In Mouth Piece

Dark fairy tale stories by Ashok Captain

The following is written with the hope that somebody who reads this has enough ‘everything’ to make life saving decisions.

DARK FAIRY TALE VERSION #1
Once upon a time, not so long ago, lived a beautiful princess. Her evil stepmother made her go into the forest to collect firewood – hoping that leopards would eat her. They didn’t. One day she stepped on a venomous serpent, which bit her. Fortunately some woodcutters were passing by and carried her to the nearest primary health center. A charming young doctor-prince, who was doing his rural internship, was certain he could save the princess’ life. He administered anti-snake venom serum – the liquid type. Despite this, she died. Unfortunately, somewhere along the chain from manufacture to treatment, the electricity had gone off. Due to global warming the temperature was much higher than 10 degrees C and the ASVS ‘died’ much before the poor princess. Our fairy tale ends unhappily ever after. It needn’t have.

LIQUID ANTI-SNAKE VENOM SERUM (ASVS) SHOULD NOT BE MADE

Liquid ASVS requires refrigeration, usually below 10 degrees C, to remain viable. Electricity in India is at best unreliable – especially in rural areas – where most cases of snakebite occur. Deaths due to snakebite compounded by electricity failing – thus causing ASVS to lose its efficacy, are avoidable if lyophilized ASVS is used.

If the stuff doesn’t work – it’s a waste of snake venom … and human life.

A government directive enforcing the manufacture of only lyophilized ASV might help . . . if such a ruling were ever passed. It probably won’t be, so when one has a choice, I suggest using lyophilized ASVS (see box). If people don’t buy it, commercial pressure may persuade manufacturers to make lyophilized ASVS only.

Capture1

 

DARK FAIRY TALE VERSION #2

Once upon a time, not so long ago, lived another beautiful princess, this time in Rajasthan. Her evil stepmother made the young maiden sleep on the floor. One night the princess got up to drink water and stepped on a venomous serpent. It bit her. Unsure of the beneficiaries of the princess’ will, the stepmother sent her to the nearest primary health center. The same charming young doctor-prince (still doing his rural internship) was dead sure that this time around he’d save the princess’ life. He administered anti-snake venom serum – the lyophilized type. Despite this, she died. Unfortunately, the snake that bit her was Bungarus sindanus. Anti-venom made in India is effective against Bungarus caeruleus (and three other species). The tale ends unhappily ever after. And it needn’t have.

THERE ARE MORE THAN 4 SPECIES OF SNAKES IN INDIA WHOSE VENOM IS CAPABLE OF CAUSING DEATH IN HUMANS

The catchy term ‘Big Four’ is probably one reason for the common misconception that there are only four species of venomous snakes in India. Absolutely untrue! Snakebite deaths caused by any snake are attributed to either – Naja naja – the Common Indian Cobra or Spectacled Cobra; Echis carinatus – the Saw-scaled Viper; Daboia russelii – Russell’s Viper and Bungarus caeruleus – the Common Indian Krait. The truth is that there are several species whose venom is capable of causing human death. Most (not all) of these are rarely encountered and recorded deaths are few. Due to the ‘only four venomous snakes in India’ misconception and the ‘Big Four’ moniker, anti-venoms have not been made for several of the venomous snakes of medical significance. Translation – has enough ‘juice’ to kill humans.

A few examples:

Bungarus-which-one

Maharashtra (also parts of the Gangetic plain, parts of U.P., Bihar and Bengal)
has two species of similar looking kraits – Bungarus caeruleus – the Common Indian Krait, and Bungarus cf sindanus walli or Bungarus cf walli. The Common Indian Krait has 15 midbody dorsal scale rows and the ‘other’ krait has 17. Two additional scale rows may seem like no big deal, but their venoms are different. No ASVS is made for Bungarus cf walli. Despite no known tests having been carried out on the efficacy of polyvalent ASVS against venom of this ‘second krait’, it is routinely administered for all cases of snakebite. If death occurs, it is usually attributed to Bungarus caeruleus.

Capture2

 

Rajasthan

Bungarus sindanus – the Sind Krait and Echis sochurecki – Sochureck’s Saw-scale Viper occur in Rajasthan (and probably adjacent Gujarat). Deaths resulting from a krait, are most often attributed to Bungarus caeruleus and ‘Saw-scaled vipers’ bites are still attributed to Echis carinatus. No specific ASVS is made for either species.

Echis-which-one

Parts of Haryana, most of the Gangetic plain, West Bengal up to Arunachal Pradesh

There are (at least) two species of cobra: Naja naja – the Common Indian Cobra/ Spectacled Cobra and Naja kaouthia – Monocellate Cobra/ Monocled Cobra. Though it is easy to recognize typical forms of both species, there is still no ASVS made specifically for Naja kaouthia in India.

An endemic cobra Naja sagittifera – the Andaman Cobra is found on some of the Andaman Islands. No ASVS is made for this species.

Though bites are extremely rare, no ASVS is made in India for Ophiophagus hannah – the King Cobra. It is uncertain whether the anti-venom made in Thailand is effective against the venom of king cobras found in India.

