Abstract

Objective:

to describe the epidemiological profile of scorpionism and to investigate factors associated with case severity in the Far South of Bahia, Brazil.

Methods:

this was a descriptive study using data on scorpion accidents reported on the Notifiable Health Conditions Information System (SINAN) from 2010 to 2017; odds ratios (OR) were calculated to investigate factors associated with severe cases.

Results:

3,055 cases were reported, of which 411 (13.5%) were severe and included 10 deaths; highest incidence occurred in 2017 (1.3 per 1,000 inhabitants); cases predominated in rural areas (62.5%), among males (70.1%), those aged 20-49 years (51%), and Black people (84%); 22.7% of those stung received serotherapy; severe cases were more frequent among children under 15 years old (OR=3.26; 95%CI 2.55;4.74), and people stung in rural areas (OR=1.40; 95%CI 1.10;1.78).

Conclusion:

scorpionism incidence increased; case severity was associated with younger people and occurrence in rural areas.

Keywords:
Epidemiology, Descriptive; Neglected Diseases; Scorpion Stings

Introduction

In several tropical countries the occurrence of scorpion envenomation accidents has taken on such serious proportions that the World Health Organization (WHO) has included them on the list of neglected tropical diseases (NTDs).¹1. World Health Organization. Rabies and envenomings: a neglected public health issue: report of a consultative meeting [Internet]. Geneva: World Health Organization; 2007 [cited 2019 Mar 15]. 15 p. Available from: Available from: https://apps.who.int/iris/handle/10665/43858
https://apps.who.int/iris/handle/10665/4... Disorderly growth of urban areas, with precarious basic sanitation and lack of adequate housing can result in the creation of environments propitious to the proliferation of scorpions and people coming into contact with them. ²2. Souza CMV. Escorpionismo no Brasil com ênfase no Rio de Janeiro: subsidiando políticas públicas para populações expostas [tese]. Rio de Janeiro: Fiocruz; 2018. Disponível em: https://www.arca.fiocruz.br/handle/icict/30545
https://www.arca.fiocruz.br/handle/icict... Scorpion accidents can give rise to local and systemic manifestations, causing harm to individual health and, consequently, causing an impact on Public Health.³3. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância em saúde: volume único [Internet]. 3.ed. Brasília: Ministério da Saúde; 2019 [citado 2020 jan 27]. 740 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

Owing to the increase in the number of cases of accidents involving venomous animals, in 1987 the Ministry of Health introduced the National Venomous Animal Accident Control Program with the aim of ensuring quality treatment of victims and mapping areas with greater risk of occurrence. ⁴4. Fracolli LA. Acidentes por escorpiões no estado de São Paulo: uma abordagem sócio-demográfica. Rev Uningá [Internet]. 2017 out-dez [citado 2019 abr 2];18(1)2318-579. Disponível em: http://revista.uninga.br/index.php/uninga/article/view/724

In Brazil, surveillance of scorpion accidents is passive, based on records held on the Health Ministry’s Notifiable Health Conditions Information System (SINAN). ⁵5. Chippaux J-P. Epidemiology of envenomations by terrestrial venomous animals in Brazil based on case reporting: from obvious facts to contingencies. J Venom Anim Toxinas Incl Trop Dis [Internet]. 2015 [cited 2020 Jan 27];21:1-17. Available from: Available from: http://www.scielo.br/pdf/jvatitd/v21/1678-9199-jvatitd-s40409-015-0011-1.pdf . doi: 10.1186/s40409-015-0011-1
http://www.scielo.br/pdf/jvatitd/v21/167... Created in 1993, SINAN made notification of all cases of accidents caused by venomous animals mandatory, thus enabling access to information to guide public health authorities on serum distribution and care of victims. ⁶6. Bochner R, Struchiner CJ. Epidemiologia dos acidentes ofídicos nos últimos 100 anos no Brasil: uma revisão. Cad Saúde Pública [Internet]. 2003 jan-fev [citado 2019 maio 12];19(1):7-16. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2003000100002&lng=en . doi: 10.1590/S0102-311X2003000100002
http://www.scielo.br/scielo.php?script=s... Despite all these efforts, Ministry data show that between 2010 and 2017 there was a sharp increase in accidents involving scorpions (from 52,509 to 124,077), totaling 644,175 cases and 740 related deaths. ⁷7. Ministério da Saúde (BR). Acidentes por animais peçonhentos - escorpião; dados 2000 a 2017, 2017 [Internet]. Brasília: Ministério da Saúde; 201- [citado 2020 jan 27]. Disponível em: Disponível em: http://portalms.saude.gov.br/saude-de-a-z/acidentes-por-animais-peconhentos/13692-situacao-epidemiologica-dados
http://portalms.saude.gov.br/saude-de-a-...

