Soumyadeep Bhaumik on a national snake bite survey in India

soumyadeepbhaumikIn January when I wrote a BMJ feature titled ” Snakebite: a forgotten problem,” little did I know that just two months down the line I would be part of something that will help change the lives of millions of marginalised people who are affected by a problem that is still neglected by policy makers, public health specialists, clinicians, researchers, the lay press, and even the general public.

The South Asian Cochrane Network and Centre, Professor BV Moses, and the ICMR Centre at the Christian Medical College, Vellore organised a protocol development workshop for the national survey of snake bites in India (venomous and non-venomous), which aims to map and identify correlations between syndromes and snake species, snake bite outcomes, and anti-snake venom dose requirements. The event was supported by the Effective Health Care Research Consortium, UK.

Snake bites are estimated to cause more than 45,900 deaths in India, and affect millions of Indians—most of them from socially and economically disadvantaged sections of the society. Strangely however, in India the species-syndrome correlation has never been studied and the appropriate dosage requirements for treatment have not been found. As was evident from the data and protocols presented by 15 centres from across India, there are wide variations in anti-venom dosage and administrations, their indications for usage, their adverse effect profile, and even the standards of care adopted. All of the experts at the workshop, who probably represented the entire gamut of possible management procedures, wondered how in spite of managing snake bites for at least a century there is still no evidence about how best to treat them. There are also substantial differences in the national and the state level management protocols being followed across the nation.

The national snakebite survey will be a multicentre prospective study of snake bites where serial samples will be collected for identification of species quantification of venom and anti-venom concentrations along with the clinical data. This study is the first of its kind and should help to address the questions of initial dose and appropriate clinical (and possible laboratory) end points for anti-venom treatment in India, and also map snake populations and their DNA profile across the anti-venom, together with the syndrome-species correlation and other details.

Identification of snake samples by a group of dedicated herpetologists, together with other methods such as DNA based diagnosis, is being planned in this study. Immediate use of such knowledge would  give physicians across India better evidence based information in terms of definite species identification. This will be tremendously useful not only in a clinical perspective, but also in other domains, for example testing the efficacy of existing anti-snake venom in different parts of India.

In the future the study might also pave the way for developing a snake-bite registry, and the data it generates will be tremendously useful for further research, including various randomised controlled trials across India. However, with the amount of work to do in this respect, it is indeed essential to understand that the study will need major assistance from the Indian government to be successful. Wildlife conservancy laws make snakes a protected species and their storage and transportation would need clearance at various levels—something that is not very easy to get. Collecting DNA samples needs another set of special permissions. The need for more snake parks in India with permission for “milking” snakes for venom is an issue that needs to be sorted out to improve the quality of anti-venoms. Another major problem with the study is the fact that none of the clinical collaborating centres are from the western part of the nation (Rajasthan, Gujarat), or the Andaman and Nicobar Islands. The study is scheduled to roll out in three months from now and is expected to be completed in another two years. A nation like India with its wide variation might need a survey for a longer time to identify the true picture that the study intends to capture.

Soumyadeep Bhaumik is a medical doctor, independent medical researcher, and freelance author  from Kolkata, India. He is also the medical sub-editor of the Your Health of Indian Medical Association, and is the editor and head of the Journal of Pakistan Medical Students. He is a country representative (India) of the Health Information for All by 2015 campaign.

Competing interests :  I have read and understood the BMJ Group policy on declaration of interests and declare that my travel and accommodation for the protocol development workshop was funded by the South Asian Cochrane Network and Centre at Christian Medical College, Vellore.