Snake Bite Epidemiology and Mortality in India
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3
RD
INTERNATIONAL SUMMIT ON
TOXICOLOGY & APPLIED PHARMACOLOGY
OCTOBER 20-22, 2014
CHICAGO, USA
Amita Srivastava
National Poisons Information
Centre (NPIC)
Department of Pharmacology
All India Institute of Medical
Sciences
New Delhi -110029, India
A twelve years retrospective analysis of telephone calls reported to the
National Poisons Information Centre, AIIMS
Snake bite poisoning
Department of Pharmacology, AIIMS, New Delhi
B
ackground
Snake bite is a major environmental and occupational hazard in
rural India and South Asian
region
India has one of the highest rates of death from snake bite in the
world
WHO has estimated the highest number of snake bites (83,000)
and deaths (11,000) per annum in India
80% of snake bite victims in most of the developing countries seek
traditional remedies before visiting a health care facility. This has
resulted in high mortality
Department of Pharmacology, AIIMS, New Delhi
Epidemiology
As per few reports there are cases of approximately 200,000 bites
and 35,000-50,000 snake bite deaths
No reliable national data available
High occurrence of snake bite reported in the states of Uttar
Pradesh, Andhra Pradesh, Tamil Nadu, Kerala, and Maharashtra
Incidences of snake bites are twice in male then female
Majority of the bites are on the lower extremities
50% of bites by venomous snakes are dry bites that result in
negligible envenomation
Department of Pharmacology, AIIMS, New Delhi
Snake bite mortality in India: Study by Mohapatra et al
(2011)
High incidence
states (Annual
snake bite deaths) -
Uttar Pradesh:
8,700
Andhra Pradesh:
5,200
Bihar: 4,500
Department of Pharmacology, AIIMS, New Delhi
Classification
Worldwide, only about 15% of the
more than 3000 species of snakes
are considered dangerous to
humans
The family Viperidae is the largest
family of venomous snakes, and
members of this family can be found
in Africa, Europe, Asia, and the
Americas
The family Elapidae is the next
largest family of venomous snakes
There are around 216 species of
snakes in India, out of which 52 are
recognized as poisonous
Traditionally big four include:
1.
Elapidae (cobra and
Krait)
2.
Viperidae (Russell’s and
saw scaled viper)
Other snakes of medicinal
significance– King cobra,
monocle cobra, Asiatic cobra,
Andaman cobra, saw scaled
viper of northern India and
the Hump nosed viper from
Kerala
Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes
•
Cobra (Naja
naja)
•
Common krait
(Bungarus
caeruleus),
•
Viperidae
•
Russell's viper
(Daboia russelii)
•
Saw-scaled
viper (Echis
carinatus).
•
(Hump-nosed
pit viper
(Hypnale
hypnale)
Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes: Characteristics
C
o
b
r
a
Head of cobra is not distinct from neck which is dilatable and hood bears a
binocellate mark on upper side.
K
r
a
i
t
The fangs are short and fixed. Steel blue coloured hexagonal scales on
dorsal side with rows of paired white stripes across belly.
V
i
p
e
r
s
Large mobile fangs which are canalized and retractable
Russell’s Viper is brown in colour, elliptical patches in three rows on body
Triangular head with prominent nasal opening
Pit viper is uncommon in India
S
e
a
S
n
a
k
e
s
Short mobile fangs
Compressed posteriorly and has a flat tail
Department of Pharmacology, AIIMS, New Delhi
Who are at risk?
Agriculture
Ecotourism
Dealing with
venom
Fishermen
Hunters
Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes bites: Characteristics
Department of Pharmacology, AIIMS, New Delhi
Monitoring period in Envenomation
Department of Pharmacology, AIIMS, New Delhi
Snake venom has different predominant effects
depending on the family…
Department of Pharmacology, AIIMS, New Delhi
Pathogenesis of Snake venom
Department of Pharmacology, AIIMS, New Delhi
Study carried out to highlight the epidemiological features
of snake bite calls reported to NPIC
Department of Pharmacology, AIIMS, New Delhi
Recording information
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?
•
Identify the caller
•
Note patient’s details- including age, occupation and sex
•
Date and time of the bite- Day/ Night
•
Site of the bite- Lower extremity/Upper extremity
•
Fang mark- (single, double, scratches: Yes/No)
•
Identification of snake: Poisonous/ Non poisonous ; Elapidae (Cobra, Krait), Russel’s viper
Saw –scaled viper, Unidentified
•
Time Interval between bite & treatment given
•
Application of tourniquet- Yes/ No
•
Local Application of substances like lime, chili, herbal remedies?