Scorpionism is a Public Health problem in Brazil, due to its high incidence, widespread geographic distribution and high lethality. ⁸8. Cupo P, Azevedo-Marques MM, Hering SE. Escorpionismo. In: Cardoso JLC, França FOS, Wen FH, Málaque CMS, Haddad Jr. V. Animais peçonhentos no Brasil: biologia, clínica e terapêutica dos acidentes. 2. ed. São Paulo: Sarvier; 2009. p. 214-24.^,99. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de controle de escorpiões [Internet]. Brasília: Ministério da Saúde; 2009 [citado 2020 jan 27]. 72 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... Three species of the Tityus genus are responsible for most of the accidents involving humans in Bahia and in other Brazilian states: Tityus serrulatus (yellow scorpion, responsible for the majority of severe accidents), Tityus bahiensis (brown scorpion) and Tityus stigmurus. ⁸8. Cupo P, Azevedo-Marques MM, Hering SE. Escorpionismo. In: Cardoso JLC, França FOS, Wen FH, Málaque CMS, Haddad Jr. V. Animais peçonhentos no Brasil: biologia, clínica e terapêutica dos acidentes. 2. ed. São Paulo: Sarvier; 2009. p. 214-24.

The objective of this study was to describe the epidemiological profile of scorpionism and to investigate factors associated with the severity of cases reported in the Far South of Bahia state.

Methods

This is a descriptive study of accidents and deaths caused by scorpions in the Far South of Bahia between 2010 and 2017.

The Far South of Bahia is a region located in Northeast Brazil, between latitude 16°40’ and 18°20’ south, and longitude 39°8’ and 40°37’ west. In 2010, the region had population of 463,163 inhabitants and geographic density of 24.9 inhab./km².¹⁰10. Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: Bahia [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011 [citado 2019 fev 17]. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/
http://www.ibge.gov.br/home/estatistica/... The territory of the Far South of Bahia¹¹11. Governo do Estado da Bahia. Secretaria de Planejamento. Territórios de identidade [Internet]. Salvador: Governo do Estado da Bahia; c2019 [citado 2019 jul 05]. Disponível em: Disponível em: http://www.seplan.ba.gov.br/modules/conteudo/conteudo.php?conteudo=17
http://www.seplan.ba.gov.br/modules/cont... is comprised of 13 municipalities occupying an area of almost 18,536 km², corresponding to approximately 3.9% of the total territory of the state of Bahia. The region has two types of climate: humid in the eastern part and subhumid-dry in the western part. The regional economy, based on trade, farming, eucalyptus forestry, sugarcane and coffee plantations, has low socio-economic indices, reflected by most of the population being in the extreme poverty and medium income brackets, housing conditions and a Gini index lower than those for Bahia state as a whole, in addition to having high endemic disease rates. ¹²12. Governo do Estado da Bahia. Superintendência de Estudos Econômicos e Sociais. Perfil dos territórios de identidade da Bahia [Internet]. Salvador: SEI; 2015 [citado 2019 maio 3]. Disponível em: Disponível em: https://www.sei.ba.gov.br/index.php?option=com_content&view=article&id=2000&Itemid=284
https://www.sei.ba.gov.br/index.php?opti...

