Venomous snakes of medical relevance in Nepal: study on species, epidemiology of snake bite and assessment of risk factors of envenoming and death

Snake bite envenoming often results in disability or death of breadwinners of poor families in the rural tropics and the subtropics of Nepal. Identification of the medically relevant snake species, circumstances of venom
Snake bite envenoming often results in disability or death of breadwinners of poor families in the rural tropics and the subtropics of Nepal. Identification of the medically relevant snake species, circumstances of venomous snake bites, prehospital care of their bites and human responses to snakes and snake bite is, therefore, crucial to enable victims or first aider to select the appropriate first aid measures, physicians to anticipate complications and to use appropriate treatment protocols as well as the local community to implement prevention strategies. Inadequate educational gaps exist in Nepal and hinder identification of snakes involved in bites. To fill this gap, I aim to provide an evidence-based list of medically relevant snake species. Snake specimens brought by patients bitten or their attendants from the tropical and subtropical regions in southeastern, southcentral, and southwestern Nepal to snake bite treatment centres over a period from 2010 through 2014, were taxonomically identified and medical records of envenoming were evaluated.
In Nepal, the epidemiology of snake bite is poorly known. Here I describe the ecological circumstances of proven krait (Bungarus spp.) and Russell´s Viper (Daboia russelii) bites to elucidate and examine, whether environmental circumstances or human behaviour contributed to envenoming. In a cross-sectional study, data about prehospital care, environmental circumstances of 46 krait and 10 Russell´s Viper bites were evaluated. Patients were interviewed using structured interview forms. Snake bite prone communities were surveyed to test people´s knowledge on snakes and their attitude towards venomous snakes in general. 
Of 349 snakes involved in bites, 199 (57%) specimens were found to be medically relevant venomous snakes that included 11 species belonging to six genera and two families. Among them, Naja naja (n = 76, 22%), Bungarus caeruleus (n = 65, 19%) and Trimeresusurs albolabris (n = 10, 3%) were the most widely distributed snakes. Daboia russelii (n = 10, 3%) was found to be restricted to the southwestern part of Nepal. For B. walli, a previously poorly known species, 13 voucher specimens represent the first country records of this species as well as the first documented cases of involvement in snake bite envenoming by this species in Nepal. 
Numerous snake bites (33%) occurred at night, during the rainy season, and are mainly due to Bungarus species, particularly B. caeruleus. Bites of cobras and Russell’s Vipers are a risk at daytime. Evaluation of data regarding the place where the bite happened, indicates that the snake bite risks appear to be as high in residential areas, in and around houses, as in rural areas. In cases of kraits (n = 46), 61% of the bites occurred while the victim was sleeping indoors, those of Russell´s Vipers mainly during agricultural activities in the fields. Analysis of socio-demographic data revealed that both krait and viper bites predominantly affected farmers or their family members. However, snake bites involved also people of higher socio-economic status, which suggests that it is not a health problem of poor people only living in the rural areas of Nepal. 
A small number of snake bite victims (n = 7) sought help from traditional healers, but most patients went to hospitals for medical treatment using motorbikes (65%) or were transferred by ambulance cars (22%). As a first aid measure, most patients (78%) had used a tourniquet, which is of doubtful value and has often severe sequelae, instead of applying the WHO recommended pressure immobilisation bandage or local compression pad. The overall case fatality rate was calculated to be 10%, but up to 17% in cases of Bungarus spp. bites. 
Rural community people were found to be extremely afraid of snakes, a major reason for indiscriminate killing of even harmless snakes, e.g., Lycodon aulicus, which were wrongly considered to be venomous. This is mainly due to the poor knowledge on snakes in general and on their role in providing ecological services, which may eventually lead to a decline in snake populations and even the extinction of rare species. 
The results of the present study strongly emphasize that snake bite is an important public health issue in Nepal. There is an urgent need to improve the knowledge of people on snakes and to try changing their attitudes towards these reptiles, in addition to documenting the biodiversity and distribution of medically relevant snakes, the epidemiology and circumstances of their bites. Avoiding high-risk behaviour (e.g., killing of snakes), using screened doors and windows are some of the suggested measures preventing snake bite. Early and accurate identification of the snakes involved should help physicians to apply timely treatment, eventually referring the patient to the appropriate hospital. This also has important implications in developing public health and conservation strategies, to the benefit of the people of Nepal.
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Metadaten
Author:Deb Prasad Pandey
URN:urn:nbn:de:hebis:30:3-382724
Publisher:Univ.-Bibliothek
Place of publication:Frankfurt am Main
Referee:Gunther Köhler, Jörg Oehlmann
Advisor:Gunther Köhler
Document Type:Doctoral Thesis
Language:English
Date of Publication (online):2015/10/08
Year of first Publication:2015
Publishing Institution:Universitätsbibliothek Johann Christian Senckenberg
Granting Institution:Johann Wolfgang Goethe-Universität
Date of final exam:2015/09/18
Release Date:2015/10/08
Tag:Bungarus; Bungarus niger; Bungarus walli ; Daboia russelii; Naja; Russell´s Viper; cobra; elapid snake; envenoming; krait; medically relevant; snake bite; venomous snakes
Pagenumber:231
HeBIS PPN:365058750
Institutes:Biowissenschaften
Dewey Decimal Classification:590 Tiere (Zoologie)
610 Medizin und Gesundheit
Sammlungen:Universitätspublikationen
Biologische Hochschulschriften (Goethe-Universität)
Licence (German):License Logo Veröffentlichungsvertrag für Publikationen

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