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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.
Shaped by some of the most dramatic tectonic events of the Cenozoic, the parts of southern and eastern Asia that have become known as the Oriental faunal region comprise vast areas of great geological complexity and ecological diversity. One of the four major groups of terrestrial elapid snakes in this region is the genus Bungarus. These nocturnal and predominantly ophiophagous snakes are widely known as kraits and are an important cause of snakebite mortality throughout their wide range that extends from Afghanistan to Vietnam and eastern China, and south to the Indonesian islands of Java and Bali. Although present on Borneo, kraits have not been found on any island of the Philippines, nor on Lesser Sunda Islands east of Bali. Despite their medical significance and the great importance of Bungarus toxins as tools in neuropharmacology, krait systematics and taxonomy have remained largely unstudied. Twelve species of Bungarus were recognized at the beginning of the present study. Many of these are rare in collections, and most aspects of their biology are unknown. While some species are highly distinct, most kraits are conservative morphologically, rendering molecular methods invaluable for the study of their diversity and biogeography. This study is the first to address the relationships within Bungarus and the historical biogeography of kraits based on molecular evidence. I inferred phylogeographic relationships based on analyses of new nucleotide sequences of the entire mitochondrial cytochrome b gene of 51 kraits and partial NADH dehydrogenase subunit 4 sequences of 40 kraits which I analyzed together with a representative sample of 32 published elapid and non-elapid outgroup taxa using Bayesian, maximum-likelihood, maximum-parsimony and neighbor-joining methods. I then used the recovered phylogeny to investigate the evolution of selected morphological characters and, together with collections-based geographical distribution information, in dispersal-vicariance analyses with models of variable taxonomic and biogeographic complexity. The phylogenetic analyses demonstrate that the current taxonomy of kraits does not adequately represent either the relationships or the genetic diversity in this genus. In contrast, I identified monophyletic groups that are congruent with recognized biogeographic units as well as extensive ecomorph evolution and morphologically cryptic speciation. The following additional conclusions are collectively supported by the mitochondrial phylogeny and morphological as well as biochemical synapomorphies: (1) Kraits are monophyletic with respect to the remaining taxa of the Elapidae; (2) Bungarus flaviceps and Bungarus bungaroides form the monophyletic sister clade of a clade formed by B. fasciatus, black-and-white-banded, and uniformly black taxa; (3) the remaining taxa are divisible into two sister clades, the South Asian species (Bungarus sindanus (Bungarus caeruleus, Bungarus ceylonicus)) vs. Himalayan, Burmese, Southeast and East Asian taxa; (4) within the latter, Burmese taxa form the sister clade to Southeast and East Asian taxa; (5) the widespread and medically significant species Bungarus candidus and Bungarus multicinctus are paraphyletic. The results of this study highlight the importance of vicariant geological events and sea level fluctuations for the cladogenesis of kraits. Events of particular importance in the evolution of kraits include the uplift of the Indo-Burman ranges (Arakan-Naga Hills) which separated black-and-white banded kraits in India and Southeast Asia, and the uplift of mountain ranges in Yunnan, China (e.g., the Gaoligong Shan), which coincided with lineage separation in two distantly related clades of kraits. Alternating dispersal and vicariance events due to Pleistocene climatic and sea level changes have caused complex phylogeographic patterns in kraits in Southeast Asia. Zones of contact between closely related evolutionary lineages of the B. candidus complex are identified in Thailand, Vietnam, and southern China (Hainan). Within this complex, two main clades are revealed. One includes populations from the Southeast Asian mainland and is in contact with B. multicinctus in southern China. The other consists of populations from Thailand, southern Vietnam, Java, and Bali. The phylogeny as well as genetic distances suggest a scenario in which a Pleistocene southward dispersal of B. candidus to Sumatra, Java, and Bali during times of low sea levels was temporarily interrupted by vicariant events (rising sea levels, especially flooding of the Malacca Strait between Sumatra and the Malay Peninsula, and of the Bali Strait between Java and Bali). In this context, the close phylogenetic relationship between haplotypes from southern Vietnam and those from Java and Bali suggests that "southern" B. candidus dispersed directly via colonization of the widely receded South Chinese Sea, and not by taking a detour via the Malay Peninsula and Thailand, which were already inhabited by other populations of B. candidus. Using these phylogenetic estimates as the framework for a study on the diversity and evolution of krait venom components, I applied biochemical and molecular genetic approaches to identify and quantify polypeptide and protein toxins in krait venom, focusing on the distribution and molecular evolution of alpha-bungarotoxin, an irreversible competitive antagonist of nicotinic acetylcholine receptors with an exceptionally high applied significance as a receptor probe. I was specifically interested in the medically relevant question of intraspecific and interspecific variability in toxin diversity, and whether receptor-binding postsynaptic toxins evolve at rates different from those of presynaptic neurotoxins like beta-bungarotoxin, which act by destroying the nerve terminal and are believed to exhibit hypervariable functional diversification due to an accelerated mode of molecular evolution. In the context of this question, I isolated and purified the major lethal neurotoxins from B. candidus venoms by sequential steps of liquid chromatography for structural and functional characterization studies. Cloning and sequence analysis of toxin-coding genomic DNAs showed that the gene encoding the alpha-bungarotoxin alanine-31 variant, originally isolated from B. multicinctus venom, is widely present and highly conserved in multiple populations of B. candidus and is expressed as the principal postsynaptic neurotoxin at least in Javan B. candidus. In addition to the widespread presence of genomic DNAs encoding the alpha-bungarotoxin alanine-31 variant, the present study also revealed the partial genes of three novel alpha-bungarotoxin isoforms in addition to the previously known alanine-31 and valine-31 variants, all of which share an invariant exon 3 coding region. While alpha-bungarotoxin is the principal postsynaptic neurotoxin of Taiwanese B. multicinctus and Javan B. candidus, the main postsynaptic neurotoxin of Thai B. candidus both by quantity and lethality was a novel polypeptide of similar toxicity with a mass of 8030 Da and 73 amino acid residues, whose characterization at the genetic and protein levels revealed a novel subgroup of krait neurotoxins, here named alpha-delta-bungarotoxins and represented by four sequences from Bungarus caeruleus and B. candidus. alpha-delta-Bungarotoxins share high sequence homology with alpha-bungarotoxins but the purified, 8030 Da alpha-delta-bungarotoxin-1 exhibits only reversible, low affinity binding to nicotinic receptors and high site-selectivity for the acetylcholine binding site at the alpha-delta-subunit interface of the receptor. These properties render alpha-delta-bungarotoxin not only the first snake long-chain neurotoxin with reversible binding and binding-site selectivity, but also an exciting natural tool with which to address structure-function relationships at the subunit interfaces of the human receptor. The results of comparisons of the number of non-synonymous nucleotide substitutions per nonsynonymous site (dN) to the number of synonymous nucleotide substitutions per synonymous site (dS) strongly suggest that positive selection is acting on exon 2 of the alpha-bungarotoxin and probably also of the alpha-delta-bungarotoxin genes. In addition, the numbers of nucleotide substitutions per site of intron (dI) compared to the dS value of the toxin-coding exon regions provide strong evidence for accelerated molecular evolution in exon 2 of alpha-delta-bungarotoxins —whose value of dI is only one-eighth of the value of dS—whereas the hypothesis of accelerated evolution is rejected for 13 unique genomic DNAs encoding five alpha-bungarotoxin isoforms from B. candidus and B. multicinctus....