See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/344888609

Envomation by venomous snakes in Pakistan

Conference Paper · October 2020

CITATION READS
1 553

1 author:

Muhammad Sharif Khan

Talim ul Islam College, Rabwah, Pakistan
251 PUBLICATIONS 1,515 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

herpetology of pakistan View project

Pakistan herpetofauna affinities View project

All content following this page was uploaded by Muhammad Sharif Khan on 27 January 2021.

The user has requested enhancement of the downloaded file.

 1
Snake envenomation

A nearly neglected health issue in Pakistan

Muhammad Sharif Khan

306 N. Morton Ave

Morton, Pa 19070

typhlops99@outlook.com

2020

Abstract: Pakistan, a temperate South-East Asian country, has extensively diversified

habitats inhabited by nearly 238 amphibian and reptile species (Khan 1999, 2006). Of the 72

species of snakes, there are 14 venomous land species localized mostly to semi-desert and

desert areas in southern Punjab, Sindh and Baluchistan and rugged sub-alpine north; while 15

species are of sea snakes (Khan 1990, 2002).

1
 2
Where there are snakes, there are snake-bite stories. Actual number of snake-bite so

far has not surfaced because of lack of proper reporting system from remote parts of the

country. Since importance of reporting id not publicized and shared (Khan 1990, 2002).

INTRODUCTION

Fear of snake is built in human psyche, since snake-man association dates back to the times

immemorial, when humans were exploring their surroundings. Before present era of scientific

research and exploration, peoples had been looking cure for snake-bite in herbs, minerals, some

in desperation resorted to worship and developed mantras to appease the snake-deity to be

spared from its wrath. This practice continues even today in many parts of the world, especially

in rural areas in Pakistan.

SITUATION IN PAKISTAN

Pakistan lies in the northwestern corner of the temperate Southeast Asia, spread over

796095 sq. km. The 72 species of diversified snakes, are widely distributed from sea to

altitudes higher than 4000 m in the Himalayas (Khan 2002, 2006). On onset of summer,

snakes are stirred in their hibernation hideouts and number of snake-bite incidents rises,

peaked during monsoons rains (June to September); while incidents are lowest in winter

when they take to their shelters from falling temperatures.

A worldwide survey indicates, mostly snake-bites are implicated with the low socio-

economic conditions, demonstrating that it a disease of poor people, since they do not have

means to adopt proper preventive measures.

Most affected parts of Pakistan

One of the most affected parts in Pakistan, is the Sindh province, with highest snake-bite

incidents (Table 1& 2), since the entire province is a vast desert habitat with meager cover, a

seasonal change drives local animals in human inhabitations seeking shelter, where they relish

on resident rodent pests etc.

2
 3
A careful estimate indicates that each year about 1200 deaths occur in Sindh due to snake

bites. Snakebite patients are the fifth large number of patients coming to hospitals.

In the rural areas first consultants are the local hakims and snake-charmers; the victim is

taken to hospital when he/she is at last leg of life. An interview of 200 snake-bite cases, in

rural Sindh, indicate that 75% cases quested treatment from local healers, while 25% were

self-treated, using tourniquets, incisions and suction by mouth.

Global Situation

Perhaps we would never know exact number of snake-bite cases; however, according to

careful estimations hundreds of thousand of people get bitten and several thousands are killed

each year (Warrell DA 2010) [48]. World Health Organization (WHO) has reported an estimate

of at least 421,000 envenoming cases each year of which 20,000 deaths occur.

South Asia with high population density and widespread agricultural activities, is the world’s

highly affected area. An estimated figures indicate that out of 125,000 deaths worldwide,

approximately 100,000 are recorded in South Asia and 20,000 in Africa (Cruz LS, Roberto V,

Antonio A. L, 2009) [7] . Annually 50,000 snake-bite cases are reported in India and 30,000 in

Sri lanka. In South Asia almost 2500 – 30,000 deaths occur annually by snake bite [ 49] . India

accounted for highest estimated number of bites and deaths in this region. Almost 80,000

people are bitten by poisonous snakes yearly in India followed by 33000 people bitten in

Srilanka [27 ] .

