Introduction

Snakebite envenoming (SBE) is one of the neglected tropical diseases (NTD) leading to around 81,410 to 137,880 deaths from 1.8 million to 2.7 million cases globally [1, 2]. SBE affects around 400,000 people every year causing permanent physical or psychological disabilities including blindness, amputation, and post-traumatic stress disorder [3]. It is estimated that in countries with a frail health system and scarcity of anti-venom, one death occurs every five minutes and four more people are disabled permanently due to SBE [4]. World Health Organization (WHO) classified SBE as a high-priority neglected tropical disease (NTD) in 2017, and subsequently, in May 2018, Seventy-first World Health Assembly (WHA) adopted a resolution providing a strong mandate to WHO for global actions on reducing the burden of SBE [5]. On May 23, 2019, WHA launched its roadmap to reduce the death and disability from snakebite by 50% by 2030 [4]. The strategy focuses on prevention of snakebite; provision of safe and effective treatment; strengthening health systems; and increased partnerships, coordination, and resources. Community education for seeking early and appropriate treatment, accelerating development and stockpiles of anti-venom, and stabilizing the market for snakebite treatments are also recognized as important aspects of this strategy [4, 6].

The recent national mortality survey [7] estimated that India had 1.2 million snakebite deaths (average 58,000/year) from 2000 to 2019 which is an increase of about 8000 cases/year compared to the earlier estimated survey (2001–2003). However, only a 10% coverage of the actual snakebite burden being captured in the government data in Maharashtra was also reported indicating gross underestimation of morbidity and mortality in Maharashtra [8]. The majority of the deaths occurred at home in the rural areas with half of the deaths happening between 30–69 years of age. Eight states (Madhya Pradesh, Odisha, Uttar Pradesh, Bihar, Jharkhand, Rajasthan, Gujarat, and Andhra Pradesh including Telangana) of India shared the burden of about 70% snakebite deaths from 2001 to 2014 [8]. A nationally representative mortality survey conducted by Mohapatra B et al 2011, included Maharashtra in the high prevalence of snakebite envenomation (SBE) group with an age standardized mortality rate of 3.0 per 100000 people. Except the high prevalence states, for the rest of the country the age standardized mortality rate was 1.8 per 100000 people during the same period. In the same study, Maharashtra was also reported to have the fifth largest number of deaths due to snakebite among the high prevalence states [9]. Snakebites usually occur in geographically remote areas and hence their burden either goes unnoticed or is underreported [10]. From 2003 to 2015, the million death study estimated about 154,000 snakebite deaths in both private and public hospitals. However, the government reported only 15,500 hospitals deaths indicating that only about 10% of the expected deaths were captured [7].

SBE is labelled as a disease of poverty [11]. Agricultural and migrant workers, tribes, hunters and often, the earning members of the family are the victims. So it is not only a public health problem but also a major socio-economic determinant in India [12]. A study conducted in the tribal region of Maharashtra, India, reported 4.5% case fatality rate [13] while a study in rural Nepal reported an annual incidence of 1162/100000 with an annual mortality rate of 162/100000 due to SBE [14]. A meta-analysis of data from 41 Sub-Saharan African countries estimated the annual burden of SBE related deaths as 1.03 million DALYs, higher than the burden of many NTDs globally [15]. Similarly, a study in West Africa revealed a higher burden of SBE compared to other NTDs found in 16 countries and labelled SBE as underappreciated [16].

