Hiss of death: Odisha faces new disaster

On Wednesday last, Shiba Patra, a native of Ganjam's Buguda was bitten by a venomous snake. Instead of rushing him to a hospital, his family members took him to nearby Baladevjew Temple for a special ritual. The temple priests poured 82 pitchers of water on Patra and performed a puja to cure him. When his condition deteriorated, he was shifted to Buguda Hospital but by then, they were 12 hours late. Doctors declared Patra brought dead.

Eight km away, Sujata Pradhan was taken to a witch doctor after she reported snake bite the same day. When the sorcerer failed to revive her, Sujata was rushed to a hospital where she succumbed.

In large parts of Odisha, sorcerers not only get the first call in snakebite cases but are also expected to revive the dead in many instances, such is the sway of superstition over basic medical science in this age.

On June 23, a sorcerer tried to resurrect a 40-year-old woman near postmortem wing of Padampur Sub-Divisional Hospital in Bargarh district. The woman Saptashila Bhoi, a native of Changria village, had already died of snakebite. When the sorcerer failed in his attempt, he told the family that he should have been intimated earlier.

Another such sorcerer was even allowed to enter District Headquarters Hospital (DHH) in Bhawanipatna to try his 'mumbo jumbo' to bring a snakebite victim Satish Gopal (21) back to life right inside the mortuary.

Calamity Vs Snake

In a natural disaster-prone State like Odisha, snakebites claim more lives every year than calamities like floods, cyclones, drowning and fire mishaps. Declared a State-specific disaster in 2015 under which family of the victims are entitled to a compensation of Rs 4 lakh, snakebite deaths account for 40 per cent of total disaster deaths.

An official estimate states that 811 people were killed in snakebite in 2018-19 which makes it two deaths every day. In first four months of 2019-20, as many as 237 deaths were registered.

In the last five years, a massive 2,954 snakebite casualties have been recorded. And the number is on the rise, improvements in health care services and their coverage notwithstanding.

Fourteen districts recorded more than 100 snakebite deaths each during the period. While Mayurbhanj topped the list with 271 deaths, Ganjam with 247 was followed by Balasore at 242, Keonjhar at 227, Bhadrak 180, Jajpur 154, Sambalpur 134, Cuttack 133, Dhenkanal 128, Sundargarh 127, Nabarangpur 123, Angul 119, Kendrapara 112 and Puri 110.

About 85 per cent deaths occur between May and October - either peak heat or monsoon seasons. Special Relief Commissioner (SRC) Bishnupada Sethi explains that maximum number of deaths are reported in July and coastal districts like Balasore, Ganjam and Bhadrak - primarily flood-prone - report more deaths.

The reptiles are not the villains though. Superstition kills more. If that is not bad enough, non-availability of adequate anti-snake venoms (ASVs) at grassroots health care centres, poor understanding of treatment system, abysmal road network coupled with fractured ambulance service have added to the toll.

On August 11, two siblings - Barsha Dandasena (13) and Abinash (8) were bitten by a snake while they were sleeping in their house at Subulia village in Sundargarh district. By the time they could be taken to Ispat General Hospital (IGH) in Rourkela, the two had died.

The Roadblocks

High fatality due to snakebite is attributed to non-availability of ASV at rural health facilities, delayed and inappropriate administration of ASV, lack of standard protocol for management and inexperienced doctors and non-availability of ventilator facility in PHC or CHC level.

26-year-old Tribikram Oram of Bhaluduguri village in Sambalpur was rushed to Paramanpur PHC after he was bitten by a snake. Since there was no ASV available, he was referred to Sambalpur DHH before being shifted to Veer Surendra Sai Institute of Medical Science and Research, Burla but doctors could not save him.

Additional District Medical Officer (Public Health), Sambalpur Dr Panchanan Nayak admits that ASVs are not supplied to PHCs primarily because these units are not equipped to manage snakebite victims if they develop complications after drug administration. Adequate numbers ASVs are available in CHCs, SDHs and DHHs, he said.

Though ASVs are supplied by Odisha Government free of cost, its non-availability in remote and rural pockets where snakebite cases are aplenty is attributed to a spike in snakebite deaths in the State.

In Rangamatia Sahi of Keonjhar district, a 14-year-old Daktara Munda suffered a snakebite on August 8. He was initially taken to nearby Phulajhar PHC where ASV was unavailable. The desperate family tried two sorcerers but in vain. "Had ASV been available in the hospital, my son could have been saved," Daktara's father Dambaru Munda laments.

Associate Professor of Forensic Medicine and Toxicology at AIIMS-Bhubaneswar, Dr Sudipta Ranjan Singh points out that awareness among people to check intrusion of snakes and prevent deaths is negligible. Patients, instead, depend more on traditional healers and sorcerers for which precious time is lost.

"Most deaths are reported during transit and referrals because confidence level of treating doctors in rural areas is low. They express reluctance to admit and treat snakebite cases fearing medical complications and reactions to ASV," he said.

Apprehensive, doctors in rural pockets refer cases to urban and semi-urban centres as supporting services like ventilators and oxygenation systems in periphery hospitals are next to nil. Just about 10 District Headquarters Hospitals in the State are equipped with ICU and ventilator systems, forget about the CHCs and PHCs.

"Delayed administration of ASV or waiting the victim to develop symptoms results in systemic envenoming and high fatality. Apart from availability of ASVs in rural centres, focus should be on identification of snakes and proper training of doctors for management of snakebite cases," Dr Singh suggests.

Response time plays a great factor in cure of snakebite victims. Even the largest venom dose of any snake can be neutralised by anti-venom but the Golden Hour must be kept in mind.

