​Tough call: On India and snakebites

A combination of snakes being ectothermic, a hotter summer than usual, difficult decision-making, and gaps in clinical infrastructure has led to a situation in Kerala where the availability of anti-snake venom (ASV) has not been able to prevent all deaths from snakebites. Snakes are driven by the heat to seek refuge in cool, damp spaces, which means homes and storerooms with firewood and coconut husks. The State is also densely vegetated with substantial human-wildlife range overlap. April-May is also the pre-monsoon breeding season for many venomous snakes, which means that they move around more and tend to be defensive. However, about 70% of snakebite presentations involve non-venomous species, and roughly half of the rest are dry bites with no venom injected. A substantial number of patients thus do not warrant ASV. Caution against administering ASV willy-nilly is merited because these compounds can also induce anaphylactic reactions, which can be fatal. At the same time, there is no commercially available diagnostic kit in India to detect venom in a patient’s blood, and the diagnosis is entirely symptomatic. The ICMR has called this syndromic approach a systemic flaw, since by the time symptoms appear, the venom may already have damaged tissue irreversibly. Together with scarce ICU beds, a lack of ventilator backups, inadequate training in managing anaphylaxis, and limited lab support for monitoring, this approach has offset the benefits of the availability of ASV.

India accounts for nearly half of all snakebites in the world, with agricultural workers and children being the worst affected. Kerala is home to over 100 snake species, including the Big Four venomous snakes: the common krait, Russell’s viper, saw-scaled viper, and spectacled cobra. The State government has made snakebite a notifiable disease. It launched the ‘SARPA’ programme to professionalise snake rescue. The SARPA Padam and the upcoming SARPA Suraksha programmes also focus on assessing risk and conducting ward-level and school awareness campaigns. Progressive as the notification and ‘SARPA’ are relative to similar measures in the rest of India, the deaths are a sign that Kerala may be prevention-heavy and that it needs to reinforce the ‘cure’ as well. ASV is already widely available; the uncertainty that prevails over doctors’ decision-making at the first point of contact needs to be mitigated. Many experts have also called for the development and use of rapid venom detection diagnostics to eliminate the risks of the syndromic approach. This must be followed by increasing hospital capacity and the availability of skilled medical workers to manage the consequences of that decision.