|Year : 2020 | Volume
| Issue : 5 | Page : 519-524
Awareness of Indian medical practitioners about snakebite and its management – Is there a need to re-evaluate medical training?
Avadhesh Singh Malik, Kunal Chatterjee
Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||15-Sep-2019|
|Date of Decision||03-Dec-2019|
|Date of Acceptance||03-Dec-2019|
|Date of Web Publication||7-Sep-2020|
Department of Community Medicine, Armed Forces Medical College, Sholapur Road, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Snakebite envenomation is an important cause of morbidity and mortality worldwide, with India contributing to the majority of cases. Effective management is important to mitigate the impact of the condition. Medical practitioners dealing with snakebite victims need to be thoroughly aware of the current guidelines to provide effective care.Objectives: The aim of this study is to determine the knowledge and awareness of Indian medical practitioners about the current guidelines regarding the management of snakebite and their opinion about the cogency of their undergraduate medical training regarding the subject.Materials and Methods: Allopathic practitioners currently practicing in India were administered a pretested questionnaire to assess their knowledge about epidemiology, diagnosis, and the treatment of snakebite.Results: Of the 143 practitioners in the study, 79.4% underestimated the burden of morbidity due to snakebite in India. About 6.8% had correct knowledge about the number of species of the highest medical importance. About 52.2%, 91.7%, and 20.2% were aware of the common presentation of Common Krait, other neurotoxic elapids (e.g., Indian Cobra) and Viper envenomation, respectively. About 32.6% had correct knowledge about the management of adverse reactions to anti-snake venom. About 72.3% responded that their undergraduate medical education was inadequate to deal with snakebite and 91.4% responded that the topic of snakebite needs more emphasis at the undergraduate level.Conclusions:The current undergraduate medical education in India, about the management of snakebite is limited to outdated concepts or those gained from Western literature, leading to gaps in knowledge in several key areas. A clinically oriented approach suited to the Indian scenario needs to be emphasized.
Keywords: Epidemiology, knowledge, practitioners, snakebite management, teaching
|How to cite this article:|
Malik AS, Chatterjee K. Awareness of Indian medical practitioners about snakebite and its management – Is there a need to re-evaluate medical training?. Med J DY Patil Vidyapeeth 2020;13:519-24
|How to cite this URL:|
Malik AS, Chatterjee K. Awareness of Indian medical practitioners about snakebite and its management – Is there a need to re-evaluate medical training?. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 24];13:519-24. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/519/294354
| Introduction|| |
Snakebite envenomation is a leading cause of morbidity and mortality in the world causing up to 138,000 deaths annually. In 2017, the World Health Organization (WHO) had included snakebite envenomation in the list of the “neglected tropical diseases” in an attempt to bring more focus on the condition.
India, alone, accounts for nearly half of the snakebite-envenomation related deaths in the world. The “million-death study” conducted by the Registrar General of India in 2005 found the mortality due to snakebite in India to be ranging from 40,900 to 50,900 and the figure has now been endorsed by the WHO. Snakebites are vivid and notable events for the victim's family and neighbors, making them easily discernible by verbal autopsy. The official figures, however, are substantially fewer as a result of gross under-reporting.
Epidemiology of snakebite-related morbidity in India is complex owing to the country's vast landmass, diverse eco-geographical regions, the widespread presence of venomous snake species, increasing human-animal interactions, and absence or poor availability of appropriate anti-snake-venom (ASV) for many species. Nearly 70% of snakebite victims in South East Asia are males in the age group of 20–50 years, and this brings in an important economic component to the problem necessitating quick and effective management of snakebite cases to prevent further aggravation of economic losses to the affected family.,
India also lags behind in the research, manufacture, and distribution of effective antivenom, which is low in potency but high in price., A large number of snakebite victims are misdiagnosed, or receive inappropriate and often arbitrary therapy with ASV, indicating inadequate knowledge about snakebite epidemiology and management among medical practitioners; which may hinder the formulation of a correct diagnosis and judicious use of ASV.
Government of India and the WHO have formulated standard guidelines for the Management of Snake bite in India and South-East Asian Region (SEAR), respectively. However, previous studies on the knowledge of medical practitioners in India regarding snakebite have demonstrated heavy reliance on Western textbooks or “on the job training,” both of which were found to be ineffective in meeting local needs for the correct management of snakebite.
This study aims to determine the awareness of medical practitioners in India about snakebite and its management and assess the medical practitioners' opinion about the cogency of their undergraduate training regarding the management of snakebite.
| Materials and Methods|| |
The study population consisted of medical practitioners trained in the allopathic system practicing in India. The responses were recorded using a pretested questionnaire consisting of 25 questions made available online. It was based on the Standard Treatment Guidelines (STG) on the Management of Snakebite issued by the Ministry of Health and Family Welfare, Government of India, and the Guidelines for the Management of Snake-bites in the SEAR issued by the WHO and collected information about the respondents' knowledge regarding epidemiology of snakebite in India, diagnosis of venomous snakebite, and the management of snakebite.
