Examining the Role of Treatment-seeking Behavior in Snakebite Mortality: A Narrative Review

Abstract

Snakebite is a neglected tropical disease that requires attention. The mortality due to snakebite is highest in India as compared to other countries. This review aims to investigate underlying factors influencing the treatment seeking behaviour and its impact on snakebite related mortality. Articles were reviewed rigorously on online databases PubMed, Medline, Web of Science, and Google Scholar. The search strings used were “snake bite” [MeSH Terms] AND “treatment seeking behavior” [MeSH Terms]. A total of 22 articles were retrieved, and 12 articles were considered relevant for the final review. Primarily, the delay in obtaining care, attributed to a lack of understanding regarding various snake species, biting behaviors, and their venomous properties attributes to the snakebite fatality. Overreliance on conventional treatments and religious beliefs significantly influences treatment-seeking behavior. The choice of treatment for snakebite directly influences snakebite mortality. Delays in seeking treatment increase mortality and the chance of long-term consequences (amputations, kidney failure, etc.). The treatment-seeking behavior impacts snakebite mortality. The main cause of delay in snakebite treatment is largely dependent on snakebite victim’s beliefs regarding snakebite management.

INTRODUCTION

Snakebite is one of the life-threatening Neglected Tropical Diseases (NTDs) that has been in the shadows for many years, resulting in the loss of countless lives. According to the World Health Organization (WHO), approximately 5.4 million people suffer snake bites each year worldwide, out of which 1.8 to 2.7 million only report clinical illness.[1]

Snake Envenoming is one of the leading causes of death, ranging from 81,000 to 138,000 cases.[1,2] Snakebite to a larger extent depends on the topography of a region. The South-East Asia region is a “Residing habitat” for various species of snakes due to its rich biodiversity and agricultural community. This region alone contributes to 70% of the deaths due to snakebite.[1] India, being a tropical country, represents a variety of poisonous and nonpoisonous snakes. Out of these poisonous snakes, the “Big Four” known as Russell’s Viper (Daboia russelii), King Cobra (Naja naja), Common Krait (Bungarus caeruleus), and Saw-Scaled Viper or Indian Viper (Echis carinatus) are the most important ones. According to WHO, India has 0.77-1.24 million cases, resulting in 58,000 deaths due to snakebite each year.[1,2]

It is challenging to predict the accurate number of snakebites in any region due to the lack of a proper reporting system regarding snakebites consequently leading to under-reporting of cases by the victims of snakebites.[3] There are similar constraints with India, where snake bite and related mortality is underreported as most patients undergo treatment from village healers or traditional healers and so the cases go unreported.[4]

In India, Suraweera et al.[5] conducted a systematic literature review on deaths due to snakebite (87,590 deaths) from 2000 to 2019. The study revealed that the rural population with the age group ranging from 30 to 69 years and children <15 years of age were largely affected. The study revealed that almost half of the snakebites were reported in the rainy season from July to September and in low-altitude areas. The authors categorized the states into low burden states, such as Karnataka, Kerala, Tamil Nadu, Assam, Jammu and Kashmir, West Bengal, Maharashtra, and other northeastern states, and high burden states, such as Andhra Pradesh, Bihar, Uttar Pradesh, Madhya Pradesh, Gujarat, and Jharkhand, based on the number of deaths reported.

In India, there are over 3 lakh instances reported annually, leading to 2000 fatalities, according to data from the Central Bureau of Health Intelligence (CBHI) from 2016 to 2020. Furthermore, according to preliminary data from the Integrated Disease Surveillance Programme (IDSP), 2,20,872 snake-bite incidents were registered in 2019. This indicates the importance of the issue.[6]

Snakebites have long-term complications leading to disability that increase the socioeconomic burden of the country. Snake bites can result in a variety of complications, of which the most serious ones include paralysis resulting in breathing issues, bleeding disorders resulting in lethal haemorrhage, irreversible kidney damage, or, in the worst-case scenario, limb amputation.[7] It was estimated that snakebite causes 400,000 amputations and other permanent disabilities worldwide.[1]

To combat this burden, WHO developed the Regional Action Plan for Prevention and Control of Snakebite Envenoming in Southeast Asia 2022-2030. It is envisaged to halve the number of deaths and disabilities due to snakebites in India by 2030.[8]

Multistakeholder efforts were being made to reduce the mortality due to snakebites. However, the beliefs and treatment-seeking behavior patterns regarding snakebites often remained neglected. Based on the literature review, we discovered that there is a scarcity of literature on the behavior of people seeking treatment in cases of snakebite in India. This highlights that the treatment-seeking behavior in snakebite cases remains poorly understood, particularly in the Indian context.

This review examines these behavioral patterns and their impact on snakebite mortality, while proposing strategies to reduce preventable deaths from snakebites.

