Battling the venom with Snakebite Mitigation project

“It was July 2014. Ranidevi’s husband, 24-year-old Mukhi Singh Khaiwar, was tilling his field to sow maize (in Ledhgai village in Latehar District, Jharkhand). It was around 12 noon. As he went about doing his work, Mukhi didn’t see the Russell’s viper in the bushes next to the fields. The snake was disturbed and Mukhi was bitten by it. Initially the family resorted to faith healing. 30 minutes into the ritual, the family realised his condition was deteriorating and they rushed him to the Mission Hospital in Barwadih, approximately 5km away from Ledhgai village. At the Mission Hospital, Mukhi was given a tetanus injection and referred to the Mission Hospital in Tumbagada, Satbaruah. No details are available about the treatment received at the Tumbagada hospital. He was later referred to the Government Hospital in Ranchi. Mukhi’s condition deteriorated in the next few days and he died on the 8th day of the bite. He was survived by his five-month-old toddler (now 3.5 years old), his widow Ranidevi, his younger brother and his mother. The family is struggling to come to terms with his untimely death.”

The narrative of Mukhi's death is among one of thousands of accounts of snakebite victims that Priyanka Kadam has been documenting since 2014. In an online repository on her non-profit's website, Snakebite Healing and Education Society (SHE), the 48-year-old publishes tales from such remote villages, such as Chipadohar in Jharkhand and Baraini in Uttar Pradesh as well as incidents from overcrowded metropolises such as Mumbai.

Mukhi's death typifies every aspect of what makes snakebite fatalities in India a cumbersome issue to resolve: bite incidences are common, and increase during the monsoon period; it's an occupational hazard that commonly affects poor, rural residents, mostly farm workers, and males in the 15-34 age group; the victim is invariably first taken to a faith healer — typically a temple priest or a “jhadoo-phoonkh” quack; a primary healthcare facility is usually at a distance, so crucial time is lost in commuting to the centre; medical professionals at such centres unfailingly have little to no knowledge and experience in dealing with snakebites, as a result, victims are referred to a “larger hospital”; if at all the attending doctors are aware, it's a matter of fortune that the facility also has an adequate stock of anti-snake venom (ASV) — the only cure for a venomous snakebite; in the event of a death, the family not only loses a loved one, but also the means to a livelihood as males are the customary breadwinners in villages.

A speck in the stats

In a land where serpents are deeply etched in religious mythology, be it Hinduism, Jainism, Buddhism and even Christianity, there is large-scale ignorance about all-things snake. “The culture around snakebites in India is very debilitating. Most people who suffer from snakebites go to faith healers and not to a hospital,” says Jose Louies, head of enforcement assistance and law at the Wildlife Trust of India and the man behind indiansnakes.org. This contributes largely to the vastly under-reported snakebite death statistics in the country — officially a few thousands, but the highest in the world, according to the World Health Organisation. It is pertinent to note here that the census-conducting office, the Registrar General of India, doesn't maintain a record of deaths resulting from snakebites as a distinct category; these deaths are taken into account under the 'Injury, poisoning & other consequences of external causes' as available from the Medical Certification of Cause of Death (MCCD) data. “The estimated total of 45,900 national snakebite deaths in 2005 constitutes about 5% of all injury deaths and nearly 0.5% of all deaths in India. It is more than 30-fold higher than the number declared from official hospital records,” say experts in the 2011 Snakebite Mortality in India: A Nationally Representative Mortality Survey. “Snakebite deaths remain an important cause of accidental death in modern India, and its public health importance has been systematically underestimated,” noted the study, which itself is a part of the Million Death Study, a path-breaking examination of premature mortality in India.

What makes the scenario around snakebite fatalities all the more crushing is the fact that many of these lives can be saved. “If taken care of early, most snakebite victims will survive, and nearly 97% will return to their productive life,” says Dr Jaideep C Menon, a cardiologist at Kochi's Amrita Institute of Medical Sciences, who has been involved in several initiatives to increase awareness about snakebites and in facilitating treatment. “We can bring this (deaths due to snakebites) down to less than a 1,000 per year by creating more awareness, ensuring adequate supply and stock of anti-snake venom at primary health facilities, and training doctors in rural areas.