The sample size was determined to be 138; taking the study population to be 900,000 (approximate number of registered medical practitioners in active practice in India), and assuming an expected frequency of correct response to be 50% for all parameters, margin of error 7% at 90% level of confidence. A wider confidence interval and margin of error were taken since the review of the literature did not reveal any similar nationwide studies in India.
The attempt was made to reach medical practitioners in all states and union territories with special emphasis on reaching those who were providing primary healthcare. Convenience sampling was carried out for obtaining the desired sample size. We received 143 responses during the data collection period, and all were included in the study.
| Results|| |
Seventy-three percent of the respondents were general practitioners having undergraduate medical education and the majority of respondents in our study had completed their undergraduate degree in the past 7–10 years (median = 8 years) [Figure 1]. This is of relevance to our study as the majority of the doctors handling snake bite victims at the primary healthcare level are general practitioners.
About 76.1% of respondents had managed at least one case of snakebite. About 33.6% had managed one or more cases independently (without any assistance from another medical practitioner). About 60.9% of respondents had administered ASV at least once. About 54.9% of the respondents were not confident that they would be able to manage a case of snakebite independently and 91.4% believed that the topic of snakebite needs more emphasis at the undergraduate level [Table 1].
About 93.2% of respondents in our study were not aware of the number of species of the highest medical importance in India as classified by the WHO. 73.2%, 73.6%, and 45.6% of the respondents were not aware of the absence of antivenom for Monocled Cobra (Naja kaouthia), Banded Krait (Bungarus fasciatus), and Himalayan Pit-viper (Gloydius himalayanus), respectively. These are important species of venomous snakes found in India. Besides, 67.2% of respondents were not aware of the hump-nosed viper (Hypnale hypnale), which has been recognized as a snake of highest medical importance in the South and South-Western India due to morbidity and mortality associated with its bite., Only 18% of the respondents correctly identified all the positive findings of envenomation from a list of signs and symptoms.
About 91.7% of respondents correctly identified signs of neurotoxic elapid envenomation, 52.2% were able to correctly recognize common presenting symptoms of common krait envenomation, but only 20.2% had correct knowledge about differentiation of elapid bite from the viperine bite. The knowledge of differentiating features of snakebites by venomous species is depicted in [Figure 2].
|Figure 2: Knowledge regarding presentations of bites of different snakes|
Click here to view
About 47.1% of the respondents were not aware of the correct method of and precautions to be taken while performing the 20 min-whole blood clotting test (20-WBCT) [Table 2].
The study also assessed the respondents' awareness about selected common misconceptions regarding envenomation and its management [Table 3].
|Table 3: Misconceptions regarding administration of anzti snake-venom and management of complications|
Click here to view
| Discussion|| |
The study was targeted toward general practitioners practicing in a primary healthcare capacity where most patients of snakebite or their attendants can bring the dead snake or its picture to the medical practitioner., The identification of venomous from nonvenomous snake forms an important component of the undergraduate medical teaching curriculum regarding snakebite. However, majority of respondents were not confident in being able to differentiate the two. Furthermore, more than 60% of respondents wrongly identified common nonvenomous snakes as venomous. Incorrect identification of a snake as venomous in the presence of psychogenic symptoms in a patient may lead to inappropriate use of ASV and resultant risk of complications.
Understanding the epidemiology of a particular disease or condition is important in clinical practice to adopt the best care practices for the patient. However, majority of the respondents in our study were not aware of the snakebite burden in India and 66% of respondents who attempted the question underestimated it.
Approximately 55% of respondents were either not confident or not sure if they would be able to manage a case of snakebite independently. This may be because of emphasis on theoretical teaching in the medical curriculum and very little emphasis on the learning management of clinical cases of snakebite. Only 21.8% of the respondents felt that their undergraduate medical education was adequate to train them to manage a case of snakebite independently and 91.4% felt that snakebite and its management needs more emphasis at the undergraduate level.
A large proportion of respondents were not aware of the STG issued by the Ministry of Health and Family Welfare or the WHO-SEAR. The knowledge about the management of snakebite is still largely dependent on medical textbooks, which predominantly describe snakebite envenomation common in Western countries and are often not applicable to India.
