In Sindh 7 venomous species are present especially in desert/ arid zone, out of which six are of medical importance. The rice cultivation districts mostly have the cobra and the kraits, the marshy areas along the sea border of Thatta and Badin are having the Russell viper in abundance. The desert districts are having saw scale viper as the major offender with cobra and kraits (Pean). The Saw Scaled viper Echis Carinatus Sochureki (Lundi) is diffusely spread over the entire province with highest concentration in desert area likewise Cobra is also commonly found in barrage as well as desert areas with larger population in Shikarpur, Sanghar, Thatta, Khairpur, Larkana, Jacobabad, Nangarparker and Umerkot.
The medical staff managing the snake bite cases at hospitals is not passably trained to differentiate between the bite of a Venomous or non Venomous snake on first arrival of the victim. Hence irrational use of already short ASV is quite common especially when the victim belongs to an influential or vocal family. The present media coverage also compels the doctors to inject immediately few vials of ASV without ascertaining the clinical findings for such. In situation where most of the snake bite cases cannot be differentially diagnosed to its type, it is safe to use a poly-venom ASV instead of mpre specific mono-venom or di-venom ASV in the province.
The situation in desert districts, where abundance of venomous snakes, the traditional believes and practices, local customs, unscientific indigenous snake bite management, drastically short trained manpower, scarce medical facilities and scanty communication ways together make it highly obnoxious and therefore almost 60% to 70% of provincial calamity occur mainly in these districts. In Thar the very few and far away health institutions (capable to manage snake bite cases), having limited quantity of ASV, with faulty storage arrangements and deficient trained staff cannot provide trust worthy life saving facility to majority of the victims. The NIH supplied ASV is in liquid form which needs proper cold chain maintenance from manufacturing till used to retain its potency. Freezing or high temperatures destroy it’s protein part hence destroying it’s clinical effectiveness. In major part of the province including desert where electric breakdown and load shedding of many continuous hours is usual phenomenon, the potency and efficacy of the ASV even if available remains doubtful.
The rice growing districts of Larkana, Shikarpur, Jacobabad, Badin and Thatta are the second in series of high risk districts of snake bite cases, where the ever stagnant water of paddy crop makes the snakes to crawl over the foot paths used by the farmers and their families and thus very often snake bite cases occurs especially during night time if someone step on a venomous snake. An eggs hatching female snake or a mating couple aggressively attack any passerby mostly women and children, not capable to kill this deadly creature or to get escape from it’s jiffy fast strike. The marshy areas of costal belt extended through Thatta, Badin and Tharparker and orchard rich Mirpurkhas and Hyderabad districts do have Russell’s viper as big threat to the working farm labor.
The scientific data about the snakes and snake bite cases in Sindh is inadequate and not much organized. The only reliable data is that of Health Management Information System commonly known as HMIS is feed only by primary health care facilities and to some extent by secondary health care facilities of public sector alone. The government operated tertiary health care facilities and the major hospitals, the armed forces hospitals, the NGOs operated health facilities does not contribute in HMIS data base, hence the same cannot be considered much representative of the entire provincial picture.
The provincial HMIS reveals some more than seven thousands snake bite cases every year throughout the province. Besides deforesting and converting more and more fallow land under cultivation, there remained an increasing trend during last many years. Whereas in each flood year the snake bite cases get doubled or even more than the usual. In 2002 the total reported cases were 6191, in 2003, 7863 and in 2004 they were 7889. The under five are hardly 0.01% but the below 15 years and the women together form 3/4th of the total cases. The highest number districts in chronicle order are Thar, Sanghar, Ghotki, Khairpur, Larkana, Thatta Dadu, Badin, Jacobabad and Shikarpur. The remaining districts also have remarkable number of snake bite cases every year.
The minimum budget required to purchase estimated quantity is around 42 Million rupees if the NIH subsidized rate product is preferred. The Sindh budget for ASV remained very low almost 1/10th of the actual requirement and interestingly such short budget could not be utilized to its fullest due to short supply from NIH. The data available with Director General Health office shows supply of 23177 vials during 2002 (flood year) 5610 vials during 2003 and only 2223 vials during 2004. It shows a continuous deterioration of ASV supply besides increase in snake bite cases each year.
The entire picture emphasizes to identify an alternate preferably a local manufacturing unit capable to meet the provincial demand to its fullest. It needs to establish and sustain an ASV serology laboratory for production of international standard liquid as well as lyophilized (in powder form) anti venom serum well appropriate to neutralize venoms of medically important venomous snakes of the province.