The following variables were investigated:

a) sociodemographic variables age range (in years: <1; 1-4; 5-9; 10-14; 15-19; 20-34; 35-49; 50-64; ≥65);

b) Clinical and epidemiological variables

We opted to dichotomize the ‘severity’ variable: (i) severe case, which included moderate and severe cases); or (ii) non-severe case, comprising mild cases only. Grouping moderate cases together with severe cases is justified by the greater proximity of their clinical characteristics, as well as by the greater possibility of comparing the results of this study with the literature. ¹⁴14. Carmo ÉA, Nery AA, Pereira R, Rios MA, Casotti CA. Fatores associados à gravidade do envenenamento por escorpiões. Texto contexto - Enferm [Internet]. 2019 jul [citado 2019 jun 06];28: e20170561. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072019000100334&lng=pt . doi: 10.1590/1980-265x-tce-2017-0561
http://www.scielo.br/scielo.php?script=s...

Scorpion accident incident rates (per 1000 inhabitants) were calculated for each of the 13 municipalities in the Far South of Bahia for the period 2010-2017. The resident population estimates for these municipalities were used as denominators, as provided by the Brazilian Institute of Geography and Statistics (IBGE), and available on the website of the Health Surveillance and Protection Superintendent’s Office / State of Bahia Health Department (http://www.saude.ba.gov.br/suvisa/).

In order to calculate lethality, the total number of deaths was divided by the total of scorpion accident cases that occurred between 2010 and 2017.

Pearson’s chi-square test was used to compare proportions. Odds ratios (OR) and respective 95% confidence intervals (95%CI) were calculated in order to compare characteristics of severe and non-severe cases, and thus investigate factors associated with accident severity.

We used TabWin32 3.6b and Microsoft Excel 2010.

We used individualized data from the Ministry of Health SINAN system, in accordance with the Access to Information Act. No data was accessed containing patients’ names or any other data enabling them to be identified, in accordance with Legislation and research ethics norms recommended in Brazil. As such the study project was not required to be submitted to a Research Ethics Committee, as determined by National Health Council (CNS) Resolution No. 466, dated December 12^th 2012.

Results

Between 2010 and 2017, 3,055 scorpion accident cases were reported in the 13 municipalities comprising the Far South of Bahia. The lowest number of cases (197) was reported in 2010 and the highest (606) in 2017. Ten deaths were reported, two every year between 2010 and 2013, one in 2014 and one in 2017. Nova Viçosa was the municipality with the highest number of deaths (5) and greatest lethality was found in Caravelas (1%) (Table 1).

Teixeira de Freitas was the only municipality in the Far South of Bahia where accident frequency in the city’s urban area (64.2%) was greater than in its rural area (23.2%) (Table 1).

Incidence rates and lethality can be seen in graph format in Figure 1. Greatest incidence was found in 2017 (1.3 per 1000 inhab.) while highest lethality was found in 2010 (1%).

Scorpion accidents in the Far South of Bahia region were distributed throughout the year, with a slight gradual increase between April and December followed by a decrease until March.

Over half the accidents (51%) were concentrated in the 20-49 years age range. The majority of deaths arising from accidents occurred among children up to nine years old (7/10). With regard to schooling, information was missing for 38.1% of cases. The majority of victims (84%) self-reported being of Black race/skin color, and all deaths occurred in this population. Males accounted for the majority of cases (70.1%) and for the majority of deaths (6/10) (Table 2).

The anatomical regions most affected by scorpion stings were the hands (61.9%) and the feet (21%). The majority of deaths (7/10) occurred in cases that were stung in the hand. With regard to the zone of occurrence, both accidents (62.5%) and deaths (6/10) were more frequent in the rural areas of the municipalities (Table 3).

The majority of cases were mild (82.8%); although there were 411 severe cases (13.5%), which accounted for the majority of deaths (7/10). Regarding symptoms, 92.0% had local clinical manifestations and 8% had systemic manifestations. The majority of victims did not have serotherapy (74,9%); among those who died, 60% received this form of treatment. The majority of victims (55.8%) and the majority of those who died (9/10) received care more than an hour after the accident. The majority of cases (57.8%) were not related to the victim’s job (Table 3).

Standing out among factors associated with case severity (Table 4) were zone of occurrence and age range. Accidents occurring in the rural areas of the municipalities had 40% more likelihood of being characterized as severe, compared to those occurring in their urban areas (OR=1.40; 95%CI 1.10;1.78). Victims under 15 years old were three times more likely to be severe cases, compared to all other victims of scorpion accidents (OR=3.26; 95%CI 2.55;4.74). There were no significant differences between the other variables with regard to case severity.

