Reducing mortality and

morbidity associated
with snakebite
envenomation in
Satara
District action plan
Contents
Background 6
Challenges 6
Need for an action plan. 7
One Health for snakebite management 8
Vision. 8
Scope 8
Goal. 8
Objectives. 8
Objective 1 9
Strategy 1.1: Strengthening promotive, preventive, and rst aid services at health and 9
wellness centers
Strategy 1.2: Awareness generation on snakebite prevention and effective rst aid through 9
community engagement
Strategy 1.3: Multisectoral engagement. 10
Strategy 1.4: Community-based surveillance... 10
Objective 2. 11
Strategy 2.1: Medicine availability for acute management of snakebites.. 11
Strategy 2.2: Equipment and diagnostics. 11
Strategy 2.3: Infrastructure strengthening. 12
Strategy 2.4: Human resource for health 12
Strategy 2.5: Reporting and record-keeping. 13
Strategy 2.6: Facility for transportation... 13
Strategy 2.7: Continuum of care... 14
Objective 3 14
Strategy 3.1: Intersectoral collaboration. 15
Strategy 3.2: Program management unit 16
Objective 4 17
Strategy 4.1: Facility assessment.. 17
Strategy 4.2: Regular monitoring and evaluation. 17
Strategy 4.3: Public notication and community-based surveillance 18
Monitoring progress.. 18
Annexure 1: Snakebite management protocol 20
Annexure 2: Medicine availability for snakebite management 21
Annexure 3: Equipment and diagnostics. 22
Endnotes 23
Background
Snakebite envenoming stands as a pressing global health issue, profoundly impacting the lives
of countless individuals worldwide. The World Health Organization (WHO) approximates an
annual occurrence of approximately 5 million snakebites, leading to up to 2.7 million cases of
envenoming. Reports in the public domain indicate an annual toll of fatalities, ranging from
81,000 to 138,000. This perilous condition also precipitates a substantial number of amputations
of up to 400,000, along with enduring disabilities like blindness, amputation, and post-traumatic
1
stress disorder, primarily owing to the absence of adequate post-treatment care. Click or tap
here to enter text. It is estimated that there are over 1,000,000 snakebites in India alone causing
58,000 deaths annually and signicant disability in almost four times the number. 2Click or tap
here to enter text. However, the National Health Prole 2019 data on snakebites reported
164,031 snakebite cases and 885 deaths in 2018, 3Click or tap here to enter text. which shows a
huge discrepancy in reported data. A signicant portion of snakebite incidents go unreported,
often as a result of victims seeking non-medical remedies or experiencing limited access to
4
proper health care facilitiesClick or tap here to enter text. India's rural population, which is
characterized by high biodiversity and densely populated areas, is particularly vulnerable to
snakebite envenoming. It is often associated with poverty, affecting vulnerable populations such
as agricultural workers, shermen, working children, and families residing in inadequately
constructed housing.

In India, around 90 percent of poisonous snakebites are caused by the “big four” among the
crawlers: common krait, Indian cobra, Russell's viper, and saw-scaled viperClick or tap here to
5
enter text. . Envenoming due to these snakes can lead to severe paralysis, bleeding disorders,
muscle breakdown, kidney failure, and extensive local tissue damage, often resulting in
permanent disability. Tragically, many of these deaths and severe consequences are
preventable through the availability and administration of safe and effective antivenomsClick or
6
tap here to enter text. . Unfortunately, due to a lack of awareness, knowledge, and access to
health care, young people and children in disadvantaged rural areas continue to bear a
disproportionate burden of snakebite envenoming. Additionally, it represents a signicant cause
of maternal morbidity and pregnancy loss, highlighting the urgent need for comprehensive
intervention strategies.

Challenges
Satara is a district situated in India's Western Ghats. Most of its terrain is covered by forests and
hills, making the local population “at risk” for snakebite envenoming. Villages along the Sahyadri
ranges are mostly separated by rivers and hills with poor road connectivity, making access to
health care a big challenge. Even though the population is vulnerable to snakebite
envenomation, most of the cases are not reported as the locals prefer traditional medicines or
die before reaching health care facilities.

At the community level, there is also a lack of knowledge about identifying at-risk areas,
preventive measures to mitigate human-snake interactions, and the availability of treatment at
public health facilities. Also, accredited social health activists (ASHAs) and staff from health and
wellness centers (HWCs) often lack training in community engagement and effective rst aid,
leading to underreporting of cases.