•
Incision over bite site: Cryotherapy, Sucking over bite
•
Any other treatments received
•
Hospital admission
•
ASV already administered
•
No. of vials, Reactions with ASV
•
Outcome
Department of Pharmacology, AIIMS, New Delhi
April 1999 –March 2011: T
otal calls 13,162 telephone
calls, snake bite cases=290
Household products
Eight groups:
Agricultural pesticides
Drugs
Industrial chemicals
Plants
Bites and stings
Miscellaneous
Unknown groups
Calls from Delhi- 71.35%
Calls from other
states of India - 28.65%
Adults involved - 77.66%
Children involved - 22.33%
Age group with the highest incidence of
reporting was between 18-40 years
(82.53%)
Males outnumbered females
(M=73.10%, F= 26.89%)
Department of Pharmacology, AIIMS, New Delhi
Incidence of snake bites
North India:
Elapids
South India:
Viperidae
Department of Pharmacology, AIIMS, New Delhi
Site of snake bites
•
The victims were bitten mostly at
night or midnight:
N
i
g
h
t
s
5
8
.
7
3
%
D
a
y
t
i
m
e
4
1
.
2
6
%
•
A significant number of cases
occurred while the victims were
asleep
Department of Pharmacology, AIIMS, New Delhi
Incidence of snake bite varies with climate…
Peak in July, August and
September
No bites
December, January and
February
Department of Pharmacology, AIIMS, New Delhi
Clinical Presentation
Department of Pharmacology, AIIMS, New Delhi
Medical aid received
The time interval:
Within 1-4 hours 51.77%
After 4 hours 48. 22%
Antivenom received 71.25%
Most of patients received 17-20 vials of Polyvalent anti-snake
venom (ASV)
Two patients were given140 ASV vials
One patient was given 350 vials of ASV over 10 days without any
clinical improvement
Department of Pharmacology, AIIMS, New Delhi
Summary of data
Majority of the snakebite cases were due to Cobras and Kraits
Increased incidence of bites during Rainy/Monsoon season
High incidence of bites reported at night
Males outnumbered females (
M= 73.10%, F= 26.89%)
Highest incidence reported between 18-40 years
Incidence of bites in lower extremities was high (50%)
Sign of local envenomation was predominant, with pain (57.14%)
Early administration of antivenom reduced the risk of complications
The limitation of this study was the data collected from telephonic calls.
We do not have the prognosis of the snake bite cases reported to the
respective hospitals
Department of Pharmacology, AIIMS, New Delhi
Management - Pre Hospital
Keep the victim calm
Wash the bite site with soap and water/wound should clean with antiseptic
Immobilize the bitten area
Do not cover the bite area and puncture marks
W
h
a
t
n
o
t
t
o
d
o
?
No cryotherpy
No incision at the bite site
Do not burn the wound
Do not suck the wound with mouth
Potassium permanganate should never be used
Department of Pharmacology, AIIMS, New Delhi
Hospital & Antivenom Therapy
Maintain airway, breathing and circulations
Oxygen supplementation
Intravenous fluid
Vasopressors for hypotensive shock
Antihistamines anaphylactic reactions
Analgesics alleviate pain
Antibiotics and antitetanus
I
n
v
e
s
t
i
g
a
t
i
o
n
Blood samples for total blood count, coagulation profile, serum
biochemistry renal and hepatic functions
20WBCT
ASV reactions Early Anaphylactic reactions & Anaphylaxis (10-180 min)
Department of Pharmacology, AIIMS, New Delhi
Anti-snake venom (ASV) is the mainstay of treatment
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liquid ASV requires a reliable cold chain and has 2-year shelf life.
Lyophilized ASV, in powder form, has 5-year shelf life and
requires only to be kept co
ol
.
No monovalent ASV
Polyvalent ASV is Questionable ?
Humpnosed pit viper (Hypnale hypnale)
Saw-scaled viper (Echis carinatus sochureki)
Department of Pharmacology, AIIMS, New Delhi
Administration of antivenom
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Skin and conjunctival “hypersensitivity” tests may reveal IgE mediated Type I
hypersensitivity to horse or sheep proteins but do not Predict the large majority of
early (anaphylactic) or late (serum sickness type) antivenom reactions. Since they
may delay treatment and can in themselves be sensitizing, these tests should not be
used.