Discussion

Between 2010 and 2017 an increase was found in the incident rate of scorpion accidents reported in the Far South of Bahia (from 0.5/1000 inhab. to 1.3/1000 inhab.). The majority of victims receiving care from the health system were of productive age, male, lived in the rural areas of the municipalities, had low schooling and were Black. Children with severe symptoms were at greater risk of dying.

Growth in case incidence in the municipalities of the Far South of Bahia follows the same trend as many other Brazilian municipalities, where scorpionism has increased and is reaching epidemic proportions.¹⁵15. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância em saúde [Internet]. 2. ed. Brasília: Ministério da Saúde ; 2017 [citado 2020 jan 27]. 705 p. Disponível em: Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/outubro/06/Volume-Unico-2017.pdf
http://portalarquivos.saude.gov.br/image...

Contrary to this trend, lethality was found to have reduced (from 1.0/1000 to 0.2/1000) in the Far South of Bahia, differently to the state’s other municipalities, where there was an almost 50% increase in the number of deaths, from 27 cases in 2010 to 40 in 2017. ¹⁶16. Ministério da Saúde (BR). Secretaria de Vigilânciaem Saúde. Acidentes por animais peçonhentos. Escorpiões. Situação epidemiológica [Internet]. Brasília: Ministério da Saúde; 201- [citado 2019 maio 1]. Disponível em: Disponível em: http://www.saude.gov.br/saudede-a-z/acidentes-por-animais-peconhentos/13692-situacao-epidemiologica-dados
http://www.saude.gov.br/saudede-a-z/acid... Reduction in scorpion accident lethality in the 13 municipalities of the Far South of Bahia also contrasted with the increasing trend seen in Brazil as a whole. ¹⁷17. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Acidentes por animais peçonhentos. Escorpiões. Situação epidemiológica [Internet]. Brasília: Ministério da Saúde; 201- [citado 2019 maio 1]. Disponível em: Disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2018/junho/25/3-Obitos-Escorpionismo-2000-2017.pdf
http://portalarquivos2.saude.gov.br/imag...

The increase in the number of reported cases may reflect not only growth in accidents, but also improved case reporting by health services. With effect from 2009, the Ministry of Health has been holding training courses on scorpion identification, management and control in the Brazilian states, in cooperation with the State Health Departments, intensifying programs to raise the population’s awareness about the risk represented by scorpion stings. These programs have resulted in health establishments being sought more in cases of scorpion accidents. ¹⁸18. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Picada de escorpião: saiba os cuidados e o que fazer em caso de acidente [Internet]. Brasília: Ministério da Saúde ; 2019 [citado 2019 set 14]. Disponível em: Disponível em: http://www.saude.gov.br/noticias/agencia-saude/45090-picada-de-escorpiao-saiba-os-cuidados-e-o-que-fazer-em-caso-de-acidente
http://www.saude.gov.br/noticias/agencia...

Of the 13 municipalities analyzed, only Teixeira de Freitas had a higher proportion of accidents in its rural area, possibly related to the high urbanization rate - 93.4% in 2010 - and to economic activity, in particular the construction industry which accounted for 61.3% of economic activity in the municipalities comprising the territory studied, especially in Teixeira de Freitas. ¹²12. Governo do Estado da Bahia. Superintendência de Estudos Econômicos e Sociais. Perfil dos territórios de identidade da Bahia [Internet]. Salvador: SEI; 2015 [citado 2019 maio 3]. Disponível em: Disponível em: https://www.sei.ba.gov.br/index.php?option=com_content&view=article&id=2000&Itemid=284
https://www.sei.ba.gov.br/index.php?opti... Moreover, some studies have suggested that occurrence of scorpion accidents may be associated with low socio-economic indices and lack of urban infrastructure. ²2. Souza CMV. Escorpionismo no Brasil com ênfase no Rio de Janeiro: subsidiando políticas públicas para populações expostas [tese]. Rio de Janeiro: Fiocruz; 2018. Disponível em: https://www.arca.fiocruz.br/handle/icict/30545
https://www.arca.fiocruz.br/handle/icict... ^,44. Fracolli LA. Acidentes por escorpiões no estado de São Paulo: uma abordagem sócio-demográfica. Rev Uningá [Internet]. 2017 out-dez [citado 2019 abr 2];18(1)2318-579. Disponível em: http://revista.uninga.br/index.php/uninga/article/view/724