Same species, different bite

“The best advice to solve the snakebite problem in India is a) to teach people about snakes and how to avoid them, and b) to make sure rapid transport to hospitals and antivenom is available to all rural people,” says Romulus Whitaker. The 'snake man of India' is as much an institution as the Madras Crocodile Bank Trust and Centre for Herpetology (MCBT) that he founded along with Zai Whitaker on the outskirts of Chennai, Tamil Nadu in 1976. On Nag Panchmi a few days ago (27 July), the Trust and others such as SHE, an advocacy and awareness platform for doctors from across the country to help and guide snakebite victims, marked an informal Snakebite Awareness Day. They circulated messages and video clips en masse on WhatsApp, Facebook and Twitter to increase awareness about snakebites. “We conducted workshops with our volunteers in 15 places in Bihar, Madhya Pradesh, Maharashtra, Chhattisgarh, Tamil Nadu and Kerala,” says Allwin Jesudasan, assistant director, MCBT. The workshop was a part of the ongoing Snakebite Mitigation Project, that the Trust has undertaken with support from Mumbai-based pharmaceutical company USV and earlier from the Infosys and the Deshpande foundations. “This is a large project with six components — snakebite education outreach, venom sample collection, venom/anti-venom research, mapping of snakebite, snake capture protocol and an attempt to form a multi-state cooperative for venom collection,” says the 37-year-old.

The last component — a multi-state cooperative for venom collection — is something most experts, from herpetologists to medical professionals and educationists, view as an ideal medical approach to treating envenomation. “I've been pushing for regional ASV banks in Maharashtra for over two decades now,” says Dr Dileep Pandurangrao Punde. The 56-year-old has treated over 4,500 snakebite victims in the last 30 years in and around Mukhed, in Maharashtra's Nanded district. Such is his popularity in the eastern, border areas of the state that some say locals place Dr Punde's photograph alongside those of gods and goddesses in their homes. “The idea is to capture snakes from one region, extract their venom for use in the production of anti-snake venom, and use that ASV to treat victims in the area.”

ASV is manufactured by using anti-bodies produced by horses who've been injected with a small quantity of venom extracted from venomous snakes; the horses naturally build immunity against the venom's toxins. In India, there are four/five pharmaceutical companies that manufacture ASV, and all of them procure venom from the Irula Snake Catchers Industrial Cooperative Society — the sole organisation authorised to extract venom from snakes captured (and subsequently released in the wild) in Tamil Nadu. If venom for ASV comes from snakes of just one region, points out Ahmedabad-based herpetologist Soham Mukherjee, it directly affects the ASV's efficacy. “On an average, between 25 to 30 ASV vials are used to treat a snake bite victim in Gujarat whereas in Tamil Nadu, two ASV vials suffice,” says Mukherjee, who probed all the head of departments of all the civil hospitals in Gujarat at a meeting to find out their ASV usage per patient. “Twenty-five vials is a tremendously high amount of serum to inject into a human body. Doctors have no option but to inject more and more ASV in order to save a life.”

More ASV is required because the venom constituents are different. “The venom of a common krait in Tamil Nadu varies from the venom of a common krait in Rajasthan. The variation is due to the difference in the snake's diet, genetics and ecological factors,” points out Indiansnakes' Louies. Or as Dr Menon puts it, “The venom profile and toxicity depends on the (snake species) predominant prey in a given area”.

