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Incidence of fatal snake bite in Loni, Maharashtra: An autopsy based retrospective study (2004–2014)
Journal of Forensic and Legal Medicine 39 (2016) 61e64
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Incidence of fatal snake bite in Loni, Maharashtra: An autopsy based retrospective study (2004e2014) Jamebaseer M. Farooqui a, *, Bimbisar B. Mukherjee a, d, Shiv Narayan M. Manjhi a, e, Anjum Ara J. Farooqui b, f, Sandesh Datir c, g a Department of Forensic Medicine & Toxicology, Rural Medical College of Pravara Institute of Medical Sciences, A/P Loni Bk, Tal. Rahata, Dist. Ahmednagar, Maharashtra 413736, India b Department of Oral Medicine & Radiology, Rural Dental College of Pravara Institute of Medical Sciences, A/P Loni Bk, Tal. Rahata, Dist. Ahmednagar, Maharashtra 413736, India c Department of Forensic Medicine & Toxicology, Dr D.Y. Patil Medical College, Hospital & Research Centre, Pune, Maharashtra, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 June 2015 Received in revised form 9 November 2015 Accepted 18 January 2016 Available online 27 January 2016
Snake bite is a major public health problem specially in a rural region where agricultural work is the major source of employment. A retrospective study was undertaken of all cases of deaths due to snake bite autopsied at the Mortuary of Pravara Rural Hospital, Loni a rural area in Western Maharashtra over a period of 10 years from January 2004 to December 2014. Data of the study was gathered from autopsy reports and hospital records. The cases represented approximately 2.13% (54) of the total 2539 medico legal autopsies conducted during the study period. Most of the deaths (42.60%) occurred in the age group of 11e30 years and both males and females were affected in almost equal proportions. There was a marked increase in the number of cases in monsoon season (59.26%). The lower extremity was the most frequently involved site of bite (62.96%). Snakes were identified in 43 cases (79.63%) and among the identified cases the most common culprit was Viper amounting to 29.63% of cases followed by Krait causing 24.07% of the deaths. The findings in our study reflects the necessity of educating the rural community regarding the hazards of snake bite, importance of early medical attention and to avoid wasting vital time being engaged by traditional healers. © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Incidence Fatal snake bite Rural India
1. Introduction India is one of the countries where snakes have been worshipped since ancient times. Since the dawn of civilization, snakes have appeared in various myths and mythologies, either as demon or as a god. It was way back in 326 BC, Alexander the Great was highly impressed by the skills of Indian physicians especially in the treatment of snakebite.1 The first data mentioning burden of snake bite from India was published by Joseph Frayer in 1864.2
* Corresponding author. Tel.: þ919860638533 (mobile). E-mail addresses: [email protected] (J.M. Farooqui), bimbimukherjee@ gmail.com (B.B. Mukherjee), [email protected] (S.N.M. Manjhi), fanjumj@ gmail.com (A.A.J. Farooqui), [email protected] (S. Datir). d Tel.: þ91 7040405775 (mobile). e Tel.: þ91 9926182376 (mobile). f Tel.: þ91 8482893458 (mobile). g Tel.: þ91 9422307579 (mobile).