Health care facility staff members are frequently inadequately trained in the latest treatment
protocols, particularly at the primary level. This lack of proper rst aid and primary management
places an increased burden on higher-level facilities. Research has shown that delayed
administration of antivenoms increases the likelihood of fatalities in cases of snakebiteClick or
tap here to enter text.7.

Unfortunately, snakebite envenomation is rarely prioritized in government facility data, resulting

in a discrepancy between reported numbers and the actual situation on the ground. A recent
cross-sectional study revealed that essential infrastructure and human resource availability for
acute snakebite management are less than 50 percent in MaharashtraClick or tap here to enter
text.8. Effective monitoring and surveillance mechanisms are crucial for planning appropriate
actions to achieve the vision of zero deaths due to snakebite envenoming.

Need for an action plan

A comprehensive health-system–strengthening approach that encompasses all health care
system components and covers the entire continuum of snakebite care within the primary health
system is essential to reduce the burden of snakebites in Satara district. Instead of a piecemeal
approach to health system strengthening, this holistic strategy is critical.

The Indian Council of Medical Research (ICMR) National Task Force for Research on Snakebite
has outlined a roadmap focused on rapid diagnostics, antivenom development, guideline
dissemination, legislative changes, awareness campaigns, and media outreach. The Mission
Steering Group, responsible for strategy development and implementation within the National
Health Mission, has emphasized community awareness and health worker capacity building to
address the issue of snakebites. However, a comprehensive health care system strengthening
approach, with a particular emphasis on timely and effective service delivery at the primary
health care level, is indispensable for snakebite preventionClick or tap here to enter text.9.

As snakebite is a medical emergency. Providing care at the primary health care level, which is in
close proximity to bite incident locations, is paramount for reducing snakebite-related mortality
and morbidity. With the operationalization of Ayushman Bharat health and wellness centers (AB-
HWCs), health care has become more accessible to communities. However, it is crucial to
establish a service delivery framework at each level of health care facilities. To effectively
implement best practices and policies at the grassroots level, it is essential to involve
herpetologists, forest department ofcials, panchayat representatives, village elders, inuential
community members, and school teachers. Emphasizing community engagement throughout
the decision-making and implementation processes calls for decentralization of both authority
and nancial resources, ensuring a more inclusive and effective approachClick or tap here to
enter text.10. Therefore, the action plan will also focus on community engagement to generate
awareness and community-level surveillance for improving health-seeking behavior. Strategies
are being designed for multisectoral engagement based on the One Health approach for
enhancing surveillance and identifying areas of improvement. This district-level plan is designed
to address the mentioned challenges and provide a comprehensive action plan that addresses
the entire ecosystem of snakebite management.

One Health for snakebite management

The district action plan aims to adapt the One Health approach by engaging with other
departments, such as veterinary, agriculture, environment, forest, and education. It is a
holistic strategy that recognizes the interaction between humans, animals, and the
environment in the context of snakebite envenoming. This comprehensive approach offers
numerous benets, notably by addressing not only the immediate health consequences
for victims but also the broader impacts on ecosystems, livelihoods, and communities. By
integrating medical, veterinary, ecological, and other sectoral perspective, the One Health
approach seeks to enhance snakebite prevention, management, and research. It
acknowledges the role of venomous snakes in local ecosystems and considers the far-
reaching effects on human and animal health. The collaboration across various
departments will result in more effective and sustainable strategies, which not only reduce
the burden of snakebite envenoming but also protect the well-being of both humans and
animals. Ultimately, this approach promotes healthier ecosystems, safer communities, and
improved quality of life for all.

Vision
To make Satara district in the State of Maharashtra free of mortality and morbidity due to
snakebite envenoming.

Scope
This is a district-specic action plan for implementation, planning, and monitoring of strategies to
prevent snakebite-related deaths. This document focuses on district- and facility-level
stakeholders including district and block ofcers, health facility staff, eld-level workers,
community members, and concern ofcers from other sectors.

Goal
To reduce snakebite-related deaths in Satara district by 50 percent by the end of 2026 (The
short-term goal is reducing morality by 20 percent by the end of 2024.).

