India has been known as “Land of Snake Charmers'' over centuries. Around 50 million people are at risk of snakebite in India which may occur anytime in their lifespan. Pediatric snakebite mortality and morbidity contribute significantly to the national statistics [1]. India is estimated to have the highest snakebite mortality in the world [2]. The estimated total deaths in India are approx. 50,000/yr [3]. It accounts for 3% of all deaths in children of age 5-14years. In 2009, snake bite was recognized as a neglected tropical disease by the World Health Organization [4].

Himachal Pradesh is a small mountainous state of India situated in the northwestern Himalayas between 30°22′- 33°12′N and 75°47′-79°04′E covering an area of 55,673 square km. The state has a total population of 68, 56,509 of which 90.2% people live in rural setup [1] while the urban population constitutes only 9.79 per cent of the total population of the state [5].  Snake bites contribute to a major amount of morbidity and mortality in the hill regions. Snake bite is generally considered a rural problem and is often linked with environmental and occupational conditions. Snake bite shows classical seasonal variations, most cases being reported in summers and rainy season. Nearly 75% cases occur outdoors and 75-90% in rural areas [6]. The risk of snake bite in children is high due to their curious nature and tendency to spend more time outdoors. The peak age for bites is children (WHO UNICEF, 2008) adolescents and young adults. The most vulnerable to snake bites are boys aged more than 5 years [7].

Various studies have been conducted on snake bite patients throughout India and abroad, but only a few studies are available on snake bite cases in children in India. This study has been planned to the time, place and personal distribution of the snake bite child patients.

This was a clinico-epidemiologic study carried out to determine the prevalence and basic demographic profile of snake bite cases reported at Deptt. 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 representative/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 were used for data analysis and analyzed data was presented in the form of tables, diagrams 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) of the bites occurred in the age group 7-12 years and 6.7% (n = 2) occurred up to 6 years of age. The number of cases of snake bite was more in male patients (56.7%) as compared to female patients (43.3%).  Except for one case, all other 96.6% (n = 29) patients belong to lower middle socioeconomic status and all of them were residents of rural areas.

Table 1: Socioeconomic and Age Wise Distribution of Snake Bite Patients

Table 2: Time of Snake Bite

Table 3: Month Wise Distribution of Snake Bite Patients

All the bites were generally non-provocative. 70% (n = 21) bites occurred while patients were working or walking/outdoors, 20% (n = 6) occurred while patients were sleeping and 10% occurred when the patients were resting/indoors.  Majority of the bites occurred between 6 pm to 12 am at night (56.66 %) followed by 30% between 12pm– 6pm and 13.33% between 12 am-6 am. No bite case was recorded in morning hours between 6am to 12pm. Table 2 shows diurnal variation in the timing of snake bite with the majority of the accidents happening in the evening.

70% of the cases occurred at home while 30% occurred while the patient was away from home. All the cases recorded were presented in the months of May to November. Maximum number of cases of snake bite occurred during the months of August (30%) and September (30%), together constituting 60% of the total. Another peak was observed during June when (20%) of cases were recorded. Not a single case was recorded from December to March as shown in Table 3.

In this study most of the patients (100%) were residents of rural areas and most of them (96.7%) belonged to lower middle socioeconomic status. Mohpatra et al. [8] stated that snake bite occurs 97% in rural areas [8] and Harrison et al., 2009 stated that snakebites are more commonly seen in poorer sections of the population [9].

Vaiyapuri et al. [10] also concluded that snakebite has a considerable and disproportionate impact on rural populations, particularly in South Asia [10]. This may be attributed to the fact that in rural hilly areas of Himachal due to extreme climatic conditions, most people still reside in houses made of stones or roofs made of wood and in some areas, the animal houses made of mud bricks, stones are located in ground floor of same residential building which provides a warm, dry habitat to snakes.

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. found the maximum incidence of snakebite occurred between 6:00 PM to midnight (30.2%), followed by midnight to 6:00 AM (24.9%). 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 [11] with 57.5% bite occurring during night time.   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.

Most of the snake bites in this study were between May to November and peak time was during the months of August to September. This fact coincides with the monsoon season in the state, when snake habitat is flooded with water, thus making them wander in search of a safe and dry place. Also the presence of rodents attracts them to human habitation. 

A total of 30 cases were enrolled in this study based on inclusion and exclusion criteria. 56.6% of the subjects were males and 43.3% were females. Mean age of the subjects was 12.23±3.31 years. Most of the patients were residents of rural areas and most of them belonged to middle socioeconomic status. Most (56.7%) of the snake bites occurred between 6pm to 12am and most of them were non provocative. Maximum snake bites were reported between May to November and peak time was during the months of August to September (rainy season). Hence, maximum vigil is needed during this season while working in agricultural fields or pastures.

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11. 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.