WELCOME TO SNAKE SITUATION IN BANGLADESH PROFMA HASSAN CHOWDHURY DEPARTMENT OF MEDICINE CHITTAGONG MEDICAL COLLEGE AND HOSPITAL NEWS PAPER মহরপর দদন অরধশত মনষক সপর ID: 308360
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Slide1
Third International Conference on TROPICAL MEDICINE AND TOXICOLOGY SYLHET BANGLADESH2014
WELCOME TO Slide2
SNAKE SITUATION IN BANGLADESH
PROF.M.A .HASSAN CHOWDHURY
DEPARTMENT OF MEDICINE
CHITTAGONG MEDICAL COLLEGE AND HOSPITAL Slide3
NEWS PAPER
মেহেরপুরে দুদিনে অর্ধশত মানুষকে সাপের
কামড়
মুন্সীগঞ্জ হাসপাতালে ভ্যাকসিন না থাকায় সাপের কামড় খাওয়া শিশুর
মৃত্যু
-চুয়াডাঙ্গার দামুড়হুদায় সাপের কামড়ে কিশোরের মৃত্যুঝিনাইদহে সাপের কামড়ে একজনের মৃত্যু ।
ধামরাইয়ে সাপের কামড়ে নারীর মৃত্যু
নবীগঞ্জে বিষধর সাপের কামড়ে কিশোরীর মৃত্যু
Slide4
INTRODUCTION---SNAKE
BITE
Acute emergency public health problem
An occupational and environmental
DISEASEAn neglected tropical disease declared by WHO
Major causes of mortality and morbidity in many areas, particularly in the rural tropicsImposes substantial economic burdens on
victims due to treatment related expenditure and loss of
productivity
Eminently treatable and preventable.Slide5
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 000Slide6
Overview of status of snake-bites in SEA Region
Country
Estimated
number of bites
Estimated number of deaths
National guidelines
Training
AVS
Prodn
/import
Reporting system
BAN
7000
6000
Yes (2008 Rev.)
Yes
Import
Nil
BHU
NA
NA
Yes
No
Import
Nil
DPRK
NA
NA
NA
NA
NA
NA
IND
77 000
1100 (20 000)
Yes (2007)
No
Yes polyvalent
Yes
INO
NA
NA
NA
NA
Yes
NA
MAV
Nil
Nil
No
No
No
NoSlide7
Cont….
Country
Estimated
number of bites
Estimated number of deaths
National guidelines
Training
AVS
Prodn
/import
Reporting system
MMR
10 000
769
No
Yes
Monovalent
and Import
Yes
NEP
1000
200
Yes
No
Import
No
SRL
35 000
100-150
No
Import
Yes
THA
10 000
<0.5%
Yes
Yes
Yes
Monovalent
Yes
TLS
NA
NoSlide8
November 2013 | Volume 8 | Issue 11 | e80090Slide9
Snake bite in Bangladesh
The
incidence of snake bite episode
was
623.4
bites per 100,000 persons per yearThe
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 OCTOBERSlide10
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 TREATMENTSlide11
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:
P
opulation densities (humans and snakes);Diurnal and seasonal variations in activity (rains, flooding, disasters
);
O
ccupations
(e.g. agricultural activities harvesting, neglect
of protective clothing
) and snakes’
“
I
rritability
” (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.Slide12
SNAKE SPECIES
82
species of snakes in
Bangladesh
28
species are venomous 54 species are non venomous. Slide13
Medically important snakes of Bangladesh
Group I: Cobra
Naja kaouthia
,
monocellete
cobra,
gokhra, gokhur
,
jati
/
jati
shap
,
dashla
gohma
. Distributed in all divisions of Bangladesh.
Naja
naja, binocellete cobra, spectacled cobra,
gokhra,
gokhur, khaiya gokhra
, gohma/goma. Distributed in all divisions, more in west of
Jamuna river.Ophiophagus hannah, king cobra, raj gokhra,sankhochur
,
padma
gokhra
,
phanos
. Distributed in
Sylhet
, Chittagong, Khulna &
Barishal
divisions. Slide14
Cobra
Naja kaouthia
Naja
naja
Ophiophagus hannahSlide15
Snakes of Bangladesh
(contd...)
Group II: Krait
Bungarus caeruleus
, common krait,
kal
kewtey,
kalas
,
maicha-alad
. Distributed in all divisions.
Bungarus fasciatus
, banded krait,
sankhini
,
shakini
, mama-
bhagne
. Distributed in all divisions, but more in Chittagong and rare in
Rajshahi.Bungarus niger (Black krait),
Bangarus
wali. Recently found in Chittagong and other parts of the country.Slide16
Krait
Bungarus caeruleus
Bungarus fasciatus
Bungarus niger Slide17Slide18
Snakes of Bangladesh
(cont…..)
