I write this as I sit in the Kerala Airport in India, waiting to start my long trip home to the U.S.
History was made on July 24th and 25th of this year in Kochi, India, when a group of physicians and scientists was brought together for the Indian National Snakebite Conference, Toxocon-2, hosted by the Amrita Institute of Medical Sciences, and sponsored by the World Health Organization. The meeting was jointly organized by the Indian Society of Toxicology and its President, Dr V. V. Pillay.
This meeting was the culmination of 2 years of very hard work by Dr. Ian Simpson, member of the W.H.O. Snakebite Group, and a number of his Indian colleagues. The purpose of the meeting was to develop a national protocol for pre-hospital management (first aid) and hospital treatment of venomous snakebites in India—the country with the highest number of snakebite deaths in the world, estimated to exceed 50 000 per year in that country alone. It was my great privilege to be asked to participate in this ambitious initiative. The attendees included herpetologists and snakebite experts from across the country.
As we are all well aware, trying to get anything of great importance accomplished in a large “committee” can be extremely frustrating. This could be especially true when the topic is as emotional and fraught with anecdote as venomous snakebite management. Despite the arguable vast importance of snakebite in terms of morbidity and mortality on human populations around the world (particularly poor, agrarian populations), the amount of research attention (especially research funding) and the number of solid research papers regarding snakebite treatment remains terribly small. Filling that gap, unfortunately, is a wealth of passionate, dogmatic opinion. Thus, when asked to participate in an initiative to develop the first comprehensive, national snakebite management protocol in the world, I was a bit skeptical of its chances for success. That was until I met Dr. Simpson and the Indian professionals with whom he has been working closely for the last 2 years. The group of individuals involved in this project impressed me immediately with their dedication and commitment to medicine in general, and to snakebite management in particular. They instilled confidence in a successful outcome for the meeting. Thus, in my inaugural address to the conference, I expressed my heartfelt anticipation of success and my sense that this would be an historical event. I was not disappointed.
Over the 2 days of the conference, experts gave evidence-based presentations on several topics. These included a presentation by Dr. Simpson on the medically important snakes of India (blasting the myth that India has only 4 truly important venomous snakes—“the big four”—the spectacled cobra (Naja naja), the common krait (Bungus caeruleus), Russell's viper (Daboia russelii) and the saw-scaled viper (Echis carinatus). Drs. J. K. Joseph, Simpson and their co-authors have recently discovered that the hump-nosed pit viper (Hypnale hypnale) is also a potentially life threatening snake. 1 Dr. Simpson emphasized, in the Kochi conference, that there is much left to be discovered about other potentially important, and largely unstudied, venomous snakes in India.
Other presentations included talks on field management of snakebite (again focusing on sound, scientific evidence), venomous snake taxonomy, management of antivenom induced anaphylactoid reactions (a significant problem in many countries, including India), and a remarkably lucid presentation on biostatistics (which emphasized the importance of statistical power, something that is greatly missing in most snakebite research).
Scattered between the educational/review presentations were 6 pragmatic workgroup discussions that were intended to come up with a consensus protocol for different aspects of snakebite management. Each of these workshops was co-led by selected experts in the field and provided a forum for input from any interested participant in the conference. The workgroups included: Pre-hospital/First aid management recommendations Signs and symptoms of venomous snakebite (with development of a syndromic classification of venomous snakebite in India to aid clinicians treating victims bitten by unidentified snakes) Ancillary investigations important in evaluating snakebite victims Antivenom dosing and re-dosing Prevention and management of acute anaphylactoid reactions Evaluation and management of snakebite complications.
By the end of the first day, a national protocol for first aid measures to be used in snakebite in India was “put to bed.” By the end of the second day, history had indeed been made. For the first time ever, a comprehensive, evidence-based, snakebite management protocol was developed for a nation. This is particularly impressive as that nation includes 1 in 6 members of the human race!
Next steps include ratification by the W.H.O. and by the India Ministry of Health, followed by dissemination of comprehensive snakebite management packages to the many hundreds of hospitals in India where victims seek care. These packages will include superbly designed snake identification posters for use in the casualty and critical care units, and, of course, the management protocols themselves. By the time this letter is “inked,” it is my hope and expectation that this process will be completed, and physicians in India will be well on their way to applying a uniform management protocol for snakebite victims, reducing the toll on human life and suffering.
This protocol will also offer a wealth of opportunity for excellent research into the problem of venomous snakebite in India. In the state of Tamil Nadu, plans are to have every dead snake brought to the hospital by a victim, preserved for later identification by skilled herpetologists, to get to the bottom of just which snakes are truly of medical importance in India.2,3
In addition, research will be conducted on such “sticky” problems as the use of prophylactic medications prior to antivenom administration (in an effort to reduce the almost 80% rate of anaphylactoid reactions to this antiserum in India), and the use of acetylcholinesterase inhibitors in neurotoxic snake venom poisoning (complete with objective measurements of effect).
My hat is off to Dr. Simpson and his Indian colleagues for their forward-thinking approach to this major medical problem. The rest of the developing world (and even those regions that consider themselves “first world”) would benefit from taking a close look at what has been accomplished by India's National Snakebite Conference. It is true testimony to what can be accomplished when opinions and anecdotes are set aside, and recommendations are based on existing, scientific evidence.