National programme for prevention & control of snakebite in India: Key challenges & recommendations

Snakebite envenomation (SBE) is an acute, life-threatening, time-limiting, medical emergency affecting 1.8-2.7 million people with estimated 138,000 deaths annually across the globe1. India contributes an average of 58,000 deaths annually2. Similar to sub-Saharan Africa3, the magnitude of SBE is underestimated in South Asia4 and South-East Asia5. India is one of the world’s most affected countries due to the large population engaged in agricultural activities, use of wattle and daub houses in snakebite-prone rural areas, several slum areas, presence of abundant venomous snakes and lack of community awareness regarding prevention and control of snakebites2,6,7. In 2019, the World Health Organization (WHO) resolved to halve the global burden of snakebites by 20308. India being a major contributor to the existing global burden of mortality5, efforts undertaken at the national and regional level would prove crucial in achieving the WHO targets 2030.

Although, standard treatment guidelines (STGs) for the management of snakebite were published in 20179; the implementation of STG protocol remains very poor in public and private healthcare systems in India10,11. Majority of the snakebites occur in rural/tribal areas with poor transportation facilities, especially during the night hours, thereby contributing to higher deaths12. A national consultation meeting of all stakeholders was organized in New Delhi, India, in August 2022. The Ministry of Health and Family Welfare (MoHFW), Government of India (GoI), declared the launch of a national programme for prevention and control of SBE in the month of September 202213. The launch of this dedicated national programme for snakebite by the Government of India is a welcome decision. In fact, India would be the first country in Asia to launch a national programme for prevention and control of snakebite. Based on our experience of snakebite research in India, we summarize the challenges and recommend the strategies at three different levels, i.e. community, health system and policy level (Table).

Table.

Key challenges at community, health system and policy level and recommended strategies for a national programme on prevention and control of snakebite in India

Key challenges	Recommended strategies
At the community level
• Lack of knowledge on venomous and non-venomous snakes, appropriate preventive measures6. • Use of harmful methods (tourniquet, incision on bite area, etc.) as a first aid, superstitions, chanting of mantras, use of unproven herbal medicines6. • Health-seeking behaviour-prefer to visit faith healers, tantriks, Ozas, Sarpa Chikitsa, etc.6,15.	• Active engagement of forest department and herpetologists for identification and mapping of circulating venomous and non-venomous snakes in a specific geographical region. • Community empowerment and active engagement of community leaders, religious leaders and school teachers to increase awareness on prevention, first aid and early transport of snakebite patients to the nearest health facility. • Adequate training must be provided to the traditional healers to identify red flags in snakebite victims that require urgent referrals to healthcare facilities. Traditional healers along with the key community persons like the Sarpanch (head of the village), the school teachers, gram sevak (government representative in the village) and village elders form an important influencing group. Awareness programmes conducted by them would be better accepted.
At the health system level
• No attention paid to snakebite in the medical curriculum. • No exposure to snakebite treatment during internship. • MOs in State health services have no experience of snakebite management9,10. • No uniform protocol followed for snakebite treatment9,10. • MOs at PHC, CHC do not have confidence of ASV administration, fear of anaphylaxis6,9,10. • Lack of life support skills15.	• To include snakebite management in the curriculum of training institutions of the State public health departments. • Periodic training of MOs in PHCs, CHCs as per the latest national snakebite management protocol. • Empowerment of frontline healthcare providers (ASHA, ANM, MPW) on prevention, first aid and timely referral for management of SBE. • Mandatory short-term training of medical graduates during internship and as a part of the induction training on joining as MOs in the State health services. • Training of nurses on treatment of snakebite with emphasis on ASV administration.
• Irrational use of the intradermal ASV test leading to wastage of precious ASV33.	• ASV manufactures in India (public and private sector) should immediately revise the ASV insert and remove the recommendation on ASV intradermal skin testing.
• ASV intradermal skin test recommended by ASV manufacturers34.	• To ensure safe, adequate supply of ASVs and other emergency medicines required for snakebite management.
At the policy level
• Huge gap between number of snakebite deaths reported from direct surveys and hospital-based data15. • Snakebite is not a notifiable disease.	• Making the disease notifiable would further help to identify hotspots for SBE and directed attempts to reduce the incidence and mortality in these hotspots can be made. • Online data entry of snakebite cases into a dedicated snakebite portal.
• The existing guidelines of MJPJAY+PMJAY provide Rs. 50,000 for snakebite patients requiring ventilator support. • Patients who do not need ventilator support are excluded from getting the benefit of MJPJAY + PMJAY leading to extensive financial burden.	• Revision of policy to include all patients of SBE for free of cost treatment in all healthcare facilities (public and private hospitals). • Financial assistance for deaths due to SBE.
• SBE disproportionately affects the rural populations, migrant workers and people engaged in agriculture32.	• Directed efforts in states with high proportion of vulnerable population and high caseload will ensure effective administration and would help in cutting the cost of implementation in the whole country. • States with high proportion of vulnerable population but low caseload should be empowered with robust surveillance systems to counter underreporting.
• Long-term complications occur in around 15 per cent of survivors (musculoskeletal deformities, amputations, visual impairment, chronic kidney disease, paralysis and disability and psychological health consequences)9,32	• Psychological counselling of family members of snakebite victims. • Rehabilitation centre for management of snakebite related complications. • Referral linkages to be established between PHCs, CHCs and tertiary care hospitals for transfer of critical patients who require higher-level management.

