Accepted Manuscript

Epidemiological profile of snake-bite cases from Haryana: A five year (2011–2015)

retrospective study

Saurabh Bhargava, Ramanjeet Kaur, Rajvinder Singh

PII: S1752-928X(17)30189-0
DOI: 10.1016/j.jflm.2017.12.004
Reference: YJFLM 1593

To appear in: Journal of Forensic and Legal Medicine

Received Date: 25 July 2017

Revised Date: 19 October 2017
Accepted Date: 18 December 2017

Please cite this article as: Bhargava S, Kaur R, Singh R, Epidemiological profile of snake-bite cases
from Haryana: A five year (2011–2015) retrospective study, Journal of Forensic and Legal Medicine
(2018), doi: 10.1016/j.jflm.2017.12.004.

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TITLE PAGE

Epidemiological profile of snake-bite cases from Haryana:

A five year (2011-2015) retrospective study

1. Saurabh Bhargava: Senior Research Fellow- University Grants Commission, Department of

Genetics, M.D. University, Rohtak-124001 Haryana, India.

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Email: saurabh.bhargava78@gmail.com

2. Ramanjeet Kaur: Research Scholar, Department of Genetics, M.D. University, Rohtak-124001

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Haryana, India
Email: ramanjeet24@gmail.com

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Corresponding author
3. Dr. Rajvinder Singh: Assistant Professor, Department of Genetics, M.D. University, Rohtak-
124001 Haryana, India.

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Email: rvsforensic@gmail.com
Mobile: +91-9896398962
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Epidemiological profile of snake-bite cases from Haryana:
A five year (2011-2015) retrospective study

Introduction
Occurrence of snake-bite incidences amongst human has been known since primeval. This
accidental clash is perhaps an immense humankind problem in several parts of the world.
India also has a long historical relationship with serpents, and added quantum of snake-bite

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typically transpires herein. Roughly, around 3,000 species of snakes are found worldwide but
only 15% are considered dangerous to humans. Elapidae and Viperidae are two major

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families of venomous snakes which are responsible for the highest human fatalities. More
than 60 species of venomous snakes have been reported from India1. Four highly venomous

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species of snakes i.e. common cobra (Naja naja), Russell’s viper (Daboia russelii), common
krait (Bungarus caeruleus) and saw scaled viper (Echis carinatus) are commonly found

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across India. They have also been traditionally attributed as the ‘Big Four’. They have been
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reported responsible for more than 90% of envenomation cases, especially in the rural parts.
A few other local snake species occurring in India were also accounted capable of causing
severe envenoming2. Epidemiologically, the snake-bite is a high risk factor amongst the
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agricultural workers, children, and fishermen etc. The problem of snake-bite in India is high-
up in the agricultural scenery especially due to tempt by rodents in the farms. In spite of
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being a matter of serious concern, this distressing problem sporadically may remain
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unnoticed, especially due to lack of complete and proper epidemiological database of snake-
bite incidences. Homemade traditional remedies for snake-bite treatment and hurdles in
reaching the hospitals from rural localities obviously make it more difficult to manage and
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publicize these sorts of incidences. Improper reporting systems and policies in India and
elsewhere also create hindrance in generating such important records in a proper manner3,4,5.
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In view of huge burden of snake-bite incidences in tropical areas, the World Health
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Organization (WHO) in year 2009 also once kept snake-bite envenomation in its list of
Neglected Tropical Disorders (NTDs)6.
Highest estimated number of snake-bites incidences and deaths occur in India due to large
population residing therein. Figures on snake-bite cases have also acknowledged India as a
country with a higher mortality than any other nation7,8. Every year, nearly 200,000 people in
India suffer from snake-bite; however 35,000 to 50,000 do not survive these bites9,10. The
‘Million Death Study’ (MDS) conducted by Registrar General of India has shown highest
number of deaths with snake-bite in Uttar Pradesh, Andhra Pradesh, and Bihar states during
2001 to 20038. Annual report on accidental deaths and suicides published by the National
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Crime Record Bureau (NCRB) also revealed 7,846 deaths out of 8,484 incidences of snake-
bite reported in India during 201411. Other vital epidemiological studies have also thrown
light on snake-bite epidemiology from India12,13,14,15. There is also a significant quantum of
snake-bite incidences in Haryana but its exposure in perspective to public awareness is
inadequate. The NCRB revealed 71 mortalities with snake-bite from Haryana in year 201411
but total numbers of morbidities were shown nil. An important study conducted on the
victims of snake-bite has depicted the problem of snake-bite from Ambala region of

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Haryana16.
It was also proposed that mortalities and morbidities due to snake envenomation can be

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reduced after implementing correct designed health policy, which demand more accurate data
on incidences of snake-bite, and types of snakes present in particular geographic region17.