The current knowledge regarding awareness about snake species of highest medical importance is still centered on the “Big Four” concept of venomous snakes implicated in most cases of snakebite envenomation in India, namely Indian Cobra, Common Krait, Saw-scaled Viper, and Russell's Viper. However, this concept (which, incidentally, also guides ASV production in India) is incomplete in light of recent identification of hump-nosed viper as an important cause of mortality and morbidity in Southern India and the reclassification of Monocled Cobra as a separate species. ASV production in India is currently limited to the venom legally sourced from a single location in Chennai – The Irula Snake Catchers' Industrial Co-operative Society (ISCICS), and few irregular sources in other parts of the country. This ASV produced from the ISCICS venom loses its efficacy against snakes from different regions of the country due to geographical variations in the venom constitution.,,
Most of the respondents were aware of the signs and symptoms of neurotoxic envenomation. We also found fair degree of awareness about the presentation of common krait bite, peculiar due to its painless nature, and difficulty in diagnosis. This awareness is important to rationalize the use of atropine/neostigmine in management. The awareness about signs and symptoms of Viperidae bite and the rational ASV use in such cases was found to be low with 63.3% of the practitioners wrongly assuming that ptosis and other neurological signs rule out viper bite, while in practice, they may be a prominent feature of Russell's viper bite.
When indicated, ASV should be started as early as possible to prevent the circulating venom from binding to target receptors in the victim's body. Test doses have been found to be ineffective in detecting anaphylactoid or late serum reactions and are therefore not to be used. Approximately 38% of respondents in our study, however, believed that the test dose should be administered before starting full dose ASV.
We identified misconceptions regarding the use of ASV in other special situations such as breastfeeding and delayed presentation with persistent coagulopathy as well as bites due to species for which ASV is not available.
The study also brings out lacunae in the knowledge of the correct method of carrying out simple tests like the 20-WBCT; and also in the management of adverse reactions to ASV, particularly that pertaining to the dose and route of administration of epinephrine and the trial of antihistaminic before administering epinephrine.
| Conclusions|| |
Snakebite envenomation is responsible for widespread morbidity and mortality in India. While this is partially attributable to the failure or delay in bringing the victims to health-care facilities; this study suggests that the knowledge and awareness of medical practitioners serving as the first point of care is limited to concepts learnt in undergraduate curriculum, which is restricted to largely theoretical aspects with little or no practical exposure to clinical cases. There is a need to incorporate the current epidemiological and clinical concepts and guidelines, tailor made to the Indian scenario, into the undergraduate medical teaching about the management of snakebite.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al
. Snakebite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis 2011;5:e1018.
Menon JC, Joseph JK, Whitaker RE. Venomous snake bite in India – Why do 50,000 Indians die every year? J Assoc Physicians India 2017;65:78-81.
Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in South Asia: A review. PLoS Negl Trop Dis 2010;4:e603.
Whitaker R. Snakebite in India today. Neurol India 2015;63:300-3.
] [Full text]
Simpson ID, Norris RL. Snake antivenom product guidelines in India: The devil is in the details. Wilderness Environ Med 2007;18:163-8.
Simpson ID. A study of the current knowledge base in treating snake bite amongst doctors in the high-risk countries of India and Pakistan: Does snake bite treatment training reflect local requirements? Trans R Soc Trop Med Hyg 2008;102:1108-14.
Joseph JK, Simpson ID, Menon NC, Jose MP, Kulkarni KJ, Raghavendra GB, et al
. First authenticated cases of life-threatening envenoming by the hump-nosed pit viper (Hypnale hypnale) in India. Trans R Soc Trop Med Hyg 2007;101:85-90.
Shivanthan MC, Yudhishdran J, Navinan R, Rajapakse S. Hump-nosed viper bite: An important but under-recognized cause of systemic envenoming. J Venom Anim Toxins Incl Trop Dis 2014;20:24.
Cox RD, Parker CS, Cox ECE, Marlin MB, Galli RL. Misidentification of copperhead and cottonmouth snakes following snakebites. Clin Toxicol (Phila) 2018;56:1195-9.
Bhalwar R, Vaidya R, Kunte R. Text Book of Public Health and Community Medicine. Pune: Department of Community Medicine, Armed Forces Medical College: World Health Organization; 2009. p. 68.
Shashidharamurthy R, Jagadeesha DK, Girish KS, Kemparaju K. Variations in biochemical and pharmacological properties of Indian cobra (Naja Naja Naja) venom due to geographical distribution. Mol Cell Biochem 2002;229:93-101.
Prasad NB, Uma B, Bhatt SK, Gowda VT. Comparative characterisation of Russell's viper (Daboia/Vipera russelli) venoms from different regions of the Indian peninsula. Biochim Biophys Acta 1999;1428:121-36.
Kumar AV, Gowda TV. Novel non-enzymatic toxic peptide of Daboia russelii (Eastern region) venom renders commercial polyvalent antivenom ineffective. Toxicon 2006;47:398-408.
Ranawaka UK, Lalloo DG, de Silva HJ. Neurotoxicity in snakebite-the limits of our knowledge. PLoS Negl Trop Dis 2013;7:e2302.
Warrell DA. Guidelines for the clinical management of snake bites in the South East Asia region. South Eastern J Trop Med Public Health 1999;30:1-83.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]