Epinephrine should always be
drawn up in readiness before
antivenom is administered.
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Department of Pharmacology, AIIMS, New Delhi
Constraints in management of snake bite
Department of Pharmacology, AIIMS, New Delhi
Present Scenario
•
Rural people trust herbal and other
traditional forms of treatment
•
Traditional practitioners are readily
available in the village and their
services are cheap
•
About 50% of bites by venomous
snakes result in envenoming
(injection of sufficient venom to
cause local and/or systemic
effects) even useless remedies will
appear effective in a proportion of
cases.
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Department of Pharmacology, AIIMS, New Delhi
Some important points
NPIC works round the clock to provide its services
Awareness in the local population on providing first aid to snake bite
Local healers/ tantriks/ojhas should be avoided in snake bites cases
Peripheral doctors should be trained on the diagnosis and
management of snake bite use of anti venom
In absence of symptoms, victim should be observed for at
least 24
hours
Country wide epidemiological picture can’t be drawn due to non existence
of central registry of cases
Department of Pharmacology, AIIMS, New Delhi
Prevention
Community education is the key to reducing the risk of snake-bite.
Encourage safer working and walking by using adequate footwear
Avoid walking through knee high grass
Wear leather ankle shoes for out door activites
Protective clothing and carrying a light after dark
Safer sleeping by using a well tucked-in mosquito net
Victims of bites are encouraged to travel to hospital without delay,
Not wasting time with traditional treatments.
Department of Pharmacology, AIIMS, New Delhi
R
e
f
e
r
e
n
c
e
s
Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, Rodriguez PS, Mishra
K, Whitaker R, Jha P; Million Death Study Collaborators. Snakebite mortality in India: a nationally
representative mortality survey.PLoS Neglected Tropical Diseases. 2011 Apr 12;5(4):e1018. doi:
10.1371/journal.pntd.0001018.
Kasturiratne A,Wickremasinghe AR,de Silva N,Gunawardena NK,Pathmeswaran A,et al. The global
burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming
and deaths. PLoS Med 2008;5e21818986210
Warell DA. Epidemiology of snake-bite in South-East Asia Region. In: Warrell DA (ed.) Guidelines for
the management of snakebite. New Delhi: WHO regional office for Southeast Asia.2010
Suchithra N, Pappachan J M, Sujathan P. Snakebite envenoming in Kerala, South India: clinical
profile and factors involved in adverse outcomes.
Emergency Medicine Journal 2008;25:200-204
Gupta YK, Peshin SS. Snake bite in India: current scenario of an old problem. Journal of Clinical
Toxicology 2014; 4:182. doi: 10.4172/2161-0495.1000182.
Gupta YK, Peshin SS. Do herbal medicines have potential for managing snake bite
envenomation?Toxicology International 2012;19(2):89-99.
Bhardwaj A and Sokhey J. Snake bites in the hills of north India. National Medical Journal of India
1998;11:264-265
Bawaskar HS, Bawaskar PH, Punde DP,, Inamdar MK, Dongare RB, Bhoite RR.Profile of snake bite
envenoming in rural Maharashtra, India. Journal of Association of Physicians of India 2008;56:88.
Department of Pharmacology, AIIMS, New Delhi
Department of Pharmacology, AIIMS, New Delhi
Snake bites pose a significant public health challenge in India, with a high incidence of deaths especially in rural regions. Lack of reliable national data hinders accurate assessment of the problem. The major venomous snakes contributing to fatalities include species from the families Elapidae and Viperidae. Traditional remedies delay proper medical care, leading to increased mortality rates. Understanding the epidemiology and mortality trends is crucial for implementing effective prevention and management strategies.