MOs, medical officers; MJPJAY, Mahatma Jyotiba Phule Jan Arogya Yojana; PMJAY, Prime Minister Jan Arogya Yojana; PHCs, primary health centres; CHCs, community health centres; ASHA, Accredited Social Health Activist; ANM, auxiliary nurse midwife; MPW, multipurpose worker; ASV, anti-snake venom; SBE, snakebite envenomation

Haffkine Institute in Mumbai, India, has been a pioneer in developing Indian polyspecific anti-venom since 189914. The currently available anti-snake venom (ASV) in India is polyvalent. The polyvalent anti-venom is developed using venoms of big four venomous snakes i.e. common Indian cobra (Naja naja), common krait (Bungarus caeruleus), Russell’s viper (Daboia russelii) and saw-scaled viper (Echis carinatus)15. The national programme should consider the diversity of venomous snake species and their toxins in different geographical regions in India. The available polyvalent anti-venoms do not neutralize the venom of certain species such as the hump-nosed pit viper (Hypnale hypnale). In addition, the effectiveness of polyvalent anti-venoms against the region-specific species such as Sochurek’s saw-scaled viper (Echis carinatus sochureki) in Rajasthan and banded krait (Bungarus fasciatus) in West Bengal is questionable15,16 Hence, the GoI should consider establishing region-specific venom banks and make provision for region-specific ASV during the process of implementation of the national snakebite programme. Another challenge is the non-compliance to the WHO standards and protocols for venom and anti-venom production. Hence, through the programme, it is essential to monitor whether ASV manufacturers adhere to the WHO’s guidelines for the production, control and regulation of snake anti-venom immunoglobulins or not17. Reports suggest that a majority of the medical officers do not administer ASV due to the fear of adverse reactions including anaphylaxis6,9,10. Also, significantly lower rates of adverse reactions are observed after the use of highly purified caprylic acid-stabilized IgG anti-venoms18. Therefore, there is a need to conduct a detailed pre-clinical evaluation of the efficacy of the current as well as newer anti-venoms. These attempts may help to reduce the time of recovery, total dose of ASV required to neutralize the circulating venom and to improve the ASV’s safety profile.

Non-availability or limited availability of ASV has been previously reported in India9,19,20 Currently, there are eight Indian manufacturers for ASV with a total installed capacity of 6,752,000 vials per annum21 while, the installed capacity of government-owned ASV manufacturers is only 460,000 vials/annum (6.8%). However, only 1.5-2 million vials of ASV are produced every year in India22-24. Therefore, the union and State governments should ensure that sufficient doses of ASV are produced and made available in both public and private hospitals. There is a need for regular monitoring of ASV availability and utilization through the national programme.