According to the Ministry of Health, in some regions scorpions have become active all year round due to global climate changes. According to a study conducted by the Ministry, ⁹9. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de controle de escorpiões [Internet]. Brasília: Ministério da Saúde; 2009 [citado 2020 jan 27]. 72 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... scorpion accidents were not found to occur seasonally and showed a certain uniformity over the months and seasons, corroborating the results found by Barros et al. ¹⁹19. Barros RM, Pasquino JA, Peixoto LR, Targino ITG, Sousa JA, Leite RS. Aspectos clínicos e epidemiológicos das picadas de escorpiões na região nordeste do Brasil. Ciênc Saúde Coletiva [Internet]. 2014 abr [citado 2019 jul 06];19(4):1275-82. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232014000401275&lng=en . doi: 10.1590/1413-81232014194.01602013
http://www.scielo.br/scielo.php?script=s... This finding may be explained by the fact of climate conditions being relatively stable and favorable to the survival and proliferation of scorpions all year round. The region’s rainfall pattern is characterized as being well distributed along with low temperature variation (between 20 and 25ºC) during the year. ¹²12. Governo do Estado da Bahia. Superintendência de Estudos Econômicos e Sociais. Perfil dos territórios de identidade da Bahia [Internet]. Salvador: SEI; 2015 [citado 2019 maio 3]. Disponível em: Disponível em: https://www.sei.ba.gov.br/index.php?option=com_content&view=article&id=2000&Itemid=284
https://www.sei.ba.gov.br/index.php?opti...

Accidents occurred predominantly in the 20-49 years age range, i.e. the economically active population. The region’s main economic activities - agriculture, cattle-rearing and the construction industry - provide conditions of high risk of scorpion stings. However, only a small part of cases was work-related, in contrast to the study conducted by Reckziegel & Pinto: ²⁰20. Reckziegel GC, Pinto JVL. Análise do escorpionismo no Brasil no período de 2000 a 2010. Rev Pan-Amaz Saúde [Internet]. 2014 mar [citado 2019 jun 09];5(1):67-8. Disponível em: Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232014000100008&lng=pt . doi: 10.5123/S2176-62232014000100008
http://scielo.iec.gov.br/scielo.php?scri... according to these authors, over half of scorpion accidents (62.5%) occurred during activities in the rural area. Due to the vulnerability of rural activities, in which employment and health rights receive little consideration, ²¹21. Peres F. Saúde, trabalho e ambiente no meio rural brasileiro. Ciênc Saúde Coletiva [Internet]. 2009 dez [citado 2019 jun 20];14(6):1995-2004. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232009000600007&lng=en . doi: 10.1590/S1413-81232009000600007
http://www.scielo.br/scielo.php?script=s... work-related accidents may have been underreported in our study. Moreover, the relevant percentage (19.6%) of notification forms with no information on work circumstances involved or not involved raises the hypothesis of the number of work-related cases being higher.

Scorpion accidents involve multiple severity and death risk factors. The most relevant is age, with risk of death and severe symptoms in children up to 9 years old, in whom venom concentration tends to be high in view of their body volume. ¹⁴14. Carmo ÉA, Nery AA, Pereira R, Rios MA, Casotti CA. Fatores associados à gravidade do envenenamento por escorpiões. Texto contexto - Enferm [Internet]. 2019 jul [citado 2019 jun 06];28: e20170561. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072019000100334&lng=pt . doi: 10.1590/1980-265x-tce-2017-0561
http://www.scielo.br/scielo.php?script=s... In this study, 70% of deaths occurred among children aged between 1 and 9 years old; and those under 15 years old were three times more likely to be severe cases in comparison to other people who had been stung by scorpions.