SBE burden coupled with a lack of awareness amongst the Medical Officers (MOs) and other healthcare providers about the National Snakebite Management Protocol (2009) and Standard Treatment Guidelines (STG, 2017) creates major hurdles in management of SBE [13]. An irrational usage of anti-venom skin test was also reported in the tribal block of Dahanu, Maharashtra [17]. Primary Health Centers in rural India face a multitude of problems including the acute shortage of trained human resources, unavailability of anti-venom and emergency ventilation services [18]. Issues with public health facilities and geographical inaccessibility supplemented by superstitions and cultural beliefs regarding snakes force SBE victims to seek care from faith healers [19, 20]. Studies in rural and tribal areas have revealed inadequate knowledge about venomous snake identification and faith healers were the first choice for about 38–68% of people for SBE management [17, 21–24]. Most of the traditional and herbal methods of first aid and management of snakebite have been found to cause more harm than benefit [25, 26]. Proper knowledge of snakes and snake-bite management was also found to be either diminutive or absent in the majority of participants as reported by a study from Haryana [27]. Fear, negativity, and unfamiliarity regarding prevention and ambivalent opinions on health-seeking are known drivers of people’s perception of snakes and snakebites [28]. These findings strongly suggest the need for community awareness on the prevention and first aid of snakebite and empowerment of frontline healthcare workers and Medical Officers for effective management of SBE in public healthcare settings.

Previously, the authors have established a successful model for the prevention and management of SBE at Dahanu block of Palghar district through the Model Rural Health Research Unit (MRHRU) [13, 21]. The model involved community awareness, training of healthcare workers, snake handlers, and faith healers, availability of anti-venom and, implementation of the National Snakebite Treatment Protocol. Indian Council of Medical Research (ICMR)-National Task Force Expert Group for ‘Research on Snakebite in India’ recommended upscale of the Dahanu model to a Health System Research project using a similar multi-sectoral approach for attaining the 2030 goal set by WHO. Based on those recommendations, this protocol was developed and it describes the National Snakebite Project that aims for prevention and management of SBE in selected districts of Maharashtra and Odisha.

The objectives of the study are:

1. To increase the awareness and empower the community on prevention, first aid, and early transport of snakebite patients to the nearest health facility
2. To evaluate the healthcare providers regarding their knowledge and practices during management of SBE and understand the anti-venom distribution and utilization at public health facilities
3. To empower the health system for management of SBE through the implementation of Standard Treatment Guidelines (STG) of the Government of India
4. To study the impact of the interventions on reducing the SBE mortality and morbidity

Materials and methods

Study scheme

The interventional study has retrospective, prospective, cross-sectional, and qualitative components and will be conducted in a community as well as hospital settings (Fig 1). It is divided into five phases (Fig 2). Phase I involves collecting retrospective data of snakebites, facility surveys, and focus group discussions (FGDs) in the community. Phase II is to increase awareness and empower the community on prevention, first aid, and early transport of snakebite patients to the nearest health facility. Phase III will be to evaluate the basic knowledge on snakebite management and anti-venom utilization among healthcare providers. Phase IV is to empower the health system for management of SBE and optimal utilization of anti-venoms through training programs and Phase V will focus on the impact evaluation of the health system and community interventions using FGDs and comparison of pre-and post-intervention data.

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Fig 1. Timeline of the study.

https://doi.org/10.1371/journal.pone.0281809.g001

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Fig 2. The outline of the study.

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Study setting

From 2001 to 2014, Odisha and Maharashtra bore the burden of about 40300 and 56000 snakebite deaths with an age-standardized death rate of 6.7 and 3.5 / 100000 respectively [8]. Deaths between the age of 5 to 14 years were greater in Odisha while deaths among females were prominent in Maharashtra [8]. SBE has been a chronic problem in these two states with an earlier county-wide survey (1941–1945) suggesting that compared to other states, snakebite mortality is a greater problem here as the majority of geographical areas are forested and infested with snakes [29]. The proposed study is a multi-center study that will be conducted in the West and East Zones of India. Under the West zone (Maharashtra state), two blocks namely, Shahapur in district Thane and Aheri in district Gadchiroli will be included. Under the East zone (Odisha state), two blocks namely, Khordha in district Khordha and Kasipur in district Rayagada will be included (Fig 3, Table 1). The population in the study areas lives with an absolute risk of ≥0.5% of dying due to snakebite before the age of 70 years with the risk being highest in Aheri and Kasipur [8].

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Fig 3. Geographical location of study areas of Maharashtra and Odisha states in India.

Source: AMCHARTS SVG Maps; https://www.amcharts.com/svg-maps/?map=india2019. Permission obtained for use.

https://doi.org/10.1371/journal.pone.0281809.g003

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Table 1. Demographic details of the study areas in Maharashtra and Odisha.