In rural India, farming is a major source of employment and snakebite is a very common occupational hazard.3 In majority of Indian states there is free supply of polyvalent antisnake venom. India is not a country where a large number of venomous snakes are found but it has constituted the largest number of deaths in the world as a result of snakebite i.e. 50,000/year.4 The fatalities due to snake bite reflected in data represent only the tip of the iceberg. It is because of various beliefs and taboos very few victims were brought in the hospitals for treatment.3 Among these few victims majority were brought lately after being treated by traditional healers. The aim of this study was to review characteristics of the victims of fatal snakebite, which were autopsied in a tertiary care hospital of Rural Medical College, Loni, a rural region of Western Maharashtra, India. Western Maharashtra includes districts of Pune, Solapur, Satara, Sangli, Kolhapur and Ahmednagar. This belt has fertile land with good irrigation and is famous for its sugar factories. Loni is a small village of Ahmednagar District (Taluka e Rahata) situated
http://dx.doi.org/10.1016/j.jflm.2016.01.013 1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
62
J.M. Farooqui et al. / Journal of Forensic and Legal Medicine 39 (2016) 61e64
26 km from Shirdi (Holy place of Saibaba) and around 250 km from Mumbai, the financial and commercial capital of India. 2. Materials and methods The retrospective descriptional study was carried out at Department of Forensic Medicine, Rural Medical College of Pravara Institute of Medical Sciences, Loni over a period of 10 years from January 2004 to December 2014. Pravara Rural Hospital is a tertiary care hospital and the teaching hospital of Rural Medical College. The hospital provides health care services especially to the rural population. Approval for study was obtained from Institutional Ethics Committee. The records of snake bite victims were obtained from the hospital records and medico legal postmortem reports. All other bites other than snake bite were excluded from the study. Data was obtained in relation to type of snake, site of bite, place and time of bite; activity during the bite and socioedemographic profile of the victims (Graph 1). 3. Results Out of the total 2539 medico legal autopsies conducted in the study period, 54 cases were due to fatal snake bite envenomation which constitutes around 2.13% of the total cases. Both males and females were affected almost in equal proportions and the male/ female ratio was 0.9. Most of the deaths (42.60%) occurred in the age group of 11e30 years followed by the paediatric age group i.e. 0e10 years contributing 22.22% of the cases. Majority of the victims (37.04%) were farmer by occupation followed by housewife (22.22%) (Table 1). The peak incidence of fatal snake bite (59.26%) was seen in the monsoon season in the months of June to September and most of the bites (74.07%) were seen during day time. Most of the cases (33.33%) occurred in the farms while 24.07% cases occurred in the street and 20.38% cases took place at indoor environment (Table 2). Snakes were identified in 43 cases out of which only 14 snakes were brought to our hospital. Among the identified cases the most common culprit was Viper amounting to 29.63% of cases followed by Krait causing 24.07% of the deaths (Table 3). Most of the cases (33.33%) occurred in outdoor environment most commonly in the farms, 16.67% cases occurred while walking and 12.96% cases took place while working at home (Table 4). The most common site of bite were the lower extremities where 62.96% of bite marks were located followed by the upper extremities (29.63%) and head and neck (Table 5). 35 victims were admitted in our rural hospital while 19 cases were brought in dead to our institute.
Table 1 Demographic profile of victims of fatal snake bite.
Total number of autopsies Total fatal snake bite Sex Male Female Marital status Married Unmarried Age 00e10 11e20 21e30 31e40 41e50 51e60 >60 Occupation Farmer Housewife Student Not known Snake-charmers Identification of snake Snake seen & not brought Snake seen & brought Snake not seen
n
%
2539 54
100 2.13
26 28
48.15 51.85
33 21
61.11 38.89
12 09 14 09 05 03 02
22.22 16.67 25.93 16.67 9.26 5.55 3.70
20 12 10 09 03
37.04 22.22 18.52 16.67 5.55
29 14 11
53.70 25.93 20.37
Table 2 Distribution in relation to season, time and place of occurrence.
Season OcteJan (winter) FebeMay (summer) JuneSep (monsoon) Time 06ame12pm 12pme06pm 06pme12am 12ame06am Place of occurrence Farms Street Indoor Jungle Not known
n
%
18 04 32
33.33 7.41 59.26
19 21 11 03
35.19 38.89 20.37 5.55
18 13 11 07 05
33.33 24.07 20.38 12.96 9.26
Table 3 Type of snake.
Viper Krait Cobra Not known
n ¼ 43
%
16 13 08 06
29.63 24.07 14.81 11.11
Table 4 Activities during bite.
Working at farm Walking Working at home Playing Lying Not known Graph 1. Yearwise distriution of snake bite cases (2004e14).
n
%
18 09 07 06 04 10
33.33 16.67 12.96 11.11 7.41 18.52
J.M. Farooqui et al. / Journal of Forensic and Legal Medicine 39 (2016) 61e64 Table 5 Site of bite.
