Why are more people dying despite fewer snakebites?
The latest NCDC data reveal that although fewer people are being bitten by snakes now compared to before, more people are dying
Snake charmer Nazrul Islam thought it was a baby python.
But the snake stuck in his fishnet was actually a Russell's Viper. The circular design on the viper's skin is similar to that of a non-venomous python, a trick that snake charmer Nazrul fell for. The locals of Faridpur's Char Bhadrashan asked him to take the snake and he obliged.
On his way back after the rescue, people asked to see the snake. While handling it this time, Nazrul got bitten on his fingertip. But he didn't pay much mind to the bite, as he was under the impression that it was a baby python.
Soon after, he struggled with his eyesight and felt a growing restlessness; he realised then that it was a venomous snake. He was taken to Bangabandhu Sheikh Mujib Medical College Hospital in Faridpur. Strangely enough, this medical college didn't have anti-venom so his poor family had to purchase the polyvalent antivenom from elsewhere. Nowadays a vial of antivenom is priced at Tk1,600, whereas before it was between Tk700 to Tk800.
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However, his situation continued to worsen and he was transferred to Dhaka Medical College Hospital. After spending several days in hospitals in Dhaka and Faridpur, Nazrul died, and his family was burdened with medical costs over Tk1,00,000.
Nazrul is one out of thousands of snake-bite victims who have died out of the several lakh snake-bitten people in Bangladesh.
According to the Directorate General of Health Services (DGHS)'s latest National Centre for Disease Control (NCDC) studies (published on 18 June 2023) titled "National Survey on Annual Incidence and Epidemiology of Snakebite in Bangladesh" in 2021-22, around 4.03 lakh people are bitten by snakes every year while 7,511 of them die from the injury.
Now this number of deaths in the latest study is curious because previously, in 2020, the health department said each year six lakh people are bitten by snakes and of this, 6,000 die. Another study published in 2017 in the American Journal of Tropical Medicine and Hygiene said almost 9 lakh people are bitten by snakes in Bangladesh of which 6,000 die each year.
So, held up against the previous data, the latest NCDC data reveal that although fewer people are being bitten by snakes now compared to before, more people are dying. The assumed yearly 6,000 has increased to more than 7,500 deaths per year.
Why?
We reached out to snake experts to learn why the number of snakebite-related deaths has increased, when data is suggesting fewer snakebites are occurring in Bangladesh. Snakebite cases have been in the limelight recently and experts have cited several factors behind the surge in snakebite death numbers.
While some of them brought to light the lack of scientific proof on whether the Indian anti-venom used in Bangladesh has been entirely effective against snakes of this area, they also mentioned how many of the available anti-venom in the hospitals are close to their expiry dates. They also mentioned the effects of increasing urbanisation which have led venomous snakes to human habitats, the overcropping in Barendra and char regions, and the lack of awareness of people regarding proper treatment in hospitals instead of at the hands of shamans.
Bangladesh National Guideline for Management of Snakebite says there are approximately 100 snake species in the country of which 37 are venomous. Of these, 16 are sea snakes, three types of cobra, five types of kraits, two types of coral snakes, six types of green pit vipers and one species of true viper which is called the Russell's Viper.
Bangladesh is not the only country in the world with so many types of venomous snakes. India has over 300 snake species and around 60 of them are venomous. Each year over 64,000 Indians die of snakebites. This figure accounts for over 80% of the global deaths in snakebites.
However, there are also several countries which have very few deaths, despite having several venomous snakes. Australia is one such example, of its 140 land snakes and 32 sea snakes, around 100 species are venomous.
Despite having so many venomous species of snakes, Australia surprisingly has only around 3,000 snakebites on record each year. While around 13% of human snakebite cases require antivenom, the country averages only about two snakebite fatalities a year.
"If you look at the number of people who actually die [in Australia] from snakes each year, it's practically nothing; the encounter rates are so low in comparison to other parts of the world," a Guardian story quoted Herpetologist Ruchira Somaweera of the Commonwealth Scientific and Industrial Research Organisation (CSIRO).
"Factors such as the quality of antivenom, our paramedical services and knowledge of first aid is really good here in Australia, which contributes to the negligible number of human deaths," he added.
The difference in nature of snake aggressiveness, human concentration and other issues have to be factored in, when comparing to other countries. Bangladesh's encounter rates are also high and preventative knowledge is poor; our farmers don't use footwear on fields nor do they have any first aid training.
