CLINICO-EPIDEMIOLOGICAL PROFILE, HEALTH CARE UTILIZATION AND PRACTICES REGARDING SNAKE BITE AT ILAM DISTRICT OF EASTERN NEPAL

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1 CLINICO-EPIDEMIOLOGICAL PROFILE, HEALTH CARE UTILIZATION AND PRACTICES REGARDING SNAKE BITE AT ILAM DISTRICT OF EASTERN NEPAL 1* Parajuli SB, Bhattarai S, Paudel IS, Pokharel PK, Rayamajhi RB, KC Heera Affiliation 1. Lecturer, Birat Medical College & Teaching Hospital, Tankisinuwari, Morang, Nepal 2. Assistant Professor, B. P. Koirala Institute of Heal Sciences, Dharan, Sunsari, Nepal 3. Professor, B. P. Koirala Institute of Heal Sciences, Dharan, Sunsari, Nepal 4. SMO, World Heal Organisation 5. College of Nursing B. P. Koirala Institute of Heal Sciences, Dharan, Sunsari, Nepal A R T I C L E I N F O Article History Received : 3 April, 2017 Accepted : 15 June, 2017 Published : 30 August, 2017 Auors retain copyright and grant e journal right of first publication wi e work simultaneously licensed under Creative Commons Attribution License CC - BY 4.0 at allows oers to share e work wi an acknowledgment of e work's auorship and initial publication in is journal. ORA 27 Citation Parajuli SB, Bhattarai S, Sharma IS, Pokharel PK, Rayamajhi RB, KC Heera. Clinico-epidemiological Profile, Heal Care Utilization And Practices Regarding Snake Bite at Ilam District of Eastern Nepal. BJHS 2017;2 (2)3 : * Corresponding Auor Dr Surya B. Parajuli Lecturer, Department of Community Medicine Birat Medical College & Teaching Hospital Tankisinuwari, Morang, Nepal info@suryaparajuli.com.np ORCID ID: ABSTRACT Introduc on Snake bite is neglected problem of e rural agrarian society of e world. Nepal is one of e vulnerable countries of snakebite. The u liza on of heal care services and prac ces regarding snake bite is not known. Objec ve This objec ve of e study was to explore clinicoepidemiological profile, heal care u liza on and prac ces regarding snake bite at Ilam District of eastern Nepal. Meodology This was a cross-sec onal study and conducted from 25 March to 25 May 2013 using a systema c random sampling of 300 people from communi es of Ilam district. The data was collected a er receiving informed consent. The collected data was entered into Microso excel and analysed by using SPSS. Results The majority (76.7%) of e respondents had seen snakes in eir locality. The major snake no ced was mountain pit viper (Ovophis mon cola)- Grube (94.8%). Among respondents, 5.3% had a history of snake bite which was predominant among produc ve age of years. The most common bi en part of e body was leg (56.3%). There was no any serious injuries and dea. Treatment was done by different modali es such as by using local an dote (31.3%) at e bite site and by soap-clean water (25%). Sixty-nine percent of e snake bite vic ms u lized modern heal care system. Charali snake bite management center, Jhapa was e major treatment center. Seven out of had knowledge of using a tourniquet. A er full recovery from a snake bite, 1 out of 5 had avoided milk due to eir false belief. Conclusion Ac ve age group was more vic mized. The commonest bi en part was a leg. The knowledge of first aid of snake bite was not adequate and many were unaware of post snake bite prac ces. Reassurance, early first aid and mely transporta on to heal center save many vic ms of snake bite. KEY WORDS Geographic loca ons, Nepal, pa ent acceptance of heal care, snake bites 179 Birat Journal of Heal Sciences ISSN: (Print) (Online)

2 INTRODUCTION Snakes have been feared, worshiped, or loaed in Sou Asia from ancient mes. In is region snakes remain a painful reality in e daily life of millions of rural peoples. Cobras snakes appear in many tales and mys and are regarded as sacred by bo Buddhists and Hindus. Though an -snake venom is produced in large quan es by several public and private manufacturers however, most vic ms of snake bite don't have access to quality care. In many countries, bo morbidity and mortality due to snake bites are alarming. The snake bite envenoming is e neglected issue of e modern 1 era. An exact measure of e global burden of snakebite remains limited despite many a