Abstract

Objective

To analyze ecological association between socioeconomic, occupational and sanitation characteristics and scorpionism in Brazil.

Methods

This was an ecological study with data on scorpion sting accidents reported on the Notifiable Health Conditions Information System (2007-2019). Negative binomial regression was used to estimate incidence rate ratios (IRR) and confidence intervals (95%CI).

Results

In the study period there were 1,079,333 scorpion sting accidents, with a cumulative incidence rate of 41.5/100,000 inhabitants. In the adjusted analysis, there was association with the municipal percentages of: women (IRR=1.65 - 95%CI 1.18;2.30) and men (IRR=0.90 - 95%CI 0.88;0.91) working in the construction industry, women (IRR=1.21 - 95%CI 1.18;1.25) and men (IRR=0.73 - 95%CI 0.69;0.77) working in domestic service, women (IRR=1.03 - 95%CI 1.02;1.04) and men (IRR=0.93 - 95%CI 0.92;0.93) working in farming, households with refuse collection (IRR=0.99 - 95%CI 0.98;0.99) and households with refuse left nearby (IRR=1.02 - 95%CI 1.01;1.02), expected years of schooling (IRR=0.88 - 95%CI 0.83;0.92), and unemployment rate (IRR=1.07 - 95%CI 1.05;1.09).

Conclusion

Scorpionism was associated with precarious infrastructure/sanitation, job availability, education and female occupation.

Keywords:
Scorpion Sting; Social Determinants of Health; Epidemiology; Ecological Studies; Occupational Health

Introduction

Scorpion poisoning, or scorpionism, is estimated to be responsible for 1.5 million new cases and 2,600 deaths worldwide every year.¹1. Chippaux JP. Emerging options for the management of scorpion stings. Drug Des Devel Ther. 2012;6:165-73. doi: https://doi.org/10.2147/DDDT.S24754.
https://doi.org/10.2147/DDDT.S24754... In Latin America, mainly in Mexico, Brazil, Guyana and Venezuela, simultaneous high incidence and clinical severity is attributed to scorpions of the Tityus and Centruroides genera.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... In Brazil, severe cases are related to four species of medical importance: T. serrulatus, T. obscurus, T. bahiensis and T. stigmurus.³3. Ministério da Saúde (BR). Guia de vigilância em saúde [Internet]. 3a ed. Brasília, DF: MS; 2019 [acesso 20 nov. 2020]. Capítulo 11, Acidentes por animais peçonhentos; p. 653-670. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf4.
http://bvsms.saude.gov.br/bvs/publicacoe... The T. serrulatus species stands out for its toxicity and abundance in urban environments.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-...

In Brazil, in the decade between 2007 and 2017, there was a 234.4% increase in scorpion sting accidents, from 37,370 (2007) to 124,982 cases (2017).⁴4. Quispe Torrez PP, Dourado FS, Bertani R, Cupo P, França FOS. Scorpionism in Brazil: exponential growth of accidents and deaths from scorpion stings. Rev Soc Bras Med Trop. 2019;52:e20180350. doi: https://doi.org/10.1590/0037-8682-0350-2018.
https://doi.org/10.1590/0037-8682-0350-2... Cases are usually more frequent among males aged 20 to 49 years, with 4 to 7 years of schooling, stung in the upper limbs, and living in urban areas, while deaths are more frequent among males aged up to 9 years, and among individuals stung in rural areas.⁵5. Reckziegel GC, Pinto V. Scorpionism in Brazil in the years 2000 to 2012. J Venom Anim Toxins Incl Trop Dis. 2014;20:2-8. doi: https://doi.org/10.1186/1678-9199-20-46.
https://doi.org/10.1186/1678-9199-20-46...

Scorpions are small, cosmopolitan, carnivorous, nocturnal, synanthropic arthropods whose prey can be anything from other scorpions to insects, such as crickets, grasshoppers, termites and cockroaches.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... During foraging, scorpions seek prey located in accumulated organic matter and debris; and in houses, where they can hide in dark places like crevices, between clothes and inside shoes.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... ^,66. Ministério da Saúde (BR). Manual de controle de escorpiões [Internet]. Brasília, DF: MS; 2009 [cited 19 nov. 2020]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

Because of these behavioral characteristics and feeding preferences of scorpions, scorpionism is also related to people’s individual attitudes, which contribute to the occurrence and permanence of this arachnid in the environment, such as letting refuse accumulate and not performing prophylactic actions: i.e. failure to use personal protective equipment and inspect clothing.⁶6. Ministério da Saúde (BR). Manual de controle de escorpiões [Internet]. Brasília, DF: MS; 2009 [cited 19 nov. 2020]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
https://bvsms.saude.gov.br/bvs/publicaco... However, these justifications put the blame on individuals for this health condition and do not explore the role of social determinants of health, such as socioeconomic, occupational and poor infrastructure/sanitation aspects, identified in the epidemiological profiles of scorpionism.⁵5. Reckziegel GC, Pinto V. Scorpionism in Brazil in the years 2000 to 2012. J Venom Anim Toxins Incl Trop Dis. 2014;20:2-8. doi: https://doi.org/10.1186/1678-9199-20-46.
https://doi.org/10.1186/1678-9199-20-46... ^,77. Chippaux J-P. Epidemiology of envenomations by terrestrial venomous animals in Brazil based on case reporting: from obvious facts to contingencies. J Venom Anim Toxins Incl Trop Dis. 2015;21:13 doi: https://doi.org/10.1186/s40409-015-0011-1.
https://doi.org/10.1186/s40409-015-0011-...

