Experts provide a comprehensive view of snakebite cases in the Middle East

Snakebite envenoming is a common problem in many parts of the world, but little is known about its magnitude in the Arab countries of the Middle East, where cases are not widely reported.

The aim is to halve the number of deaths and cases of disability due to snakebite envenoming over the next 12 years through a program that targets affected communities and their health systems, and by ensuring access to safe, effective treatment through increased cooperation, collaboration and partnership at all levels.

An interdisciplinary group of zoologists and snakebite experts recently reviewed existing English and Arabic literature on terrestrial venomous snakes and snake bites in Arab countries of the Middle East providing an up to date and comprehensive view of the situation in the region.

With a wide range of habitats, the review found that the region hosts 19 species of terrestrial venomous snakes of varying medical importance. These include 14 viperids (excluding a very dubious record of Montivipera xanthina in Syria) (Photo 1), 3 elapids (Photo 2) and 2 atractaspidines.

D.A. Warrell / Oman saw-scaled viper (Echis omanensis) specimen from Rustaq, Oman

The review shows that available scientific literature is heterogeneous across the region, and that epidemiological and clinical data on snakebite are generally limited or even absent from some countries.

Iraq, Jordan, Lebanon, Oman, Saudi Arabia, and Yemen report the largest numbers of snakebite cases (for example, a study in Saudi Arabia described 1,019 snakebite cases for the period 2005-2010), with common epidemiological patterns: males being predominantly bitten outdoors on their feet. On the other hand, only two snakebite case reports were found from Kuwait and no information was available from Qatar.

Countries in this region should be encouraged to make snake bites and scorpion stings notifiable diseases, and to record associated mortality and morbidity, so that the public health importance of these conditions can be more reliably assessed."

David Warrell, Study Coordinating Author and Professor, University of Oxford, United Kingdom

Antivenoms

There are only two antivenom producers in this region. The Scientific Studies & Research Centre SYRIA now manufactures only scorpion antivenom. Their "Polyvalent Anti snake Venom sera" is no longer obtainable.

National Antivenom & Vaccine Production Center (NAVPC), National Guard Health Affairs, Riyadh, Saudi Arabia, manufactures bivalent Naja/Walterinnesia Snake Antivenom, polyvalent Snake Antivenom, and polyvalent Scorpion Antivenom.

Imported Indian Vins "Snake Venom Antitoxin (Biosnake)" is claimed to neutralize Naja haje, Naja nigricollis and Cerastes cerastes venoms, but the geographical origin of these venoms and the clinical effectiveness of the antivenom for snakebites in Arab countries is unproven.

"Current political turbulence in the region is jeopardizing local production, and importation from adjacent Middle Eastern countries. It also makes the development of a coordinated regional initiative to overcome this deficiency far more difficult. Responsible international producers outside the region should consider developing appropriate antivenoms to meet the humanitarian need and marketing opportunity."

"However, new regional antivenoms must be designed based on sound knowledge of the species known to be of the greatest medical importance and raised using venoms obtained from snakes in Arab countries" said Professor Zuhair S. Amr, lead author, Jordan University for Science and Technology, Irbid, Jordan.

Adequate prevention and increased awareness of this public health problem in the region should also be promoted, particularly among farmers and other groups in rural areas, and exposed to encounters with snakes in their everyday life.