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

* Corresponding Author Dr Surya B. Parajuli Lecturer, Department of Community Medicine Birat Medical College & Teaching Hospital Tankisinuwari, Morang, Nepal Email: info@suryaparajuli.com.np ORCID ID: 0000-0003-0386-9273 ABSTRACT Introduc on Snake bite is neglected problem of the rural agrarian society of the world. Nepal is one of the vulnerable countries of snakebite. The u liza on of health care services and prac ces regarding snake bite is not known.

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 the respondents had seen snakes in their 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 15-39 years.The most common bi en part of the body was leg (56.3%).There was no any serious injuries and death.Treatment was done by different modali es such as by using local an dote (31.3%) at the bite site and by soap-clean water (25%).Sixty-nine percent of the snake bite vic ms u lized modern health care system.Charali snake bite management center, Jhapa was the major treatment center.Seven out of 10 had knowledge of using a tourniquet.A er full recovery from a snake bite, 1 out of 5 had avoided milk due to their 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 health center save many vic ms of snake bite.

KEY WORDS
Geographic loca ons, Nepal, pa ent acceptance of health care, snake bites

INTRODUCTION
Snakes have been feared, worshiped, or loathed in South Asia from ancient mes.In this region snakes remain a painful reality in the daily life of millions of rural peoples.Cobras snakes appear in many tales and myths and are regarded as sacred by both 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, both morbidity and mortality due to snake bites are alarming.The snake bite envenoming is the neglected issue of the modern 1 era.An exact measure of the 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 each year more than 20,000 cases of envenoming occur with 1,000 3 recorded deaths.The district hospital records review of Nepal showed that na onal figures underes mated the 4 incidence of snake bite.In a community based research conducted in southeast Nepal in 2002 found that annual incidence and mortality rates of snake bite envenoming was 5 1,162/100,000 and 162/100,000, respec vely.In Nepal and Bangladesh, envenoming by green pit vipers is very 4 common.In a study, it was reported that bites by the mountain pit viper (Ovophis mon cola) occur in Nepal where it is the 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 that many people s ll use tradi onal healers service for their day to day health care and the use of government health facility u liza on was low as compared to private health care facility.The people having the concept that modern health centres are costly and living for a longer period in that place were the primary user of tradi onal health care system.This will challenge the modern

METHODOLOGY
This study was community-based cross-sec onal study and th th conducted between 25 March to 25 May 2013.The site of study was Pashupa nagar and Fikal community of Ilam district of eastern Nepal.The systema c random sampling method was used to select 300 household for collec on of the necessary informa on.Data was collected by the house to house visit with pretested ques onnaire.The collected data was entered in Microso excel and analyzed using SPSS.Ethical clearance was taken from concerned authority and informed consent was taken prior to the study.

RESULTS
The various socio-demographic characteris cs of respondents was presented in table 1. Regarding distribu on of age of respondents more than half (51.3%) were of age 20-39 years with mean age of 38.90 years.Majority (58.3%) of the respondents were male.The major ethnicity was hill Janaja (49%).The majority (83%) were literate among whom onefourth were middle school cer ficate holders.Four in every five respondents were married and living together.Nine out of ten (92%) head of households was employed and their major occupa on was tea plugging and farming.

Primary School
Figure 1 shows the respondents who had seen asnake in their locality.Among the respondents, almost every 8 out of 10 (76.7%) had seen snakes in their locality.

Table 3: Awareness on Snake bite treatment © Dr. Surya B. Parajuli
Table 2 provides different characteris cs of snake bite.Among the respondent, 16 persons were bi en by a snake.Snake bite was commonest in the ac ve age group of 15-39 years (43.75%) with no gender difference.The majority (56.3%) were bi en in the leg.None of them have any serious injuries and death.Regarding the first aid measure tourniquet was applied by 31.25% at the bite site followed by cleaning bite site by soap/clean water (25%).Among the snake bite vic ms, the majority (68.75%) received treatment from Charali snake bite management center, Jhapa where an -snake venom is available.All the vic ms were completely cured.Table 3 shows the awareness on snake bite treatment.Regarding awareness on first aid management of snake bite vic ms, every seven out of 10 responded that tourniquet should be used as a method 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