In Nepal almost 20,000 snake bites and 200 deaths in hospitals happens predominantly in

Eastren Terai. [38] . Recent survey in Bangladesh revealed 700,000 snakebite case per year

causing 6000 deaths [14] .

Situation in Pakistan

Presence of over a half dozen of venomous snakes, all over Pakistan, presents a great health

hazard to the community, mainly in villages and in under developed areas.

3
 4
A survey reports, out of 5337 envenomed patients, 57% were Cobra victims and rest of 35%

were bitten by Kraits and Vipers.

Snake bite incidence has always been over or under estimated due to lack of proper

reporting system. WHO has reported 20,000 cases of snake bite deaths per year[ 7,49] In

Pakistan reliable figures on incidence, mobidity and mortality are limited to 40,000 annually

resulting in 8200 fatalities annually [ 1, 14, 33]

The annual snakebite mortality rates for individual districts of Pakistan shows:

Muzaffargarh district (lying along the Indus River) has a relatively high rate of snakebite

mortality, followed by the adjoining district of Dera Ghazi Khan. [ 42]

The snake bite envenoming is one of the eighteen priority health problems as reported by HMIS

reports by the Sindh govt. The five year data from 1999- 2004 has revealed that the most

affected district of Sindh region is Tharparkur followed by Mirpurkhas, Dadu, Thatta, Badin.

The highly affected areas are Mithi, Diplo, Chachro, Umerkot, Nagarparka followed by Sijwal

& Mirpurkhas etc. The five year data reveals that the number of cases have shown a continues

rising trend year wise. [ 28]

WHO CATAGORIES OF OFFENDING SNAKES IN PAKISTAN

Of the 82 species of snakes recorded in Pakistan:

WHO Category I: Medically important snakes in Pakistan includes:

i. Five elapids:
Bungarus caeruleus, Bungarus sindanus; Naja naja, and N. oxiana which are mostly
distributed in the plain, under plough round the year, thus cause most of the fatalities.

ii. Four viperids:

Daboia russelii, Echis carinatus astolae, E. carinatus multisquamatus, E. carinatus
sochureki which are comparatively drier plain dwellers, causing much less fatalities
as compared to elapids.

WHO Category II: Includes snakes with inadequate epidemiological and clinical data or
are less frequently concerned are:
a. Eristicophis macmahonii, Pseudocerastes bicornis, P. persicus. Macrovipera
lebetina and, Gloydius himalayanus species of less populated areas where human
encounters are rare. [. [51]
4
 5
b. And 15 sea-snakes: Astrotia stokesii, Enhydrina schistose, Hydrophis
caerulescens,H. cyanocinctus, H, fasciatus, H.lapemoides, H.mamillaris, H.
ornatus, H. spiralis, L. curtus, M. cantoris, Microcephalophis gracilis.Pelamis
platurus.Praescutata viperina are widely distributed along Pakistan shore-line,
rarely come on land except stranded. They are not vicious like land snakes, even
in sea, reports of their bites are rare (Khan 1990, 2002, 2006).

RECOMMENDATIONS

 Antivenin manufacturers must be helped in practical ways to improve the safety and

efficacy of their products.

 Snake handling courses should be conducted at local /district level to create awareness

among the people, regarding species of venomous snakes in respective areas.

 Proper monitoring/reporting cells should be established at District, Provincial as well

as Federal level to record the factual snake bite situation in Pakistan.

 Policies for antivenin distribution must be developed to provide antivenins where are

most needed.

 Medical personnel must be trained in the modern ways of management of snake bites

and, most crucially, in the selective use of antivenins.

 Communities must be educated regarding snake-bite risks and realistic solutions that

may help people themselves to manage the problem in practical and sustainable ways.

 Research directed at improving the available methods of first aid, primary clinical care

and patient rehabilitation must be accorded priority and funded at national, regional

and global levels.

 Dedicated reference laboratories for treating Snakebite cases should be established at

Federal level, for compiling the data and to establish the system for intra provincial

coordination.

5
 6
 Epidemiological studies and reporting systems need to be developed and

implemented, and the data used to prioritization of snake bite as a neglected tropical

disease at all levels.