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Therefore, the fundamental aim of this retrospective inspection was to bring in being snake-
bite related vital figures for the sake of public and research awareness. Diverse localities of

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Haryana were chosen to collect the data of snake-bite incidences and deaths amongst humans.
This retrospective databasing would definitely support the better management of
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envenomation programs in this particular region.
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Methods
Haryana state is located at 29.0588°N, 76.0856°E in the Northern region of India. Currently,
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around 2.73 crore (27.3 million) people have been residing in 44,212 km2 geographical area
of Haryana administered into 22 districts. Present study excluded district Charkhi Dadri
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which was not established till year 2015 but its all related data was collected from its parent
district Bhiwani. The data of snake-bite cases from January 2011 to December 2015 were
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obtained from the government district/civil hospitals of Haryana, and Pandit Bhagwat Dayal
Sharma, Post Graduate Institute of Medical Sciences, Rohtak (also known as PGIMS,
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Rohtak). Medical assistance by the snake-bitten patients from Haryana is also sought from
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Postgraduate Institute of Medical Education and Research (PGIMER) situated in Chandigarh,

thus; this medical institute was also taken into consideration for the purpose of this study.
Information about annual frequency of snake-bite cases, district-wise cases reported, gender
involved, numbers of cases treated with polyvalent anti-snake venom (ASV), victims
survived and died after ASV treatment were inquired from all the selected localities. Data
also included number of snake-bitten victims brought dead to the hospitals.
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Results
Retrospective data in the present study revealed a total of 6,555 cases of snake-bite from the
study spots of Haryana. Year-wise numbers of snake-bite cases from Haryana have been
given in Fig. 1. It is evident from data that maximum (24.3%) and minimum (16.1%) number
of cases were reported in year 2012 and 2015, respectively. Year-wise records have revealed
large number of snake-bite incidences from Haryana (Table 1). Highest numbers i.e. 51.6%
cases of snake-bite were reported from PGIMS, Rohtak followed by 8.74% from PGIMER,

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Chandigarh. District wise data also depicted few vital figures on snake-bite incidences. These
figures portrayed district Panchkula the highly affected area due to snake-bite incidences

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wrapping maximum (367) number of snake-bite cases during the study period. More than two
hundred cases of snake-bite were reported from each district Ambala, Sonipat and Faridabad

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during 2011-15. Records of the civil hospitals of Jind and Rohtak revealed only 11 cases each
during the study period. No district was devoid of snake-bite incidences, except Nuh where

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related data were not available. Fig. 2 revealed a diversified quantum of snake-bite cases
observed in Haryana. District wise data illustrating gender involvement in different districts
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of Haryana during 2011 to 2015 were also assessed (Table 2 & Fig. 3). Although the district
Jind turned out with a noteworthy gender ratio (10:1) but total number of snake-bite reported
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case were 11 only. Maximum (286) snake bitten males were reported from Panchkula district
whereas the highest (99) number amongst females was recorded from Faridabad. The average
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gender ratio around 2.5:1 was calculated from Haryana. The study also showed gender based
adequacy documented from district Ambala, Gurugram, Jajhar and Medical Institutes of
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Rohtak and Chandigarh. In totality, no gender information was available in 4,559 cases
(69.5%).
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Cases of ASV treated, not survived after ASV treatment and snake-bitten brought dead from
study sites were also recorded (Table 3). Maximum (27) victims who didn’t survive after
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ASV treatment and snake-bitten brought dead (18) were reported in year 2014. Data related
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to mortalities after ASV therapy and brought dead was not available from PGIMS, Rohtak. It
is evident from Table 4 that out of 5,956 snake-bitten patients, a total of 3,012 victims were
treated with ASV in the government hospitals and institutes. After this treatment, around
96.3% survived while 3.7% lost their lives. After treatment records exclude 772 cases from
PGIMS, Rohtak where no data on these aspects were available. An important finding from
district Karnal exposed 16.8% mortalities even after treating snake-bitten victims with ASV.
On the other side, discerned 100% recover rate after treating with ASV was noted from
district Panchkula and Bhiwani. In total, 1.5% snake-bitten individuals were brought dead.
These types of fatalities were highest in district Sonipat (16), followed by Sirsa (15).
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Discussion
Findings of this study have pointed a noteworthy increase in reported incidences of snake-
bite from 2011 to 2012 but a marginal reduction in 2013, and again significant reduction was
noted in year 2014. The NCRB has also shown similar pattern at all India level from 2011 to
201411,18,19,20. The NCRB report has not revealed cases from different localities of Haryana
whereas the present investigation has revealed it clearly and broadly. A study has reported 92
cases of snake-bite from rural areas of Haryana registered at Maharishi Markandeshwar