Objectives
Major local challenges can be effectively addressed through the following four measures:

Ÿ Prevent snakebites and improve rst aid management through effective community
engagement
Ÿ Provide access to quality life-saving treatment services by ensuring continuum of care at all
levels of health facilities

Ÿ Strengthen institutional capacity for effective leadership and management of the program to
ensure progress

Ÿ Establish effective surveillance and monitoring mechanisms for snakebite-related

emergencies

Objective 1
Prevent snakebites and improve rst aid management through
effective community engagement
Snakebite emergencies are often linked to environmental conditions, lack of access to proper
education, and occupations such as agriculture, shery, forest dwellers, children engaged in
labor work. The majority of the population in Satara district resides in the hills of the Sahyadri
ranges, living in poorly constructed housing in isolation due to poor road connectivity to city.
Lack of transportation options due to unique geographical conditions render them particularly
vulnerable to snakebite-related emergencies.

Also, as most of the young population migrated to metro cities for livelihood opportunities, the
elderly population often resorts to traditional healers as their preferred health care providers.
Lack of awareness on prevention of snakebites and of the availability of a public health care
system also affects decision making, causing high levels of unreported snakebite-related
morbidity and mortality cases. These emergencies can be prevented by spreading awareness
on prevention, medicine availability, and proper rst aid measures at the community and HWC
levels.

Strategy 1.1: Strengthening promotive, preventive, and rst aid

services at health and wellness centers
Ÿ Capacity building of HWC staff including community health ofcers (CHOs), auxiliary nurse
midwives (ANM), multipurpose workers (MPWs), and accredited social health activists
(ASHAs) on prevention, identication, and effective rst aid for snakebites.

Ÿ Training of CHOs on effective rst aid, primary clinical management, and referral of cases.

Ÿ Availability of the required material for rst aid and emergency drugs at HWCs. Provision of
cots, bed nets, footwears, and torches for vulnerable groups.

Strategy 1.2: Awareness generation on snakebite prevention and

effective rst aid through community engagement
Ÿ Community-level bodies such as Jan Arogya Samitis, gram sabhas, traditional healers,
farmer movements, and Village Health, Sanitation, Nutrition Committees (VHSNC) to be
 sensitized by CHO and ASHAs to identify at risk groups/areas depending on societal
practices and geographic conditions.

Ÿ Community training on prevention, effective rst aid, availability of treatment options and
proper methods of transportation. This training should be based on updated guidelines and
tailored based on the local context.

Ÿ Display IEC material at HWCs and PHCs on rst aid after snakebite and prevention of
snakebites in panchayats and other public places.

Ÿ Involvement of “local champions”, political leaders, and faith healers who have high inuence
on society to address the community on seeking better health care.

Strategy 1.3: Multisectoral engagement

Ÿ The forest department can help identify locally found species of snakes, which will be
reported to block or district authorities for ensuring availability of potent treatments.

Ÿ Plan awareness programs at schools where modules on snakebite prevention can be

incorporated in environmental education curriculum. Extra sessions can be conducted by
HWC staff. Additionally, display IEC material on rst aid at schools as children are one of the
most vulnerable groups.

Ÿ Gram sabha members should ensure availability of basic tools for rst aid such as wooden
splints and crape bandage at every gram panchayat.

Ÿ The agriculture and forest departments can help identify practices leading to human snake
interactions and participate in public awareness campaigns.

Strategy 1.4: Community-based surveillance

Reporting of snakebite-related deaths can be improved through regular monitoring at the
community level so that effective measures can be taken.

ASHAs and MPWs will be responsible to notify the HWC of potential snakebite deaths.

Review of potential snakebite deaths during Jan Arogya Samiti meetings to identify causes and
plan appropriate actions.

Priority actions
Ÿ Development and distribution of IEC material, toolkits, posters on awareness
generation for the prevention of snakebite emergencies.
Ÿ Capacity building of ASHAs and ASHA supervisors on prevention and community
mobilization for snakebite prevention
Ÿ Sensitization of community and Jan Arogya Samiti members.
Objective 2
Access to quality life-saving treatment services by ensuring
continuum of care at all levels of health facilities
Health system strengthening through a comprehensive primary care preparedness across all
domains is crucial to prevent snakebite-related casualties in India. Structural capacity at all
levels of health facilities needs to be developed in terms of medicine, equipment, infrastructure,
human resources, and health management information system. Strategies need to be
developed in a holistic way after considering all these domains.

Strategy 2.1: Medicine availability for acute management of

snakebites
Ÿ Capacity building of CHOs and pharmacy ofcers at PHCs, CHCs, and DHs about supply
chain management for emergency drugs and anti-snake venoms (ASVs).

Ÿ Ensure correct indenting and proper storage at the facility level to avoid wastage of drugs.

Ÿ Availability of ASV, emergency drugs, and other required medicines at highly remote HWCs.
Dedicated snakebite management kits are to be prepared for each facility (see Annexures)

Ÿ The district store is to ensure availability of quality ASVs and uninterrupted supply from the
state.