Group III: Russell’s viper
Daboia (
Daboia russelli
,
Russel’s viper, Chandrabora
.)
Distributed mainly in
Rajshahi
and Khulna division and may be found in Chittagong division.Slide19
Russell’s viper
Daboia russelli
Daboia russelliSlide20
Snakes of Bangladesh
(cont….)
Group IV: Green pit viper
Ovophis
(
Trimeresurus
) spp., green pit vipers, green snakes, bansh-bora,
sabuj
bora
, gal
tawa
.
Distributed
in
Sylhet
, Chittagong, Khulna and
Barishal
divisions.Slide21
Green pit viper
Cryptelytrops erythrurus
Green Snake (
Trimeresurus
spp
)Slide22
Snakes of Bangladesh
(cont…)
Group V: Sea snakes
Enhydrina schistosa
,
hooknosed
sea snakes, samudrik
shap
.
Distributed in sea and coastal saline water of Bangladesh.
Hydrophis
spp.,
Microcephalis
spp.,
Lacticauda
spp., sea snakes,
samudrik
shap.
Distributed
in sea and coastal saline water of Bangladesh.Slide23
Sea snakes
Hydrophis cyanocinctus
Lacticauda colubrina
Enhydrina
schistosaSlide24
Snakebite – 2014
WARD -16 OF MEDICINE UNIT 3
CMCHSlide25
Venomous = 17.6%Slide26
Gender DistributionSlide27
Monthly admissionSlide28
Age distributionSlide29
Type of Venomous SnakebiteSlide30
Locality of Neurotoxic SnakebiteSlide31Slide32Slide33
TREATMENT AND OUTCOME
Anti-venom = 44 + 1 = 45
Total number of death = 5 (1 in ICU)
Two Green pit bite developed AKI Slide34
Snakebite CMCH in 2013
Total patient admitted in ward16 = 13,723
Total snakebite patient = 1278
Percentages of snakebite = 10.8%
Total venomous snake-46,
Nonvenomous and locally venomus-1236Total death=3Death
rate = 7.5 %Slide35Slide36
2013
Death rate = 7.5 %Slide37
Monthly admissionSlide38
Gender distributionSlide39
Age distribution
Number of PatientsSlide40Slide41Slide42Slide43
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 biteSlide44
First Aid Method Immobilization
DO IT R.G.H.T
R=REASSURES the patient
I=IMMOBILIZED the affected area
G.H.=GET TO HOSPITAL
T= TELL the doctorsSlide45
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. Slide46
P
erspective
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
.Slide47
CLINICAL SYNDROMES
SNAKE
LOCAL
NEURO
BLEED
MISC.
COBRA
+
++
Nil
Shock +/-
KRAIT
Nil
+
Nil
Pupils -dilated, fixed
VIPER
+++
+ / -
++
Renal failure, ShockSlide48
Local signs of envenoming
Fang marks
Local bleeding
Swelling, blistering & bruising
Haemorrhagic
blister
Tissue necrosisSlide49
Signs of Haemotoxic
Envenomation
Gingival
Bleeding,
Ecchymoses on the TrunkLateralising Neurological Signs of Intracranial Bleeding,Bleeding from aPre Existing Condition i.e. Prolapsed Piles.Slide50
Neurological manifestations
Ptosis
External ophthalmoplegia
Broken neck sign
Difficulty in opening mouth & protruding tongueSlide51
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
ANTIVENOMSSlide52
Cause
of
death
Prolonged
visits to traditional healers (
ojhas
)
Problems with transportation
Inadequate treatment facilities in hospitals. Slide53
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.Slide54
Prevention, Community Education & Pre-hospital Care
Surveillance & Reporting, Clinical & Lab. Research
Education & Training, Improved Medical
Management
ADRESSING THE ISSUSESSlide55
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 Slide56
Acknowledgements
PRO. M.A. FAIZ.
PROF DAVID WARELL
PRO. DR. RIDWANUR RHAMAN
WHO GUIDELINE
NATIONAL GUIDELINESNAKEBITE STUDY GROUP OF CHITTAGONG,DHAKA,RANGPURMYMENSINHG.RAJSHAHI,SYLET
ALL MY COLLEGUES AND DOCTORS OF WARD 16 ,CMCHALL PUBLICATIONS - BOTH NATIONAL AND INTERNATIONALSlide57
Thank YouSlide58
Venomous = 17.6%Slide59Slide60
monthlySlide61Slide62Slide63
Locality of Neurotoxic SnakebiteSlide64Slide65Slide66
Anti-venom = 44 + 1 = 45Patient
admitted in ICU =
5
Total number of death = 5 (1 in ICU)
Green pit developed AKI = 2Slide67Slide68
2013
Death rate = 7.5 %Slide69
Gender distribution
Male – 912 & Female – 366 Slide70
Age distribution
Number of PatientsSlide71
Monthly admission in 2013