The increase in scorpion accidents is directly related to the disorderly growth of urban centers, inadequate household structure and environmental imbalance. ²²22. Mcmichael AJ, Nyong AC. Global. environmental change and health: impacts, inequalities, and the health sector. BMJ [Internet]. 2008 Jan [cited 2020 Jan 27];336:191-4. Available from: Available from: https://www.bmj.com/content/336/7637/191 . doi: 10.1136/bmj.39392.473727.AD
https://www.bmj.com/content/336/7637/191... ^,2323. Albuquerque ICS, Albuquerque HN, Albuquerque EF, Nogueira AS, Cavalcanti MLF. Escorpionismo em Campina Grande-PB. Rev Biol Ciênc Terra [Internet]. 2004 [citado 2019 abr 20];4(1). Disponível em: http://www.redalyc.org/pdf/500/50040114.pdf In view of this situation, socio-economically vulnerable individuals, self-reported as being Black (84.0%), living in the rural areas of the municipalities and with low schooling (illiterate and with up to 7 years of schooling) were those who most suffered scorpion accidents. Production activities in rural areas are mainly performed by men, thus increasing their risk of exposure to scorpions, as reported in a recent study by Silva et al. ²⁴24. Silva EP, Monteiro WM, Bernarde PS. Scorpion stings and spider bites in the Upper Juruá, Acre - Brazil. J Hum Growth Dev [Internet]. 2018 Sep-Dec [cited 2019 out 14];28(3):290-7. Available from: Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S0104-12822018000300010&lng=en&nrm=iso . doi: 10.7322/jhgd.152178
http://pepsic.bvsalud.org/scielo.php?scr...

In our study, as in the study conducted by Bucaretchi et al., ²⁵25. Bucaretchi F, Fernandes LC, Fernandes CB, Branco MM, Prado CC, Vieira RJ, et al. Clinical consequences of Tityus bahiensis and Tityus serrulatus scorpion stings in the region of Campinas, southeastern Brazil. Toxicon [Internet]. 2014 Oct [cited 2020 Jan 27];89:17-25. Available from: Available from: https://www.sciencedirect.com/science/article/pii/S0041010114001901?via%3Dihub . doi: 10.1016/j.toxicon.2014.06.022
https://www.sciencedirect.com/science/ar... the hands were the anatomic region most affected by scorpion accidents. This finding is justified both by domestic activities²⁶26. Nunes CS, Bevilacqua PD, Jardim CCG. Aspectos demográficos e espaciais dos acidentes escorpiônicos no Distrito Sanitário Noroeste, Município de Belo Horizonte, Minas Gerais, 1993 a 1996. Cad Saúde Pública [Internet]. 2000 jan-mar [citado 2019 jun 23];16(1):213-23. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2000000100022&lng=en . doi: 10.1590/S0102-311X2000000100022
http://www.scielo.br/scielo.php?script=s... and also by failure to use personal protective equipment (PPE) by workers in their activities. ²⁴24. Silva EP, Monteiro WM, Bernarde PS. Scorpion stings and spider bites in the Upper Juruá, Acre - Brazil. J Hum Growth Dev [Internet]. 2018 Sep-Dec [cited 2019 out 14];28(3):290-7. Available from: Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S0104-12822018000300010&lng=en&nrm=iso . doi: 10.7322/jhgd.152178
http://pepsic.bvsalud.org/scielo.php?scr... Scorpion accidents are characterized above all by activities involving handling objects and places where scorpions gather. PPEs could be an important instrument for avoiding scorpion accidents at work.