Ÿ Forecasting the need for ASVs is crucial. Annual requirement is to be calculated based on
the past year's use at PHCs and ensuring adequate quantity plus 10 percent extra.

Ÿ Availability of ASVs and emergency drugs should be a part of regular weekly and monthly
reviews at the block and district levels.

Ÿ Cases in which ASV was administered in time but not found to be effective should be
reported.

Strategy 2.2: Equipment and diagnostics

Ÿ Deployment of essential equipment required for management of snakebite at all levels (see
Annexure 3).

Ÿ It is important to follow a top-to-bottom approach by ensuring facility preparation starting from

DH to the CHC, PHC, and the HWC level. This will require active collaboration between the
District Civil Surgeon and District Health ofcer

Ÿ Availability of proper drug storage facility, especially at the AB HWC SC where ASV is
provided.
Strategy 2.3: infrastructure strengthening
Ÿ Assessment of the existing facilities will be done for following elements:

Ÿ Designated government building with daycare facilities

Ÿ Availability of 24x7 running water

Ÿ Electricity with power back-up

Ÿ Operational laboratory with essential diagnostic services (see Annexure 3)

Ÿ Residential facility inside the campus for the medical ofcer and staff nurse

Ÿ Designated emergency room or department as per guidelines (IPHS/NQAS)

Ÿ Blood storage unit at the CHC and blood bank at the DH

Ÿ Availability of functional toilets

Ÿ Ambulance facility connected to numbers 102 or 108

Ÿ Fund management to be done by district account management under supervision of the

district committee (DHO, CS, CEO, DM) for identied gaps.

Strategy 2.4: Human resource for health

Ÿ The district will identify facility-level human resource gaps and appropriate action will be
undertaken by the concerned authorities to ll the vacancies based on following indicators:

Ÿ DH: At least 3 medical ofcers, 4 staff nurses, and 2 attendants round the clock for the
emergency department; medical ofcers and staff nurses as per ICU beds; and 1 full-time
specialist physician, lab technician, and pharmacy ofcer

Ÿ SDH / CHC: 2 medical ofcers 2 staff nurses, and 2 attendants for the emergency
department and 1 physician, lab technician, and pharmacy ofcer

Ÿ PHC: At least 1 medical ofcer and 1 staff nurse, lab technician, and pharmacy ofcer

Ÿ HWC: 1 CHO, ANM, and attendant (MPW desirable)

Ÿ 108 ambulances: 1 medical ofcer and paramedical staff

Capacity building of health facility staff at all levels for clinical management of snakebite cases
and management of complications for CHC and DH as per latest guidelines and protocols.
Technical support can be provided by the existing development partners—presently, PATH.
 Community HWC-HSC HWC-PHC CHC DH

Provide rst aid to Look for obvious
patient and follow Right evidence of a bite,
approach: bleeding, swelling of the
R: Reassure the patient bitten area:
I: Immobilize the limb - Reassure the patient
using splint - Immobilize the
G H: Get to the Hospital limb/body part with bite
immediately where ASV - Remove shoes, rings,
is available watches, jewelry, and
T: Tell about the tight clothing from the
symptoms developed bitten area
- Leave the blisters
undisturbed
- Identify signs of
envenoming
- Conduct WBCT while
refrring patient to higher
facility and communicate
the results
- Primary treatment can
be initiated by a CHO in
remote HWCs
- Arrange transport of the
patient to nearest facility
with ASV by ambulance
- Follow up of discharged
cases
- ABC (Airway, breathing,
circulation)
- Secure IV/IO line in
HWC-PHC
and use normal saline to
keep IV access open.
- IV uids, if patient is in
shock.
- Draw 20 ml blood for
Whole Blood Clotting
Time and send results to
higher centre (if patient
has already left the
HWC-PHC)
- Evaluate and monitor
for sign of poisoning,
toxicity and early
administration of
antivenom
-ABC - ABC
- Administer ASV - Administer ASV
immediately if signs of immediately if signs of
envenomation observed envenomation observed
- Follow treatment - Follow treatment
protocol (Annexure 1) protocol (Annexure 1)
- Investigations for PT - Investigations for PT
INR, LFT, RFT, urine INR, LFT, RFT, Urine
examination, urine examination, urine
output to be observed output to be observed
- Ventilation support if - Ventilation support if
required required
- Discharge only if kidney - Transfer to nephrology /
function is normal and dialysis if abnormal urine
patient is stable output observed
- Follow up for post- - Discharge only if kidney
discharge complications function is normal and
- Availability of blood patient is stable
products, Blood storage - Follow up for post-
unit is desirable discharge complications
- Availability of blood
bank

Figure 1: Service delivery framework across facilities.

