- What’s the story on snakebite management and the crisis?
In general, snakes strike fear in one’s heart. While this aura of fear is mostly undeserved, the basis of that fear stems from the fact that some snakes are venomous. And of course, these venomous snakes get a huge amount of screentime, both literally and figuratively. The fact that snakes are venomous and can pose a danger to humans is extremely important and not at all something to be overlooked, but, our fear of snakes also colours our interactions with them, and not for the better.
Take, for example, Thailand, which once went too far in controlling its snake populations and found itself facing an entirely different problem of too many rats, lizards, frogs, and other animals that the snakes had been preying on the entire time.
Then, of course, you have the number of snakes that are killed on sight. Sometimes, yes, these snakes are easily identifiable as those that pose a danger to humans, but you also find an equal number of non-venomous snakes that are killed, both from fear and the risk of them becoming pests.
In June, a snakebite fatality that was reported from Anuradhapura sparked controversy. It is no secret that Sri Lanka is in crisis, but what drew controversy was reports that the victim (a 16-year-old boy) succumbed to his injury due to a lack of availability of medicine as a result of shortages.
Towards the end of June, the Sri Lanka Medical Association (SLMA) Expert Committee on Snakebite, following an emergency assembly and investigation, held a press conference to address fears of shortages in medicine for snakebite treatment (antivenom and so on). They noted that there was no shortage of essential medications to treat snakebites, urging the public to continue seeking prompt treatment for snakebites from government hospitals, as these hospitals and their staff were competent enough to cope with such admissions.
With snakebites and their treatment being a cause for concern at present, Brunch reached out to General Sir John Kotelawala Defence University Professor in Medicine and Colombo East Teaching Hospital Department of Medicine Consultant Physician and Head Prof. Kolitha Sellahewa for more insight. Prof. Sellahewa is a former Chairman and current committee member of the SLMA Expert Committee on Snakebite and an envenomation consultant for Anti Venom Research International.
The true story behind snakebites in Sri Lanka
Addressing reports that incidences of snakebites are increasing, Prof. Sellahewa provided some perspective on snakebites in Sri Lanka over the last 35 years, explaining that when SLMA’s Expert Committee on Snakebite was formed in 1983, hospital admissions for snakebites were very low – in 1985, for instance, there were only 3,820 snakebites reported and 132 deaths. This very low reporting of snakebites was because 
the vast majority of snakebites were treated at the community level with ayurvedic remedies or similar. The number of annual deaths by snakebite (reported at hospitals) during this period stood in the region of 130 deaths.
This high death rate for snakebite and the observation of a general lack of awareness and training on snakebites and snakebite management was what led to the formation of the Expert Committee on Snakebite, with the committee focusing not only on training hospitals on how to better manage snakebites, but also on awareness building at the community level to seek treatment from the nearest government hospital in the event of being bitten. These awareness efforts paid off very quickly, and 1986 saw 27,082 hospital admissions, but also 164 deaths.
Over the next few decades, the Expert Committee on Snakebite would work tirelessly to streamline snakebite management and minimise the number of deaths, and as of 2019, it was able to report that there had only been 50 deaths by snakebite that year against 34,239 admissions. In this respect, Prof. Sellahewa explained that it was possible to argue that snakebites have increased exponentially, but careful reviewing of the data and the factors behind the data would show that this increase in incidence was due to awareness and better infrastructure allowing more people to report snakebites and better care and management of snakebites.
Has the national crisis impacted snakebite management?
Media reports of an avoidable death by snakebite taking place because of mismanagement and lack of medical supplies caused understandable concern, especially with other areas of healthcare suffering from devastating shortages.
However, Prof. Sellahewa observed that there was no shortage of antivenom, the medicine used to treat envenomed snakebites (bites by a venomous snake, where venom has been released into the wound. There are many cases, even when bitten by a venomous snake, where there is no venom in the bite. These are referred to as dry bites). Prof. Sellahewa also explained that this was investigated personally by the Expert Committee on Snakebite and no shortage of antivenom had been found.
Addressing the specific case of snakebite death that was widely reported in the media, Prof. Sellahewa shared that the committee received convincing data that the patient in question had in fact been administered antivenom but had died as a result of the reaction to antivenom. Adverse reactions to antivenom are fairly common, which is why antivenom is only administered when medical teams are certain the snakebite is envenomed, which is easy to identify when looking at the wound.
“I feel the media statements are wrong and very damaging,” Prof. Sellahewa said. “When statements like these are made, people lose confidence in coming to hospitals. There are lots of quacks in communities who treat snakebites and they will capitalise on this issue. These statements have a negative impact on the hard work we have put in to persuade people to come into hospitals and get the appropriate treatments and the progress we have made in this regard. Irresponsible reporting can have a very damaging impact.”
Commenting on the unavailable medicine that sparked media reports of antivenom shortage in the first place, Prof. Sellahewa explained that to his knowledge, the medicine that was unavailable was an antihistamine to balance the effects of adrenaline given to counter the patient’s reaction to the antivenom.
