Tuesday, July 5, 2016

Myanmar - Fighting snake venom in rural Myanmar: a special report

It was a cool December afternoon, in a field outside Mawlamyine, Mon State. Fourteen-year-old Ko Aung (not his real name) stood sentry over his family’s herd, watching the cows as they munched on knee-high weeds.

When he looked down, the snake was already poised at his feet. Brown with black spots and 4 feet long, it was a Russell’s viper, one of Asia’s deadliest and most aggressive snakes. Ko Aung froze.

Without warning the triangular head snapped forward, and the serpent sunk its teeth into his foot, releasing about 70 milligrams of venom into his bloodstream.

The strike started an anatomical stopwatch. From the moment he was bitten, Ko Aung had about three hours to get the proper dosage of anti-venom before his body entered a fatal stage of kidney failure.

Bites like Ko Aung’s happen every day in Myanmar. The Ministry of Health logged 18.3 cases of poisonous snakebites – and 1.4 deaths – per 100,000 people in 2012, its most recent report. That amounts to about 28 known poisonous bites per day, with more likely unreported.

But in Mandalay and Sagaing regions, known instances go up nearly 80 percent from the average. In Magwe Region, mortality more than doubles. The entire Myanmar heartland – a fertile, primarily agrarian stretch where snakes lurk throughout hundreds of thousands of acres of rice paddy – is one of the most dangerous places in the world to get bitten by a snake.

The Myanmar Snakebite Project (MSBP), or more formally “Improving the outcomes for snakebite patients in Myanmar”, an Australian/Myanmar effort between the two governments, is working to address the snakebite threat. Begun in 2014, the A$2.3 million grant (US$1.66 million, or K1.96 billion) from the Australian government has transformed the way Myanmar produces, distributes and uses anti-venom.

“There’s never enough,” said David Bacon, the project manager based in Mandalay.

The MSBC began after Daw Aung San Suu Kyi drew attention to Myanmar’s snakebite problems during a 2013 speech in Sydney. Cyclone Nargis had ravaged the country in 2008, and anti-venom stores never recovered from the spike in snakebites during the crisis. Myanmar was producing just 15,000 vials per year – well below the international standard of 80,000.

Clinical Associate Professor Chen Au Peh from Adelaide University worked with Myanmar colleagues to develop a project with Myanmar’s Ministry of Health, which administers and distributes anti-venom, and the Ministry of Industry, which produces it.

Australian and international experts advise Myanmar staff on best practice across the anti-venom supply chain, from producing vials to distributing them more widely. Myanmar provides the anti-venom for free, as well as dialysis treatment if necessary, but travel costs are a heavy burden on poor rural families like Ko Aung’s.

Shortening the distance to treatment is another aim of the MSBP. After Ko Aung was bitten, his family rushed him to the nearest township health centre in Paung township, where he received four vials of anti-snake venom before transferring to the Mon State hospital several hours away.

The venom, which causes blood clotting as well as a host of other life-threatening conditions, created a hemorrhagic blister that ruptured his foot. Even though he received anti-venom within the three-hour time window, he still suffered a severe loss of kidney function. Doctors in Mon State transferred him to Yangon’s Specialty Hospital, where six sessions of dialysis probably saved him from organ failure.

Sitting in a hospital bed, he surveys the mangled mess of bandages around his foot. The dressings hide a gaping wound where his flesh once was, but Ko Aung is one of the lucky ones.

Health education

According to Dr Khin Thida Thwin, the renal physician at Yangon Specialty Hospital and head of the Snakebite Unit who treated Ko Aung, many victims end up turning to traditional healers, who often treat snakebites with tourniquets, cutting or tattooing – all of which are more harm than help.

“This traditional medicine has been around a long time,” she said. “Some people still believe in it. That’s why we have to provide health education.”

That’s the primary thrust of the MSBP’s public health work in Mandalay Region. Using Myanmar’s education resources, the team is supporting community prevention and education programs across Kyaukse and Madaya township areas in Mandalay Region.

Bacon said the project team was helping local health professionals create a pilot model for early treatment and improved referral of snakebite victims. Ko Aung’s case was a model in that the township health centre communicated with the regional hospital, which then managed a rapid transfer to Yangon. Most cases don’t flow so smoothly.

By organising training for more than 700 healthcare workers, the project hopes to streamline the treatment process while at the same time building the capacity of an educated professional workforce that knows exactly what to do when the next farm worker gets bitten.

In early May, the Ministry of Health ordered the Mandalay Region Rural Health Centres to stock a minimum of four vials. “The doctors and health workers in the townships and RHCs can now demand that [snake anti-venom] be provided and make sure that it arrives,” said Mr Bacon.


A visit to the Ministry of Industry’s new anti-venom production facility, which Industry Minister U Khin Maung Cho opened on May 20, reveals a shiny world-class laboratory filled with state-of-the-art equipment. Deputy general manager Dr Aung Zaw said K5 billion (US$4 million) went into the structure, which contains a large freeze-drying machine that will allow the anti-venom to be stored as powder.

Australian experts advised the ministry on what equipment to buy and partly funded the freeze dryer. As for the horses used to generate the anti-venom, veterinarians helped Myanmar staff make key changes.

Because the horses are so large, they can develop more anti-venom antibodies. These antibodies are extracted, purified and concentrated for human use.

But horse mortality reached 20pc, an expensive loss of investment and time. Part of the problem was treatment; They were keeping nearly 300 horses on a 9-acre pasture, repeatedly injecting them with the venom.

“There was a shortage of anti-venom because there was a scarcity of healthy horses,” Dr Aung Zaw said. “At the time we could only produce 15,000 vials a year.”

Now, after consulting with Australian veterinarians, horse mortality has been improved by half. And with the new facility, freeze-dried anti-venom will soon be available to rural townships that lack electricity for refrigeration.

The Australian government has donated 30 solar-powered refrigerators to selected rural health centres in Madaya and Kyaukse. The refrigerators will serve until the new, German-engineered freeze-drying equipment begins producing the powdered versions that do not require refrigeration.

It’s a turning point for one of Myanmar’s deadliest problems. After years of producing well below the national requirement of 80,000 vials per year, Dr Aung Zaw said 2016 would be the first year that Myanmar met international standards.

The MSBP will run its course by the end of 2018, and Dr Afzal Mahmood, an expert on healthcare in developing nations, says the goal is to leave behind a sustainable blueprint for the Myanmar government.

“International aid is not sufficient for improving the healthcare of a country. It’s local government that must do it,” he said. “Our role is to create, and assist the local government in creating, a model.”

RJ Vogt

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