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Study of snake bite cases admitted in tertiary care hospital in Nagpur

Worldwide, Snakebite is an important and preventable health hazard in many tropical and subtropical countries. Globally, 421,000 envenomings and 20,000 deaths occur each year due to snake bite. 1 It is estimated that on average, nearly 200000 are bitten by snakes every year in India out of which 35,000-50,000 die annually and most of them were earning members of family (WHO Bulletin 2012). 2 Its incidence India is usually underestimated because of lack of epidemiological data. 3 According to a new analysis, Snake bites cases are recently included in list of neglected tropical diseases drawn up by the World Health Organization and it could be the most neglected of all tropical diseases in the 21 st century. 4 The majority of snakebites and consequent mortality is attributed to only 4 species in India, which includes King /Common Cobra (Naja naja), Russell’s Viper (Vipera rusellii), Common Krait (Bungarus caeruleus), and Saw Scaled Viper (Echis carinata). 5 Viper bites are more common than other ABSTRACT

poisonous snakebites in human beings. 6 The peak incidence of snakebite cases is reported during the paddy sowing and harvesting periods. 7 Use of ineffective firstaid treatment and delay in getting antivenom combined leads to systemic envenoming by the time they seek medical treatment. 8 It has been reported that in most developing countries major portion of the individuals bitten by snakes first consult traditional practitioners before visiting a medical centre and resulting delay in transportation leads to mortality. To substantiate the existing epidemiological gaps in snake bite cases, the present study is planned, which will help to adopt adequate preventive and control measures. Aim of study were to assess the clinical profile and outcome of snake bite cases admitted in tertiary care hospital in Nagpur and to study some epidemiological factors related to snake bite cases.

METHODS
A hospital based observation study was planned at tertiary care hospital in Nagpur after approval from the Institutional Ethics Committee was sought. All snake bite cases admitted in Government Medical College and Hospital, Nagpur from April to December 2014 were included in the study whereas Patients not willing to participate in the study were excluded. A pilot study was carried out on 50 cases of snake bites to test the Proforma. Government medical college and hospital (GMCH) Nagpur is tertiary care health centre in central India, catering services to Vidharbh region of Maharashtra, parts of Madhya Pradesh and Chhattisgarh. As per Government of Maharashtra, all snakebite cases are classified as medico-legal cases and should be admitted in emergency department. A total of 156 confirmed cases of snake bites were admitted in GMCH during the study period. All patients of snake bite were admitted to intensive care unit and were monitored for at least 24 hours. Details history of snake bite was obtained from study subjects, their relatives and from case papers in predesigned proforma. Information on sociodemographic factors, clinical manifestations, health care seeking behavior, first aid taken, complications if any and outcome were collected. Diagnosis of envenomation is based on clinical manifestation. Venomous bites were defined by the presence of signs and symptoms of local and/or systemic toxicity. Local toxicity is defined as presence of a local reaction in the form of swelling, bleeding from fang marks and cellulites, or necrosis. Signs and symptoms of systemic toxicity are either neuroparalytic or haemostatic abnormalities such as bleeding from muco-cutaneous sites, any systemic bleeding, intravascular haemolysis, or a deranged laboratory coagulation profile anytime during hospital stay. A neuroparalytic syndrome included sensory or motor paralysis in the form of paresthesias, taste and smell abnormalities, ptosis, cranial nerve palsy, general flaccidity, or respiratory paralysis. Recovery from envenomation is defined by the resolution of local and systemic signs clinically and/or on laboratory investigations. Outcome measures are recorded as "Relieved" if there is relief of symptoms but patient didn`t get cured fully, "Cured" if the patient become free from symptoms and complications, "Expired" if cases died in due course of treatment and "LAMA" if cases left against medical advice. Data was analyzed using statistical software Epi Info 7. Association between two categorical variables was analyzed by using Chisquare test. P value <0.05 was considered to be statistically significant.

RESULTS
A total 156 study subjects were admitted in hospital, 66.04% snake bite cases out of it were in the month of July to September, which corresponds to rainy season. There were 100 (64.10%) male and 56 (35.90%) female study subjects.           Table 6 showed outcome of the study subjects depending on place residence and it was observed that proportion of study subjects who died was higher in urban area as compared to rural area; however this difference was not statistically significant. (P=0.104).Proportion of study subjects died was higher among those who had bitten on upper limb or other part (11.67%) as compared to bite on lower limb (2.08). This difference of proportion was found to be statistically significant (X 2 = 6.237, df =1, P =0.012). Table 7 shows outcome of the study subjects depending on First aid measure received. Proportion of study subject who died was higher among those who did not receive first Aid measures or took herbal medicine as compared to those who received first Aid measures. This difference was found to be statistically significant (P =0.022). Table 8 showed mortality was significantly higher among study subjects with complications as cellulites and DIC (P =0.006; P =0.03) as compared to other complications in subjects.

DISCUSSION
Mean age of the present study subjects was 37.78±14 years in, which were similar to the findings of Mahmood et al, Rahman et al, Sharma et al Kalantri et al. [10][11][12][13] Maximum study subjects were 53.84% , predominantly the younger population was involved (20-40 years of age), probably due to their more ambulant nature which was similar to earlier reported. [14][15][16][17] 24,25 The high mortality rate in India has been attributed to the geographical factors and a predominantly rural population that was dependent on agriculture as an occupation.

CONCLUSION
Common age group was between 21-40 years involved in Snake bite (53.84%). Less number of study subject died (5.56%) who received first aid before coming to the hospital than among those who did not receive first aid (6.25%). Death number is more in study subjects who had history of bite had upper limb (11.67%) than in history of bite in lower limbs (2.08%). Snake bite was seen more among rural adult male agricultural laborers and farmers during the period of rainy season from July to September.

Recommendations
Need for a community based epidemiological study to identify the actual magnitude of the problem present in this region. There is an urgent need to educate the rural population about the hazards and the treatment of snake bite.

Limitations
Being a hospital based study; it leads to underestimation of the exact number of cases occurring in the community. Study has limited generalisability.