Lower extremity Upper extremity Head & Neck Trunk Back
n
%
34 16 04 00 00
62.96 29.63 7.41 00 00
4. Discussion Out of the total number of autopsies carried out in the study period, deaths as a result of snakebite constituted around 2.13% of cases. Whereas it was 0.56% in Gujarat, a neighbouring state to Maharashtra.5 In our study the male/female ratio was 0.9 i.e. both genders were affected nearly in equal proportions. This might be due to the fact that the primary occupation of any rural population of India is agricultural work and all family members have to reside in the farms working together. Hence both male and female were at risk of exposure to snakebite. This is in contrast with the study of other researchers done in urban areas not only from India3,6e8 but also from Bangladesh,9 Sri Lanka10 and Malaysia.11 The most common at-risk population appears to be between 11 and 30 years as they actively involves contact with vegetative areas. This would be definitely affecting the economy of the family of a victim as they are the breadwinner of their families. This is in contrast with the study conducted in Brazil by Oliveira HFA et al.,12 where majority of the victims were in the age group of 10e19 years. Our findings are in agreement with the studies carried out by Harsha et al. and Kirte et al. in India.3,6 In our study significant mortality was also observed in the age group of 0e10 years. This might be due to both carelessness of the parents, who leave the children in unprotected environment and also behavior of the child, who while playing approaches areas frequented by snakes. The monsoon season in India is between June to September when there is a considerable rise in snakebites. This is due to the fact that rain water floods the burrows of the snakes forcing them to come out and enter human habitat. Also this is the time when more activity in agricultural sector takes place. This results in accidental human envenomation. Studies conducted by various researchers in different parts of the world as well as Indian subcontinent show similar findings.3,5,9,12e19 Most of the incidence of snake bite was seen during the day time as the rural people work in the farms all day long causing exposure to snakes. This was in contrast to the study conducted by Rahman et al.9 in Bangladesh and Whitehall et al.10 in Srilanka, where majority of bites occurred at night. Agricultural work is the chief source of income in any rural region of India. So snake bite is regarded as an occupational hazard of rural India. We observed in our study most of the victims affected were farmers by occupation and most of the cases occurred in outdoor environment commonly in the farms. Also the rural people are less literate and do not take any preventive measures while working in the fields to protect themselves from snake bite.3 Identification of the snake is an important aspect while managing a case of snake bite, particularly in a country like India which helps to initiate timely treatment. 20 In this study snakes were identified in 43 cases and among these only 14 snakes were brought along with the victim to our hospital. In our hospital for the purpose of identifying the snake generally we ask various questions related to the morphology and characteristics of snakes or show photographs. Among the identified snakes, majority 29.63% of the bites were caused by the Viper followed
63
by Krait 24.07%. Our findings were in concordance with other Punam et al.16 and Bhalla et al.21 and Cobra was found to be the commonest offending snake in study conducted in Malaysia11 and Singapore.22 We noticed that in 62.96% cases, snake bites were on the lower extremities. This is due to fact that rural people usually work barefoot both at workplace and at home which make them vulnerable to snake bite.13 19 cases were brought in dead to our institution who lost their precious time being engaged by traditional healers. In rural and remote region of India road conditions are not proper and become worse during the rainy season. Also there is lack of accessibility of transportation means to reach hospital in time. 5. Conclusion Death associated with snake bite is a occupation related preventable