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3RDINTERNATIONAL SUMMIT ON TOXICOLOGY & APPLIED PHARMACOLOGY OCTOBER 20-22, 2014 CHICAGO, USA Amita Srivastava National Poisons Information Centre (NPIC) Department of Pharmacology All India Institute of Medical Sciences New Delhi -110029, India
Snake bite poisoning A twelve years retrospective analysis of telephone calls reported to the National Poisons Information Centre, AIIMS Department of Pharmacology, AIIMS, New Delhi
Background Snake bite is a major environmental and occupational hazard in rural India and South Asian region India has one of the highest rates of death from snake bite in the world WHO has estimated the highest number of snake bites (83,000) and deaths (11,000) per annum in India 80% of snake bite victims in most of the developing countries seek traditional remedies before visiting a health care facility. This has resulted in high mortality Department of Pharmacology, AIIMS, New Delhi
Epidemiology As per few reports there are cases of approximately 200,000 bites and 35,000-50,000 snake bite deaths No reliable national data available High occurrence of snake bite reported in the states of Uttar Pradesh, Andhra Pradesh, Tamil Nadu, Kerala, and Maharashtra Incidences of snake bites are twice in male then female Majority of the bites are on the lower extremities 50% of bites by venomous snakes are dry bites that result in negligible envenomation Department of Pharmacology, AIIMS, New Delhi
Snake bite mortality in India: Study by Mohapatra et al (2011) High incidence states (Annual snake bite deaths) - Uttar Pradesh: 8,700 Andhra Pradesh: 5,200 Bihar: 4,500 Department of Pharmacology, AIIMS, New Delhi
Classification Worldwide, only about 15% of the more than 3000 species of snakes are considered dangerous to humans Traditionally big four include: 1. Elapidae (cobra and Krait) 2. Viperidae (Russell s and saw scaled viper) The family Viperidae is the largest family of venomous snakes, and members of this family can be found in Africa, Europe, Asia, and the Americas Other snakes of medicinal significance King cobra, monocle cobra, Asiatic cobra, Andaman cobra, saw scaled viper of northern India and the Hump nosed viper from Kerala The family Elapidae is the next largest family of venomous snakes There are around 216 species of snakes in India, out of which 52 are recognized as poisonous Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes Cobra (Naja naja) Common krait (Bungarus caeruleus), Viperidae Russell's viper (Daboia russelii) Saw-scaled viper (Echis carinatus). (Hump-nosed pit viper (Hypnale hypnale) Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes: Characteristics Cobra Head of cobra is not distinct from neck which is dilatable and hood bears a binocellate mark on upper side. Krait The fangs are short and fixed. Steel blue coloured hexagonal scales on dorsal side with rows of paired white stripes across belly. Vipers Large mobile fangs which are canalized and retractable Russell s Viper is brown in colour, elliptical patches in three rows on body Triangular head with prominent nasal opening Pit viper is uncommon in India SeaSnakes Short mobile fangs Compressed posteriorly and has a flat tail Department of Pharmacology, AIIMS, New Delhi
Who are at risk? Agriculture Ecotourism Dealing with venom Fishermen Hunters Department of Pharmacology, AIIMS, New Delhi
Common Indian snakes bites: Characteristics Cobra Krait Vipers Sea Snakes Local Effects Pain Swelling May be followed by necrosis Mild local pain Mild Swelling Weakness Swelling at the site of bite Severe pain at the site Discoloration of skin around the site of bite Sharp initial prick Generalized aching Tenderness Stiffness Systemic Effects Ptosis Glossopharyngeal paralysis Rapid pulse Death due to respiratory paralysis Nausea Abdominal pain Visual disturbances Diarrhea Tachycardia Shock Arrhythmias Hematuria Hemorrhage Epistaxis Melena hemoptysis Headache Myalgias Myopathy Rhabdomyolysis Thick feeling of tongue Department of Pharmacology, AIIMS, New Delhi
Monitoring period in Envenomation Common Snakes Average period Range Cobra 8 hours 12 min 120 hours Krait 18 hours 3 hours 63 hours 3 days 15 min 264 hours Russell s Viper Saw-Scaled Viper 5 days 25 hours 1 day Department of Pharmacology, AIIMS, New Delhi
Snake venom has different predominant effects depending on the family Neurotoxic Cardiotoxic Nephrotoxic Elapidae Hemotoxic Necrotoxic Viperidae Crotalidae Necrotoxic Department of Pharmacology, AIIMS, New Delhi
Pathogenesis of Snake venom Signs/Sympt oms and potential treatments Local Tissue Damage/pain Ptosis/ Neurotoxicity Coagulation Renal Problems Neostigmine & Atropine Cobra Krait Russell Viper Raw Scaled Viper Other Vipers Yes No Yes Yes Yes Yes Yes Yes No No No No No No Yes Yes Yes No Yes Yes Yes No? No? No No Department of Pharmacology, AIIMS, New Delhi