empts to es mate it. Apart from few countries, reliable figures on snake bite incidence, 2 morbidity, and mortality are not well defined. In Nepal, each year more an 20,000 cases of envenoming occur wi 1,000 3 recorded deas. The district hospital records review of Nepal showed at na onal figures underes mated e 4 incidence of snake bite. In a community based research conducted in soueast Nepal in 2002 found at annual incidence and mortality rates of snake bite envenoming was 5 1,162/0,000 and 162/0,000, respec vely. In Nepal and Bangladesh, envenoming by green pit vipers is very 4 common. In a study, it was reported at bites by e mountain pit viper (Ovophis mon cola) occur in Nepal where it is e most commonly encountered poisonous snake at 6 al tudes of 900 2,700 m. In a study from hilly region of eastern Nepal, it was reported at many people s ll use tradi onal healers service for eir day to day heal care and e use of government heal facility u liza on was low as compared to private heal care facility. The people having e concept at modern heal centres are costly and living for a longer period in at place were e primary user of tradi onal heal care system. This will challenge e modern 7 heal care service u liza on in eastern Nepal. In Nepal, snake bite is an important cause of many deas. It is due to poor heal services in rural areas especially for e lack of 8 an snake venom(asv) treatment facility. Hence is study was conducted wi e objec ve to explore clinicoepidemiological profile, heal care u liza on and prac ces regarding snake bite at Ilam district of eastern Nepal. METHODOLOGY This study was community-based cross-sec onal study and conducted between 25 March to 25 May The site of study was Pashupa nagar and Fikal community of Ilam district of eastern Nepal. The systema c random sampling meod was used to select 300 household for collec on of e necessary informa on. Data was collected by e house to house visit wi pretested ques onnaire. The collected data was entered in Microso excel and analyzed using SPSS. Eical clearance was taken from concerned auority and informed consent was taken prior to e study. RESULTS The various socio-demographic characteris cs of respondents was presented in table 1. Regarding distribu on of age of respondents more an half (51.3%) were of age years wi mean age of years. Majority (58.3%) of e respondents were male. The major enicity was hill Janaja (49%). The majority (83%) were literate among whom onefour were middle school cer ficate holders. Four in every five respondents were married and living togeer. Nine out of ten (92%) head of households was employed and eir major occupa on was tea plugging and farming. Table 1: Socio-demographic characteris cs of respondents (n=300) Characteris cs Number Percent Age (years) ³ Mean ± S.D ± Sex Male Female Case / Enicity Brahmin/Chhetri Hill Janaja Terai Dalit Marital Status Married & Living togeer Widowed/Separated Never Married Major Occupa on of HOH Employed Unemployed Literacy Status Illiterate Literate Graduate/Post 25.0 graduagte Cer ficagte Level High School Middle School Primary School ISSN: (Print) (Online) Birat Journal of Heal Sciences 180

3 Figure 1 shows e respondents who had seen asnake in eir locality. Among e respondents, almost every 8 out of (76.7%) had seen snakes in eir locality. Figure 1: Respondents who had seen snake in eir locality (n=300) As shown in figure 2 and 3,e major snake iden fied was Gurbe (mountain pit viper, Scien fic name: Ovophis mon cola) (95%) followed by Sabe (eastern trinket snake, Scien fic name: Orriophis cantoris) (3.5%) and Dhaman (Rat Snake, Scien fic name: Ptyas mucosa) (1.8%). Figure 3 illustrate e Gurbe which was iden fied in eastern Nepal % % 3.4 % Yes No 1.8 Gurbe Sabe Dhaman Figure 2: Types of snake seen by respondents (n=230) Table 2: Snake bite characteris cs Characteristics Number Percent History of snake bite (n=300) Yes No Frequency of snake bite (n=16) 1 bite Age (years)of snake bite victim (n=16) < > Gender distribution among snake bite (n=16) Male Female Parts of body bitten (n=16) Hand Leg Snake bite first aid used (n=16) Soap/clean water Tourniquet