hazard. Hence by taking simple measures we are able to reduce the incidence. Rural community especially farmers should be educated with regards to identification of poisonous snake, importance of wearing proper footwear, hazards of sleeping on floor and discouraging treatment from quacks and traditional healers. Law enforcement agencies should initiate criminal proceeding against quacks and traditional healers. The parents should keep strict vigilance on the children and restrict them from the places which are likely to be inhabited by snakes. By these measures we are surely able to reduce the incidence of mortality due to snake bite. Conflict of interest We declare no conflict of interest. Funding None declared. Ethical approval Approval for study was obtained from Institutional Ethics Committee. References 1. Jaggi OP. Medicine in India: modern period (History of Science, Philosophy and Culture in Indian Civilization, Vol. IX: Part I). New Delhi: Oxford University Pres; 2000. p. 384. 2. Fayrer J. Destruction of life in India by poisonous snakes. Nature 1882;27:205e8. 3. Halesha BR, Harshavardhan L, Lokesh AJ, Channaveerappa PK, Venkatesh KB. A study on the clinic-epidemiolgical profile and the outcome of snake bite victims in a tertiary care centre in southern India. J Clin Diagn Res 2013 January;7(1):122e6. 4. Simpson ID, Norris RL. Snakes of medical importance in India: is the concept of the “Big 4” still relevant and useful? Wilderness Environ Med 2007;18:2e9. 5. Pathak AK. Death rates of snakebites in Vadodara, mid-Gujarat: a 3-year study. Int J Med Sci Public Health 2015;4:339e41. 6. Kirte RC, Wahab SN, Bhathkule PR. Record based study of snake bite cases admitted at Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal (Maharashtra). Indian J Public Health 2006;50(1):35e7. 7. Sharma N, Chauhan S, Faruqi S, Bhat P, Varma S. Snake envemonation in a north Indian hospital. Emerg Med J 2005;22:118e20. 8. Rao CPS, Shivappa P, Mothi VR. Fatal snakebite e sociodemography, latency pattern of injuries. J Occup Med Toxicol 2013;8:7. 9. Rahman R, Faiz MA, Selim S, Rahman B, Basher A, Jones A, et al. Annual incidence of snake bite in rural Bangladesh. Plos Negl Trop Dis 2010;4(10):e860. 10. Whitehall JS, Yarlini M, Arunthathy M, Varan M, Kaanthan M, Isaivanan M. Snake bites in north east Sri Lanka. Rural Remote Health 2007;7:751. 11. Chew KS, Khor HW, Ahmad R, Rahman NH. Int J Emerg Med 2011;4:41. 12. Oleivera HFA, Barros RM, Pasquino JA, Peixoto LR, Sousa JA, Leite RS. Snake bite cases in municipalities of the state of Paraiba, Brazil. Rev Soc Bras Med Trop 2013;46(5):617e24. 13. Chattopadhyay S, Sukul B. A profile of the fatal snake bite cases in tha Bankura district of West Bengal. J Forensic Leg Med 2011 Jan;18(1):18e20.
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14. Brunda G, Sashidhar RB. Epidemiological profile of snake bite cases from Andhra Pradesh using immunological approach. Indian J Med Res May 2007;125:661e8. 15. Panna Lal, Dutta S, Rotti SB, Danabalan M, Kumar A. Epidemiological profile of snake bite cases admitted in JIPMER. Indian J Community Med 2001;26(1):36e8. 16. Gosavi PA, Jaju JB, Pawar GR, Dharmadhikari SC, Ubale VM, Parekar SM. A study on the clinico-epidemiolgical profile and the outcome of snake bite cases in the tertiary care hospital. Int J Basic Clin Pharmacol 2014;3: 298e302. 17. Hansdak SG. Clinico epidemiological study of snake bite in Nepal. Trop Doct 1998;28(4):223e6.
18. Dehghani R, Rabani D, PanjehShahi M, Jazayeri M, Sabahi Bidgoli M. Incidence of snake bite in Kashan, Iran during an eight year period (2004e2011). Arch Trauma Res 2012;1(2):67e71. 19. Plowman DM, Reynolds TL, Joyce SM. Poisonous snakebite in Utah. West J Med 1995;163:547e51. 20. Silva A, Gamlaksha D, Waidyaratne D. Medico-legal significance of the identification of offending snake in a fatal snake bite: a case report. J Forensic Leg Med 2013;20:965e7. 21. Bhalla G, Mhaskar D, Agarwal A. A study of clinical profile of snake bite at a tertiary care centre. Toxicol Int 2014;21(2):203e8. 22. Tan HH. Epidemiology of snakebites from a general hospital in Singapore: a 5-year retrospective review (2004e2008). Ann Acad Med Singap 2010;39:640e7.