Strategy 2.5: Reporting and record-keepi

Ÿ Training of all levels of facility staff on the HMIS and IHIP portal

Ÿ All facilities should ensure timely and correct reports on both portals

Ÿ Record-keeping of reported, treated, referred cases, and death should be maintained at

facility level

Ÿ The HWC will include record-keeping for cases of morbidity and deaths not reported to the
hospital. Information to be collected from community, discussed during Jan Arogya Samiti
meetings, and reported to district

Ÿ Ensure reporting of adverse drug reaction events

Strategy 2.6: Facility for transportation

Ÿ Availability of functional ambulance services at all facilities—connected to helpline numbers
102/108

Ÿ Operationalize fully equipped boat ambulances along with trained medical/paramedical staff
for areas only or better accessible by water ways

Ÿ Ensure availability of emergency drugs (e.g., adrenaline, oxygen, atropine, neostigmine,

hydrocortisone) and equipment (e.g., oral airway, endotracheal tube, bag valve mask, oxygen
mask) in ambulances

Ÿ Training of ambulance staff on basic life support and the clinical recognition of envenoming
and rapid effective response to life-threatening emergencies such as shock, major bleeding,
airway obstruction, respiratory paralysis, and anaphylactic reactions while in-transit to referral
facility.
Strategy 2.7: Continuum of care
Development and distribution of appropriate IEC, toolkits, posters based on standard protocols
across districts

Develop district-specic standard referral protocols based on availability of services, which will
include early signs of complications, list of standard transfer criteria, steps to prevent clinical
worsening during transit (such as importance of maintaining hemodynamic and respiratory
stability before and during transfer).

Provision of cue cards to facilities having information of higher referral centers having ASVs and
essential critical care services for snakebite management. Cases should be referred to only
such facilities to avoid delay in treatment. Ensure communication between facilities.

All facilities will maintain record for referral cases and ensure follow up especially at HWC level
for discharged cases so that post treatment morbidities can be avoided.

Provision of referral slip specically for snakebite cases mentioning clinical observations,
investigations and specic treatment provided for effective communication to higher referral
center.

List of nearby health centers with availability of snakebite management services should be
provided to communities / Jan Arogya Samitis in at risk areas.

Establishing a team of snakebite mentors at the district level who can be available to answer
queries from the eld about snakebite management.

Priority actions
Ÿ Distribution of standard treatment protocols at all facilities as per latest guidelines
and capacity building of facility staff on treatment guidelines.
Ÿ Develop standard referral protocols as per service availability at higher referral
facilities.
Ÿ Development of standard protocols for ambulance staff to manage complications
in transit.
Ÿ Ensuring regular reporting and record-keeping for identication, management,
and referral of cases.

Objective 3
Strengthen district capacity for effective leadership and
management of the program to ensure progress
A stronger leadership and effective program monitoring specic to snakebite envenoming is
required to boost activities and improve delay in treatments, unavailability of ASVs, loss-to-
follow-up cases, underreporting and ultimately increased casualty. A continuous structure
process improvement model will be adopted to plan necessary actions in a timely manner.
Also, as mentioned earlier, multisectoral engagement (One Health approach) will be a crucial
part of district leadership to achieve our vision. Having sectors such as agriculture, environment,
veterinary, education, forest on board can contribute to planning and monitoring actions in a
holistic manner.

Strategy 3.1: Intersectoral collaboration

A district-level steering committee is to be formed under chairmanship of district collector, with
district nodal ofcers from health, education, agriculture, veterinary department for planning
activities specic to local context. This committee will meet quarterly to review progress on
activities, review of casualty, and plan specic actions.

