness to snakes
  habits, habitat, behaviors and identification of
  medically significant venomous snakes
• Regular training and follow up programs on
  snakebite management should be provided
• Adequate and timely supply of ASVS should be made
  in advance to the hospitals and PHCs where it is
  needed.

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• It is strongly recommended that snake bite should
  be made a specific notable disease in in Nepal
• Also, data keeping should be up to date and well
  managed.

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• It is recommended to include issues of snakes and
  its problem management in curriculum of schools
  , college and university courses
• The national protocol should be updated with
  reference to research results

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ACKNOELEDGEMENT

• We would like to extend our sincere thank to Dr.
  Mahendra Bahadur Bista, Director General of
  Health Service Nepal.
• Dr. Jiendra Man Shrestha, Chief Zoonosis Section,
  EDCD, Nepal
• Mr. Lat Narayan Shah, Zoonosis Assistant, EDCD,
  Nepal.
• Mr. Dilli Ram Paudel. Dumkauli Primary Health
  Care Center, Nawalparasi, Nepal.

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Acknowledgement (contd.)

• Prof. David Warrell, center for tropical Medicine
  and infectious disease, university of Oxford, UK.

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References

• Chippaux, JP. Snake bites Appraisal of the
  Global Situation. Bull. WHO 1998. 76(5)
  515-524.
• WHO. Blood Products and Related Biologicals
  Animal sera- Available from website-
  http//www.who.int/bloodproducts/animal_sera/en
  (accessed 2005).
• Gaitonde BB., Bhattacharya S. A n Epidemiological
  Survey of Snake bite victims in India. Snake
  1980.12129-133.

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• 5. WHO. Zoonotic Disease Control Baseline
  Epidemiological Study on Snake bite, Treatment
  and Management in Nepal. WHO weekly Epidemiolog.
  Rev. 1987. 42 319 - 20.
• 6. Hansdak, SG., Lallar, KS., Pokharel, P.,
  Shyangwa, P., Karki P., Koirala SA.
  Clinico-epidemiological study of snake bite in
  Nepal. Tropical Doctor 1998. 28223-226.
• 7. Sharma SK., Koirala S., Dahal G., Sah C.
  Clinico-epidemiological features of snake bite a
  study from Eastern Nepal. Tropical. Doctor, 2004.
  34(1) 20-2.

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• 8. Pandey, DP. Epidemiology of Snake bites Based
  on Field Survey in Chitwan and Nawalparasi
  District. Under publication in Journal of Medical
  Toxicology.
• 9. Pandey, DP. Epidemiology of Snake bite in
  Chitwan and Nawalparasi District. Research Report
  Submitted to University Grant Commission. 2005
  38p.
• 10. Russell FE. 1980. Snake-venom Poisoning.
  Philadelphia, JB Lippincott Company 235-285.

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• 11. Ministry of Health, EDCD. Incidence of
  Poisonous Snake bite in Nepal. Cited from Annual
  Report 2002 and 2003. March 2005 58-64p.
• 12. Carrol, T., Smith, R. 2005. Snake Venom
  Detection Kit. Pub. by CSL limited, 45 poplar Rd,
  Parkville VIC 3052, Australia

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Thank You