Published in IRIN News on 11 December 2013

A snake bite prevention poster by WHO and The Ministry of Health Myanmar

A snake bite prevention poster by WHO and The Ministry of Health Myanmar

Public education about snakebites in Myanmar has been largely successful in shifting people away from dangerous traditional practices to clinical treatment, but the inability to produce enough anti-venom is stalling progress in one of the world’s most snakebite-affected countries.

Day Wi, 14, was walking barefoot through a palm forest in Mon state, southern Myanmar, on 21 November, when she was bitten by a Russell’s viper, one of the most dangerous snakes in Asia. Its bite can result in acute kidney failure. She was taken to the nearest health centre and then transferred to San Pya Hospital in Yangon, one of four hospitals with specialist kidney departments.

The wound on Day Wi's leg caused by a Russell's viper

The wound on Day Wi’s leg caused by a Russell’s viper

She was treated by Khin Thida Thwin, a snakebite specialist at San Pya, and head of the Snake Bite Control Project – a joint undertaking with the World Health Organization (WHO) initiated in 1994 in response to Myanmar’s high number of deaths caused by snakebite.

In both Thailand and Myanmar, the average number of bites per year is 12,000. Yet just 10 victims die annually in Thailand while in Myanmar up to 1,000 have perished in recent years. The WHO has designated snake bite as a “neglected tropical disease”, estimating that it may kill more people than dengue fever and cholera across Asia.

Lauding Myanmar’s successful interventions, Khin Thida Thwin told IRIN: “The number of people being bitten every year hasn’t decreased in the last few years but morbidity rates have lowered.” Experts credit education campaigns with reducing reliance on traditional methods, such as rubbing a chicken carcass over the bite wound, and increasing the uptake of clinical treatments for snakebite.

A farmer being treated for a Russell's viper bite in San Pya Hospital.

A farmer being treated for a Russell’s viper bite in San Pya Hospital.

However, shortfalls in locally produced anti-venom threaten to stall progress, as treatment should be specifically tailored to an area’s snake venom types in order to ensure efficacy, experts say. “Imported anti-venom is less effective [in treating snake bites] but we have no choice but to use it because we don’t have enough funding [to produce it locally],” said Zaw Htun, a doctor in San Pya’s kidney department.

Plenty of education, but not enough anti-venom

Some 650 people died as a result of snake bites in 2001 (18 percent of those bitten), the Ministry of Health reported, but until 2009 that figure hovered between 500 and 1,000 deaths per year. By 2011 the number of deaths had dropped to 253, a case fatality rate of 2.19 percent.

Professor Khin Thida Thwin with specimens at San Pya Hospital

Professor Khin Thida Thwin with specimens at San Pya Hospital

According to Maung Maung Lin, the WHO-Myanmar manager of the Snake Bite Control Project, the Ministry of Health and WHO have been funding capacity building among local practitioners, technical assistance from international experts, and research including local anti-venom production and regional meetings, which led to the WHO Guidelines for the Management of Snake Bites.

Despite these gains, Maung Maung Lin said more attention is needed to developing effective local anti-venom.

Shortage solved by sheep?

Anti-venom is typically produced by injecting a non-fatal amount of venom into a thoroughbred horse and then extracting antibodies from its blood. Citing the high cost of horses, Myanmar began substituting less expensive sheep in 2012 in an effort to scale up domestic anti-venom production.

“However a sheep produces 20 percent less anti-venom than a horse,” Khin Thida Thwin said. This drop-off, coupled with budget constraints, means Myanmar is only able to produce half the amount of anti-venom it needs.

“Anti-venom imported from Thailand and India has a different neutralization capacity. What this means is that the amount of anti-venom required may be different from the prescription on the vial.” She also noted that knowing how to adjust the dosage can be difficult for health workers.

The concentration of venom in a Russell’s viper bite, which the Ministry of Health estimates caused 80 percent of the snake bite-related hospital admissions in 2012, can vary according to its geographical location even within Myanmar, underscoring the importance of local production.

“Russell’s vipers in central Myanmar are more likely to cause brain haemorrhage than those in other parts of Myanmar, which zoologists say is due to having different food sources,” Khin Thida Thwin explained.

Receiving the incorrect amount of anti-venom leaves venom in the patient’s body, potentially causing a range of complications from kidney failure to eye or brain haemorrhaging, and bleeding.

Lives at stake

Khin Thida Thwin is optimistic that her teenage patient, Day Wi, will survive because she has begun to pass more urine and her kidney functions have returned to normal. Hospital staff continue to dress the lesion left by the bite twice daily but it remains unclear whether the wound on her ankle will require a skin graft.

According to Zaw Htun, future funding should be increasingly directed toward the development of local anti-venom. “We are trying to get more funding next year [2014]. I’m hopeful that we will, because Myanmar’s political reforms include allocating more of the national budget to health issues.”