Catch 22

Administering ASV is the only medical treatment for a snakebite. The ASV used is 'polyvalent' i.e. it is effective against the venom of multiple snakes; in India, polyvalent ASV is effective against the common krait, the spectacled cobra, the Russell's viper and the saw-scaled viper; these species are responsible for the highest envenomation deaths in the country (see box: Meet the big four). “But in some parts of the country, the deadliest snakes are not the big four,” says Louies. “There are others, such as the banded krait, the Himalayan krait, the Malabar pit viper, the hump-nosed pit viper and many other species in the northeast. The polyvalent ASV, based on the venom of the big four, isn't necessarily effective in the case of bites of other venomous snakes. The ideal solution would be to have region-specific ASV.”

Dr Menon and Dr Punde illustrate this point by citing how Australia manages snakebites. “Australia has some of the most venomous snake species, yet they have no more than 6-7 incidences of bite deaths per year,” says Dr Menon. “They use venom detection kits, which allow a medical expert to tell which snake has bitten the victim. This is also why they have monovalent anti-venom, which is far more effective,” adds Dr Punde. “We don't have venom detection kits in India, and so doctors end up following a symptomatic approach i.e., they deduce which snake might've bitten the victim based on symptoms because victims are unaware or ignorant.”
But while monovalent ASV may sound ideal, Whitaker feels it isn't a practical solution for India. “The need of the hour is a greatly improved, stronger and cleaner polyvalent antivenom. Snakebite detection kits are expensive and time consuming. There is no time to waste with a venomous snakebite — get the patient to a hospital NOW!” His colleague Jesudasan too sounds a cautious note. “It is possible to have venomous snakes from different regions at a serpentarium to enable region-specific venom collection. But we have a long way to go to achieve that. Also, we do not have adequate knowledge as yet,” he says.

The gap is on two fronts — first, knowing the distribution of venomous snake species across the country and second, comparing venom samples to learn about the extent of variation within each species. The first one is being dealt with through www.snakebiteinitiative.in — a mobile platform to 'map' the big four across the country. “It's a platform where basic information on snake-human conflict is crowd-pooled and documented on a map of India. By conflict, I mean when experts or rescuers are called to remove a snake from a house, a school or an office,” says Louies. “These rescuers then take a photo and add it to the database. The software filters out false data by only allowing a photo shot on the very device from which the image is being sent or uploaded. This is how it also adds the GPS location, time, date, and other details. So we automatically get authentic data.”
snakebiteinitiative.in went live in May and is already yielding rich information, and will soon hit the 10,000 data mark. “Until now, we've never had answers to many questions — when and where does a snakebite occur, at what time of the day is it most common, which is the snake involved and so on. But now that we are mapping the snakes, we can prepare for such answers,” adds Louies. “For instance, based on all the information on the snakes present in the outskirts of Hyderabad, I can tell you that most are cobras. There's been just one incidence of a saw-scaled viper. So we can predict that the possibility of a snakebite by a cobra is higher than that from a saw-scaled viper, and accordingly prepare for it by tailoring awareness and outreach activities, first-aid and more.”

While Louies tracks the 20-25 fresh entries on the snake map every day, Mukherjee is busy laying the groundwork for venom sampling in 13 states. He is hoping to get 20 specimens each of the big four species from 13 states to extract small amounts of their venom. Given that snakes are protected under the Wildlife Protection Act, he's been seeking permits to capture snakes for venom collection in Madhya Pradesh, Maharashtra, Gujarat, Telangana, Andhra Pradesh, Kerala, Chhattisgarh and West Bengal. “It's a legal process and requires a lot of coordination with each state's forest department, working with local snake rescuers, maintaining records and tracking the release of snakes, etc. We hope to complete the field work by the end of the year,” says Mukherjee. “Extracting venom always has the potential for a risk of a bite.”
The saviours, we pray, will be spared the poison.

Meet the big four

India is home to nearly 300 snake species, most of which are non-venomous. Of the 62 venomous species, the spectacled cobra, the common krait, Russell's viper and the saw-scaled viper — known as the big 4 — are the ones whose bites lead to the most number of deaths in the country.

For help in case of a snakebite:

Call Priyanka Kadam of Snakebite Healing and Education Society, at +91 9820 523 297 or visit www.she-india.org/snakebite-first-aid/