Assignment on

Snakebite

Prepared by
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Department of Community Medicine and Public Health

Ahsania Mission Medical College
Introduction
Snakebite is a neglected public health issue in many tropical and subtropical countries. Most
of these occur in Africa, Asia and Latin America. In Asia up to 2 million people are
envenomed by snakes each year, while in Africa there are an estimated 435 000 to 580 000
snake bites annually that need treatment. Envenoming affects women, children and farmers
in poor rural communities in low- and middle-income countries. The highest burden occurs
in countries where health systems are weakest and medical resources sparse.

Living snakes are found on every continent except Antarctica. Of the roughly 3,000 known
species of snake found worldwide, only 15 % are considered dangerous to humans. Most
species are non-venomous and most snakebites are caused by non-venomous snakes. Those
that have venom use it primarily to kill and subdue prey rather than self-defense. Bites from
non-venomous snakes can also cause injury, often due to lacerations caused by the snake's
teeth, or from a resulting infection.

A bite may also trigger an anaphylactic reaction, which is potentially fatal. First-aid
recommendations for bite depends on the snakes inhabiting the region. Bites by venomous
snakes can cause acute medical emergencies involving severe paralysis that may prevent
breathing, cause bleeding disorders that can lead to fatal haemorrhage, cause irreversible
kidney failure and severe local tissue destruction that can cause permanent disability and
limb amputation. Children may suffer more severe effects and can experience the effects
more quickly than adults due to their smaller body mass.

In contrast to many other serious health conditions, a highly effective treatment exists. Most
deaths and serious consequences of snakebites are entirely preventable by making safe and
effective antivenoms more widely available and accessible. High quality snake antivenoms
are the most effective treatment to prevent or reverse most of the venomous effects of snake
bites. They are included in the WHO List of essential medicines and should be part of any
primary health care package where snake bites occur.

In many parts of the South East Asian region, snake-bite is an important medical emergency
and cause of hospital admission. It results in the death or chronic disability of many active
younger people, especially those involved in farming and plantation work. However, the true
scale of mortality and acute and chronic morbidity from snake-bite remains uncertain
because of inadequate reporting in almost every part of the region. To remedy this deficiency,
it is strongly recommended that snakebite should be made a specific notifiable disease in all
countries in the South East Asian region.

High-risk groups of snakebites include rural agricultural workers, herders, fishermen,

hunters, working children, people living in poorly constructed houses and those with limited
access to education and healthcare. Morbidity and mortality occur most frequently among
young people and children suffer higher case fatality. Furthermore, women experience
increased barriers to accessing medical care in some cultures and pregnant women are
extremely vulnerable.

Epidemiology of Snake bite around the world

Snakebites occur most frequently in the summer season when snakes are active and humans
are outdoors. Agricultural and tropical regions report more snakebites than anywhere else.
Victims are typically male and between 17 and 27 years of age. Most cases occur in rural,
low-resource settings, affecting vulnerable populations. Annually 4.5–5.4 million people get
bitten by snakes and 1.8–2.7 million develop clinical illness. 81, 000 to 138,000 dies from
complications.

Asia is home to a wide variety of poisonous snakes and it is the continent that is home to the
most poisonous snake bites every year. Poisonous snake bites In Asia around 2 million
people /each year and in sub-Saharan Africa: 435, 000 to 580, 000 /each year.

Epidemiology of snakebite in Bangladesh

Snake Bite in Bangladesh is a major public health problem because:

 Agricultural country-60% population lives in rural areas and most of them works in
fields Lack of basic education Snakes abundant
 Weather conditions favourable June to October : primarily due to increased outdoor
activity and environmental conditions.
 Due to floods and rain with migration to highlands
 Sleeping outside in summers
 Monsoon season is breeding season

According to a nationwide community-based epidemiological study of snakebite and its

socioeconomic consequences in Bangladesh the incidence density of snakebite in rural
Bangladesh (which is substantially higher than previously estimated) is 623.4/100,000
person years with an estimated 6,041 death annually. The majority of the bite (71%)
happened in the lower extremities. Eighty six percent of the victims receive some form of
management within two hours of snakebite, although only three percent of the victims went
directly to either a medical doctor or a hospital.