MATERIAL AND METHODS

A narrative review was conducted which included PubMed, Web of Science, and Google Scholar databases. A proper search strategy was used with MeSH terms like “Morbidity” “Mortality” “snake “, “bites”, “envenomation” [MeSH Terms], AND “health-seeking” [MeSH Terms]. On searching “snakebite” AND “Health seeking” [MeSH Terms], 41 articles were retrieved after careful screening by two independent reviewers. Twelve studies were found relevant. The included studies were original studies and review papers extracted from various states with an intent to explore the scenario in India.

This review primarily included observational studies published in English that addressed snakebite and snakebite envenomation and treatment seeking behavior related to same meeting our topic of interest. Studies published in other languages and unrelated to our research topic were excluded from the analysis.

Common beliefs and practices regarding snakebite management

Across different geographical regions, the beliefs and practices of managing snakebites are also different. There are numerous myths among people regarding snake bites. Some of them include tying the site of snakebite tightly using a tourniquet, making an incision at the site, and going to the traditional healers immediately for relief. These myths are the leading cause of unreported snakebite cases. There are similar traditional practices in other countries as well. For instance, in Kenya, the use of “black stone”, herbs, tourniquets, and charcoal in the management of snakebites is very common.[9]

In a qualitative inquiry in Maharashtra, India, concentrating on a specific indigenous group, it was observed that the locals hold deep-rooted beliefs regarding snakes as sacred beings, often linking their appearance with thunderstorms. Common practices included the application of tourniquets, the use of tamarind seeds, and magnets to counteract snake venom effects. Additionally, there was a prevalent inclination toward traditional healing modalities rather than seeking hospital-based medical aid. These insights underscore the enduring influence of indigenous customs in managing snakebites within the community, signaling a necessity for culturally attuned strategies to advance contemporary medical care.[10]

In research carried out in Sikkim, it was found that a considerable majority, 89%, of individuals bitten by snakes sought treatment from traditional healers. This highlights a notable preference for traditional remedies in managing snakebites within the region. However, it is imperative to recognize that delays in seeking professional medical assistance can lead to exacerbated conditions, as observed in cases where individuals’ health deteriorates before hospital intervention. These findings emphasize the critical need to ensure prompt access to modern medical treatments for snakebite victims.[11] This finding indicated the strong belief of the community in traditional treatment practices rather than seeking immediate medical relief, the same traditional practices were adopted in regions of West Bengal and Tamil Nadu.

In a study led by Manna and colleagues, they investigated how well people in a rural area near a medical college in Kolkata, West Bengal understand and deal with snakebites. The outcomes showed that a significant majority (71.6%) favored the practice of venom extraction from the wound, while the use of tourniquets was notably infrequent (4.4%). These findings highlight the predominant reliance on traditional methods for addressing snakebites within the surveyed community.[12]

A cross-sectional study was conducted in the rural population of Tirunelveli district, South India, among 200 participants. Twelve percentage of the participants went for traditional treatment. Some of the common practices were tying above the site of snakebite, using herbal medicine, and washing the site with soap and water.[13]

Importance of treatment-seeking behavior in snakebite management

As defined Healthcare-seeking behavior (HSB) is “any action or inaction undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy”.[14] In snakebites, HSB plays a crucial role. “Time is very precious in snakebite management,” which means the patient must be brought to the Health Care Facilities (HCF) without delay following a snakebite.

The loss of crucial time in snakebite management can lead to serious complications or death in many situations when there is delayed care because of misconceptions and a lack of awareness.

Treatment-seeking behavior patterns in the world

After interviewing 21 snakebite victims in rural Cameroon, located in Central Africa, Chuat et al.[15] found that “traditional treatments were found cheaper than the Antivenom and hospital care” for the snakebite victims. Furthermore, it was noted that individuals bitten by snakes often adhere to traditional healing methods in their community, including using black stones, tourniquets, and medicinal plant decoctions. Regarding the efficacy of these approaches, opinions were divided. While some sufferers have voiced the desire to seek medical attention at a hospital, others have cited inadequate transportation options as a reason to stick with more conventional methods of care. In another cross-sectional study conducted in Kenya, it was found that “to assess the treatment-seeking behavior across a region is a very complicated task.” Out of the 453 households that were surveyed, more than half of the participants preferred treatment from traditional healers, while the others preferred healthcare facilities or both. The study also estimated that a delay in treatment-seeking was found to be significantly associated with increased odds of having a serious outcome.[16]

Treatment-seeking behavior patterns in South-East Asia region

Ralph et al.[17] noted in a review identifying the factors influencing snakebite deaths that “Delayed treatment can be fatal.” In South-East Asia, only half of the people get to hospitals in time, even though snakebite patients should get there within 6 hours of the bite to prevent catastrophic outcomes. It was shocking to learn that some patients visited hospitals 12–13 days after the bite.

