WELCOME TO Third International Conference on TROPICAL MEDICINE

WELCOME TO Third International Conference on TROPICAL MEDICINE AND TOXICOLOGY SYLHET BANGLADESH 2014

SNAKE SITUATION IN BANGLADESH PROF. M. A. HASSAN CHOWDHURY DEPARTMENT OF MEDICINE CHITTAGONG MEDICAL COLLEGE AND HOSPITAL

INTRODUCTION---SNAKE BITE • Acute emergency public health problem • An occupational and environmental DISEASE • An neglected tropical disease declared by WHO • Major causes of mortality and morbidity in many areas, particularly in the rural tropics • Imposes substantial economic burdens on victims due to treatment related expenditure and loss of productivity • Eminently treatable and preventable.

Global estimates of snake-bites Bites Envenomings Deaths Americas 500 000 200 000 (40%) 4000 (2%) Africa 1 million 400 000 (40%) 20 000 95%0 Asia 3 million 1. 2 million (40%) 60 000 (5%) (India 50 000) Oceania 5000 2500 (50%) 250 (10%) Total >4. 5 million ~ 2 million >80 000

Overview of status of snake-bites in SEA Region Country BAN Estimated National number of guidelines bites deaths 7000 6000 Yes (2008 Rev. ) BHU DPRK IND NA NA 77 000 INO MAV NA Nil NA NA 1100 (20 000) NA Nil Training Yes NA Yes (2007) No NA No AVS Reporting Prodn/im system port Import Nil Import NA Yes polyvalent Yes No Nil NA Yes NA No

Cont…. Country Estimated number of deaths 769 National guidelines MMR Estimated number of bites 10 000 NEP SRL THA 1000 35 000 10 000 200 100 -150 <0. 5% Yes TLS NA Training No Yes No No Yes AVS Prodn/imp ort Yes Monovalent and Import Reporting system Import Yes Monovalent No Yes

November 2013 | Volume 8 | Issue 11 | e 80090

Snake bite in Bangladesh The incidence of snake bite episode was • 623. 4 bites per 100, 000 persons per year • The highest incidence was found in -Barisal division (2667. 7) • The lowest incidence in Sylhet division (321. 6) • 8, 000 cases of snakebite over 20% mortality in Bangladesh annually. • 45% of victims are farmers, 23% are housewives. • 70% of cases are aged 11 -30 years, 75% are males. COMMON OCCURRENCE FROM JUNE TO OCTOBER

• 71% BITE AT LOWER EXTREMITIES • 75% PT RECEIVED TREATMENT WITH IN 2 H • 86% TREAED BY TRADITIONAL HEALERS CALLED OZAS • 3%NSEEK MEDICAL DOCTORS OR HOSPITAL TREATMENT

Risk factors of snake bite Incidence of snake-bites varies geographically and depends upon frequency and nature of contact between snakes and humans. The factors affecting this interaction are: • Population densities (humans and snakes); • Diurnal and seasonal variations in activity (rains, flooding, disasters); • Occupations (e. g. agricultural activities harvesting, neglect of protective clothing) and snakes’ • “Irritability” (readiness to strike) when alarmed/provoked, which varies between species. • Climate change is also believed to have the potential to increase human and snake interaction.

SNAKE SPECIES • 82 species of snakes in Bangladesh • 28 species are venomous • 54 species are non venomous.

Medically important snakes of Bangladesh • Group I: Cobra 1. Naja kaouthia, monocellete cobra, gokhur, jati/jati shap, dashla gohma. Distributed in all divisions of Bangladesh. 2. Naja naja, binocellete cobra, spectacled cobra, gokhur, khaiya gokhra, gohma/goma. Distributed in all divisions, more in west of Jamuna river. 3. Ophiophagus hannah, king cobra, raj gokhra, sankhochur, padma gokhra, phanos. Distributed in Sylhet, Chittagong, Khulna & Barishal divisions.

Cobra Naja kaouthia Naja naja Ophiophagus hannah

Snakes of Bangladesh (contd. . . ) • Group II: Krait 1. Bungarus caeruleus, common krait, kal kewtey, kalas, maicha-alad. Distributed in all divisions. 2. Bungarus fasciatus, banded krait, sankhini, shakini, mama-bhagne. Distributed in all divisions, but more in Chittagong and rare in Rajshahi. 3. Bungarus niger (Black krait), Bangarus wali. Recently found in Chittagong and other parts of the country.

Krait Bungarus fasciatus Bungarus caeruleus Bungarus niger

Snakes of Bangladesh (cont…. . ) • Group III: Russell’s viper ØDaboia (Daboia russelli, Russel’s viper, Chandrabora. ) Distributed mainly in Rajshahi and Khulna division and may be found in Chittagong division.

Russell’s viper Daboia russelli

Snakes of Bangladesh (cont…. ) • Group IV: Green pit viper Ø Ovophis ( Trimeresurus) spp. , green pit vipers, green snakes, bansh-bora, sabuj bora, gal tawa. Distributed in Sylhet, Chittagong, Khulna and Barishal divisions.