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Institute of Medical Sciences and Research (MMIMSR), Ambala16 but this attempt was
pointing Ambala region. Although complete gender based information amongst snake-bite in

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the present study was unavailable even then 2.5:1 male to female ratio was calculated in
30.5% of cases. This gender base difference was notably lower than India as per study made

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from 2001 to 20038. Gender based data on snake-bite from MMIMSR, Ambala during 2012-
14 revealed 1.4:1 male to female ratio but point here to remember is that this data pertained to
small region of Haryana16. Obviously, the men working outdoors and usually sleeping in

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farmyards during harvest seasons have more likelihood of encounter and interaction with
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venomous snakes than females. Overall mortality due to snake-bite recorded in the present
study was noted around 2.2% (5956/130) while it amounts 2.7% amongst ASV treated
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patients. In terms of snake-bite incidences from the rural Haryana reported to MMIMSR,
Ambala during 2012-14, the overall mortality shown was 16.46%16.
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Cases of snake-bite were reported from all the districts expect Nuh district. Local government
hospitals of district Rohtak and Jind located in the central part of Haryana produced lowest
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number of snake-bite cases. Proximity of these areas to PGIMS, Rohtak providing more
advanced facilities for snake-bite treatment definitely makes it apparent but contrary to this
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were the uppermost snake-bite affected Panchkula and Ambala districts in spite of their just
about distance to PGIMER, Chandigarh. It is imperative here to understand that majority of
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the snake-bite cases from these two districts are also referred to PGIMS, Rohtak under
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emergent conditions. Therefore, number reported in these localities was comparatively less;
otherwise whopping 51.6% cases were reported from PGIMS, Rohtak alone. Being outer side
of Haryana, the reporting from PGIMER, Chandigarh was relatively not as much as PGIMS,
Rohtak but overall percentage (8.7%) was significantly higher than other districts of Haryana.
Obviously, cases from nearby states of Punjab, Himachal Pradesh and Uttrakhand also add to
this enormity. Apart from districts of Haryana, the highest death toll amongst ASV treated
victims during the study period (2011-15) came from PGIMER, Chandigarh. Northern and
Eastern districts of Haryana were highly affected with snake-bite incidents as compared to
Western parts. Any sort of snake-bite related data were not available from district Nuh which
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is closest to the Aravali hills. In study point of view, 82 causalities with snake-bite even after
treatment with ASV poses a serious remarks either on potential of ASV or existence of
poisonous snake species other than the ‘big four’. Otherwise, probability of severity of injury
to the vital organs due to snake-bite can’t be ruled out. Heavy envenomation, lack of
knowledge and appropriate resources, and ignorance can be thought for heavy troll of snake-
bitten brought dead.

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Same set of questions were put for obtaining the required information but study stayed
limited due to lack of a uniform index of record keeping sheets in different hospitals.
Therefore, this retrospective study has certain limitations as it didn’t provide a socio-

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economic status of victims, neither does it provide any idea about age groups of victims,
activity during which victims were bitten, hour of day at which the incidences happened, and

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seasonal frequency of incidences etc. This study also lacks private hospital records of snake-
bite victims.

Conclusion
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Snake-bite is an avoidable injury which can be prevented with proper awareness, but for that
to happen we need to identify the regions which require urgent attention. Epidemiological
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profiles of such types can be significant in making better health policy. This study has
explored burden of snake-bite incidences in different localities of Haryana. All informative
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databasing of snake-bite cases can be used for awareness programmes and also further
training of health personnel. Most importantly this effort highlighted the significance of an
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accurate epidemiological profile of such a gross and significant problem of society.

Systematic reporting on snake-bite mortalities must be made mandatory throughout the world
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to generate accurate database of snakebites at the international level.

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19. Accidental Deaths and Suicides in India 2012, National Crime Records Bureau (NCRB),
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Acknowledgments

Authors acknowledge all the Public Relation Officers of Government authorities for
providing useful information about snake-bite cases. Researchers also show hearty gratitude
towards the University Grants Commission for providing fellowship.