This study also indicated that in the Southeast Asia region, there is inadequate knowledge regarding snakebite treatment among healthcare providers. Also, the lack of critical care infrastructure (mechanical ventilation, dialysis facilities, etc.) at primary healthcare centres (PHCs) and hospitals leads to frequent referrals of patients to other higher medical facilities resulting in loss of crucial time.[17]

In Southeast Asian countries, this “Referral Approach” frequently results in a delay in treating snakebite victims, which leads to serious consequences. The Indian antivenom is produced against the big four venoms, excluding the other indigenous venomous species. At a primary health care center, the management of adverse effects of antisnake venom is also limited, making it a big challenge in snakebite case management.[17]

Communities also suffer from a lack of knowledge about immediate first aid measures in the event of a snakebite. This forces patients and their caretakers to seek help from traditional faith healers who use a variety of techniques, including incisions, mouth suction of snake venom, tourniquets, topical application of herbs, cow dung, or snakestone, and even chanting.[17]

Treatment-seeking behavior patterns in India

Das et al.[18] conducted a study in West Bengal, intending to assess the care-seeking behavior of snake bite victims visiting the medical college. The study revealed that 55.2% of participants used the correct measures at the bite site, while the remaining followed incorrect practices, such as 29.5% practiced tourniquet application, 7.1% practiced herbal preparation, and 2.8% used blade shaving at the site, etc.

The study also revealed that 15% of participants sought first care from traditional healers, 29.9% from village quacks, and 3.8% from both. Overall, 39.9% of participants followed an unfavourable care-seeking pathway as they went for local treatment first instead of visiting a healthcare facility. Only 15% of the participants visited tertiary health centers.[18]

The most significant reason for adopting traditional treatment methods among the participants with unfavourable care-seeking was the easy and nearby availability of local help (31.2%) while 26.1% visited the traditional healers just to know whether the snakebite was poisonous or not. This study assessed the care-seeking behavior of the participants along with the possible reasons for following the unfavourable pathways. This study also showed that care-seeking for snake bite was significantly dependent on caste, religion, education, and socioeconomic class.[18]

There is a marked degree of variation in the reporting of cases in hospitals. Mainly hospital studies provide information about snake bites, but some cases remain unreported due to preference of treatment. Sometimes the snakebite case may require early referral to a larger hospital, where Anti Snake Venom (ASV) is readily available along with ventilator support. Thus, adoption of the right treatment-seeking behavior can help reduce mortality.[19]

A prospective hospital-based study in North Bihar revealed that preferring treatment from a traditional healer over hospital care was the main factor in determining the outcome. An unfavourable outcome depends on the mode of treatment preferred; a delay in taking a snakebite patient to the hospital increases the risk of mortality among victims, and this risk is considerable among the under-15 age group, as they need to inform adults in case of such incidents.[20]

Initiatives for reducing snakebite envenoming in India

In the Indian subcontinent, snake bite envenomation is a major problem that affects countless lives. An accidental/occupational hazard that has been overlooked for many years, snakebite envenomation typically affects villagers or those engaged in agricultural work, including farmers, plantation labourers, herders, and laborers. The National Action Plan for Prevention and Control of Snakebite Envenoming (NAPSE), created by the Centre for Ministry of Health and Family Welfare, One Health, National Centre for Disease Control, and Directorate General of Health Services, aims to curb the number of snakebite envenoming-related deaths and disabilities in half by 2030.[21] To meet the World Health Organization’s (WHO) target of a 50% reduction in snakebite death by 2030, the Indian Council of Medical Research (ICMR) established a National Task Force Expert Group for Snakebite Research in India. Furthermore, an information booklet titled “Snakebite Information Booklet for Healthcare Workers” was released by the National Institute for Research in Reproductive and Child Health (ICMR) in Mumbai. It contains important details such as how to distinguish between venomous and nonvenomous snakes, common hiding places, prevention, symptoms of snake bite envenomation, first aid, treatment, and management.[22]

Limitation

There are several limitations of this review, such as a lack of robustness as compared to a systematic review. Although authors tried to conduct a systematic literature review, but lacked robustness in search terms and data extraction due to time constraints. Also, only the published articles, which were in the English language, were considered, which may have led to publication bias. At last, this review focuses on the role of treatment-seeking behavior in snakebite mortality in the context of India while ignoring other Southeast Asian countries despite the region having similar snakebite burdens. Hence, the finding cannot be generalized and should be read with caution.

CONCLUSION

After a careful review of the available evidence, it is quite clear that the treatment-seeking behavior regarding snakebites is directly associated with increased mortality due to snakebites. There are numerous factors responsible for mortality among snakebite victims, with major factors being different beliefs and sociocultural norms.

Awareness generation regarding ASV, which is the only viable option to achieve favourable outcomes in case of snakebite. The lack of adequate living conditions for the rural population coupled with other factors such as a lack of appropriate information on different snake species and snakebite prevention increases the risk of snakebites. Awareness and media outreach programs regarding “snakebite prevention” should be conducted at ground level specifically during the rainy season. In addition, collective efforts should be made to raise awareness regarding the lack of scientifically validated alternate forms of treatment that are commonly practiced in these cases. A snakebite case registry system and toll-free number operating round the clock, seven days a week for resolving queries related to snake and snake bites will further help achieve positive outcomes in terms of morbidity and mortality among snakebite victims.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.