Snake bites contribute to a major amount of morbidity and mortality in Himachal Pradesh. The state has reported 1095 envenomings and 40 deaths per annum [1], which as per estimates maybe as high as 208 deaths per annum [2]. The state has a total population of 68, 56,509 of which 90.2% people live in rural setup [3] while the urban population constitutes only 9.79 per cent of the total population of the state [4]. In the rural areas of Himachal, most people are engaged in agricultural activities and animal rearing, hence they spend most of their time in fields, hence are bitten in an agricultural field or jungle. So, the probability of human beings coming in contact with snakes in rural areas is very high. Children over 5 years of age are at a greater risk of snakebite because of their curious and playful nature. Children may suffer more severe effects, and can experience the effects more quickly than adults due to their smaller body mass. Envenomation due to snakes is multifactorial and depends on a number of factors like age, site of bite, activity while bite, season, snake type etc. Hence, this study was conducted at Department of Paediatrics, Indira Gandhi Medical College and Hospital, Shimla (H.P) from June 2018 to September 2019 to study the site of snake bite and time taken between snake bite and presentation for treatment.

This was a clinico-epidemiologic study carried out on the snake bite cases reported at Department of Pediatrics, IGMC, Shimla over a period of one year. All the demographic characteristics, history and details of envenomation and referral history, if any were recorded in pre-designed proforma (PDP). Informed consent was obtained from parents or authorized representatives /guardians before inclusion into study.      

Ethical Considerations 

Approval for the study was obtained from the Hospital Ethics Committee. All parents were explained briefly regarding methodology of study. Participants were informed about the study in their own language before obtaining written consent.

Statistical Analysis

Data collected was entered and analyzed using Epi Info (Version 7.2.2.6). Data was expressed in its frequency and percentage. Data analysis was done by necessary descriptive and inferential statistics. Appropriate descriptive statistical techniques like mean, median, mode, percentile and standard deviation was used for data analysis and analyzed data was presented in the form of tables, diagram and graphs based on findings.

Thirty cases of snake bite were admitted in children less than 18 years of age of which 56.66% were males (n = 17) and 43.33% (n = 13) were females. 50% (n = 15) of the patients were in the age group of 13-18 years, 43.33% (n = 13) were in the age group of 7-12 years and 6.66 % (n = 2) were between 0-5 years. Mean age of the patients was 12.23 ±3.31 years. 

Lower extremities were observed to be the most bitten part of the body (70%) and the common sites were foot/fingers of foot/ankle/sole of feet as shown in Table 1 43.33% (n = 13) victims reached hospital within 1 hour of snake bite, 36.66% (n = 11) reached within 6-12 hrs, 13.34% (n = 4) were admitted within 12-24 hrs and 6.66% were admitted after 24 hours. Out of 30 studied patients, 16.7% (n = 5) patients were primarily treated by medical personnel at primary institution (Primary health centre), 60% (n = 18) were treated at a secondary institution (Community health centre or Zonal Hospital) and 23.3% (n = 7) patients reported directly at tertiary institution i.e. Indira Gandhi Medical College, Shimla.  73.33% (n = 22) patients received primary treatment within 1-6 hours of bite at any of primary, secondary or tertiary institutions. Among them, 73.33% (n = 22) were referral cases and had received pre-hospital treatment. Data is represented in Table 2.

Snake bite attributes significantly to pediatric morbidity and mortality in rural areas because of tough hilly terrain, preference to traditional therapy rather than scientific medical approach and presence of a large number of conflicting protocols.

Lower extremities were mostly bitten (70%) either due to accidental stepping on snakes while walking or playing in the dark and the common sites were foot, ankle, toe or sole of feet. This result was in agreement with various studies conducted throughout the world [5].

Table 1: Site of Snake Bite

Table 2: Time Taken Between Snake Bite and Presentation for Treatment

In this study, 30% of bite cases were on upper extremities. Children are very curious and have the habit to explore various holes and crevices which may be the hiding places of snakes [6]. This explains the 30% bite marks on the upper limbs. No unusual bite location like head, trunk was observed in the study [7]. Similar types of observations were reported in previous studies [8]. 

It was observed that most (56.7%) of the snake bites occurred between 6pm to 12am and most of them were non provocative. Anjum et al., [9] found the maximum incidence of snakebite occurred between 6:00 PM to midnight (30.2%), followed by midnight to 6:00 AM (24.9%) [9]. It may be due to the fact that snakes are nocturnally active and due to low visibility snakes could be accidently stepped upon. Similar observations were made by Meshram et al., 2017 in his study with 57.5% bite occurring during night time [8].  

Children may be educated in this regard not to unnecessarily explore holes and crevices. Hence awareness can be created in this regard to reduce the snake bite incidence in rural areas by educating the children to wear high boots during travel at night time. Hence, some camps or educational lectures about snakes, snake-bite, basic first aid and treatment protocol should be organized in high risk areas.

1. Gaitonde B.B., Bhattacharya S. “An epidemiological survey of snake-bite cases in India.” Snake, vol. 12, 1980, pp. 129–133.

2. Fernando P., Dias S. “A case report: Indian kraits bite poisoning.” Ceylon Medical Journal, vol. 27, 1982, pp. 39–41.

3. Central Bureau of Health Intelligence. National health profile (NHP) of India – 2011.

4. Warrell D.A. “Treatment of bites by adders and exotic venomous snakes.” BMJ, vol. 331, no. 7527, 2005, pp. 1244–1247.

5. Bawaskar H.S., Bawaskar P.H. “Profile of snake bite envenomation in western Maharashtra, India.” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 96, no. 1, 2002, pp. 79–84.

6. Punde D.P. “Management of snake-bite in rural Maharashtra: a 10-year experience.” National Medical Journal of India, vol. 18, no. 2, 2005, pp. 71–75.

7. Kshirsagar V.Y. et al. “Clinical profile of snake bite in children in rural India.” Iranian Journal of Pediatrics, vol. 23, no. 6, 2013, pp. 632–636.

8. Meshram R.M. et al. “Clinical profile and outcome of snake bite in children.” International Journal of Contemporary Pediatrics, vol. 4, no. 3, 2017, pp. 910–914.

9. Anjum A. et al. “Epidemiological profile of snake bite at tertiary care hospital, North India.” Journal of Forensic Research, vol. 3, no. 4, 2012, p. 146.