Snakes are widely feared in Papua New Guinea, and with very good reason. Venomous snake bite is a serious public health problem, with localized incidence among the highest of any tropical region in the world. In Central Province (which surrounds the national capital, Port Moresby), the incidence averages 215.5 victims per 100,000 people, but in some sub-provinces, such as Kairuku (which includes Yule Island and the villages of Bereina and Veifa’a) localized incidence exceeds 1,300 victims per 100,000 – among the highest rates of snake bite in the world. Each year in Central Province an average of 7.9 victims per 100,000 die as a result of snakebites, and this figure may in fact be far higher – many victims die before they can reach Aid Posts and Rural Health Centres, and these deaths rarely register in official statistics. In studies conducted during the early 1990’s in Central Province, it was found that children accounted for 16% of envenomed patients, with 8.5% being below 10 years of age, while the overall mean age of patients was 25.0 years. Very little detailed information available about the incidence, or mortality arising from snakebites in other provinces of southern Papua New Guinea.

Perhaps the most astonishing revelation in Central Province has been that despite the view of the general community that Papuan blacksnakes (Pseudechis papuanus) are the most dangerous species; the opposite is in fact true. More than 90% of patients admitted to Port Moresby General Hospital with symptoms of snake bite, are the victims of a much more dangerous snake, the Papuan taipan (Oxyuranus scutellatus) – a large (to 3.4 metres), fast-moving snake with the third most toxic venom of any snake in the world! Papuan taipans are also common across Milne Bay, Gulf and Western Provinces, and in southern Irian Jaya, and there is evidence that in remote communities, the mortality rate after bites by this species is 100%. There are also five other species that are considered medically important, and these are distributed throughout Papua New Guinea and Irian Jaya, including: death adders (Acanthophis spp.), the Papuan blacksnake (Pseudechis papuanus), the Papuan brown snake (Pseudonaja textilis), New Guinean small eyed snake (Micropechis ikaheka) and the Papuan mulga snake (Pseudechis rossignolii).



Currently the only medical treatment available for snake bite victims includes the use of extremely expensive (US$1800.00/vial) antivenom purchased from Australia, combined with the use of mechanical ventilation and other drugs. The high cost often leads to shortages, and for many victims, there simply is no antivenom available when required.

AVRU-UPNG Snake Bite Research Project

David Williams from the Australian Venom Research Unit has spent the last 10 years living in Papua New Guinea and working to improve the plight of snake bite patients, and develop a better understanding of the extent of the problems and the steps that are needed to effect sustainable change. Since 2005 David has been conducting research towards his PhD as a Nossal Institute for Global Health supported researcher working in collaboration with staff and students at the University of Papua New Guinea's School of Medicine and Health Sciences in Port Moresby.
The aims of David's work have been to use a combination prospective clinical studies, epidemiological investigations, phylogenetic analyses, community education initiatives, targeted medical training in snake bite treatment, local infrastructure and personnel development, and vocal advocacy to improve the management of snakebite in a developing country setting.

Research Questions

David's project examines the key question of how the burden from snakebite can be dealt with most effectively and efficiently by developing nations, such as Papua New Guinea. In order to answer this question it is essential that a fundamental understanding of the state of health infrastructure and administration, and its capacity to make dynamic responses to health issues be sought out. To obtain this measure of systems performance the research needs to explore not just the clinical fundamentals of snakebite, but also the larger health service framework within which the problem must be addressed.

In the case of Papua New Guinea a fractured and largely ineffectual health service is as much to blame for high morbidity and mortality as are problems experienced in the individual clinical management of each snakebite emergency. Resolving the question of how to deal with the high human and financial costs of the problem necessitates a broad approach encompassing epidemiological, clinical, zoological, toxinological and public health management research. The projects undertaken during this candidature for Doctor of Philosophy seek to accumulate the answers to individual questions that will cumulatively provide practical and sustainable solutions to the broader issues that apply not just in Papua New Guinea, but in many other of the world's tropical developing nations.

Specifically this project seeks to resolve a number of questions:

1. How best can quantitative measures of injury burden, such as crude incidence and mortality at regional, provincial and national levels be reliably measured, and what systems can be established to facilitate surveillance and dynamic monitoring within the health infrastructure?

2. Who are the culprits? Which species of venomous snakes are responsible for injury in particular regions of the country? What relationships exist between populations and are all populations homogenous, or do significant variations in phylogeny translate to significant variations in venom composition and clinical syndromes?

3. What are the clinical syndromes of envenomation at species level? How are these conditions managed? What sustainable improvements to the clinical care of patients and to the operations of service delivery systems can be made that will produce tangible benefits in the form of reduced morbidity and mortality at all levels of the system?

4. Can public education and first aid training be effective tools for reducing the incidence of snakebite, and for improving the prognosis of the snake-bitten? Can the techniques of snakebite first aid be successfully taught to those in most need of these skills, and what is the efficacy of the training approach?

5. Does ongoing professional training, education and access to information functionally improve the skills of the medical and paramedical workforce? Can we measure tangible improvements in the outcomes for envenomed patients over time? Does a structured program of training combined with standardisation of treatment protocols and procedures translate into real improvement in patient prognosis?