It is up to herpetologists (me included), animal rights groups (instead of shutting down ASVS manufacturing facilities, they could regulate them), pharmaceutical companies (nix the liquid ASVS folks. You might need it yourselves one day) and politicians (dead people can’t vote) – to work together to ensure that dark fairy tales like those above never happen. The beautiful princess might easily be related to you.

Written by Ashok Captain

13 Comments

  • Ashok Captain
    Jan 11, 2016 at 01:57 pm

    Hi Priyanka,

    A few things:

    1. We don’t know if antivenom (apparently the correct term) is partially/ wholly effective against bites of kraits from Rajasthan, nor the ’17 midbody scale row’ kraits from Maharashtra and adjacent areas.

    2. Some folks (not me) may be trying to find out with lab tests. Rather mysterious, but if it happens, you’ll see it published.

    Cheers, or not.

    A

    • admin
      Jan 24, 2016 at 06:31 pm

      Ashok…Thanks for such a relevant article. There is a lot that needs to be done regarding ASV and venom research.

  • Dr Vijay Vasudev Pillay
    Jan 15, 2016 at 04:59 am

    Hi Captain! Dark fairy tales with underlying message. I like that. I hope such messages can be carried forward to reach the ears of those that matter. On my part I have posted these Grim Fairy Tales on the online forum of the Indian Society of Toxicology. And congrats Priyanka for the excellent work you are doing in this neglected area, and to unsung heroes and heroines like Sr Stella for their stellar contributions (pun unintentional) to the cause of the thousands of hapless victims of snakebite.

    • admin
      Jan 24, 2016 at 06:35 pm

      Dear Dr Pillay….Many thanks for your proactive role in dispersing issues pertaining to Snakebites in India on various forums. We are also very honored to receive feedback and guidance from you.

  • Vishal Santra
    Jan 15, 2016 at 06:41 am

    That is a fantastic note by Captain. The point on liquid ASV is remarkable and has been voiced by some from quite some time. The fairy tales were brilliant in telling a critical scientific stuff in such an easy way. The distribution of Naja kaouthia was a bit cryptic though. Enjoyed it thoroughly… Thanks for the update.

    Hope these words and sentences said and repeated will fall on some working ears soon…

    Cheers to Captain!

    • admin
      Jan 24, 2016 at 06:37 pm

      Dear Vishal…Thanks for your inputs regarding the article and also the support to the snakebite initiative that you have working tirelessly on…to save snakes and humans alike in West Bengal.

  • Dr Dayal Bandhu Majumdar
    Jan 17, 2016 at 02:40 am

    I am thankful to Mr. Asoke Captain for his valuable article published in this site. Probably all of us know that, motivating Pharmaceutical Companies to produce quality drugs reducing their profit is next to impossible. No Company had never considered for quality, they only know their profit. Here in this matter of ASV, which has least interest of the so called educated urban policy makers , the condition is more notorious. As ASV is used mainly in the Govt Hospitals , the process of ” Tender” is a dangerous process. Govt policy is to purchase the lowest cost medicines by ” Tender” . No body bother for the quality here.
    Maintenance of cold chain is predominantly a human factor. And in the Govt. setups you cannot rely upon anybody. Everybody is trying to de-shoulder his responsibility. Have you ever noted any ” Criminal Negligence” case against any doctor or any institution for any Snakebite death ? If you can create some example of such legal action against some health institutions , then only the quality of ASV would be addressed.
    The issue of ” Regional Venom Collection” is another strong agenda. Probably giving some way to escape responsibility by reluctant people. If a 300 bedded ESI Hospital can refuse treatment to a Venomous Snakebite case , everybody can do it.

    • admin
      Jan 24, 2016 at 06:42 pm

      Dear Dr Dayal Bandhu…Many thanks for your response and providing inputs regarding the current scenario of snakebite mitigation in India.

  • Dr. Ashok k. Ghosh
    Jan 17, 2016 at 06:07 pm

    Wonderful endeavour Ashok, wonderful fairy tale sequence to make things easily understandable. But a happy ending of the fairy tale is no easy task. At present, polyvalent (4), asvs are not available at times so specific asvs for specific snakes is possibly day dreaming at present, but lypholysed serum can be practised. Any body hearing?

    • admin
      Jan 24, 2016 at 06:44 pm

      Dear Dr Ashok Ghosh….Many thanks for your response and opinion.

  • Dilip rahurkar
    Jan 18, 2016 at 02:33 pm

    This is a great article written by Ashok Captain. Really very helpful information for doctors as well as those who organize snakebite awareness workshops in different state in India .

    • admin
      Jan 24, 2016 at 06:46 pm

      Dear Dilip…Thanks for your response. Such articles are definitely relevant for people like you who provide awareness workshops across the state of Maharashtra.

  • Dr. Shashank Shekhar
    Aug 23, 2016 at 06:14 am

    I request the administrators of the website to start an online campaign on some site like “Change.org” and request GoI to (a) Pass a government directive enforcing the manufacture of only lyophilized ASV (b) Develop ASVs for other commonly found venomous snakes in India.

    I should have started this campaign on my own instead of requesting you to do this, however, I feel that there are some advantages if this campaign is started by you. (i) You have domain knowledge and hence people will pay heed to you. (ii) You may have a database of people who visit this website and may be ready to support this campaign.

    Shashank

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