General Secretary of Snake Help Line Subhendu Mallik, also a honourary wildlife warden, says deaths are on the rise due to prevailing superstition among rural populace. "When medical science has definite treatment for snakebite cases, people first visit faith healers or sorcerers. Timely treatment only can prevent snakebite deaths," he points out.

Inadequate infrastructure in rural areas such as lighting, sewerage systems and roads co-contribute to snake bites. Habit of people sleeping on the floor, presence of livestock and agricultural fields near human habitations which attract prey for snakes are add-ons.

State to act fast

With snakebite deaths emerging as a major headache, the State Government has decided to scale up deployment of doctors at primary health centres in vulnerable areas and make ambulances available for swift transfer of patients to hospitals.

"We have asked Health and Family Welfare Department to ensure availability of medical officers at PHCs in snakebite-prone areas. Districts have been directed to sensitise people to bring victims to nearest health institutions at the earliest and ensure they are not treated by sorcerers and quacks," SRC Sethi says.

Though production and distribution of ASV in the country remains a matter of great interest, Odisha provides it free of cost. Managing Director of Odisha State Medical Corporation Limited (OSMCL) Yamini Sarangi says health centres up to block level are adequately supplied with ASVs.

"As many as 37,066 vials of ASV are in stock with 37 warehouses in the State. Snake venom antiserum (polyvalent) with diluents in plastic container, 10 ml/vial (Lyophilised powder form) is now available. The ASV in powder form does not require refrigerator for stocking. As per requirement, PHCs can also pick it from block warehouses," she informs.

Standard ASV not effective for all venomous snakes

Grey areas still exist. A study on Venomous Snake Bite in India by cardiologist Jaideep C Menon, nephrologist Joseph K Joseph and herpetologist Romulus E Whitaker says that ASVs available in India may not be ideal for treating venomous snakebite in the East, West and Northern parts of the country.

The standard ASV neutralises the venom of Russell's Viper, Common Cobra, Saw-scaled Viper and Common Krait. However, the study published in the Journal of The Association of Physicians of India claims a significant number of bites by Banded Krait, Hump nosed Pit Viper, Malabar Pit Viper, Bamboo Pit Viper, Sochurek's Saw-scaled Viper, Monocled Cobra, Sind Krait and King Cobra are also reported and venom of these snakes is not neutralised by the standard ASV available.

"Since it is difficult to distinguish the species of snake at the primary level and PHCs lack expertise in identifying the snake on the basis of signs and symptoms, the ASV administered are mainly polyvalent. Though ASV is the only scientifically proven treatment for venomous snakebite, it is not effective for
all venomous snakes found in Odisha," Dr Singh points out.

Change in medical curriculum need of hour

As per the prevailing medical curriculum, venomous snakebite is covered in Forensic Medicine and Toxicology subject. Identification of venomous species symptomology is covered from a forensic angle. The focus of medical education should shift from knowledge-based approach as taught in most of medical colleges from Western texts to a more practical one based on the disease conditions medical
graduates are likely to encounter during their practice, the study stated.

A person in respiratory distress due to a neurotoxic snakebite (especially krait bite) is unlikely to survive a one-hour journey to a tertiary care centre without ventilator support. Doctors in PHCs, especially in areas where neurotoxic bites are common, should be trained to maintain oxygen saturation till definitive treatment is given, the study added.

Snake Help Line General Secretary Mallik says, awareness campaigns apart, stringent legal action against sorcerers will help bring snakebite cases to hospitals. He feels that the number of reported cases is on the rise after the State Government hiked the ex gratia amount to Rs 4 lakh in 2015.

"Nearly 3,000 people are reported to have died of snakebite since the ex gratia was enhanced and Government has shelled out Rs 120 crore. If doctors are properly trained to manage the cases and hospitals are well equipped, the problem can be mitigated," Mallik added.

Snakes found in Odisha

As many as 300 species of snake are found in India, of which 52 are considered venomous. The standard treatment guidelines issued by the Ministry of Health and Family Welfare (MoHFW) for management of snakebite cases say it is a preventable public health hazard.

Nearly 80 species of snakes are found in Odisha, including 17 species which are dangerously venomous. Ten species of potentially dangerous snakes are Binocellate and Monocellate Cobras, Common and Banded Kraits, King Cobra, Coral Snake, Russell's Viper, Saw Scale Viper and Bamboo Pit Viper. However, there is hardly any report of death caused by sea snake bites in the State.

Mostly deaths are reported due to bite of Spectacled Cobra (Naga), Monocellate cobra (Tampa), Common krait (Chitti), Banded krait (Rana), Russell's viper (Chandan Boda) and Saw scaled viper (Dhulia Boda) snakes.

Pratyush Mohapatra, a Scientist with the Zoological Survey of India, Jabalpur said deaths in north Odisha districts like Balasore, Bhadrak, Jajpur and Mayurbhanj are mainly due to Monocellate cobra bites.

The region has a good population of Monocellate cobras which reside in aquatic surroundings. Though Binocellate (Gokhara) snakes are noticed in the region, numbers are negligible. While Banded Krait survives in wetland areas, Common Krait and Russell's Viper are found near human habitations.

Snake venoms are generally of four types - neurotoxic (in the venom of elapids), cardiotoxic (mostly in cobra venom), haemotoxic (venom of viperids) and myotoxic (venom of sea snakes). Some snakes also possess both neurotoxins and haemotoxins.

"Typical symptoms of neurotoxic venom are observed within 30 minutes to three hours. Since polyvalent anti snake venom is available in CHCs and SDHs, people should make use of such benefits. Availability of ventilators in all Government hospitals can reduce neurotoxic snakebite deaths cases drastically," Mohapatra added.

Snake bite data

Snakebite has been declared as a 'State Specific Disaster' by Odisha Government with effect from April 1, 2015. As many as 2954 snakebite deaths have occurred in the State during the last 5 years.

District-wise deaths