The tragic death of Shehala Sherin after she was bitten by a snake while inside her classroom at Sulthan Bathery in Wayanad on Wednesday is the culmination of a series of negligent acts, right from the delay in rushing her to a hospital equipped to treat snakebites to the failure of doctors to understand a classic case of envenomation and act quickly.
It is also a typical case of how snakebite envenomation, formally listed by the WHO in June 2017 as the highest priority neglected tropical disease, can be mismanaged because of the lack of knowledge and awareness among the public and clinicians.
Children vulnerable
Snake venoms can be either neurotoxic or hemotoxic and children may suffer more severe effects and can experience the effects more quickly than adults due to their smaller body mass.
Venomous snakebites are thus an acute medical emergency and the only thing that can be done is to ensure that the patient is immobile and rush him/her to the nearest hospital equipped to administer antisnake venom (ASV). In Kerala, ASV is available in all public sector institutions from taluk hospital upwards.
Cobra envenomation
From all descriptions of the symptoms exhibited by the child, it was a case of cobra envenomation. Yet it took 45 minutes for the Bathery taluk hospital to confirm this and even then, the clinician was not confident to administer ASV.
“There are national guidelines on snakebite management. Bites and the pattern of neurotoxicity can vary and the patient has to be observed closely. The only ASV available in India for snakebites is polyvalent (combination of antivenom for four common snakes) and its administration can definitely trigger some complications. The patient could go into coma or a cardiac arrest and the hospital should be equipped to manage the complications in a coordinated manner. This is probably one of the reasons why hospitals are reluctant to take on the responsibility of snakebite cases,” says R. Dileepkumar, a researcher who has been working in the area of snake envenomation therapeutics for the past 15 years.
Private hospitals
Very few private hospitals manage snakebites or stock ASV. There is an ASV shortage in the open market because it is a price-controlled drug and brings in little profit for pharma companies because the government is the main purchaser. Also, the quality of ASV available in the market is also suspect.
Doctors wait for symptoms to develop to administer ASV because there are no detection methodologies for the fast diagnosis of snake envenomation status. Even then, the right dosage of ASV might not be administered. Sometimes the onset of symptoms could be delayed by hours. Government medical colleges are well equipped to manage snakebites but often the reaction of the public is to rush the patient to the nearest hospital.
According to the Kerala Medical Services Corporation, there is no shortage of ASV in government hospitals. The annual indent for ASV in the State is around 20,600 vials and the current stock position is about 28,470 vials.