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Incidence of fatal snake bite in Loni, Maharashtra: An autopsy based retrospective study (2004e2014) Jamebaseer M. Farooqui a, *, Bimbisar B. Mukherjee a, d, Shiv Narayan M. Manjhi a, e, Anjum Ara J. Farooqui b, f, Sandesh Datir c, g a Department of Forensic Medicine & Toxicology, Rural Medical College of Pravara Institute of Medical Sciences, A/P Loni Bk, Tal. Rahata, Dist. Ahmednagar, Maharashtra 413736, India b Department of Oral Medicine & Radiology, Rural Dental College of Pravara Institute of Medical Sciences, A/P Loni Bk, Tal. Rahata, Dist. Ahmednagar, Maharashtra 413736, India c Department of Forensic Medicine & Toxicology, Dr D.Y. Patil Medical College, Hospital & Research Centre, Pune, Maharashtra, India
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 June 2015 Received in revised form 9 November 2015 Accepted 18 January 2016 Available online 27 January 2016
Snake bite is a major public health problem specially in a rural region where agricultural work is the major source of employment. A retrospective study was undertaken of all cases of deaths due to snake bite autopsied at the Mortuary of Pravara Rural Hospital, Loni a rural area in Western Maharashtra over a period of 10 years from January 2004 to December 2014. Data of the study was gathered from autopsy reports and hospital records. The cases represented approximately 2.13% (54) of the total 2539 medico legal autopsies conducted during the study period. Most of the deaths (42.60%) occurred in the age group of 11e30 years and both males and females were affected in almost equal proportions. There was a marked increase in the number of cases in monsoon season (59.26%). The lower extremity was the most frequently involved site of bite (62.96%). Snakes were identified in 43 cases (79.63%) and among the identified cases the most common culprit was Viper amounting to 29.63% of cases followed by Krait causing 24.07% of the deaths. The findings in our study reflects the necessity of educating the rural community regarding the hazards of snake bite, importance of early medical attention and to avoid wasting vital time being engaged by traditional healers. © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Incidence Fatal snake bite Rural India
1. Introduction India is one of the countries where snakes have been worshipped since ancient times. Since the dawn of civilization, snakes have appeared in various myths and mythologies, either as demon or as a god. It was way back in 326 BC, Alexander the Great was highly impressed by the skills of Indian physicians especially in the treatment of snakebite.1 The first data mentioning burden of snake bite from India was published by Joseph Frayer in 1864.2
* Corresponding author. Tel.: þ919860638533 (mobile). E-mail addresses: [email protected] (J.M. Farooqui), bimbimukherjee@ gmail.com (B.B. Mukherjee), [email protected] (S.N.M. Manjhi), fanjumj@ gmail.com (A.A.J. Farooqui), [email protected] (S. Datir). d Tel.: þ91 7040405775 (mobile). e Tel.: þ91 9926182376 (mobile). f Tel.: þ91 8482893458 (mobile). g Tel.: þ91 9422307579 (mobile).
In rural India, farming is a major source of employment and snakebite is a very common occupational hazard.3 In majority of Indian states there is free supply of polyvalent antisnake venom. India is not a country where a large number of venomous snakes are found but it has constituted the largest number of deaths in the world as a result of snakebite i.e. 50,000/year.4 The fatalities due to snake bite reflected in data represent only the tip of the iceberg. It is because of various beliefs and taboos very few victims were brought in the hospitals for treatment.3 Among these few victims majority were brought lately after being treated by traditional healers. The aim of this study was to review characteristics of the victims of fatal snakebite, which were autopsied in a tertiary care hospital of Rural Medical College, Loni, a rural region of Western Maharashtra, India. Western Maharashtra includes districts of Pune, Solapur, Satara, Sangli, Kolhapur and Ahmednagar. This belt has fertile land with good irrigation and is famous for its sugar factories. Loni is a small village of Ahmednagar District (Taluka e Rahata) situated
http://dx.doi.org/10.1016/j.jflm.2016.01.013 1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
62
J.M. Farooqui et al. / Journal of Forensic and Legal Medicine 39 (2016) 61e64
26 km from Shirdi (Holy place of Saibaba) and around 250 km from Mumbai, the financial and commercial capital of India. 2. Materials and methods The retrospective descriptional study was carried out at Department of Forensic Medicine, Rural Medical College of Pravara Institute of Medical Sciences, Loni over a period of 10 years from January 2004 to December 2014. Pravara Rural Hospital is a tertiary care hospital and the teaching hospital of Rural Medical College. The hospital provides health care services especially to the rural population. Approval for study was obtained from Institutional Ethics Committee. The records of snake bite victims were obtained from the hospital records and medico legal postmortem reports. All other bites other than snake bite were excluded from the study. Data was obtained in relation to type of snake, site of bite, place and time of bite; activity during the bite and socioedemographic profile of the victims (Graph 1). 3. Results Out of the total 2539 medico legal autopsies conducted in the study period, 54 cases were due to fatal snake bite envenomation which constitutes around 2.13% of the total cases. Both males and females were affected almost in equal proportions and the male/ female ratio was 0.9. Most of the deaths (42.60%) occurred in the age group of 11e30 years followed by the paediatric age group i.e. 0e10 years contributing 22.22% of the cases. Majority of the victims (37.04%) were farmer by occupation followed by housewife (22.22%) (Table 1). The peak incidence of fatal snake bite (59.26%) was seen in the monsoon season in the months of June to September and most of the bites (74.07%) were seen during day time. Most of the cases (33.33%) occurred in the farms while 24.07% cases occurred in the street and 20.38% cases took place at indoor environment (Table 2). Snakes were identified in 43 cases out of which only 14 snakes were brought to our hospital. Among the identified cases the most common culprit was Viper amounting to 29.63% of cases followed by Krait causing 24.07% of the deaths (Table 3). Most of the cases (33.33%) occurred in outdoor environment most commonly in the farms, 16.67% cases occurred while walking and 12.96% cases took place while working at home (Table 4). The most common site of bite were the lower extremities where 62.96% of bite marks were located followed by the upper extremities (29.63%) and head and neck (Table 5). 35 victims were admitted in our rural hospital while 19 cases were brought in dead to our institute.
