Integration of snakebite management in rural Nepal: Challenges and solutions

Author(s) Sanjib Kumar Sarma1, Anup Ghimire2, Gabriel Alcoba3, Ulrich Kuch 4, Francois Chappuis 5
Affiliation(s) 1Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal, 2School of Public Helath and Community Medicine, B P Koirala Institute of Health SCiences, Dharan, Nepal, 3Division of Tropical and Humanitarian Medicine , Geneva University Hospitals, Geneva, Switzerland, 4Institute of Biomedical Research and Climate change, Institute of Biomedical Research and Climate Change, Frankfurt , Germany, 5Division of Tropical and Humanitarian Medicine , Geneva University Hospitals, Geneva, Switzerland.
Country - ies of focus Nepal
Relevant to the conference tracks Advocacy and Communication
Summary Snakebite envenoming is one of the most neglected public health problems in poor rural communities living in sub-tropical and tropical regions. In Nepal, proper management of snakebite envenoming relies on rapid access to a health facility where trained staff are able to administer antivenom and provide ventilatory support. Here, we report on an integrated care approach by which paramedics in the region were empowered in the prevention, management and research of snakebite envenoming.
Background Despite recent community-based data demonstrating the high burden it causes on health, snakebite has received little attention from stakeholders. South Asia is the world’s most affected region, with reported annual incidence and mortality rates of up to 1,162 and 162 per 100,000 population in rural southeastern Nepal.
Objectives We aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region
Methodology Community-based surveys, an intervention study, prospective and retrospective hospital-based surveys, a prospective observational clinical study and a randomized controlled trial were conducted to integrate different prospect of snakebite related issues in rural area of eastern Nepal.
Results Snakebite victims’ first encounter with the health care system in rural Nepal is with sub-health posts or primary health centers, where facilities for antivenom administration are non-existent. Access to adequate care is often not possible at secondary or even tertiary health care centres, from where patients are in fact sometimes referred to from smaller centres that are entirely specialized in the management of snakebite. In the absence of sufficient human resources to manage snakebite in rural Nepal, we aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region. Rapid transportation of victims by motorbike to a specialized snakebite treatment centre was identifed as a key life-saving measure in southern Nepal and a volunteer program was subsequently set up in this region. Research efforts have then focused on (i) the identification of snakes that bite patients in this region, (ii) the development of rapid diagnostic tests to identify the species of biting snakes and (iii) optimizing the dosage of antivenoms.
Conclusion The development of simple diagnostic tools and evidence-based antivenom dosage and ancillary treatment guidelines should facilitate the integration of snakebite management in the public health system as well as in the specialized centers run by paramedics. These efforts should be complemented by the routine integration of pre- and post-graduate training of healthcare personnel in snakebite management and an adequate commitment of medical authorities at both central (e.g., purchasing and deployment of free-for-patients antivenoms) and peripheral levels.

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