Green pit viper Green Snake (Trimeresurus spp) Cryptelytrops erythrurus

Snakes of Bangladesh (cont…) • Group V: Sea snakes Ø Enhydrina schistosa, hooknosed sea snakes, samudrik shap. Distributed in sea and coastal saline water of Bangladesh. Ø Hydrophis spp. , Microcephalis spp. , Lacticauda spp. , sea snakes, samudrik shap. Distributed in sea and coastal saline water of Bangladesh.

Sea snakes Hydrophis cyanocinctus Enhydrina schistosa Lacticauda colubrina

Snakebite – 2014 WARD -16 OF MEDICINE UNIT 3 CMCH

Total Snakebite = 1092 192 Nonvenomous Venomous 900 Venomous = 17. 6%

Gender Distribution Total Snakebite = 1092 347 Male Female 745

Monthly admission 180 160 140 120 100 160 80 133 60 101 93 40 149 97 54 46 40 20 165 54 r r No ve m be be to Oc em be r t pt us Se Au g ly Ju ne Ju ay M ril Ap ch M ar ry ua br Fe Ja nu ar y 0

Age distribution 350 300 250 200 150 100 50 0 94 311 276 188 118 68 31 5 0 -10 10 --20 20 -30 30 -40 40 -50 50 -60 60 -70 70 -80

Type of Venomous Snakebite Venomous Total = 192 44 Local tissue damage (Green Pit) Neurotoxic (Cobra & Krait) 148

Locality of Neurotoxic Snakebite 40 38 35 30 25 20 15 10 5 0 6 Urban Area Rural Area

Distribution of neurotoxic snake bite by district 40 35 30 25 20 15 35 10 5 0 Chittagong 2 2 2 3 Cox's Bazar Rangamati Feni Noakhali

nd o da na ish Bo al kh al Ba i ns hk ha li Ra ng un ia M irs ho ra i Fa tik ch ar i S Ci ho ty Co ndip rp or at io n an Ch n ri ja ha ja 3 ku Sit a ta Ha 8 7 6 5 4 3 2 1 0 Ra w tia Pa Distribution of neurotoxic snake bite by upazilla 7 1 2 3 2 4 6 1 1

TREATMENT AND OUTCOME • Anti-venom = 44 + 1 = 45 • Total number of death = 5 (1 in ICU) • Two Green pit bite developed AKI

Snakebite CMCH in 2013 • • Total patient admitted in ward 16 = 13, 723 Total snakebite patient = 1278 Percentages of snakebite = 10. 8% Total venomous snake-46, Nonvenomous and locally venomus-1236 Total death=3 Death rate = 7. 5 %

Total = 1278 46 Venomous Nonvenomous 1232

2013 Total = 46, Death = 03 3 Alive Death 43 Death rate = 7. 5 %

Monthly admission Number of patients 250 200 150 100 142 139 94 r m De ce be m ve be r r be to Oc No Se pt em be r st gu Au ly Ju Ju ne 40 ay ril Ap ch ar M ry br ua Fe Ja nu ar y 0 71 36 16 115 84 M 50 155 198 188

Gender distribution Total = 1278 28. 6 Male Female 71. 4

Age distribution Number of Patients 350 315 300 285 250 200 150 198 175 144 100 92 50 0 45 0 -10 10. -20 20 -30 30 -40 40 -50 50 -60 60 -70 22 70 -80 2 80 -90

Traditional treatments commonly practiced in Bangladesh • Application of multiple tight arterial tourniquet. • Shedding of profuse blood by multiple incisions over & around the bite site. • Incision & suction of bite site by mouth or chick • Cauterization by using chemicals like carbolic acid. • Application of different herbal paste or even cow dung or mud. • Ingestion of oil, ghee, pepper, crude herbal product to induce vomiting. • Application of stones, seeds, saliva, over the bite

First Aid Method Immobilization IT R. G. H. T the patient • DO R=REASSURES • I=IMMOBILIZED the affected area • G. H. =GET TO HOSPITAL • T= TELL the doctors

FIRST AID TREAMENT Pressure immobilization method: Crape bandage or long strip of cloth is wrapped around the entire limb from distal fingers to proximally to include a rigid splint tightly so that a little finger can be introduced with difficulty.

Perspective of Bangladesh, In coagulable blood is diagnostic of a viper bite (Russell’s viper, Green pit viper), and rules out an elapid bite. 20 minute whole blood clotting test. The blood is incoagulable indicating venom-induced consumption coagulopathy.