Most often the victim of snakebite is a poor, young and active individual. Biting occurs
mostly when individuals are at work, engaged in activities such as cultivation, fishing,
plantation, wood collection, or tending crops or gardens. Snakebite envenoming in
Bangladesh is thus an occupational health hazard of the rural poor people who suffer bites
while engaged in physical work, most often during cultivation. However, bites were fairly
common when the victims were walking on rural foot paths or while sleeping on the floor.
Children have a high risk of dying or suffering permanent disability from snakebite
envenoming. During the monsoon, snakebite occurrences increase as snakes leave their
shelter due to rainfall. Most of the houses in countryside of Bangladesh are not brick-built
and the snakes sometimes live in the holes of the muddy floors.

Moreover, most of the houses have homestead bush, which offers an ideal habitat for snakes.
As a result, events of snakebite are also common when people are at home. To go to the toilet
and for other domestic purposes, people often come out of their houses, without light and
become victims. Village people store grains including paddy, rice in their bedroom, and keep
the poultry in the same dwelling house, which also provides shelter to the snakes, increasing
the risk of snakebite.

Due to its geographical location and climatic conditions Bangladesh is a disaster-prone

country. Based on records of the surveillance system of the Directorate General of Health
Services (DGHS), Bangladesh, snakebite envenoming was identified as a leading cause of
mortality in several flood disasters, second only to drowning.

Snakes of Bangladesh:

Medically important snakes of Bangladesh can be placed into five groups:

Group I: Cobra 1. Naja kaouthia, monocellete cobra,.
(‘Zoura’) Distributed in all administrative divisions of Bangladesh.
2. Naja naja, binocellate cobra, spectackled cobra, gokhra,
gokhur, khaiya gokhra, gohma/ goma.
Distributed in all administrative divisions of Bangladesh, but
more
common in west of the Jamuna river
3. Ophiophagus hannah, king cobra, raj gokhra, sankhochur,
padmo gokhra, phanos.
Distributed in Sylhet, Chattogram, Khulna and Barishal
divisions. Not common.
Group II: Krait – 1. Bungarus niger- Black krait
Different species are 2. Bungarus wali- Wall’s krait
available 3. Bungarus caeruleus, common krait, kalas, maicha-alad.
Common krait is not common in Bangladesh (common in India)
4. Bangarus fasciatus, banded krait, sankhini, shakini, mama
bhagna.
5. Bungarus lividus
Distributed in all administrative divisions of Bangladesh.
Predominantly these snakes are seen in Chattogram, Dhaka and
northern part of Bangladesh.
Group III: Russell’s 1. Daboia (= Daboia, russelii, Russell’s viper, ‘Chadrabora’)
Viper mainly in Rajshahi and Khulna division and recently found in
Chattogram
division, Faridpur, Shariotpur, Chandpur, Patuakhali
Group IV: Green Pit 1. Ovophis (=Trimeresurus) spp., green pit vipers, green snakes,
Viper bansh-bora, sabuj-bora, gal tawa. Distributed in Sylhet,
Chattogram, Khulna and Barishal Divisions.
Group V: Sea Snakes 1. Enhydrina schistose, hooknosed sea snake, samudrik shap.
Distributed in sea and costal saline water of Bangladesh.
2. Hydrophis spp., Microcephalis spp., Laticauda spp., sea
snakes, samudrik shap distributed in sea and coastal saline
water of Bangladesh.
Medically important venomous snakes of Bangladesh:

Scientific name: Naja kaothia

English Name: Monocellete Cobra
Distribution: Distributed in all administrative divisions of
Bangladesh.

Scientific name: Naja naja

English Name: Binocellate Cobra
Spectackled cobra
Distribution: Distributed in all administrative divisions of
Bangladesh, but more common in west of the Jamuna
river

Scientific name: Ophiophagus hannah

English Name: King Cobra
Distribution: Distributed in Sylhet, Chattogram, Khulna
divisions. Not common.

Scientific name: Bungarus fasciatus

English Name: Banded Krait
Distribution: Distributed in all administrative divisions of
Bangladesh.

Scientific name: Bungarus niger

English Name: Greater Black Krait
Distribution: Distributed in Sylhet and Chattogram
divisions as well as northern part of the country.

Scientific name: Bungarus lividus

English Name: Lesser BlackKrait
Distribution: Distributed in Rangpur, Dinajpur, Khulna
and Chattogram divisions of Bangladesh.

Scientific name: Bungarus walli

English Name: Wall’s Krait
Distribution: Distributed in Rangpur, Dinajpur, Khulna
divisions of Bangladesh as well as Tangail and
Mymensingh districts of Dhaka division.
 Scientific name: Bungarus caeruleus
English Name: Common Krait
Distribution:Distributed in all administrative divisions of
Bangladesh.