REFERENCES:

1. Ali Z, 1990. Snake bite: A medical and public health problem in Pakistan. In:

Ghapulakrisakone P, Chou LM, editors, Snakes of Medical importance (Asia Pacific

region). Singapore National University Singapore, pp447-461.

2. Alirol E, Sanjib Kumar Sharma, Himmataro Saluba bawaskar,Ulrich Kuch, and Francois

Chappuis, 2003. Snake bite in South Asia: A Review. Int J Antimicrob Agents. Feb; 21

(2): 164-9.

3. Ansari AK, Sikandar AS, 2000. Management of Viperadae snake bite.pak Armed forces

medical Journal. Jun.50(1):26-8.

4. Benjamin N, Rawlins M, Vale JA, 2002. In: Kumar P, Clark M. eds. Kumar and Clark

Clinical Medicine. 5th ed. United Kingdom: WB Saunders. 985-7.

5. Balentine JR, and Charles P. Davis, MD, 2011. Snake WebMD, Inc. All rights

reserved.bite,www.emedicinehealth.com/snakebite/article_em.htm. Last visited on 30th

July 2011.

6. Chandio AM, pervaiz Sandelo, Ali Akbar Rahu, S. Tousif Ahmed, Amir Hamzo Dahri and

Rashida Bhatti, 2000. Snakebite: Treatment seeking behavior among Sindh Rural

population. JAMC Vol. 12 No.3.

7. Cruz LS, Roberto V, Antonio A. L, 2009. Snakebite envenomation and Death in the

Developing World. Ethnicity and Disease, Vol 19, (supplement 1): S1-42- S1-46.

8. Chippaux JP, 1998. Snakebite: Appraisal of the global situation. Bull World Health Organ

76 (5): 515-524.

6
 7
9. Chippaux JP, 2002.Snake envenomation in French Guinae.Med Trop(mars).62(2);177-

84.(Article in French)

10. Chew KS, Khor HW, Ahmad R, Rahman NH, 2011. A five year retrospective review of

snakebite patients admitted to a tertiary university hospital in Malaysia. International

journal of Emergency Med.Jul 13, 4; 41.

11. Desliva J, Anslem and Rnasinghe, 1983. Epidemiology of snakebite in Srilanka: A review:

Ceylon Medical Journal 28:118-127.

12. Daley BJ,Snakebite.http://emedicine.medscape.com/article/168828-overview.Last visited

25th December 2011.

13. Gutie´rrez JM, Theakston RD, Warrel DA.2006. Confronting the neglected problem of

snake bite

envenoming: the need for a global partnership. PLoS Med. 2006;3(6):e150.

14. Hayat AS, Abdul HK, Tariq ZS, Rafi AG, Naila S, 2008. Study of Snakebite cases at Liaqat

University Hospital Hyderabad, jamshoro. JAMC; 20 (3).

15. Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG (2009) Snake

Envenoming: A Disease of Poverty. PLoS Negl Trop Dis 3(12):

e569.doi:10.1371/journal.pntd.0000569.

16. Rehman R, Faiz MA, Rahman B, Basher A, Jones A et al. (2010).Annual incidence of

snakebite in rural Bangladesh.Plos Neglected tropical Disease (in press).

17. Johnson CA, 1991.Management of snakebite. Am Family Physician.Jul:44(1:174-80).

18. Khan MS, 1990. Venomous terrestrial snakes of Pakistan and snake bite problem. In:

Snakes of Medical importance (Asia-Pacific Region):419-446. (Ed.) P. Gopalakrishnakone

and L. M. Chou. National University of Singapore.

19. Khan MS, 1993. Snakes of Pakistan (in Urdu). Publication # 276. Urdu Science Board, 299

Upper Mall, Lahore, pp.229, (in Urdu).

7
 8
20. Khan MS, 2002. A Guide to Snakes of Pakistan. Edition Chimaira Frankfurt am Main.

(www.chimaira de).

21. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, et

al. (2008) The Global Burden of Snakebite: A Literature Analysis and Modelling Based on

Regional Estimates of Envenoming and Deaths. PLoS Med 5(11): e218.

doi:10.1371/journal.pmed.0050218.