Study carried out to highlight the epidemiological features of snake bite calls reported to NPIC Recording of Calls of the enquirers, providing Information after consulting database, journals, referral books, Micromedex, US Healthcare series etc, Documentation, Data analysis and publications National Poisons Information Centre, Department of Pharmacology, AIIMS Provides round the clock service (24 x 7) (91) -11-26589391 (91) -11-26593677 1800 116 117 Receives calls from: Physicians Health care professionals/consultants General Public Government agencies Department of Pharmacology, AIIMS, New Delhi
Recording information Call Details Identify the caller Note patient s details- including age, occupation and sex Date and time of the bite- Day/ Night Site of the bite- Lower extremity/Upper extremity Fang mark- (single, double, scratches: Yes/No) Identification of snake: Poisonous/ Non poisonous ; Elapidae (Cobra, Krait), Russel s viper Saw scaled viper, Unidentified Time Interval between bite & treatment given Prior First-aid received? Application of tourniquet- Yes/ No Local Application of substances like lime, chili, herbal remedies? Incision over bite site: Cryotherapy, Sucking over bite Any other treatments received Hospital admission ASV already administered No. of vials, Reactions with ASV Outcome Department of Pharmacology, AIIMS, New Delhi
April 1999 March 2011: Total calls 13,162 telephone calls, snake bite cases=290 Eight groups: Household products Calls from Delhi- 71.35% Calls from other states of India - 28.65% Agricultural pesticides Drugs Industrial chemicals Adults involved - 77.66% Children involved - 22.33% Age group with the highest incidence of reporting was between 18-40 years (82.53%) Males outnumbered females (M=73.10%, F= 26.89%) Plants Bites and stings Miscellaneous Unknown groups Department of Pharmacology, AIIMS, New Delhi
Incidence of snake bites Cobra and Krait Unidentified Vipers Non-poisonous 3% North India: Elapids 5% 9% South India: Viperidae 83% Department of Pharmacology, AIIMS, New Delhi
Site of snake bites The victims were bitten mostly at night or midnight: 8% 10% Nights 58.73% Daytime 41.26% 50% 32% A significant number of cases occurred while the victims were asleep Lower limb Upper limb Eyebrow,abdomen,ear,neck,face Unidentified bite area Department of Pharmacology, AIIMS, New Delhi
Incidence of snake bite varies with climate 60.00% Peak in July, August and September No bites December, January and February 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Monsoon season Spring season Summer season Autumn season Department of Pharmacology, AIIMS, New Delhi
Clinical Presentation Local effects observed at the bite site Systemic manifestations Neurological 46.44% Respiratory 28.08% Generalized weakness 11.61% Bleeding disorder 8.23% Ocular paralysis 1.49% Renal failure 2.99% Asymptomatic 1.15% Pain 57.14% Bleeding 7.14% Swelling 26.98% No local reaction 8.73% Department of Pharmacology, AIIMS, New Delhi
Medical aid received The time interval: Within 1-4 hours 51.77% After 4 hours 48. 22% Antivenom received 71.25% Most of patients received 17-20 vials of Polyvalent anti-snake venom (ASV) Two patients were given140 ASV vials One patient was given 350 vials of ASV over 10 days without any clinical improvement Department of Pharmacology, AIIMS, New Delhi
Summary of data Majority of the snakebite cases were due to Cobras and Kraits Increased incidence of bites during Rainy/Monsoon season High incidence of bites reported at night Males outnumbered females (M= 73.10%, F= 26.89%) Highest incidence reported between 18-40 years Incidence of bites in lower extremities was high (50%) Sign of local envenomation was predominant, with pain (57.14%) Early administration of antivenom reduced the risk of complications The limitation of this study was the data collected from telephonic calls. We do not have the prognosis of the snake bite cases reported to the respective hospitals Department of Pharmacology, AIIMS, New Delhi
Management - Pre Hospital Keep the victim calm Wash the bite site with soap and water/wound should clean with antiseptic Immobilize the bitten area Do not cover the bite area and puncture marks What not to do ? No cryotherpy No incision at the bite site Do not burn the wound Do not suck the wound with mouth Potassium permanganate should never be used Department of Pharmacology, AIIMS, New Delhi
Hospital & Antivenom Therapy Maintain airway, breathing and circulations Oxygen supplementation Intravenous fluid Vasopressors for hypotensive shock Antihistamines anaphylactic reactions Analgesics alleviate pain Antibiotics and antitetanus Investigation Blood samples for total blood count, coagulation profile, serum biochemistry renal and hepatic functions 20WBCT ASV reactions Early Anaphylactic reactions & Anaphylaxis (10-180 min) Department of Pharmacology, AIIMS, New Delhi