Manufacturing of anti-venoms in India is equine based22. Therefore, another aspect to consider during manufacturing and testing is to safeguard equine health. The GoI issued the amended protocol for the use of equines for production of hyperimmune sera (ASVS) in 2005 that sets out clear rules pertaining to their age and weight, bleeding schedule and amount of blood to be collected and their rehabilitation after use25. The national programme should provide for mechanisms to ensure ethical treatment of the equine and to improve the process of harvesting equine sera in the most productive ways. A coordinating centre at the national level is hence required for framing guidelines and policies, managing snakebite mortality and morbidity database, ensuring quality controls, following ethical obligations and, monitoring and evaluation of the snakebite programme. The government should appoint experts on snakebite management as programme managers of such a centre at national and State levels. A physician with experience in snakebite management should be designated as Neglected Tropical Diseases Officer in each district of the high burden States such as Bihar, Jharkhand, Uttar Pradesh, Andhra Pradesh, Telangana, Odisha, Maharashtra, Madhya Pradesh, Rajasthan and Gujarat. Periodic policy inputs and research should also be an integral part of the programme. There is also a need to establish a dedicated snakebite clinical research cum training centre (SCRTC) in one of the high burden States such as Maharashtra where both clinical expertise in snakebite treatment and, clinical and public health research expertise on snakebite are available6,10,11,26-29. A periodic review of the challenges and shortcomings of STGs needs to be conducted for evidence-based update on management of SBE. An underestimation of the snakebite morbimortality due to reliance on hospital based data is another challenge. Making snakebites notifiable in the national programme can aid in gauging the actual burden. These activities can be coordinated through the SCRTC.

Another point is that, presently SBE is not included in the medical graduation (MBBS) curriculum and no attention is paid to the diagnosis and management of SBE during the internship of MBBS doctors. Through the proposed national programme on snakebite, teaching activities in medical and nursing colleges may be undertaken and regular training programmes for doctors and nurses, especially in regions of high incidence of snakebites may be organised. The evaluation of baseline knowledge and improvement after training may also be assessed for medical officers and frontline health workers. Training materials and culturally appropriate information, education and communication strategies may be adopted to disseminate to public health facilities all over India. The long-term goal of the programme should be to establish Model Snakebite Management Centre at a community health centre, District Hospital, in the high-burden States.

In India, nearly 70 per cent the population lives in rural areas and depends on agriculture, hunting, fishing, forestry and poultry for livelihood30. Therefore, humans and livestock in rural areas are vulnerable to snakebites. Along with the burden on human population, snakebite also causes heavy economic losses by affecting the domestic animals and livestock population6. The case fatality rate due to snakebites in livestock is reportedly as high as 47 per cent31. Hence, a collaboration between human and veterinary health systems, as recommended by the WHO’s ‘One Health’ model, should be sought to bring out a coherent change32. There is a need for integrating the national snakebite prevention and control programme with institutions such as National Institute of One Health and other institutions of human and veterinary medicine at State as well as central levels.

The communities affected by snakebites are often those with the least access to healthcare services and treatment. Hence, flexible policies should be designed to accommodate the geographical and cultural diversity of India. Herpetologists, forest department officials, Panchayat officials, village elders and other influential people along with tribal residential school teachers should be an integral part of the process to implement best practices and policies at the local level. Community engagement at every level of decision-making and implementation warrants decentralization of power and finances.

The plan of action for the prevention and control of snakebites in India should be considered as per the objectives of the WHO strategy for the prevention and control of snakebite envenoming32. To develop a national programme that engages communities, ensures safe and effective treatment, builds health system capacity and promotes intersystem collaborations for reducing the impact of snakebite envenoming in the Indian population is, therefore, most crucial. Such a programme will play a major role in reducing the mortality and morbidity in India, thereby achieving the targets of WHO 2030.

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Conflicts of interest

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