The judicious administering of antivenom is what has helped reduce Sri Lanka’s annual snakebite deaths, with Prof. Sellahewa sharing that previously, physicians’ approaches to snakebite treatment were taken directly from textbooks, administering antivenom to every snakebite. “When I was Chairman of the Expert Committee on Snakebite, we changed these guidelines. We realised we didn’t have to give antivenom to all these victims, and clearly identified pathways of care based on whether it was a dry bite. I have personally had victims of venomous snakes like cobras come in with the cobra captured, but have not had to give antivenom because it was a dry bite with no envenoming.”
Prevention is better than a cure
While there is no shortage of antivenom, Sri Lanka as a country is going through its biggest economic crisis to date, and the effects of this crisis are far-reaching. With snakebites, as with all unpleasant things in life, prevention is better than a cure, and so Brunch asked Prof. Sellahewa how we can look to avoid snakebite in this time of trouble, where even getting to a hospital has been made more difficult with almost no fuel available in the country.
It should be noted that most reported snakebites come from the North Central Province, with farmers being the group most vulnerable to snakebites. “Snakebite is a highly neglected tropical disease,” Prof. Sellahewa said. “The higher authorities and politicians are not interested in it because it’s the poor people who are affected. Even globally, there are five million snakebites every year, affecting farmers and similar groups in mostly Asian, Saharan, and South American countries. Locally, it is during the harvest peak time that we see a surge in the incidence of snakebites, especially from the Anuradhapura and Polonnaruwa areas.”
The profile of snakes varies across the island – cobras are found all around the island (Prof. Sellahewa even shared that he once came across a cobra on Duplication Road in Colombo, though this was an unusual sight), but Russell’s vipers and kraits are more common in paddy fields. The hump-nosed viper, though common in all parts of the island, is most common in the Sabaragamuwa Province. This said, Prof. Sellahewa did note that if one were to come across a snake (venomous or non-venomous), the most important thing to do was to back away because snakes usually only bite when provoked (or afraid). The only real exception to this with venomous snakes is the krait which does bite unprovoked, and often bites sleeping farmers and families who sleep on the floor in wattle and daub huts.
“Key to avoiding snakebites is being aware of where these snakes are, taking all precautions when walking, and keeping your environment clean,” Prof. Sellahewa noted. “Clean and cut undergrass and bushes and dispose of garbage properly. Garbage breeds rats, lizards and frogs, and snakes come in search of that. Keep your environment clean and dispose of garbage so there are no unnecessary breeding sites.”
Piles of firewood, coconut husks, and other such things that create good hiding places are likely places for snakes, especially vipers and cobras, Prof. Sellahewa highlighted, and so, when disturbing these kinds of stores in any way, and especially before putting your hands on them, it is important to poke the region first with a long pole so that the snake slithers out. Being extra vigilant of children playing near anthills (cobras popularly inhabit the inside of anthills) is also important.
Wearing thick clothing like long denim and especially thick boots when cleaning undergrowth is also important so that even if a snake does bite it will not be able to penetrate through the boot. When walking, especially at night, and even in the day because snakes do easily camouflage into their surroundings, it’s good to stamp your feet because snakes are sensitive to vibrations and will move away. At night, it’s imperative to carry a strong torch so you can see at least three to four feet in front of you and avoid inadvertently trampling a serpent (the snake will, of course, respond to being stepped on by biting).
When best efforts fail
The best-laid plans can go to waste, and if someone does find themselves bitten by a snake, the most important thing to do is get to the hospital as quickly as possible and to leave the wound alone.
“Don’t worry about trying to catch and kill the snake. We will know how to identify the snake from the wound. If you want to take a picture, take one quickly, but this is not necessary,” Prof. Sellahewa said. “The most important thing to do is to reassure the victim. Don’t give them any medication, and immobilise the limb – every movement will increase the spread and so morbidity can also increase. Go as quickly as possible to your closest State hospital. Don’t cut, chop, or suck the wound, and don’t tourniquet it. A tourniquet must be applied by an expert. If it’s too tight, it can cut down blood supply to the limb which can cause tissue necrosis and even result in loss of the limb. Tourniquets also don’t help so much in preventing the spread of the venom.”
Snakes in cities are not uncommon, even in Colombo, and snakes are quite common in the suburbs, though mostly non-venomous. Snakes pose more of a threat in agricultural areas. At the scene of the snakebite, especially if the snake poses a danger to others (like a snake trapped in a house, for example), a snake-handling expert needs to be called to come and catch the snake and then release it to an appropriate environment. “People shouldn’t try to handle the snake themselves, they’re putting themselves at risk of being bitten,” Prof. Sellahewa said. “In villages where snakes are common, there might be people who know how to handle snakes, but you should always call in an expert.”
In the years since its creation, SLMA’s Expert Committee on Snakebite has worked tirelessly to build awareness on the prevention of snakebites at the community level, and on the proper treatment and management of snakebites at the healthcare level. Some resources that both the public and healthcare professionals can use to get 24-hour access to snake and snakebite experts include the SLMA Snakebite Hotline and the SMLA Snake Identification Information Hub – services that can be used to gain information and support for both preventing and managing snakebites.