22. Kularatne SA, 2003. Epidemiology and Clinical picture of the Russel Viper (Daboia

russelii russelii) bite in Anuradhapura, Srilanka: a prospective study of 336 patients. South

Cost Asian J Trop Med Public Health. Dhaka University J. Biol Sci 8: 53-68.

23. Khan MS Hussain, 2011. Country report for Pakistan, Cites Asian snake trade

workshop,Guangzhou,China.www.cites.org/eng/com/ac/25/Snake/Pakistan.pdf.

24. Khan, M. S. 1993. ‫( سر زمين پا کستا ن کے سا نپ‬Snakes of Pakistan). Publication # 276.

Urdu Science Board, 299 Upper Mall, Lahore, pp.229, (in Urdu).

25. Khan, M. S. 2002. A guide to the snakes of Pakistan. Edition Chimaira, Frankfurt
am Main, pp. 265.

26. Khan, M. S. 2002. Die Schlangen Pakistans. Edition Chimaira, Frankfurt am

Main, pp. 265.

27. Khan, M. S. 2006. Amphibians and Reptiles of Pakistan. Krieger Publishing

Company, Malabar, Florida, pp. 311.
28. Kose R, 2007. The management of Snake envenomation: evaluation of twenty one snake

bite cases. Ulus Travma Acil Cerrahi Derg(article in Turkish).Oct;13(4):307-12.

29. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, Rodriguez PS,

Mishra K, Whitaker R, Jha P; Million Death Study Collaborators.2011.Snakebite

mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis. Apr

12;5(4):e1018.

30. Mario L, 2008. www.venomland.net,last visited on 29 th Nov 2011.

8
 9
31. Memon M.I., 2004. Cases of Snakebite with Sign and Symptoms of Poisoning in Sindh

Province. Provincial HMIS feedback report Oct 2004, Issued by Provincial HMIS Cell,

DG Health services Sindh , Hydrabad, Pakistan.

32. Mahmood K, Naqvi IH, Talib A, Salkeen S, Abbasi B, Akhter T, Iftikhar N, Ali A, 2010.

Clinical course and outcome of snake envenomation at a Hospital in Karachi. Singapore

Med J, Apr; 51 (4): 300-5.

33. Meir J, Stocker KF, 1995. Biology and distribution of venomous snakes of medical

importance and the composition of snake venom: In: white MA, editor Handbook of

Clinical Toxicology of anima venoms and poison. CRC Press, pp 367-402.

34. Naseem A, Moin S, 2001. Snakebite with multi system involvement PAFMJ; 5 (2): 187-9.

35. Punde DP (2005) Management of snake-bite in rural Maharashtra: a 10-year experience.

Natl Med J India Mar-Apr,18: 71–75.

36. Quraishi NA, Huma Qureshi, Ian D Simpson, 2008. A Contextual Approach to Managing

Snake Bite in Pakistan: Snake Bite Treatment with Particular Reference to Neurotoxicity

and the Ideal Hospital Snake Bite Kit. J Pak Med Assoc. Vol. 58, No. 6.

37. Rana MM, Yosouf Hassan, Obaid-Ur-Rehman and Mohammad Alam, 2003.. Clinical

Manifestations of Poisonous Snakebite and its Management in a referral Hospital. Int J

Agri Biol, Vol. 5, No. 4. http://www.ijab.org.

38. Sheikh MZ, Ghulam Rasool Maken, Shahzeb Ahmed Satti 2008. Clinical spectrum of

snakebite and therapeutic challenges, Pak Armed Forces Medical Journal, Issue Number:

3, Issue Month: September.

39. Simpson ID. 2007 Snakebite Management in India, the First Few Hours: A Guide for

primary care

Physicians. J. Indian Med Assoc; 105: 324-35.

40. Simpson ID, Norris RL, 2009. Snake Antivenom Product Guidelines in India: The

9
 10
Devil is in the Details. Wilderness and Environmental Medicine. 2007;18: 163-8.