CLINICAL SYNDROMES LOCAL NEURO BLEED MISC. + ++ Nil Shock +/- KRAIT Nil + Nil Pupils -dilated, fixed VIPER +++ +/- ++ Renal failure, Shock SNAKE COBRA

Local signs of envenoming Haemorrhagic blister Fang marks Local bleeding Swelling, blistering & bruising Tissue necrosis

Signs of Haemotoxic Envenomation Gingival Bleeding, Ecchymoses on the Trunk Lateralising Neurological Signs of Intracranial Bleeding, Bleeding from a Pre Existing Condition i. e. Prolapsed Piles.

Neurological manifestations Ptosis Difficulty in opening mouth & protruding tongue External ophthalmoplegia Broken neck sign

ANTIVENOMS • No anti venom produced in our country. it is imported from india. • Polyvalent antivenom from Haffkine (india) is available in lyophilized powder form. • Each vial contain 10 mg of antivenom, which is effective against systemic envenoming by Cobra, Krait, Russell's Viper and Saw scaled viper only • there is no evidence of Saw scaled viper in Bangladesh • No antivenom for Green snake, Sea snakes. • We need species specific monovalent antivenoum

Cause of death 1. Prolonged visits to traditional healers (ojhas) 2. Problems with transportation 3. Inadequate treatment facilities in hospitals.

How can snake bite be avoided • Keeping granary & livestock, esp. poultry away from house & store food in rat-proof container. • If possible avoid house made-up of thatched roovs with open eaves, mud & straw walls. • Avoid sleeping on ground; or use insecticide impregnated mosquito net well tucked under the mat. • Clear termite mounds, heaps of rubbish, building materials & bushes from the house & vicinity. • Use proper shoes or boots and long trousers and torch esp. while walking in the dark. • Keep children away from snake-infested areas.

ADRESSING THE ISSUSES • Prevention, Community Education & Pre-hospital Care • Surveillance & Reporting, Clinical & Lab. Research • Education & Training, Improved Medical Management

Cont…. . • Immunotherapeutics – Establishing simple, cheap methods of immunodiagnosis – Optimising antivenom production, ensuring safety & efficacy • Rehabilitation from Disability – Repairing shattered lives, advocating basic human rights, restoring opportunity, human dignity and independence

Acknowledgements • SNAKEBITE STUDY GROUP OF • PRO. M. A. FAIZ. CHITTAGONG, DHAKA, RANGPUR • PROF DAVID WARELL MYMENSINHG. RAJSHAHI, SYLET • PRO. DR. RIDWANUR • ALL MY COLLEGUES AND DOCTORS OF WARD 16 , CMCH RHAMAN • ALL PUBLICATIONS - BOTH • WHO GUIDELINE NATIONAL AND • NATIONAL GUIDELINE INTERNATIONAL

Thank You

Total = 1092 192 Nonvenomous Venomous 900 Venomous = 17. 6%

Total = 1092 347 Male Female 745

monthly Male=745, Female = 347 180 160 140 120 100 160 80 60 101 93 40 97 54 46 40 20 133 165 149 54 r r No ve m be be to Oc em be r t pt us Se Au g ly Ju ne Ju ay M ril Ap ch M ar ry ua br Fe Ja nu ar y 0

350 300 250 200 150 100 50 0 94 311 276 188 118 68 31 5 0 -10 10 --20 20 -30 30 -40 40 -50 50 -60 60 -70 70 -80

Venomous Total = 192 44 Green Pit Cobra & Krait 148

Locality of Neurotoxic Snakebite 40 38 35 30 25 20 15 10 5 6 0 Urban Area Rural Area

Distribution of neurotoxic snake bite by district 40 35 30 25 20 35 15 10 5 0 Chittagong 2 2 2 3 Cox's Bazar Rangamati Feni Noakhali

ty n tio rp or a Co 1 Ci on di p 1 Sh ar i ch tik 2 Fa ai ho r irs 2 M ni a ng u 3 Ra i hk ha l ns 2 Ba i kh al al 3 Bo na ish an da 1 Ch nd o ku Si ta i ar ha j ta Ha n ja w Ra tia Pa Distribution of neurotoxic snake bite by upazilla 8 7 6 5 4 7 3 6 3 4 2 1 0

• Anti-venom = 44 + 1 = 45 • Patient admitted in ICU = 5 • Total number of death = 5 (1 in ICU) • Green pit developed AKI = 2

Total = 1278 46 Venomous Nonvenomous 1232

2013 Total = 46, Death = 03 3 Alive Death 43 Death rate = 7. 5 %

Gender distribution Total = 1278 28. 6 71. 4 Male – 912 & Female – 366 Male Female

Age distribution Number of Patients 350 315 300 285 250 200 150 198 175 144 100 92 50 0 45 0 -10 10. -20 20 -30 30 -40 40 -50 50 -60 60 -70 22 70 -80 2 80 -90

Monthly admission in 2013 Number of patients 250 200 198 188 150 155 142 139 115 100 71 50 94 84 40 36 m be De ce be m ve r r r be to Oc No Se pt em be r t us Au g ly Ju ne Ju ay M ril Ap ch M ar Fe br ar y nu Ja ua ry 16 0