Snakes and snakebites have been known to the people of Bangladesh since ancient time. Snakebite results most often from an unfortunate accidental interaction between a snake and a human victim. It is the single most important toxin-related injury,causing substantial mortality and morbidity in Bangladesh, especially in rural areas. Snakebite has a significant impact on human health and economy through treatment related expenditure and loss of productivity (Hasan S M et al 2012).

Traditionally snakebite cases are treated by traditional healers, ‘Ozhas’ using non-scientific methods often leading to harms to the victims.

The scientific management of snakebite envenomation requires appropriate first aid, quick transfer of victims to hospital, training material, training of health care professionals, availability of antivenom and other ancillary drugs and organ support systems.

Recently on May 24, 2018 “addressing the burden of snakebite envenoming” the World Health Assembly (71st) has passed a resolution providing a strong mandate for the World Health Organization to implement an ambitious snakebite “roadmap,” mobilizing governments and donors to respond to snakebite with the urgency and attention this neglected public health crisis demands (WHO agenda item 4.1; 2018).

Government of the People’s Republic of Bangladesh has already taken several praiseworthy steps to deal with this important health issues even long before this resolution. For creating uniformity among the health professionals MOHFW through DGHS is sponsoring the development of updated version of a national guideline and several training modules, provision of antivenom to hospitals, training of heath care professionals. The recommendations from WHO SEARO Guidelines for the Management of Snakebites were primarily used in the development of Bangladesh guidelines.

Recently the MOHFW and DGHS have initiated a project to collect venoms from medically important local snakes with an aim to develop antivenom specific to venoms of local snakes. This project is expected to ‘revolutionize’ the treatment of snakebite and a great leap forward in the field of research in toxinology. Yet there are many unaddressed issues including nationwide public awareness and education.

Pre hospital  Management

1. First aid:

Effective first-aid treatment should be carried out immediately or very soon after the snake bite; before the patient reaches hospital.1It can be performed by the snakebite victim or by anyone present who has skill to provide first aid.

Incorrect first aid may cause more harm than good.

Aims of first aid:

1. Attempt to slow down spread of venom that may have been introduced into the tissues.

2. Prevent mortality and complications before reaching hospital.

3. Control dangerous early symptoms of envenoming.

4. Not to harm the snakebite victim.

Recommended first aid methods

1. Reassurance: Patient should be advised not to get panicked. He should be told that majority of snakes are non-venomous; moreover, venomous snakes sometimes fail to inject enough venom effectively during bites.

2. Immobilization: Make sure that bitten limb (hand or leg) is immobile and the victim must be kept still. Advise:

Bite in lower limb: “Sit down, do not walk”. Bite in upper limb: “Do not move the limb”.

Immobilize the bitten limb with a splint or sling as practiced in fracture of long bone. Ideal is to provide pressure immobilization. (O)

Look for fang marks at bite site

3. Wash the bitten area: gently with soap and water, or wipe with a wet cloth and cover with bandage.

4. Remove as early as possible all rings, bangles, anklets, cords or clothing, ‘Tabij’, ‘Taga’ etc, which may cause constriction if swelling occur.

5. Quick transport: seek help to get the patient rapidly transferred to a hospital by motorbike or ambulance. (O)

6. Place patient in the lateral recumbent position.

7. If non-breathing, insert an oral airway or perform rescue breathing if necessary.

8. If the snake is killed somehow, bring it to hospital. Be careful and do not handle snakes bare handedly as they might pretend to be dead. Do not waste time for catching or killing the snake.

Please do not do: Some Don’ts

1. Do not apply tourniquets/ligature in the bitten limb.

2. Do not cut or prick with needles or use any topical cream.

3. Do not waste time unnecessarily seeking treatment provided by traditional healers (Ozhas).

4. Do not provide anything by mouth if the victim has difficulty in swallowing/talking, vomiting, nasal voice or excessive salivation.

5. Do not cauterize by using chemicals.

6. Do not apply herbal medicines, stones, seeds, saliva, potassium permanganate solution or cow-dung and mud.

7. Do not give herbal products like oil, ghee, pepper to induce vomiting.

8. Do not apply alcohol.

9. Do not give aspirin to relieve pain.

10. Do not panic and be tempted to do anything detrimental to the victim.

11. Do not delay in reaching health facility.

Note: There is no scientific proof of benefit (evidence) of application of torniquet. In case torniquet has already been applied they should not be released until the patient is under medical care in hospital, medical staff and resuscitation facilities are available and antivenom (if indicated) has been started.

2. How to avoid snakebites?

1.    It is good to avoid keeping food items like paddy, poultry and pigeon within bedroom which might attract rats, which in turn attract snake to enter.

2. Use long shoes or boots and watch out while you walk through bushes or long grasses. Do not put your hands and legs in holes. Handle carefully piled woods or hay. Do not turn around big stones or wooden pieces. Watch out while stepping on stones or woods. If you have to walk in the grass or in the bush, watch very carefully and take long shoe boots.

3. Check out presence of snakes while handling fishing nets.

4. Take special precaution, such as, flash light, stick during walk at night. Because, snakes usually move actively at night.

5. Know about venomous snakes and their habitat in Bangladesh, so that you can try to avoid them.

6. Take special precaution during sleep: use ‘cot’, avoid sleeping on the floor (E). Use mosquito net during sleep. (E) Do not sleep in the floor particularly during harvesting of crops, fruits, vegetables or while watching crops, fruit garden or fish farm.

7. Clean the four sides of the house. Keep distance between dwelling house and cultivation land.

8. Keep your yard free of clutter

Snakes are ambush predators, meaning they like to attack their prey from dark hiding places.

As such, clutter is essentially an open invitation to snakes, giving them perfect hiding spots. Piles of leaves, compost piles, straw mulch, wood chip mulch, stacks of firewood, and piles of cut grass are all comfortable places that snakes like to hide in, so these should be removed from your yard.

Instead of wood mulch, consider crushed stone. It’s not as comfortable or effective for snakes to hide in.

9. Get rid of any possible source of food-snakes will only hang around your yard if there’s something there they can eat. Depending on the species, this could mean a problem with large insects such as cockroaches and grasshoppers, or small mammals such as mice and rats.

10. Patch up any holes or cracks in your building’s foundations provide great hiding places for snakes.

11. Switch on the light before entering into a room.

12. Look carefully on the bed and under the pillow, make sound so that if there is any snake it can go away. Warn snakes of your approach by treading heavily. Snakes are relatively deaf to air borne sounds, but are sensitive to ground vibrations.

13. Do not put your hand into anthills, cavities in trees and thick undergrowth and under logs. It is prudent to clear sites likely to be occupied by snakes around human habitations.

Destroy anthills and fill up cavities in trees. Do not let fallen trees, logs and firewood lie around. Exercise caution if you have to move logs, rocks, etc in the course of your work, as there may be snakes under these.

14. Dispose of garbage and junk regularly, and try to keep your dwelling and surroundings free of rats, mice, frogs, lizards, etc., which attract snakes.

15. Only trained persons should handle or rear snakes. An apparently dead snake should be handled with great care as it may still be alive, and even when dead, may inflict a reflex bite.

3. What to do if you see a snake?

1. Do not be afraid

2. Do not get close to them

 3. Allow the snake to go away

4. Do not kill the snake unnecessarily

5. Snakes do not attack man. They bite defensively or when agitated

Hospital

CAUTION: Delay the release of tight bands, bandages and ligatures: if the patient has already applied these, they should not be released until the patient is under medical care in hospital, medical staff and resuscitation facilities are available and antivenom treatment (if indicated) has been started (Watt et al., 1988).