Anti-snake venom (ASV) is the mainstay of treatment ASV is produced both in liquid and lyophilized liquid ASV requires a reliable cold chain and has 2-year shelf life. Lyophilized ASV, in powder form, has 5-year shelf life and requires only to be kept cool. No monovalent ASV Polyvalent ASV is Questionable ? Humpnosed pit viper (Hypnale hypnale) Saw-scaled viper (Echis carinatus sochureki) Department of Pharmacology, AIIMS, New Delhi
Administration of antivenom Freeze-dried (lyophilised) antivenoms are reconstituted, usually with 10 ml of sterile water. The freeze-dried protein may be difficult to dissolve Skin and conjunctival hypersensitivity tests may reveal IgE mediated Type I hypersensitivity to horse or sheep proteins but do not Predict the large majority of early (anaphylactic) or late (serum sickness type) antivenom reactions. Since they may delay treatment and can in themselves be sensitizing, these tests should not be used. Epinephrine should always be drawn up in readiness before antivenom is administered. Antivenom should be given by the intravenous route whenever possible. Department of Pharmacology, AIIMS, New Delhi
Constraints in management of snake bite Superstitions surrounding snake bites, apprehension and terror towards non-traditional medicine Time wasted in going to traditional/local healers Lack of awareness among people for seeking early medical help Problem in management Sensitized early administration of ASV results in better outcomes ASV neutralizes circulating snake venom, as while time elapses more and more, venom is bound to the target tissues becoming less amenable to neutralization by ASV. Availability of ASV reduces the bite to needle time Department of Pharmacology, AIIMS, New Delhi
Present Scenario However, these treatments have no scientifically demonstrable effectiveness, may be harmful and will delay the patients arrival in hospital. Rural people trust herbal and other traditional forms of treatment Traditional practitioners are readily available in the village and their services are cheap About 50% of bites by venomous snakes result (injection of sufficient venom to cause local and/or effects) even useless remedies will appear effective in a proportion of cases. in envenoming Alternative therapies should therefore be discouraged or the traditional practitioners educated to refer patients with definite symptoms of envenoming systemic Department of Pharmacology, AIIMS, New Delhi
Some important points NPIC works round the clock to provide its services Awareness in the local population on providing first aid to snake bite Local healers/ tantriks/ojhas should be avoided in snake bites cases Peripheral doctors should be trained on the diagnosis and management of snake bite use of anti venom In absence of symptoms, victim should be observed for at least 24 hours Country wide epidemiological picture can t be drawn due to non existence of central registry of cases Department of Pharmacology, AIIMS, New Delhi
Prevention Community education is the key to reducing the risk of snake-bite. Encourage safer working and walking by using adequate footwear Avoid walking through knee high grass Wear leather ankle shoes for out door activites Protective clothing and carrying a light after dark Safer sleeping by using a well tucked-in mosquito net Victims of bites are encouraged to travel to hospital without delay, Not wasting time with traditional treatments. Department of Pharmacology, AIIMS, New Delhi
References Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, Rodriguez PS, Mishra K, Whitaker R, Jha P; Million Death Study Collaborators. Snakebite mortality in India: a nationally representative mortality survey.PLoS Neglected Tropical Diseases. 2011 Apr 12;5(4):e1018. doi: 10.1371/journal.pntd.0001018. Kasturiratne A,Wickremasinghe AR,de Silva N,Gunawardena NK,Pathmeswaran A,et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008;5e21818986210 Warell DA. Epidemiology of snake-bite in South-East Asia Region. In: Warrell DA (ed.) Guidelines for the management of snakebite. New Delhi: WHO regional office for Southeast Asia.2010 Suchithra N, Pappachan J M, Sujathan P. Snakebite envenoming in Kerala, South India: clinical profile and factors involved in adverse outcomes.Emergency Medicine Journal 2008;25:200-204 Gupta YK, Peshin SS. Snake bite in India: current scenario of an old problem. Journal of Clinical Toxicology 2014; 4:182. doi: 10.4172/2161-0495.1000182. Gupta YK, Peshin SS. Do herbal medicines have potential for managing snake bite envenomation?Toxicology International 2012;19(2):89-99. Bhardwaj A and Sokhey J. Snake bites in the hills of north India. National Medical Journal of India 1998;11:264-265 Bawaskar HS, Bawaskar PH, Punde DP,, Inamdar MK, Dongare RB, Bhoite RR.Profile of snake bite envenoming in rural Maharashtra, India. Journal of Association of Physicians of India 2008;56:88. Department of Pharmacology, AIIMS, New Delhi