Education
Introduction of snakebite awareness
and rst aid training into the
educational curriculum
Educate students and teachers
about snakebite prevention, rst
aid, and appropriate responses
Collaborate with health care
facilities (HWCs) to conduct public
awareness campaigns about
snakebite prevention, safe
environmental practices, and the
importance of timely medical
intervention
Health
Organize training programs for
health care for prevention and
effective management of snakebites
and administration of ASVs
Ensure a constant supply of ASVs
with proper storage and adequate
distribution to health care facilities
Prepared facilities with essential
infrastructure and equipment for
snakebite management
Community engagement through
Jan Aarogya Samitis at the HWC
level for snakebite prevention
Agriculture
Identify and address issues related
to snake habitats in areas where
agriculture practices contribute to
snake-human conicts. Changes in
land use or farming practices to can
be recommended in at-risk farming
such as paddy.
Strategies to be developed to
mitigate conicts between
agriculture activities and snakes,
ensuring the safety of both farmers
and local snake populations.
Monitor incidences among farmers
and provide nancial assistance to
dependents of snakebite victims

Forest
Maintain ecosystems in forested
areas to reduce snake-human
conicts through habitat
conservation, addressing factors
that attract snakes to human
habitats, and preserving natural
snake habitats.
Educate Forest personnel to rescue
and relocate venomous snakes
found in or near human settlements.
Data Collection on forest snake
populations, species, their
behaviors, and distribution. And
share it with other departments for
understanding and mitigating
snakebite risks.
Participate in snakebite awareness
programs, helping to educate local
communities on snakebite
prevention and rst aid and
conservation of endangered
species
Veterinary
The veterinary department will
collaborate on animal husbandry
practices aimed at minimizing
snake-human conicts. This
Snakebite includes ensuring the safety of
prevention and livestock and pets and advocating
for the humane handling of snakes
management
to prevent unnecessary harm to
both humans and snakes.
Communicate incidents of
snakebites among animals reported
to understand at risk areas and
practices

Figure 2: District Steering Committee for snakebite prevention and management.

Roles and responsibilities of the committee

Planning and coordination: The committee will be responsible for developing comprehensive
plans for snakebite envenoming prevention, treatment, and awareness. It will coordinate the
efforts of various departments and organizations involved in these initiatives within the district.
This coordination will ensure a holistic approach to tackle the issue effectively.

Progress review: The committee should have a bimonthly or need-based meetings to review
progress of planned activities and revise actions based on enablers and challenges.

Capacity building: Snakebite emergencies cannot be prevented in silos. It is pivotal to build

capacities of stakeholders from all departments and communities to achieve the goal. The
committee will identify opportunities for training and capacity enhancement across relevant
sectors and prepare plan for trainings of health care professionals, teachers, veterinary staff,
farmers, other relevant personnel to improve their skills in snakebite management and
prevention.

Casualty/death review: The committee will analyze data on snakebite casualties within the
district to identify patterns, locations with a higher incidence of snakebites, and emerging trends.
This data-driven approach is crucial for targeting interventions where they are most needed.

Action planning: Based on the ndings from casualty reviews, the committee will develop and
implement specic action plans. Based on the latest ndings, these plans may cover a range of
measures, including enhancing rst aid responses, ensuring adequate medical facilities,
managing the ecosystem, and raising public awareness about snakebite prevention.

Resource allocation: To ensure readiness for snakebite emergencies, the committee will make
recommendations for the allocation of resources with a particular focus on availability of ASV
and other necessary medical supplies, availability of trained HR, and logistics for public
campaigns.

Local context analysis: Challenges regarding snakebite emergencies vary according to

geographies. Therefore, it is important to analyze trends in local context and tailor interventions
according to local conditions, accounting for factors such as the types of snake species found in
the area and geographical variations that affect snakebite incidence. This will also aid in
advocating for district-specic issues such as availability of ASVs potent for local snake species
and policy modications.

Financial assistance to victims: The committee will verify that nancial aid is provided to the
victims. Presently, the schemes exclusively address accidents involving farmers in accordance
with state policy. A review should be conducted to assess any potential amendments in the
future.

Strategy 3.2: Program management unit

Ÿ Within department, a program management unit (PMU) will be established under leadership
of DHO
Ÿ The PMU team will be responsible for implementation, monitoring, and evaluation of planned
activities
Ÿ This team will include the IDSP(Integrated disease surveillance program) nodal medical
ofcer, epidemiologist, program coordinator, district account manager, ASHA coordinator, and
M&E coordinator.
 Plan: Establishing the core
Act: Modifying training committee, developing
3 1
programs, expanding evidence-based guidelines,
community outreach efforts, or enhancing infrastructure, and
reallocating resources to ACT PLAN setting clear goals for data
address specic needs. collection, training, and public
awareness campaigns

Check: Continuous data Check: Continuous data

collection, analysis, and collection, analysis, and
monitoring of performance
CHECK DO monitoring of performance
metrics metrics
3 2

Figure 3: Continuous structure and process improvement model for snakebite prevention (district approach).