Corroborating other studies, ¹⁴14. Carmo ÉA, Nery AA, Pereira R, Rios MA, Casotti CA. Fatores associados à gravidade do envenenamento por escorpiões. Texto contexto - Enferm [Internet]. 2019 jul [citado 2019 jun 06];28: e20170561. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072019000100334&lng=pt . doi: 10.1590/1980-265x-tce-2017-0561
http://www.scielo.br/scielo.php?script=s... ^,2020. Reckziegel GC, Pinto JVL. Análise do escorpionismo no Brasil no período de 2000 a 2010. Rev Pan-Amaz Saúde [Internet]. 2014 mar [citado 2019 jun 09];5(1):67-8. Disponível em: Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232014000100008&lng=pt . doi: 10.5123/S2176-62232014000100008
http://scielo.iec.gov.br/scielo.php?scri... the majority of accidents in this study were clinically classified as being mild. Occurrence of severe cases and deaths may be related to the time until care is received by the victims: the majority of deaths were caused by accidents in rural areas, with precarious logistical conditions for immediate and efficient health care. In 70% of deaths, time until receiving care ranged between 1 and 3 hours. Deaths were practically restricted to cases classified as being severe, mostly cased by T. serrulatus, a commonly found species in Bahia. ⁹9. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de controle de escorpiões [Internet]. Brasília: Ministério da Saúde; 2009 [citado 2020 jan 27]. 72 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... In order to avoid negative outcomes, related to sequelae and death, it is essential for the interval of time between accident and care to be smaller. ²⁰20. Reckziegel GC, Pinto JVL. Análise do escorpionismo no Brasil no período de 2000 a 2010. Rev Pan-Amaz Saúde [Internet]. 2014 mar [citado 2019 jun 09];5(1):67-8. Disponível em: Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232014000100008&lng=pt . doi: 10.5123/S2176-62232014000100008
http://scielo.iec.gov.br/scielo.php?scri... ^,2727. Guerra CMN, Carvalho LFA, Colosimo EA, Freire HBM. Análise de variáveis relacionadas à evolução letal do escorpionismo em crianças e adolescentes no estado de Minas Gerais no período de 2001 a 2005. J Pediatr (RJ) [Internet]. 2008 nov-dez [citado 2019 jul 06];84(6):509-15. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0021-75572008000700007&lng=en . doi: 10.1590/S0021-75572008000700007
http://www.scielo.br/scielo.php?script=s... ^,2828. Gampini S, Nassouri S, Chippaux J-P, Semde R. Estudo retrospectivo sobre a incidência de envenenamento e acessibilidade ao antiveneno em Burkina Faso. J Venom Anim Toxinas Incl Trop Dis [Internet]. 2016 abr [citado 2019 jun 18];22:10. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1678-91992016000100309&lng=en . doi: 10.1186/S40409-016-0066-7
http://www.scielo.br/scielo.php?script=s... It is therefore fundamental for the population to be informed about health centers where serotherapy is provided, so that victims can be taken to them immediately.

Intense pain is the most common local symptom, as described in the majority of cases. ¹⁵15. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância em saúde [Internet]. 2. ed. Brasília: Ministério da Saúde ; 2017 [citado 2020 jan 27]. 705 p. Disponível em: Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/outubro/06/Volume-Unico-2017.pdf
http://portalarquivos.saude.gov.br/image... ^,1919. Barros RM, Pasquino JA, Peixoto LR, Targino ITG, Sousa JA, Leite RS. Aspectos clínicos e epidemiológicos das picadas de escorpiões na região nordeste do Brasil. Ciênc Saúde Coletiva [Internet]. 2014 abr [citado 2019 jul 06];19(4):1275-82. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232014000401275&lng=en . doi: 10.1590/1413-81232014194.01602013
http://www.scielo.br/scielo.php?script=s... However, in more severe accidents, pain may be camouflaged by systemic symptoms which progress as time goes by until care is provided. ⁸8. Cupo P, Azevedo-Marques MM, Hering SE. Escorpionismo. In: Cardoso JLC, França FOS, Wen FH, Málaque CMS, Haddad Jr. V. Animais peçonhentos no Brasil: biologia, clínica e terapêutica dos acidentes. 2. ed. São Paulo: Sarvier; 2009. p. 214-24. System symptoms were reported in 8% of accidents analyzed in this study. They are important for triggering the decision as to treatment most indicated for the patient. Vagal systemic symptoms (arterial hypotension, dizziness, blurred vision, bradycardia, abdominal colic and diarrhea) were present in 60% of patients who died. For this reason, the patient’s clinical symptoms at the time care is provided need to be assessed with due attention, as they determine case classification and whether serotherapy is to be used or not. ¹⁵15. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância em saúde [Internet]. 2. ed. Brasília: Ministério da Saúde ; 2017 [citado 2020 jan 27]. 705 p. Disponível em: Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/outubro/06/Volume-Unico-2017.pdf
http://portalarquivos.saude.gov.br/image...