Mud/soil Noing Snake bite treatment center (n=16) Charali snake bite treatment center (Anti-venom available) Local healing Outcome of treatment (n=16) Completely cured Figure 3: Gurbe (mountain pit viper, Scien fic name: Ovophis mon cola) Dr. Surya B. Parajuli Table 2 provides different characteris cs of snake bite. Among e respondent, 16 persons were bi en by a snake. Snake bite was commonest in e ac ve age group of years (43.75%) wi no gender difference. The majority (56.3%) were bi en in e leg. None of em have any serious injuries and dea. Regarding e first aid measure tourniquet was applied by 31.25% at e bite site followed by cleaning bite site by soap/clean water (25%). Among e snake bite vic ms, e majority (68.75%) received treatment from Charali snake bite management center, Jhapa where an -snake venom is available. All e vic ms were completely cured. Table 3 shows e awareness on snake bite treatment. Regarding awareness on first aid management of snake bite vic ms, every seven out of responded at tourniquet should be used as a meod of first aid. Regarding awareness on post snake bite food taboos, a er full recovery from a snake bite, 22% had a wrong belief of avoiding milk followed by water (6%). Figure 4a, 4b illustrate e viper bite vic ms showing eir hands. Table 3: Awareness on Snake bite treatment Characteristics Number Percent Awareness on snake bite first aid Traditional meods Incision and drainage Tourniquet Post Snake bite food Taboos Avoid Milk Avoid Water 18 6 Avoid Medicine 3 1 No Avoidance Birat Journal of Heal Sciences ISSN: (Print) (Online)

4 Figure 4a, 4b: Viper bites vic ms showing eir hand at eastern Nepal Dr. Surya B. Parajuli Dr. Surya B. Parajuli DISCUSSION In e present study, e majority of e head of households were employed. Ilam is e city which has a rich source of tea farming. Tea farming gives employment to lot of people in Ilam which ul mately strengen eir economic status. Tea plucking was major occupa on because of famous tea farming culture in Ilam district. Similar to is study, dominant profession among e vic ms of snake bite were farmers, planta on workers, herders, fishermen, snake 8 restaurant workers and oer food producers. In is study majority of e snake seen were of viper groups such as Gurbe and Sabe. This is furer supported by e studies conducted by Shah KB et a land Tillack F et al where e mountain pit viper encountered at al tudes of 900 2,700 6,9 meters was e most common. The present study found at e majority of snake bite envenoming vic ms were from e produc ve age of years. Similarly to is study, e mean age of snake bite envenoming vic ms was 32 5 years. Almost similar result was found, where majority of e snake bite envenoming vic ms were in e produc ve age of 15 and 45 years. No gender difference on snake bite envenoming was found in e present study. In contrast, e study done by Jarwani B et al showed e majority of e vic ms were male. It was found at e snakebite cases were almost equally distributed in bo e sexes alough, 11 males have shown slightly higher propor on. The lower extremi es were e most common site of snake bite envenoming in our study which is similar to e study by 11 Devkota U N et al. Similar to is study it was reported at, 12 snake bite was mostly on e lower extremi es (83%). In e present study, none of e vic ms had any serious complica ons and dea. It may be due to non-fatal poisoning from viper group of e snake. The mely transfer of snake bite vic ms to snake bite management center may be e anoer region behind no serious complica on and fatality from snakebite. Palangasinghe DR et al reported a previously healy male who is young 18 years had bilateral severe pulmonary hemorrhages resul ng in a fatal outcome 13 following Russell's viper envenoming. Seignot Preported 44 year European who was bi en on e foot in Djibou, 14 probably by an African viper had fatality. Regarding e use of first aid measure in is study, tourniquets were applied followed by cleaning bite site wi soap/clean water. This is a wrong prac ce of snake bite envenoming first aid management. This study is supported by e study of Deb Prasad Pandey which