41. Shahani R,Sajida A,Salman AF, 2010.Pattern of snakebite cases visiting at rural health

centre of Sindh,Pakistan. Pakistan Armed Forces Medical Journal.Sep;3

42. Simpson ID, Ingrid M Jacobsen, 2010. Anti Snake Venom Provision in Asia and Papua

New Guinea: A Guide to Potential Anti Venom Products for Clinicians, Purchasers and

Manufacturers. Pak J Med Research Vol.49, No. 2.

43. Sitprija V, 2006. Snakebite nephropathy. Nephrology 11: 442-448.

44. Suleman MM, Shahab MA, Rab MA, 1998.Snakebite in the Thar Desert. J Pak Med Assoc

Oct; 48(10):306-8.

45. Swaroop S. and B. Grab, 1953. Snakebite Mortality In The World. Bull. Org. Mond. Sante,

10, 35-76.Bull. Wld Hlth Org.

46. Theakston RD, Phillips RE, Warrell DA, Galagedera Y, Abeysekera DT, et al. (1990)

Envenoming by the common krait (Bungarus caeruleus) and Sri Lankan cobra (Naja naja

naja): Efficacy and complications of therapy with Haffkine antivenom. Trans R Soc Trop

Med Hyg 84: 301–308.

47. Tintinnalli JE, Kelen GD, Stapcynski JS, eds 2004. Emergency Medicine: A

Comprehensive Study Guide. 6th ed. New York, NY: McGraw Hill.

48. Venomous Terrestrial Snakes of Pakistan 1997-2003. Wildlife of Pakistan- All right

Reserved.www.wildlifeofpakistan.com/ReptilesofPakistan/venomousterrestrialsnakesofP

akistan.htm

49. Warrell DA 1995. Clinical Toxicology of Animal bites in Asia. In: white MA, editor.

Handbook of clinical toxicology of animal venoms and poisons. CRC Press pp 493-588.

50. Warrell DA 1999. WHO/SEARO Guidelines for the Clinical Managements of Snakebite

in the South East Asian Region. South East Asia J. Trop. Med. Pub. Health. 30, Suppl 1,

1-85.

10
 11
51. Warrell DA 2010. Snake bite. Lancet Vol 375, 77-88.

52. WHO 2005. “Annual Sera” Retrieved December 30.

53. http://apps.who.int/bloodproducts/snakeantivenoms/database/snakeframeset.html,WHO

2010. Last visited 14th Oct, 2011.

54. WHO 2010. Guidelines for the Production, Control and Regulation of Snake Antivenom

Immunoglobulin. World Health Organization. www.who.int/bloodproducts/snake

antivenoms.

55. Zafar J, Aziz S, Hamid B, Qayyum A, Alam MT, Qazi RA. Snake Bite Experiences at

Pakistan Institute of Medical Sciences. J Pak Med Assoc 1998;48: 308-10.

TABLES
Table -1 District-wise cases of snakebite with sign of envenoming from Jan – June 2004 (Memon,

2004)
11
 12
Serial District January February March April May June Total

# cases

1 Badin 8 33 87 7 4 82 221

2 Dadu 18 22 44 53 35 100 272

3 Hyderabad 26 13 45 19 10 10 123

4 Thatta 59 13 49 38 26 72 257

5 Karachi 0 1 0 0 o 0 1

6 Shikarpur 0 2 8 14 10 7 41

7 Larkana 10 6 20 12 16 22 86

8 Jacobabad 6 8 9 27 15 31 96

9 Sanghar 7 11 38 27 32 49 164

10 Mirpor 14 27 88 89 35 85 338

khas

11 Tharparker 40 68 133 147 184 289 861

12 Nawabshah 24 11 6 5 4 5 55

13 N. Feroz 6 3 9 16 17 38 89

14 Khanpor 5 14 28 34 39 57 117

15 Ghorki 0 0 0 1 1 2 4

Table. 2. Snakebite cases recorded with Sign of envenomation in Districts of

Sindh province (Data 2005-2010)
Year No. Of Districts Cases Under Cases above 5 Total
no. of cases
Studied 5 years

12
 13
2005 18 189 6685 6874
2006 18 213 6795 7008
2007 21 178 6595 6773
2008 21 198 6178 6376
2009 20 376 5065 5441
2010 16 176 2677 2853
Total 330 33995 35325

Table. 3. Number of snake species in Pakistan (Khan, 2002, 2006).