The Health Surveillance Guide (2017) recommends serotherapy only for cases classified as moderate and severe, which may progress to death¹⁵15. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância em saúde [Internet]. 2. ed. Brasília: Ministério da Saúde ; 2017 [citado 2020 jan 27]. 705 p. Disponível em: Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/outubro/06/Volume-Unico-2017.pdf
http://portalarquivos.saude.gov.br/image... and which, in the case of this study, accounted for 13.5% of patients. Notwithstanding, 22.7% of patients received serotherapy, suggesting an error in case classification or treatment with serotherapy. Another mistake in the records are deaths classified as mild (30%), having only pain and edema as local symptoms, and no systemic symptoms or serotherapy, with time until care between 1 and 3 hours (two cases) and 3 to 6 hours (one case). These facts suggest either an interpretation error or a SINAN investigation form typing error on the part of health professionals responsible for this. ²⁰20. Reckziegel GC, Pinto JVL. Análise do escorpionismo no Brasil no período de 2000 a 2010. Rev Pan-Amaz Saúde [Internet]. 2014 mar [citado 2019 jun 09];5(1):67-8. Disponível em: Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232014000100008&lng=pt . doi: 10.5123/S2176-62232014000100008
http://scielo.iec.gov.br/scielo.php?scri... Over half the cases that died received serotherapy, which is a treatment with resolutive capacity when the correct dose is given. It is possible that further factors may have contributed to deaths occurring and as such future and more in-depth investigation of these determinants is recommended.

High occurrence of scorpionism in the Far South of Bahia region between 2010 and 2017, associated with socio-economic factors, forms an epidemiological scenario with increased cases, despite the reduction in deaths, suggesting improvement in the service provided by the health care network. Nevertheless, the increase in accidents needs to be better understood in order for prevention and health care actions to be adopted, especially in the case of the male rural population and children.

The main economic activities of the Far South of Bahia region include sugarcane and coffee production, eucalyptus forestry and cattle-rearing. ¹⁰10. Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010: Bahia [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011 [citado 2019 fev 17]. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/
http://www.ibge.gov.br/home/estatistica/... These activities lead to land clearing and occupation by humans, altering the natural habitat of scorpions and favoring human contact with scorpions and potential accidents. Studies of scorpion ecology are needed in order to better understand the impact of agriculture and forestry on the incidence of scorpion accidents in the region. ²⁹29. Lourenço WR. Scorpions and life-history strategies: from evolutionary dynamics toward the scorpionism problem. J Venom Anim Toxins Incl Trop Dis [Internet]. 2018 Sep [cited 2019 Oct 14];24:19. Available from: Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1678-91992018000100206&lng=en . doi: 10.1186/s40409-018-0160-0
http://www.scielo.br/scielo.php?script=s... ^,3030. Araújo KAM, Tavares AV, Marques MRV, Vieira AA, Leite RS. Epidemiological study of scorpion stings in the Rio Grande do Norte State, Northeastern Brazil. Rev Inst Med Trop São Paulo [Internet]. 2017 Aug [cited 2019 Oct 15];59:e58. Available from: Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0036-46652017005000231&lng=en . doi: 10.1590/s1678-9946201759058
http://www.scielo.br/scielo.php?script=s...

This study has limitations related to using a secondary data source. Errors occur with SINAN investigation form filling in and typing and this can compromise the results of local level analysis results. Even though such shortcomings exist, they do not invalidate the results obtained, given the size of the sample used in the study period. Moreover, in the 13 municipalities studied, information duplication does not occur frequently, given that serotherapy is restricted to the few health centers where care - and notification - take place.

The results presented allow the conclusion to be reached that scorpion accident incidence in the Far South of Bahia is high and, apparently, is increasing, differently to most of Brazil. The increase in scorpionism frequency in recent years calls for intensification of health surveillance actions in the region, above all with regard to continuing training of health professionals, aimed at adequate diagnosis, treatment and filling in of investigation forms.

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