Snake and Animal Bites

Snake Bites

Snake bites are common in most rural areas and particularly so in forest and forest fringe villages. Deaths due to poisonous snake bites are an important preventable cause of death in our area. Educating our health workers about this was therefore felt necessary. Since over 80% of venomous bites in this region are krait bites, training was focused on this. Training involved discussion on how common the problem is, and what people currently do to manage snake bites. Most people kill the snake as soon as it bites someone, and treatment options included "jhaad phoonk" and consumption of herbal remedies. Often the patient is taken to hospital too late to be saved.

There is reliable data from literature. Based on an epidemiological survey of 26 villages with a total population of nearly 19,000 individuals in Burdwan district of West Bengal state in India, Hati et al worked out an annual incidence of 0.16% and mortality rate of 0.016% per year . Maharashtra, one of the states of India with the highest incidence, reported 70 bites per 100,000 population and mortality of 2.4 per 100,000 per year . In our area, the annualized snake bite rate was the same as Burdwan at 1.58 per 1000 population, and the annual mortality of 1.3 per 10000 population. Snake bites continue to kill.

What was also obvious is the loss of lives among the livestock. Of 25 snake bites in large animals which are expensive assets for people, as many as 12 died.

A video clip of a patient with envenomation following a krait bite (the patient was seen in our clinic at Ganiyari) was shown to the health workers. Only two of the 104 workers (who had relatives who had died of a snake bite), recognized what it was. Even among the nearly two hundred health workers (doctors, ANMs, and others) who were shown the video clip, only a handful could recognise the symptoms.

It is essential for communities to be able to recognise envenomation early in order to be able to seek help at an early stage. Therefore a CD has been prepared with a powerpoint presentation in hindi about snake bites, and has been distributed in the programme villages.

In addition, a programme was broadcast on the local radio regarding snake bites. This programme was a question and answer session, in both Hindi and Chhatitsgarhi. It was broadcast several times over a period of two weeks, and was widely heard in the surrounding villages. Subsequently, patients attending the outreach clinics as well as the clinic at Ganiyari were interviewed about whether or not they had heard the programme, and asked some basic questions about snake bites. 20% of the respondents had listened to the programme. Information obtained during the interviews is being compiled and analysed.

Animal Bites

We maintain that animal bites resulting in death and disability to human and their animals is an overwhelmingly rural problem and these people suffer from gross negligence of our primary health care system. Drugs, vaccine and antisera and information and skill base to manage these at the peripheral outposts are scant. In fact the exact information about their incidence is also lacking.

In order to answer this question, we have been documenting the prevalence of animal bites since August 2008 in 54 programme villages with a population of 26565. Information is collected from all sources- the health workers who come for their monthly training programmes, the senior health workers when they visit the individual villages on their beat programme, and the field coordinators who hold nukkad or hamlet level meetings. House to house surveys were not done, we feel that the data for snake and suspected rabid animal bites is accurate, but for the scorpion and bee/ wasp bites they would be incomplete as many would think that they are rather usual.

We discuss here the preliminary results of data collected over 10 months. The annualized dog bite rate is 51.9 per 10000 population, which is at least four times higher than the published data from emergency room reporting from a US emergency room reporting or from an Italian clinic. The average yearly incidence of dog and cat bite/scratches was 58.4 and 17.9 cases per 100 000 residents, respectively in the Italian clinic. In a Pittsburgh Clinic, the bite rate was 12.9 per 10000 persons (95% confidence interval [CI], 10.5-15.4).

Data from India is different. WHO sponsored a national multi-centric rabies survey to find out the incidence of animal bites, anti-rabies treatment practices, Pet dog population and their care. Twenty-one medical colleges chosen with geoscatter representation conducted the survey during February-August, 2003. The survey was conducted in 18 states, covering a population of 52,731 chosen randomly from 8500 households. The annual incidence of animal bites was high, as high as 18 per 1000 population in rural areas , which is certainly much higher than our area. The same group also concluded that the annual incidence of rabies is 2 per 100000 population. This year we have already lost one person due to rabies.

What does not seem being of obvious importance, we saw a large amount of livestock and other draught animals' mortality due to these suspected rabid animal bites. In this same population's livestock, we saw them losing 25 animals in these 10 months, which causes significant economic burden on the people. This should be factored in for considering the importance of animal bites and for resource allocation in the primary health care system.

Other Bites

While our data on scorpion and bee and wasp bites may not be complete, we had one death among 43 scorpion stings among humans (1.93 per 1000 population). One cow also died during this period.

Simililarly, bee and wasp bites were 61 among the people giving an annualized rate of 2.75 per1000 population.

Improving Treatment

Taking cognizance of this, we decided to start animal bite centres at all our sub-centres. Here we provide information regarding each animal bite, offer definitive first treatment for its care and document its burden and pattern carefully.

These animal bite care centres were opened in the months of June and July 2009. There has been a sharp increase in the number of people seeking primary care for the animal bites in all the sub centres in the first 6 months!

We have also been able to design a solar powered refrigerator that has been commissioned at the Bamhni sub-centre to be able to preserve the antisera and the vaccines for snake and suspected rabid animal bites. This is almost a first that has been done in primary health care. This refrigerator has been made at a cost of Rs 40,000. only, whereas the cheapest in the market is not available for less than Rs. 125,000.. The refrigerator has a volume of 80 litres and has passed the acid test of surviving through the entire monsoon of 2009, where we monitored the inside temperature, which never went over 6 degrees Celsius. The availability of the refrigerator in areas where there is no power or assured regular and reliable voltage power opens solutions for problems like keeping heat labile but life saving drugs like insulin and important reagents like rapid diagnostic kits safe.