Table 1 Demographic profile of victims of fatal snake bite.
Total number of autopsies Total fatal snake bite Sex Male Female Marital status Married Unmarried Age 00e10 11e20 21e30 31e40 41e50 51e60 >60 Occupation Farmer Housewife Student Not known Snake-charmers Identification of snake Snake seen & not brought Snake seen & brought Snake not seen
n
%
2539 54
100 2.13
26 28
48.15 51.85
33 21
61.11 38.89
12 09 14 09 05 03 02
22.22 16.67 25.93 16.67 9.26 5.55 3.70
20 12 10 09 03
37.04 22.22 18.52 16.67 5.55
29 14 11
53.70 25.93 20.37
Table 2 Distribution in relation to season, time and place of occurrence.
Season OcteJan (winter) FebeMay (summer) JuneSep (monsoon) Time 06ame12pm 12pme06pm 06pme12am 12ame06am Place of occurrence Farms Street Indoor Jungle Not known
n
%
18 04 32
33.33 7.41 59.26
19 21 11 03
35.19 38.89 20.37 5.55
18 13 11 07 05
33.33 24.07 20.38 12.96 9.26
Table 3 Type of snake.
Viper Krait Cobra Not known
n ¼ 43
%
16 13 08 06
29.63 24.07 14.81 11.11
Table 4 Activities during bite.
Working at farm Walking Working at home Playing Lying Not known Graph 1. Yearwise distriution of snake bite cases (2004e14).
n
%
18 09 07 06 04 10
33.33 16.67 12.96 11.11 7.41 18.52
J.M. Farooqui et al. / Journal of Forensic and Legal Medicine 39 (2016) 61e64 Table 5 Site of bite.
Lower extremity Upper extremity Head & Neck Trunk Back
n
%
34 16 04 00 00
62.96 29.63 7.41 00 00
4. Discussion Out of the total number of autopsies carried out in the study period, deaths as a result of snakebite constituted around 2.13% of cases. Whereas it was 0.56% in Gujarat, a neighbouring state to Maharashtra.5 In our study the male/female ratio was 0.9 i.e. both genders were affected nearly in equal proportions. This might be due to the fact that the primary occupation of any rural population of India is agricultural work and all family members have to reside in the farms working together. Hence both male and female were at risk of exposure to snakebite. This is in contrast with the study of other researchers done in urban areas not only from India3,6e8 but also from Bangladesh,9 Sri Lanka10 and Malaysia.11 The most common at-risk population appears to be between 11 and 30 years as they actively involves contact with vegetative areas. This would be definitely affecting the economy of the family of a victim as they are the breadwinner of their families. This is in contrast with the study conducted in Brazil by Oliveira HFA et al.,12 where majority of the victims were in the age group of 10e19 years. Our findings are in agreement with the studies carried out by Harsha et al. and Kirte et al. in India.3,6 In our study significant mortality was also observed in the age group of 0e10 years. This might be due to both carelessness of the parents, who leave the children in unprotected environment and also behavior of the child, who while playing approaches areas frequented by snakes. The monsoon season in India is between June to September when there is a considerable rise in snakebites. This is due to the fact that rain water floods the burrows of the snakes forcing them to come out and enter human habitat. Also this is the time when more activity in agricultural sector takes place. This results in accidental human envenomation. Studies conducted by various researchers in different parts of the world as well as Indian subcontinent show similar findings.3,5,9,12e19 Most of the incidence of snake bite was seen during the day time as the rural people work in the farms all day long causing exposure to snakes. This was in contrast to the study conducted by Rahman et al.9 in Bangladesh and Whitehall et al.10 in Srilanka, where majority of bites occurred at night. Agricultural work is the chief source of income in any rural region of India. So snake bite is regarded as an occupational hazard of rural India. We observed in our study most of the victims affected were farmers by occupation and most of the cases occurred in outdoor environment commonly in the farms. Also the rural people are less literate and do not take any preventive measures while working in the fields to protect themselves from snake bite.3 Identification of the snake is an important aspect while managing a case of snake bite, particularly in a country like India which helps to initiate timely treatment. 20 In this study snakes were identified in 43 cases and among these only 14 snakes were brought along with the victim to our hospital. In our hospital for the purpose of identifying the snake generally we ask various questions related to the morphology and characteristics of snakes or show photographs. Among the identified snakes, majority 29.63% of the bites were caused by the Viper followed