"We have antivenoms but these antivenoms are not our own [imported from India]. There is no scientific study on how effective they are against our snakes. These anti-venoms are now used, but ideally, each country should develop their own anti-venom," said Dr Robed Amin, Line Director at the Department of Non-communicable Disease Control Program, Directorate General of Health Service of Bangladesh.
The anti-venoms used in Bangladesh are 'polyvalent' and used against four types of venomous snakes, including the Kraits, Cobra and Russell's Viper. Incepta is the only pharmaceutical company that brings these anti-venoms from India.
"The krait snakes that we have are not similar to Indian krait snakes. So these anti-venoms are not made with these snakes in mind. There is no scientific proof that these anti-venoms will be effective against the kraits in our country. That is why deaths are occurring even after applying anti-venom in some cases," Dr Robed said.
Could that be a reason why more deaths are happening?
This could be a possibility, he said. "You may think so. These all have to be proven scientifically, actually."
He also mentioned that the increasing number of deaths reported in the recent data was more inclusive, robust and extensive across the nation, because cases of snakebite-related deaths have been more in the limelight compared to before.
"Our number of snakebites has reduced as a whole, there is no doubt about that. But when you take both rural and urban data, the number of deaths may have risen," Dr Robed said, adding that, "the previous data was incomplete because they were only based in villages. The latest study was conducted on a cluster basis. This is more robust."
Abu Saeed is a snake expert with decades of experience.
He said that Chattogram Medical College Hospital keeps records of snake bites each year and the data says that 1,457 people underwent treatment for snakebites in 2022, 864 people in 2021, 755 people in 2020 and 612 people till June in 2023.
So there are reasonable grounds to wonder whether more people are coming to hospitals because of rising awareness about hospitals, or because people are actually encountering more snakes.
Furthermore, a lot of anti-venom was distributed among government hospitals over the last ten years, which have been used on patients for free. However, these anti-venoms expire in five years.
"The doctors don't use them often. Why? The upazila level doctors are new doctors, they don't have the experience. They fear that there could be an allergic reaction as a side effect of the anti-venoms and treating that will require facilities they do not have, like an ICU.
When patients arrive at hospitals, they usually already start exhibiting complications such as breathing difficulties, as they often delay in seeking medical assistance. Since there is no ICU support [in local hospitals], the patient's condition usually worsens. So they are referred to bigger hospitals," Saeed said.
Dr Robel Amin said that they distributed 50,000 anti-venom vials in 2020-21 through the government to the hospitals.
"If Upazila or Zila level hospitals don't use them, they will go to waste. Many of the anti-venoms have expired already," he said. "Although they can use anti-venoms six months after the expiry date, they don't do that. As a result, sometimes they say that they don't have it, even though the anti-venoms are available."
He said that they are trying to improve the situation by training and motivating doctors.
"We call on the experts in both online and offline training to make them understand. Many upazila hospitals formed teams to address these issues, but many are not doing anything. It may take a while for our efforts to work, but it will eventually work out," he added.
According to experts, Incepta's anti-venoms used to cost around Tk700 to Tk800 per vial, but now the prices have increased to Tk1400 per vial.
A snakebite patient requiring anti-venom needs ten vials, which means they will need to spend Tk14,000 to Tk16,000 in total from pharmacies, that is if they cannot receive free doses from government hospitals.
And in most cases, snakebite patients are poor people including farmers, snake charmers and village people.
"Previous studies found that snake-bites patients spend from Tk50,000 to Tk1,00,000 on treatment. The Faridpur patient [Snake Charmer Nazrul] had to spend over Tk1,00,000 before dying. Can poor patients afford that kind of money to purchase antivenom? And poor people are usually bitten by snakes," Abu Saeed said.
The experts we interviewed also suggested that ending the monopoly of one company could benefit the current scenario.
Abu Saeed said instead of purchasing five years worth of anti-venom at once, it should be bought gradually each year to ensure the latest productions are in stock.
"Another reason for increasing deaths is in the name of urbanisation and development, people are filling up agricultural lands, ponds and water bodies. As a result, snakes are losing their natural habitat and moving into human habitats, especially in the fall. As a result, the frequency of snake bites is increasing," Abu Saeed said.
"Besides, in the Barendra region, there used to be one crop a season. Now they produce three crops, and as a result, the snake's living spaces are shrinking. Similarly in the char, lands do not remain idle any more as every piece of land is being cultivated. Consequently, more people are being bitten by snakes," he added.