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TABLES

District 2011 2012 2013 2014 2015 Total Percentage

Panchkula 82 49 86 89 61 367 5.59
Ambala 51 66 43 62 61 283 4.31
Sonipat 60 50 43 40 33 226 3.44
Faridabad 59 48 39 45 22 213 3.24
Gurgaon 40 32 51 25 28 176 2.68
Kaithal 24 33 41 42 29 169 2.57
Panipat 30 49 46 24 14 163 2.48
Kurukshetra 28 27 24 34 32 145 2.21

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Jhajjar 38 00 14 44 44 140 2.13
Karnal 28 16 25 24 38 131 1.99
Yamunanagar 14 16 26 27 21 104 1.58
Mohindergarh 16 19 15 20 10 80 1.22

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Palwal 06 18 08 20 21 73 1.11
Sirsa 04 12 08 23 24 71 1.08
Rewari 12 08 16 16 13 65 0.99

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Hisar 03 11 14 10 22 60 0.91
Bhiwani 13 14 13 09 10 59 0.90
Fatehabad 08 08 09 18 05 48 0.73
Jind 04 01 01 01 04 11 0.16
Rohtak 03 03 01 03 01 11 0.16

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PGIMS, Rohtak 654 1,022 945 359 407 3,387 51.6
PGIMER, Chandigarh 72 91 112 141 157 573 8.74
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Total 1,249 1,593 1,580 1,076 1,057 6,555
Percentage (19.05) (24.30) (24.10) (16.41) (16.12)
Table 1. Locality wise snake-bite cases reported in 2011 to 2015 from Haryana
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District Male Female Total Ratio (M/F)

Panchkula 286 81 367 3.5:1
Sonipat 163 63 226 2.5:1
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Faridabad 114 99 213 1.1:1

Kaithal 129 40 169 3.2:1
Panipat 127 36 163 3.5:1
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Kurukshetra 121 24 145 5.0:1

Karnal 86 45 131 1.9:1
Yamunanagar 85 19 104 4.5:1
Mohindergarh 43 37 80 1.1:1
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Palwal 44 29 73 1.5:1
Sirsa 51 20 71 2.5:1
Rewari 39 26 65 1.5:1
Hisar 47 13 60 3.6:1
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Bhiwani 36 23 59 1.5:1
Fatehabad 34 14 48 2.4:1
Jind 10 01 11 10:1
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Rohtak 06 05 11 1.2:1
Total 1,421 575 1,996 2.5:1
Table 2. Locality wise gender based snake bitten cases from Haryana during 2011 to 2015
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Year/ 2011 2012 2013 2014 2015

Place TR NS BD TR NS BD TR NS BD TR NS BD TR NS BD
Districts 454 07 07 362 05 13 396 12 03 440 08 18 353 06 07
PGIMER, 72 02 00 91 02 00 112 01 00 141 19 00 157 20 00
Chd.
PGIMS, 149 - - 101 - - 109 - - 334 - - 79 - -
Rohtak
Total 675 09 07 554 07 13 617 13 03 915 27 18 589 26 07
TR- Treated with ASV; NS- Not survived after ASV; BD- Brought dead (snake bitten)

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Table 3. Year-wise ASV treated, not survived after ASV, brought dead from all study areas

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District Total Treated Survived Causalities Snake bitten
reported with ASV after ASV after ASV brought dead

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cases therapy
Panchkula 367 367 367 00 00
Sonipat 226 226 225 01 16
Faridabad 213 213 212 01 00

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Kaithal 169 77 75 02 03
Panipat 163 163 161 02 04
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Kurukshetra 145 145 140 05 00
Karnal 131 95 79 16 06
Yamunanagar 104 00 - - 02
Mohindergarh 80 80 79 01 00
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Palwal 73 62 56 06 00
Sirsa 71 49 48 01 15
Rewari 65 65 64 01 00
Hisar 60 19 18 01 00
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Bhiwani 59 59 59 00 00
Fatehabad 48 26 26 00 02
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Jind 11 10 09 01 00
Rohtak 11 11 11 00 00
PGIMS, Rohtak 3387 772 - - -
PGIMER Chandigarh 573 573 529 44 00
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Total 5,956 3,012 2,158 82 48

Table 4. Cases of Anti-snake venom (ASV) treated and causalities during 2011-2015
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FIGURES

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Fig. 1: Year-wise number of snake-bite cases during 2011 to 2015
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Fig 2. Magnitude of snake-bite cases in Haryana during 2011 to 2015

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Fig. 3. Year-wise display of gender along with ratios involvement of snake-bitten
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during 2011 to 2015
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Highlights

• This research article represents huge burden of snake-bite in Haryana.

• Various localities have been surveyed for the occurrence of snake-bite incidences for
strategizing future policies.
• A great deal of data has been collected for Poison Control Centres and common
public prospective.

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• The data has some limitations but does provide a broad picture of the problem in
Haryana.

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