Global Snake Bite Initiative

A national health system emerging from the past

Despite the near complete devastation of its infrastructure and human resources during the period from 1975‐1979, and the further challenges that beset the nation during the following two decades as it sought to divest itself of the Khmer Rouge insurgency and reopen doors to international engagement and development, the Cambodian health system is recovering rapidly, and while numerous challenges remain, Cambodians are fortunate to have a proactive reformist Health Ministry. While many hospitals still lack adequate equipment, trained personnel and basic capacities, both the management of the Ministry of Health, and the management and staff of health facilities themselves appear to share a commitment to improving services and expanding service delivery capacity. There are currently 8 national and 69 referral hospitals functioning in 77 Operational Districts that each service a population of between 100‐200K people. Within this framework are a further 972 health centres and 72 health posts. Numerous NGO’s also operate special purpose health facilities (i.e.: trauma centres, rehabilitation clinics or specialist paediatric hospitals) throughout the country.

Snake bite recognised as an important public health problem

Concern about the burden of envenoming by snake bite in Cambodia was prompted by a perception that cases increase during the “rainy season” (late May to August), particularly in Provinces along the Mekong and Tonle Sap floodplains1. Despite this perception a lack of accurate data within the Ministry of Health has made it difficult for health managers to make informed decisions on the extent of resourcing required to deal with snake bite accidents. Snake bite is not currently a notifiable injury, and as a consequence centralised reporting of incidence, disability and mortality does not occur. It is perceived by health authorities that a majority of snake bite injuries are not treated in a health facility, and while there is some direct evidence that supports this from at least one Province, there is no specific data that would enable calculation of the proportion of non‐presenting cases at provincial or national level. In 2007 WHO/WPRO engaged consultants from the SEAMEO TropMed Network to conduct a preliminary investigation of the snake bite problem in Cambodia, and as a result a report was presented to the Cambodia Ministry of Health identifying several priority issues:

1) Need for epidemiological data;
2) Requirement for comprehensive information on the types and distributions of venomous snake species;
3) Development of national guidelines for the management and prevention of snake bites;
4) Review of current and future antivenom procurement and distribution policies;
5) Development of a relevant clinical management training programme;
6) Increased effort to prevent snake bites;
7) Overseas study visit by a technical working group to either Thailand or Viet Nam to examine commercial antivenom production and distribution methods.



In response to this initial report, the Ministry of Health requested further assistance through WHO/WPRO to action some of these identified priority issues. The WHO engaged toxinologist David Williams to carry out an initial assessment and collect information to enable us to address specific terms of reference. The major priorities were to:

a) Develop an understanding of the capacity of the Cambodian health system (and in particular, its hospitals and personnel) to treat and manage envenomed snake bite patients;
b) Collate and examine any snake bite data available from Cambodian hospitals or other sources;
c) Obtain an appreciation for the practical issues that may influence the outcome of any proposed intervention strategies;
d) Determine which antivenom products are available, and investigate the current supply and distribution of antivenoms throughout Cambodia;
e) To seek information on the distributions of various medically important snake species.

This work led to the production of a detailed report to WHO and the Cambodian government which recommended a proposed action plan for improving several aspects of the management of snake bite in Cambodia, focusing on:

1). Improved reporting and surveillance;
2). Community awareness and education;
3). Specific paramedical and medical education and training.
4). The procurement of snake antivenoms, with specific advice on the appropriate types and dosages of antivenoms suitable for use in Cambodia.

Positive Outcomes

The Cambodian Ministry of Health have responded very positively to recommendations of the report written by David Williams and colleagues Dr Simon Jensen and Dr Mark O'Shea. Steps are being taken to improve the reporting of snake bites to the Ministry so that national data can be acquired and use to make informed planning decisions. Snake bite education and first aid training has been incorporated in new Cambodian first aid courses, and a variety of educational materials are being prepared.

In August 2009, David Williams and Simon Jensen returned to Cambodia to launch a national training course in snake bite treatment for doctors and health workers. The course which runs over three days is comprised of a comprehensive curriculum that teaches all aspects of the assessment, diagnosis, primary treatment and ongoing medical care and rehabilitation of snake bite victims.



At the Calmette Hospital in Phnom Penh, the course was taught first to 12 National Master Trainers who were senior specialists from National Hospitals. These doctors will in turn be responsible for teaching the course content to their colleagues and students, and will take the leadership role in the transition to making the Cambodian Snake Bite Treatment Course a wholly localised initiative that will be taught around the country.



Further training courses were then stage in Siem Reap. 30 doctors from Provincial Referral Hospitals around the country were introduced to the curriculum over three days. These doctors will go on to assist the primary Master Trainers in teaching the course to their colleagues in their respective provinces, once the course teaching begins in earnest. A shortened 1 day course in first aid, assessment, resuscitation, referral and transport was run for 34 rural health centre staff, and this basic course which comprised 6 lectures and some practical sessions will also be rolled out nationwide to improve the ability of primary healthworkers to recognise severe snake bite cases, stabilise the patients, and then safely refer then onwards for treatment in a larger Provincial or National level hospital.



The Cambodian Ministry of Health is also moving to replace their existing antivenom supplies from India with species specific antivenoms manufactured in Thailand. For more than a decade, Cambodia had been a dumping ground in inefficacious, non-specific Indian antivenoms that are often poor quality and carry an unacceptably high risk of producing potentially life-threatening adverse drug reactions. None of the products were made using venom from snake species that occur in Cambodia, and in one case, a particularly unscrupulous supplier had provided an Indian-made product intended for treating snake bite in Africa, but which had also been shown to fail miserably in that regard as well as being entirely inappropriate for treating Cambodian snake bites.

Thanks to a progressive, proactive Ministry of Health, a responsive Regional WHO Office, and some hard work by dedicated experts, the prognosis for snake bite patients in Cambodia is looking up!