Priority actions
Ÿ Form of district core committee and conduct orientation meeting to dene vision,
goals, and primary responsibilities.
Ÿ Sensitize PMU on individual responsibilities and implementation of priority action
items dened by the steering committee.

Objective 4
Establish effective surveillance and monitoring mechanisms for
snakebite-related emergencies
One of the primary challenges faced at the district level in preventing and managing snakebite
envenoming is the scarcity of high-quality epidemiological surveillance data. Access to timely
and dependable data is crucial for making informed decisions and planning effective strategies.
Such data is an essential component of a robust primary health care system and vital for
addressing snakebite-related emergencies.

Strategy 4.1: Facility assessment

Ÿ Rapid health facility assessments using a systems approach, with snakebite care specic
indicators will be conducted by district team to understand gaps in terms of knowledge,
health infrastructure, human resources, medicine availability, diagnostics, and reporting
mechanisms.

Ÿ Existing facility assessment tools will be used after integrating the mentioned indicators.

Strategy 4.2: Regular monitoring and evaluation

Ÿ District or block teams to prepare supervision plan with focus on snakebite management for
at-risk blocks.
Ÿ Regular and correct reporting of snakebite incidents will be ensured by the district monitoring
and evaluation cell.

Ÿ District and block managers will ensure that all snakebite incidents are discussed during
review meetings.

Strategy 4.3: Public notication and community-based

surveillance
Ÿ Communities to be encouraged for notication of snakebite cases / deaths to the nearest
ASHA or HWCs.

Ÿ WhatsApp groups can be used for notications at village or HWC level.

Ÿ Regular review during Jan Arogya Samitis can help identify risk areas and factors that will be
notied to the district PMU by the CHO.

Priority actions
Ÿ Conduct gap assessment for facilities across all domains and identify gaps for
developing plan for gap lling by district authorities.
Ÿ Identify gaps in reporting and communicate to facilities for validation of data.
Ensure regular reporting on HMIS and IHIP.
Ÿ Establish mechanism for reporting of adverse drug reactions during treatment.
Ÿ Sensitize Jan Arogya Samiti members on the importance of community-based
surveillance and create WhatsApp groups for immediate notication of incidents.
Same should be communicated to the district by CHOs.

Monitoring progress

To ensure the effectiveness of the action plan, a systematic monitoring process should be set in
place. This involves baseline, midline, and endline assessments of health care facilities to
gauge the impact of the designed plan. Regular progress checks are vital to ensure the correct
implementation of strategies. The following indicators will be monitored through existing
reporting channels and regular support visits by district and block teams:

Facility-level indicators
Ÿ The total number of facility staff trained in the latest snakebite management protocols
Ÿ The number of ASHAs trained in preventive measures, rst aid, and surveillance
Ÿ The number of community training sessions conducted in the catchment area for AB-HWCs
Ÿ The total number of snakebite cases reported to the facility
Ÿ The total number of snakebite cases provided with primary aid at the facility
Ÿ The total number of snakebite cases managed at the facility
Ÿ The total number of snakebite cases referred to higher-level facilities
Ÿ The total number of deaths attributed to snakebites
Ÿ The number of instances of stock-outs of ASV
Ÿ The number of instances of stock-outs of emergency drugs
Ÿ The number of Jan Arogya Samiti meetings conducted (check for minutes of meeting)

District-level indicators
Ÿ The number of district steering committee meetings conducted
Ÿ The number of PMU meetings conducted.
Ÿ The number of district- or block-level meetings conducted where snakebite incidents were
discussed.
This monitoring system ensures that the action plan progresses effectively and that the
necessary adjustments are made to achieve our goal of reducing snakebite-related morbidity
and mortality in Satara district.
Annexure 1: Snakebite management protocol
Annexure 2: Medicine availability for snakebite
management
HWC-SC
Ÿ Adrenaline inj 1mg/ml (desired for remote
HSC)
Ÿ Anti-snake venom (desired for remote HSC)
Ÿ Normal saline

HWC-PHC
Ÿ Inj Adrenaline
Ÿ Inj Atropine
Ÿ Inj Neostigmine
Ÿ Inj Tetanus toxoide
Ÿ Anti-snake venoms
Ÿ Normal saline

RH / SDH
Ÿ Inj Adrenaline
Ÿ Inj Atropine
Ÿ Inj Neostigmine
Ÿ Inj Tetanus toxoide
Ÿ Anti-snake venoms
Ÿ Chlorpheniramine / cetrizine
Ÿ Analgesics
Ÿ Epinephrine
Ÿ Antibiotics
Ÿ Normal saline
Annexure 3: Equipment and diagnostics
Equipment Diagnostics