Scientific name: Trimeresurus erythrurus

English Name: Spot-tailed Pit viper
Distribution:Distributed in Sylhet, Chattogram, Khulna
and Barishal Divisions

Scientific name: Trimeresurus albolabris

English Name: White-lipped Pit viper
Distribution: Distributed in Sylhet, Chattogram, Khulna
and Barishal Divisions

Scientific name: Daboia russelii

English Name: Russell’s Viper
Distribution: Distributed mainly in Rajshahi and Khulna
division and recently found in Barishal and Chattogram
divisions. Specially in the floodplain of padma and
Jamuna river.

Scientific name: Enhydrina schistosa

English Name: Hook-nosed Sea
Snake
Distribution: Distributed in sea and coastal saline water of
Bangladesh
Scientific name: Hydrophisspp., Microcephalis spp.,
Laticauda spp.,
English Name: Sea Snake
Distribution: Distributed in sea and coastal saline water of
Bangladesh

Venomous snake bite

Snakebite envenoming is a life-threatening medical emergency. Caused by toxins injected

through venomous snake bites. A bite by a venomous snake which produces specific
symptoms and signs or a syndrome is considered as a venomous snakebite. It is important to
note that a bite by venomous snake may not always produce features of envenoming.
A bite by a non venomous snake does not produce the specific features due to venom. But
the care giver should be cautious about the psychological impact and effect of various
commonly practiced local treatment (e.g. by 'Ozhas') of snakebite. A victim may develop
some features due to anxiety or apprehension after bite by a venomous as well as non
venomous snake. Most snakebite in the community are non venomous.

Clinical Features of snakebite

 General features: flushing, breathlessness, palpitations, and dizziness, tightness in
the chest, sweating and acroparaesthesiae. Apart from these, early symptoms in
elapid bites include vomiting, heaviness of eyelids, blurring of vision,
hypersalivation, congested conjunctivae and ‘gooseflesh’. In krait bites, cramping
abdominal pain followed by diarrhoea and collapse may occur. Sea snake
envenomation causes headache, a thick feeling of the tongue, thirst, sweating and
vomiting.
 Systemic features: Clotting defects and haemolysis, Neurotoxicity, Myotoxicity,
Cardiotoxicity, Nephrotoxicity, Shock.

Management of snake bite

First aid: The patient should be reassured and moved to the nearest hospital as quickly as
possible. Active movements should be as minimal as possible. The bitten part should be
immobilized with a splint or sling.
Evaluation in the hospital: A bite is considered to have been poisonous in case any of the
following features are present:
 Swelling, blistering or necrosis at the site of the bite and its extension
 Hypotension / shock, Haemorrhage
 Laboratory evidence of coagulation defect
 Neuroparalytic manifestations
 Arrhythmias / bradycardia / tachycardia
 Myoglobinuria
Monitor pulse, blood pressure, respiratory rate, and muscle weakness hourly. Local swelling
and necrosis should also be charted hourly. Examine gingival sulci carefully for bleeding.
Monitor ECG and CPK, serum transaminases, blood urea and serum creatinine daily. Serum
electrolytes, especially potassium, should be estimated 6 hourly in case of sea snakebite.

Antivenom therapy
Indications for antivenom: Antivenom treatment is recommended if and when a patient
with proven or suspected snakebite develops one or more of the following signs:
Haemostatic abnormalities such as spontaneous systemic bleeding, incoagulable blood, or
thrombo-cytopaenia, Neurotoxicity, Impaired consciousness of any cause Generalised
rhabdomyolysis

Prevention of snakebite:
 Regularly cut short grasses around household.
 Remove pile of woods, bamboo so that snakes don’t find places to hind out
 Be careful about rats. Store food in rat-proof containers.
 Doors, windows should be closed properly so that no gaps exist between doors and
floor
 Cut short plant or branches close to roof top, loan, doors, windows.
 Try to avoid sleeping in floor.
 Avoid those types of house construction that will provide snakes with hiding places
 Surrounding Households:
o Clear termite mounds, heaps of rubbish, building materials etc. from near the
house, Trim or remove any tree branches touching or overhanging the house.
o Keep your granary away from the house, it may attract rodents that snakes
will hunt.
 Water sources, reservoirs, and ponds may also attract prey animals.
 Listen to wild and domestic animals, especially birds, as they warn of a snake nearby
attract prey animals like frogs and toads.
 Use a light when walking outside or going to the latrine at night.