state at no vic ms followed e first-aid recommended by World Heal 15 Organisa on in Nepal. This is also supported by e study of Hansdak G et al where more an half of snake bite vic ms used harmful and inappropriate first aid meods a er snake 16 bite envenoming. Two studies in Nepal and Bangladesh showed at 90% and 98% of snake bite envenoming, respec vely, used tourniquets. The majority of vic ms of snake bite envenoming first report to tradi onal healers. Tourniquets were e main first aid measure used by e 19 vic ms (86%). Incisions at and around e bite site were made in 28% of envenomed vic ms of snake bites and in 18 13% 14% of ose wiout signs of snake bite envenoming. A er snake bite envenoming first aid given was use of tourniquet (16.2%), local applica on of chillies, herbal medicine and lime, etc., (1%). In contrast to e above prac ce reassurance to e vic m, immobiliza on of e bi en part, applying a pressure bandage and mely referral to e appropriate heal centre is a correct technique in 20 snake bite management. However, me factor plays a very important role in e survival of e vic ms of snake bite envenoming. The strong aspect of our study was at majority received treatment from Charali snake bite management center which is biggest snake bite treatment centre in eastern Nepal wi modern heal care system where an -snake venom is available regularly. Even ough e distance was quite long. Cruz LS reported at delay and scarcity of administra on of an venom in vic ms of snake bite envenoming, poor heal care services, and transporta on difficul es from rural areas to heal centers are important significant factors at contribute to e high 21 case-fatality ra o of snakebite vic ms. In is study regarding awareness on first aid management, 70 percent cited e use of tourniquet, 22 percent tradi onal meod and 8 percent of prac cing sucking blood by mou ISSN: (Print) (Online) Birat Journal of Heal Sciences 182

5 from bite site and doing incision and drainage. These first aid prac ces deteriorates e condi on of e vic ms of snake bite envenoming. We have to encourage em to change is type of awareness on snake bite envenoming. Pandey DP reported at first aid training on snake bite envenoming changes e people's a tude in management of snake bite envenoming vic ms and is is one of e effec ve ways in decreasing mortality of snake bite vic ms. 15 This research also assessed awareness on post snake bite food taboos, a er full recovery. Es mated figure showed at, 22 percent had wrong mys of avoiding milk, 1 percent medicine and 6 percent water. These all mys are wrong. They can con nue ese food items a er full recovery of snake bite envenoming. CONCLUSION The snake bite in e hilly region of eastern Nepal is common. The most common snake reported was Gurbe. The produc ve age group was e major vic ms of snake bite. The leg was e common site of envenoming wiout serious complica on and dea. Lack of awareness regarding snake bite first aid and post snake bite food consump on prac ces were common among e surveyed popula on. REFERENCE 1. Simpson ID, Norris RL. The global snakebite crisis--a public heal issue misunderstood, not neglected. Wilderness & environmental medicine Spring;20(1): PubMed PMID: Epub 2009/04/15. eng. 2. Chippaux JP. Snake-bites: appraisal of e global situa on. Bulle n of e World Heal Organiza on. 1998;76(5): PubMed PMID: Pubmed Central PMCID: PMC Epub 1998/12/30. eng. 3. WHO. Wkly Epidemiol Rec Sharma SK, Khanal B, Pokhrel P, Khan A, Koirala S. Snakebitereappraisal of e situa on in Eastern Nepal. Toxicon : official journal of e Interna onal Society on Toxinology Mar 01;41(3): PubMed PMID: Epub 2003/02/05. eng. 5. Sharma SK, Chappuis F, Jha N, Bovier PA, Loutan L, Koirala S. Impact of snake bites and determinants of fatal outcomes in soueastern Nepal. The American journal of tropical medicine and hygiene Aug;71(2): PubMed PMID: Epub 2004/08/13. eng. 6. 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Snakebite envenoma on and dea in e developing world. Enicity & disease Spring;19(1 Suppl 1): S PubMed PMID: Epub 2009/06/02. eng. 183 Birat Journal of Heal Sciences ISSN: (Print) (Online)