HWC-SC IV sets, pulse oximeter, Ambu bag (adult WBCT

and neonatal), wooden splints, crape
bandage, BP apparatus

PHC IV sets, pulse oximeter, Ambu bag WBCT, RFT (D), Urine (D), LFT(D)
(adult and neonatal), wooden splints,
crape bandage, BP apparatus,
laryngoscope, ET tube

RH IV sets, pulse oximeter, Ambu bag PT INR, RFT, LFT, Urine,

(adult and neonatal), wooden splints, blood grouping, CBC, imaging
crape bandage, BP apparatus,
laryngoscope, ET tube, mobile ventilators

SDH IV sets, pulse oximeter, Ambu bag PT INR, RFT, LFT, Urine,
(adult and neonatal), wooden splints, blood grouping, CBC, imaging
crape bandage, BP apparatus,
laryngoscope, ET tube, mobile
ventilators, blood bank, oxygen supply,
critical care units

DH IV sets, pulse oximeter, Ambu bag (adult PT INR, RFT, LFT, Urine,
and neonatal), wooden splints, crape blood grouping, CBC, imaging
bandage, BP apparatus, laryngoscope,
ET tube, ventilator, dialysis unit, blood
bank, debrillator, oxygen supply,
critical care units
Endnotes
1
Snakebite envenoming [Internet] [cited Nov 17, 2023], https://www.who.int/news-room/fact-
sheets/detail/snakebite-envenoming#cms

2
B. Mohapatra, D.A. Warrell, W. Suraweera, P. Bhatia, N. Dhingra, R.M. Jotkar, et al, “Snakebite
mortality in India: a nationally representative mortality survey,” PLoS Negl Trop Dis [Internet].
2011 Apr [cited Nov 17, 2023]; 5(4):e1018,
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Warrell, R. Whitaker, G. Menon, R. Rodrigues, S.H. Fu, et al, “Trends in snakebite deaths in
India from 2000 to 2019 in a nationally representative mortality study,” Elife [Internet]. 2020 Jul 1
[cited Nov 17, 2023]; 9:1–37, https://pubmed.ncbi.nlm.nih.gov/32633232/

3
Central Bureau of Health Intelligence, National Health Prole 2019, 14th Issue [Internet]. 2019
[cited Nov 17, 2023], https://cbhidghs.mohfw.gov.in/showle.php?lid=1147

4
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https://pubmed.ncbi.nlm.nih.gov/34145096/

5
Snakebite envenoming India [Internet]. [cited Nov 17, 2023], https://www.who.int/india/health-
topics/snakebite

6
J.M. Gutiérrez, J.J. Calvete, A.G. Habib, R.A. Harrison, D.J. Williams, D.A. Warrell, “Snakebite
envenoming,” Nature Reviews Disease Primers 2017 3:1 [Internet]. 2017 Sep 14 [cited Nov 17,
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7
J.M. Gutiérrez, J.J. Calvete, A.G. Habib, R.A. Harrison, D.J. Williams, D.A. Warrell, “Snakebite
envenoming,” Nature Reviews Disease Primers 2017 3:1 [Internet]. 2017 Sep 14 [cited Nov 17,
2023];3(1):1–21, https://www.nature.com/articles/nrdp201763

8
S. Bhaumik, R. Norton, J. Jagnoor, “Structural capacity and continuum of snakebite care in the
primary health care system in India: a cross-sectional assessment,” BMC Primary Care
[Internet]. 2023 Dec 1 [cited Nov 17, 2013]; 24(1):1–11,
https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-023-02109-2

9
R.K. Gajbhiye, I.K. Chaaithanya, H. Munshi, R.K. Prusty, A. Mahapatra, S.K. Palo, et al.
“National snakebite project on capacity building of health system on prevention and
management of snakebite envenoming including its complications in selected districts of
Maharashtra and Odisha in India: a study protocol,” PLoS One [Internet]. 2023 Feb 1 [cited Nov
17, 2023]; 18(2):e0281809,
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0281809

10
R.K. Gajbhiye, H. Munshi, H.S. Bawaskar, “National programme for prevention and control of
snakebite in India: key challenges and recommendations,” Indian J Med Res [Internet]. 2023
Apr 1 [cited Nov 17, 2023]; 157(4):271, /pmc/articles/PMC10438420/
NOTE
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New Delhi - 110001