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Discussion

SBE remains a major public health hazard predominantly in tropical countries [3]. In Asia up to two million people are bitten by snakes every year; the majority of them are women, children, and poor rural communities [32]. SBE has highly effective treatment and severe complications can be prevented with a correct dose of anti-venom [33]. Snakebite treatment remains a complex issue in countries like India due to various factors—poor community knowledge, ill-equipped hospitals, treatment accessibility, travel time, and reliance on faith healers for treatment [34]. Very little attention is drawn towards the assessment of basic knowledge of medical doctors on management of snakebite and its complications [35, 36].

A study conducted in India and Pakistan concluded that standard protocols and training are required to empower doctors to reduce snakebite mortality [35]. Another study from Bangladesh revealed that peripheral healthcare workers lack knowledge, experience, and adequate skills required to treat snakebite victims [37]. In a recent study from Bhutan, only 25% of health workers had adequate knowledge of snakebite management. However, 63% of medical doctors were found to have adequate knowledge compared to other healthcare workers [23]. A study in Haryana on farmers, teachers, medical residents, and students reported that only 13% participants, were aware of the ‘big four’ snakes [27]. Lack of appropriate knowledge on snakes, first aid, treatment, and prevention among the clinicians was also reported in northern Nigeria [38]. In Hong Kong, only 29% of clinicians were confident about treating snake bites [36].

India is a major manufacturer of anti-venoms. However, there is a paucity of satisfactory data regarding the number of anti-venom vials needed to reverse the clinical effects of SBE [39]. Passivity, inaction and supply-demand incoordination have resulted in both unavailability and inadequacy of anti-venom marginalizing the effective cure to SBE [40]. A study in Africa reported that compared to requirements, the number of effective treatments available for SBE might be as little as 2.5% [41]. In many African and Asian countries, anti-venom production is either at standstill or stopped altogether [42].

From the community point of view, preventing life-threatening snakebite incidences is the holy grail. Simple measures including use of bed-net while sleeping, use of torch and stick while walking in the dark, ban on open defecation practices, using knee length footwear in farms can aid in prevention [43, 44]. Community engagement using an integrated approach that involves strengthening the knowledge and awareness supplemented by efforts to tackle the sociocultural and economic barriers to seeking early healthcare can improve the management experience of many victims [6, 33]. Establishment of useful referral mechanisms between various stakeholders including community members, key influential persons in the area, administrative bodies and the healthcare system can go a long way in dealing with the SBE burden.

The National Snakebite Project will use a multi-sectoral, multi-stakeholder approach to reduce the burden of SBE. Encouraging community participation, healthcare provider empowerment, and wide-scale IEC activities are the strengths of the study. Health facility based retrospective and prospective data collection might result in underreporting of the SBE burden. However, an effort would be made to collect data from municipal corporation records, gram panchayat, crematorium or any other institutions in the study areas to ensure that maximum snakebite deaths are captured in addition to hospital records. Further, the evidence generated from the study may be useful to the Government of India for developing national strategies to reduce SBE burden. Model clinical snakebite management centers can be established all over the country based on the outcome of this study. The engagement of community members, local authorities, healthcare providers, herpetologists, social scientists, and public health experts is envisioned to accentuate the efforts for the prevention and control of snakebites in India.

Supporting information

Acknowledgments

The authors thank Dr. Geetanjali Sachdeva, Director, ICMR—NIRRCH, Mumbai, Dr Ashoo Grover, ICMR, New Delhi. The authors thank the members of the Technical Advisory Committee: Dr. Jaideep Menon, Dr. Yogesh Kalkonde, Dr. Dayal Majumdar, Dr. Milind Vyawahare, Dr. Kedar Bhide, and Dr. Joy Kumar Chakma for their critical inputs in the revision of data collection tools. INSP Project staff Ms. Bijaylaxmi Mohanty, Mr. Ganesh Bhad, Mr. Milind Gavhande and Mr. Jagdish Prasad Dash are acknowledged. The authors also thank the Public Health Departments in Maharashtra and Odisha states for providing administrative permissions for the study.