DISCUSSION
In the present study, the of the of households majority head were employed.Ilam is the city which has a rich source of tea farming.Tea farming gives employment to lot of people in Ilam which ul mately strengthen their economic status.Tea plucking was major occupa on because of famous tea farming culture in Ilam district.Similar to this study, dominant profession among the vic ms of snake bite were farmers, planta on workers, herders, fishermen, snake restaurant workers and other food producers.In this study 8 majority of the seen were of viper such as snake groups Gurbe and Sabe.This is further supported by the studies conducted by Shah KB et a land Tillack F et al where the mountain pit viper encountered at al tudes of 900-2,700 6,9 meters was the most common.The present study found that the majority of snake bite envenoming vic ms were from the age of 15-39 years.Similarly to this produc ve study, the mean age of snake bite envenoming vic ms was 32 years.Almost similar result was found, where majority of 5 the snake bite envenoming vic ms were in the produc ve age of 15 and 45 years.No gender difference on snake bite 10 envenoming was found in the present study.In contrast, the study done by Jarwani B et al showed the of the majority vic ms were male.It was found that the snakebite cases 10 were almost equally distributed in both the sexes although, males have shown slightly higher propor on.

11
The lower extremi es the most common site of snake were bite envenoming in our study which is similar to the study by Devkota U N et al.Similar to this study it was reported that, 11 12 snake bite was mostly on the lower extremi es (83%).
In the present study, none of the vic ms had any serious complica ons and death.It may be due to non-fatal poisoning from viper group of the .The mely transfer snake of snake bite vic ms to snake bite management center may be the another region behind no serious complica on and fatality from snakebite.
et al reported a Palangasinghe DR previously healthy male who is young 18 years had bilateral severe pulmonary hemorrhages resul ng in a fatal outcome following Russell's viper envenoming.Seignot Preported 44 Regarding the use of first aid measure in this study, tourniquets applied followed by cleaning bite site with were soap/clean water.This is a wrong prac ce of snake bite envenoming first aid management.This study is supported by the study of Deb Prasad Pandey which state that no vic ms followed the first-aid recommended by World Health Organisa on in Nepal.This is also supported by the study of 15 Hansdak G et al where more than half of snake bite vic ms used harmful and inappropriate first aid methods a er snake bite envenoming.Two studies in Nepal and Bangladesh 16 showed that 90% and 98% of snake bite envenoming, respec vely, used tourniquets.
The majority of vic ms of [17][18] snake bite envenoming first report to tradi onal healers.Tourniquets were the main first aid measure used by the vic ms (86%).Incisions at and around the bite site were 19 made in 28% of envenomed vic ms of snake bites and in 13%-14% of those without signs of snake bite envenoming.

18
A er snake bite envenoming first aid given was use of tourniquet (16.2%), local applica on of , herbal chillies medicine and lime, etc., (1 ).In contrast to the above 10 % prac ce reassurance to the vic m, immobiliza on of the bi en part, applying a bandage and mely referral pressure to the health is a technique in appropriate centre correct snake bite management.However, me factor plays a very 20 important role in the of the vic ms of snake bite survival envenoming.The strong aspect of our study was that majority received treatment from Charali snake bite management center which is biggest snake bite treatment centre in eastern Nepal with modern health care system where venom is available regularly.Even though an -snake the distance was quite long.Cruz LS reported that delay and scarcity of administra on of an venom in vic ms of snake bite envenoming, poor health care services, and transporta on difficul es from rural areas to health centers are important significant factors that contribute to the high case-fatality ra o of snakebite vic ms. 21  In this study regarding awareness on first aid management, 70 percent cited the use of tourniquet, 22 percent tradi onal method and 8 percent of prac cing sucking blood by mouth Parajuli SB et al from bite site and doing incision and drainage.These first aid prac ces deteriorates the condi on of the vic ms of snake bite envenoming.We have to encourage them to change this type of awareness on snake bite envenoming.Pandey DP reported that first aid training on snake bite envenoming changes the people's a tude in management of snake bite envenoming vic ms and this is one of the 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 that, 22 percent had wrong myths of avoiding milk, 1 percent medicine and 6 percent water.These myths are wrong.They can con nue these food items a er full recovery of snake bite envenoming.

CONCLUSION
The snake bite in the region of eastern Nepal is common.hilly The most common snake reported was Gurbe.The produc ve age group was the major vic ms of snake bite.The leg without serious was the common site of envenoming complica on and death.Lack of awareness regarding snake bite first aid and post snake bite food consump on prac ces were common among the surveyed popula on.

RECOMMENDATIONS
We recommended series of awareness program conduc ng on snake bite focusing on tea-pluckers.Proper transporta on facility to snake bite vic ms and local availability of venom in primary health care an -snake centre is the utmost need.

LIMITATION OF THE STUDY
Being a short dura on study, we are not able to include large geographical area and respondents.There may be a selec on bias, as we asked the ques on to one of the family members.Due to ques ons related to past events, we could not fully omit the recall bias.