6. Can we develop a model system in Papua New Guinea for the successful sustainable management of resources such as antivenoms? Can the rising costs of treatment be curtailed by a coordinated national approach and the establishment of local research and clinical capacity? Can new avenues for reducing cost and maintaining the supply of antivenoms be established within nations such as Papua New Guinea, and can a successful international model be established through cooperation with more affluent neighbours or through strategic regional alliances?

7. Can all of these approaches, collectively, be maintained, and can lives be saved?

Key Accomplishments

Some of the projects key accomplishments have been:

1. Development and introduction of annual Snake Bite Management Courses for doctors and healthworkers

NDoH-sponsored clinical toxinologist, David Williams, and visiting UPNG Senior Lecturer in Emergency Medicine, Dr Simon Jensen set out in 2004 to develop a National training course in the treatment and management of the bites and stings of venomous snakes and other toxic animals. The philosophy behind the course is that the declining prognosis of snakebite patients can be reversed if key issues, including health worker and community education and training, are addressed with situationally relevant education and training. The inaugural National Snakebite Management Course was conducted at the UPNG School of Medicine and Health Sciences in Port Moresby in September 2004. Taught by a volunteer faculty of physicians and snakebite specialists from Australia & PNG the course is aimed at rural HEO’s, CHW’s and NO’s, and hospital-based doctors and NO’s. Annual courses have been conducted in Port Moresby and Madang, with expansion to Alotau and Popondetta in 2007. A 1 day Intensive Care Management of Snake Bite Patients Course was started in 2007 to cater to the training and education needs of doctors at Port Moresby General Hospital.

2. Publication of a handbook for doctors and healthworkers: Venomous bites and stings in Papua New Guinea

To coincide with the inaugural Snakebite Management Course in 2004, the course organizers, David Williams and Dr Simon Jensen edited and produced a 200 page course handbook ‘Clinical management of snakebite in Papua New Guinea’ which was produced in a print-run of 100 copies. The aim of this handbook was to provide course participants with a comprehensive resource to take back to their health facilities and use as a reference when dealing with cases of snakebite. In 2005 a major revision and rewrite of this 2004 Snakebite Management Course Handbook resulted in the publication of ‘Venomous bites and stings in Papua New Guinea: A guide to treatment for health workers and doctors’ in a print run of 2,000 copies at a cost of K47,125.00. The publication was funded by donations from the AVRU, Oil Search Limited, CSL Limited and Melbourne’s St. Vincent’s Hospital. ‘Venomous bites and stings in Papua New Guinea’ was edited by David Williams in collaboration with Drs Simon Jensen, Bill Nimorakiotakis and Ken Winkel. The book comprises 20 chapters, spread over 416 A5 pages, including 48 pages of colour photographs. The individual chapters follow the same format as the curriculum of the Snakebite Management Course, dealing with all aspects of snakebite, marine envenomation, insect and arthropod bites and stings. A number of chapters were contributed by internationally recognised experts in snakebite treatment including Dr Bart Currie (Menzies School of Health Research, Darwin) and Professor David A Warrell (Centre for Tropical Medicine, Oxford University, UK).

3. Establishment of a Venom Research Laboratory and development of a low-cost antivenom for treating Papuan taipan bites

One of the priorities for enabling Papua New Guinea to achieve greater control over the future antivenom requirements within the country is the development of sustainable infrastructure. Any move by Papua New Guinea to investigate alternatives to current supply arrangements, such as developing their own antivenom production facilities, requires that there be a reliable source of snake venoms available for use in basic research and as antigens with which to raise antivenom. In 2004 the University of Papua New Guinea and Department of Environment & Conservation approved the development of a Serpentarium at UPNG's School of Medicine & Health Sciences. An unused animal housing building was allocated for the project as the UPNG contribution, and since then the building has been improved and fitted out by AVRU to accommodate highly venomous snakes, and the rodents that must be bred to supply them with food. The Serpentarium which presently houses approximately 60 snakes, will eventually accommodate several hundred specimens collected from locations right across Papua New Guinea. A National Reference Collection of Snake Venoms is being created by regularly extracting venom from snakes in the collection. These venoms are currently being used in basic research projects that have been developed through the collaboration between David Williams and UPNG Associate Professor Dr Teatulohi Matainaho, and provide learning opportunities in the fields of biochemistry, protein purification and pharmacology for UPNG Medical School students. Venom has also been used to enable the development of a new, whole IgG equine antivenom for treating Papuan taipan bites. The development of this antivenom has been undertaken by the Instituto Clodomiro Picado at the Universidad de Costa Rica in Costa Rica, and there are plans to conduct clinical trials in 2010-12. The antivenom is expected to cost less then 15% of the current price paid for Australian antivenom.




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The ABC Foreign Correspondent Story

In 2007 Australia's ABC Television network featured some of David's work in an episode of Foreign Correspondent. During film the story took a dramatic turn when David was bitten and almost killed by a large Papuan taipan. In another twist, a trip to a local City Pharmacy outlet by reporter Steve Marshall uncover a lucrative racket in the sale of ineffective and unsafe Indian antivenoms, that had been illegally imported and were on sale for more than 30 times their normal (Indian) retail price. Watch the story to learn more...

Produced by ABC Australia