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Management of Snakebite and Research 2 effective methods are immobilization of the bitten limb and transport to hospital on a stretcher. For Russell’s viper bites, pressure pad with immobilization has proved safe and capable of preventing systemic uptake of venom. For neurotoxic elapid bites (Krait, Cobra, King cobra) pressure - immobilization using a long crepe bandage is recommended. Hospital Treatment Resuscitation, diagnosis of the biting species (by examining the dead snake or by inference from clinical signs and simple bed-side tests) are followed by the decision whether or not to give antivenom, ancillary treatment and rehabilitation. Myanmar Pharmaceutical Factory formerly produced a freeze dried mono-specific antivenom which neutralized 2 mg of Russell’s viper venom per ml. Recently, a lower titre liquid antivenom has been issued, neutralizing 0.6 mg per ml venom. Clinical trials have not yet been carried out to determine the initial dose of new antivenom. The old MPI antivenom was effective at an initial dose of 40 ml (80 ml for severe cases). Indications for antivenom treatment are under review. In Myanmar, much antivenom is wasted by being given to nonenvenomed patients. The old MPI antivenom was commonly pyrogenic and there were some anaphylactic reactions. Reactogenicity of the new MPF antivenom is unknown. Treatment of acute renal failure in Russell’s viper victims can save many lives. Peritoneal dialysis is available in Yangon, Mandalay, Magway and in a few township hospitals. Haemodialysis is an option only in tertiary referral centres such as Yangon General Hospital. Assisted ventilation is needed in victims of neuotoxic envenoming. Basic skills of endotracheal intubation are essential in township doctors. Diagnosis of Biting Snake Hospital staff must be trained to recognize the medically- important species of snakes, in case the dead snake is brought with the patient. Rapid tests include the 20 minutes whole blood clotting test, a new dot blot colloidal dye dipstick. EIA test (developed at DMR) and urine tests including NAG and simple protein assessment by dipstick. New Strategies to Combat Snakebite in Myanmar The occupational risk of Russell’s viper bite can be reduced if farmers and other agricultural workers can be persuaded to wear snake-proof boots and gloves. Effective protective boots and gloves have been manufactured by DMR and tested in a pilot study. Pressure pad with immobilization is a very promising first aid method for Russell’s viper bite.
Early use of antivenom by health workers, administered by intramuscular or intravenous injection is an important idea that should be tested for safety and feasibility in properly designed randomized controlled studies. Close communication between DMR scientists, Myanmar doctors and the national antivenom producer MPF should help to ensure that the potency and safety of MPI’s traditionally excellent antivenom is maintained. To compensate for the known variations in venom antigenicity and composition in different areas of Myanmar, venom used to immunize horses in antivenom production should be a pool of samples from snakes of different lengths (and hence ages) and from different parts of the country. The advantages of freeze-drying (lyophilization) antivenom (prolonged shelf-life) must be balanced against the advantage of liquid antivenom (cost and ease and administration). In rural areas, liquid antivenom can be kept cool in the water pot room. Because of problems with demand and supply, Myanmar is now faced with the prospect of importing antivenom (e.g. from India). However, the foreign antivenoms show low potency in laboratory mouse tests compared to the old standard MPI lyophilized Russell’s Viper Antivenom and there are no data on clinical efficacy or safety (reactogenicity). The basis for all these new initiatives is education of doctors, nurses and members of the community. The recommendation from the meeting were very much in line with those of the WHO Meeting on Antivenom held in NIBSC, Potter’s Bar, London 7-9 Feb, 2001, reported by the temporary advisors. Conclusions and Recommendations Report of the Seminar (1) Population based studies are needed in Myanmar to establish the true incidence, mortality and long-term morbidity of snakebite. (2) More research is needed on the distribution of venomous snake species in Myanmar perhaps in collaboration with the Department of Forestry. (3) Improved first aid methods, notably the pressure-pad/immobilization method should be implemented. (4) Early deployment of antivenom in health stations by specially trained health assistants should be explored. (5) Snake diagnosis using the new DMR dot blot technique should be implemented. (6) Initial dose, efficacy and reactogenicity of the new liquid MPF antivenom should be studied as a matter of urgency. (7) Use of the 20 minute whole blood clotting test (20 WBCT) to diagnose and control the dose of antivenom should be promoted. (8) Education of doctors, nurses, health assistants, other medical personnel and members of the community should be promoted as a priority. 3
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