Name of Family No. of species Venomous/ non-Venomous Common name

Genus Indotyphlops 05 non-Venomous Blind snakes

Ramphotyphlopidae 01 non-Venomous Thread snakes

Family Leptotyphlopidae 02 non-Venomous

Family Pythonidae 01 non-Venomous Pythons/Azdha

Family Boidae 03 non-Venomous Sand Boas

Family Colubridae 41 non-Venomous Colubrids

Family Elapidae 05 Venomous Kraits and Cobras

Family Hydrophiidae 14 Venomous Sea Snakes

Family Viperidae 09 Venomous Pitl-ess vipers

Family Crotalidae 01 Venomous Pit vipers

Bibliography snakes of Pakistan

BOOKS

Khan, M. S. 1993. ‫( سر زمين پا کستا ن کے سا نپ‬Snakes of Pakistan). Publication # 276. Urdu

Science Board, 299 Upper Mall, Lahore, pp.229, (in Urdu).

Khan, M. S. 2002. A guide to the snakes of Pakistan. Edition Chimaira, Frankfurt am

Main, pp. 265.
13
 14

Khan, M. S. 2002. Die Schlangen Pakistans. Edition Chimaira, Frankfurt am

Main, pp. 265.

Khan, M. S. 2006. Amphibians and Reptiles of Pakistan. Krieger Publishing

Company, Malabar, Florida, pp. 311.

Research papers

Khan, M. S.1982 . An annotated checklist and key to the reptiles of Pakistan.

Part III: Serpentes (Ophidia). Biologia (Lahore), 28:215-254.

Khan, M. S. 1983. Venomous terrestrial snakes of Pakistan. The Snake, 15:101-105.

Khan, M. S. 1984. Rediscovery and validity of Bungarus sindanus Boulenger. The Snake,
16:43-48.

Khan, M. S. 1984. A cobra with an unusual hood pattern. The Snake, 16:131-134.

Khan, M. S. 1985. Taxonomic notes on Bungarus caeruleus (Schneider) and Bungarus

sindanus Boulenger. The Snake, 17:71-78.

Khan, M. S. 1990. Venomous terrestrial snakes of Pakistan and snake bite problem. In: Snakes
of Medical importance (Asia-Pacific Region):419-446. (Ed.) P. Gopalakrishnakone
and L. M. Chou. National University of Singapore.

Khan, M. S. 1995. A report on an unborn litter of chain viper Vipera russelii (Shaw and
Nodder, 1797). Pakistan J. Zool., 27(2):119-122.

Khan, M. S. 1997. A report on an aberrant specimen of Punjab Krait Bungarus sindanus razai
Khan 1985 (Ophidia:Elapidae) from Azad Kashmir. Pakistan J. Zool., 29:203-205.
Khan, M. S. and Tasnim, Rashida, 1986. Balling and caudal luring in young Bungarus
caeruleus. The Snake, 18:42-46.

Khan, A. Q., and Khan, M. S. 1996. Snakes of State of Azad Jammu and Kashmir. Proc.
Pakistan Congr. Zool., 16:173-182.

Minton, S. A. 1962. An annotated key to the amphibians and reptiles of Sind and Las Bela,
West Pakistan. Am. Mus. Novit. (2081):1-21.

Minton, S. A. 1966. A contribution to the herpetology of West Pakistan. Bull. Amer. Mus.
Nat. Hist. 134(2):31-184.

Mertens, R. 1974. Die Amphibien und Reptilien West-Pakistans. Senckenb. Biol. 55(1-3):35-
38.

Minton, S. A. 1962. An annotated key to the amphibians and reptiles of Sind and Las Bela,
West Pakistan. Am. Mus. Novit. (2081):1-21.

14
View publication stats

15
Minton, S. A. 1966. A contribution to the herpetology of West Pakistan. Bull. Amer. Mus.
Nat. Hist. 134(2):31-184.

Mertens, R. 1974. Die Amphibien und Reptilien West-Pakistans. Senckenb. Biol. 55(1-3):35-
38.

………………….

15