63
by Krait 24.07%. Our findings were in concordance with other Punam et al.16 and Bhalla et al.21 and Cobra was found to be the commonest offending snake in study conducted in Malaysia11 and Singapore.22 We noticed that in 62.96% cases, snake bites were on the lower extremities. This is due to fact that rural people usually work barefoot both at workplace and at home which make them vulnerable to snake bite.13 19 cases were brought in dead to our institution who lost their precious time being engaged by traditional healers. In rural and remote region of India road conditions are not proper and become worse during the rainy season. Also there is lack of accessibility of transportation means to reach hospital in time. 5. Conclusion Death associated with snake bite is a occupation related preventable hazard. Hence by taking simple measures we are able to reduce the incidence. Rural community especially farmers should be educated with regards to identification of poisonous snake, importance of wearing proper footwear, hazards of sleeping on floor and discouraging treatment from quacks and traditional healers. Law enforcement agencies should initiate criminal proceeding against quacks and traditional healers. The parents should keep strict vigilance on the children and restrict them from the places which are likely to be inhabited by snakes. By these measures we are surely able to reduce the incidence of mortality due to snake bite. Conflict of interest We declare no conflict of interest. Funding None declared. Ethical approval Approval for study was obtained from Institutional Ethics Committee. References 1. Jaggi OP. Medicine in India: modern period (History of Science, Philosophy and Culture in Indian Civilization, Vol. IX: Part I). New Delhi: Oxford University Pres; 2000. p. 384. 2. Fayrer J. Destruction of life in India by poisonous snakes. Nature 1882;27:205e8. 3. Halesha BR, Harshavardhan L, Lokesh AJ, Channaveerappa PK, Venkatesh KB. A study on the clinic-epidemiolgical profile and the outcome of snake bite victims in a tertiary care centre in southern India. J Clin Diagn Res 2013 January;7(1):122e6. 4. Simpson ID, Norris RL. Snakes of medical importance in India: is the concept of the “Big 4” still relevant and useful? Wilderness Environ Med 2007;18:2e9. 5. Pathak AK. Death rates of snakebites in Vadodara, mid-Gujarat: a 3-year study. Int J Med Sci Public Health 2015;4:339e41. 6. Kirte RC, Wahab SN, Bhathkule PR. Record based study of snake bite cases admitted at Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal (Maharashtra). Indian J Public Health 2006;50(1):35e7. 7. Sharma N, Chauhan S, Faruqi S, Bhat P, Varma S. Snake envemonation in a north Indian hospital. Emerg Med J 2005;22:118e20. 8. Rao CPS, Shivappa P, Mothi VR. Fatal snakebite e sociodemography, latency pattern of injuries. J Occup Med Toxicol 2013;8:7. 9. Rahman R, Faiz MA, Selim S, Rahman B, Basher A, Jones A, et al. Annual incidence of snake bite in rural Bangladesh. Plos Negl Trop Dis 2010;4(10):e860. 10. Whitehall JS, Yarlini M, Arunthathy M, Varan M, Kaanthan M, Isaivanan M. Snake bites in north east Sri Lanka. Rural Remote Health 2007;7:751. 11. Chew KS, Khor HW, Ahmad R, Rahman NH. Int J Emerg Med 2011;4:41. 12. Oleivera HFA, Barros RM, Pasquino JA, Peixoto LR, Sousa JA, Leite RS. Snake bite cases in municipalities of the state of Paraiba, Brazil. Rev Soc Bras Med Trop 2013;46(5):617e24. 13. Chattopadhyay S, Sukul B. A profile of the fatal snake bite cases in tha Bankura district of West Bengal. J Forensic Leg Med 2011 Jan;18(1):18e20.
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