8. Quispe Torrez PP, Bertolozzi MR, França FOS. Vulnerabilities and clinical manifestations in scorpion envenomations in Santarém, Pará, Brazil: a qualitative study. Rev Esc Enferm USP. 2020;54:e03579. doi: https://doi.org/10.1590/S1980-220X2018050403579.
https://doi.org/10.1590/S1980-220X201805... ^-99. Silva-Domínguez R, Paredes-Solís S, Cortés-Guzmán AJ, Flores-Moreno M, Baldazo-Monsivaiz JG, Anderson N, et al. Factores asociados con la picadura de alacrán en escolares: estudio transversal en dos comunidades rurales de Guerrero, México. Bol Med Hosp Infant Mex. 2019;76(2):79-86. doi: https://doi.org/10.24875/bmhim.18000104.
https://doi.org/10.24875/bmhim.18000104...

Despite the accumulation of evidence about people’s individual aspects that favor the occurrence of scorpion sting accidents, the role played by the jobs they do and other municipal descriptors capable of interfering in the occurrence of this health condition remain unexplored.

In view of this scenario, the objective of this study was to analyze ecological association between socioeconomic, occupational and infrastructure/sanitation characteristics and occurrence of scorpionism in Brazil.

Methods

This is an ecological study on the occurrence of scorpionism, taking the Brazilian municipalities as its units of analysis.

Located in South America, in 2020 Brazil covered an area of approximately 8,510,295.914 km², with 211,049,519 inhabitants, demographic density of 25.25 inhab./km² and 5,570 municipalities distributed over its five geographic macro-regions: Northeast, North, Midwest, Southeast, and South. The country borders 11 other countries and has a vast coastal area along the Atlantic Ocean. Most of the Brazilian population resides in urban areas (86.8%) and has a life expectancy of around 75.9 years.¹⁰10. Instituto Brasileiro de Geografia e Estatística. Países [Internet]. [Brasília, DF]: IBGE; 2020 [acesso 4 fev. 2021]. Disponível em: https://paises.ibge.gov.br/#/dados/brasil
https://paises.ibge.gov.br/#/dados/brasi...

Only municipalities that had become independent before 2007 were eligible for the study, so that all municipalities covered by the study were in existence right from the first year of the study period. Six municipalities were not included in this research because they became independent after 2007.

The Notifiable Health Conditions Information System comprised the data source for reported scorpionism cases. The municipal variables were obtained from the 2010 Demographic Census, conducted by the Brazilian Institute of Geography and Statistics (IBGE), and the population estimates were also provided by IBGE (Box 1). All data sources were accessed electronically, on August 20, 2020.¹¹11. Instituto Brasileiro de Geografia e Estatística. Sistema IBGE de recuperação automática - SIDRA [Internet]. [Brasília, DF]: IBGE; 2020 [acesso 20 out. 2020]. Disponível em: https://sidra.ibge.gov.br/acervo#/S/Q
https://sidra.ibge.gov.br/acervo#/S/Q... ^,1212. Ministério da Saúde (BR). Sistema de informação de agravos de notificação (SINAN) [Internet]. [Brasília, DF: MS; 2020 [acesso 20 out. 2020]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinannet/cnv/animaisbr.def
http://tabnet.datasus.gov.br/cgi/deftoht...

This study’s outcome variable was the cumulative number of scorpionism cases registered between 2007 and 2019 in each Brazilian municipality. The cumulative number of records was used to increase case-by-case assessment and avoid distortions in case reporting due to turnover in the teams responsible for reporting them. Accidents that occurred before 2007 were not selected, due to changes made in 2006 to the Notification Form for Accidents Involving Venomous Animals, used on the Notifiable Health Conditions Information System.

Municipal independent variables or descriptors were selected so as to take into consideration structural determinant categories (municipal occupation and socioeconomic descriptors) and intermediate determinants (infrastructure/sanitation descriptors) of the Social Determinants of Health model adopted by Solar & Irwin.¹³13. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: debates, policy and practice, case studies [Internet]. Geneva: WHO; 2010 [acesso 19 nov. 2020]. Disponível em: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
https://www.who.int/sdhconference/resour...

The independent variables were summarized according to measures of central tendency (average and median) and dispersion (standard deviation; minimum and maximum values). The factors associated with cumulative scorpionism cases occurring in Brazilian municipalities between 2007 and 2019 were analyzed using negative binomial regression, since the outcome variable presented overdispersed count data, identified by alpha>0 in the multivariate regression (alpha=2.33).¹⁴14. Hilbe JM. Negative binomial regression. 2nd ed. New York: Cambridge University Pres; 2011. The geographic macro-region of occurrence (North, Northeast, Southeast, Midwest or South) was included as an adjustment variable in both the bivariate and the multivariate regression analysis.

Negative binomial regression assumes that μ_j=exp(ßx_j+offset_j), where µ is the average occurrence of accidents, ß is the regression coefficient and x is the covariable. The estimated regression coefficients were transformed into incidence rate ratios (IRR), given that IRR=exp^ßi. The cumulative population estimates for each municipality, between 2007 and 2019, were logarithmized and included as an offset variable, i.e., an offset factor of total cases that allows model counts such as IRR.¹¹11. Instituto Brasileiro de Geografia e Estatística. Sistema IBGE de recuperação automática - SIDRA [Internet]. [Brasília, DF]: IBGE; 2020 [acesso 20 out. 2020]. Disponível em: https://sidra.ibge.gov.br/acervo#/S/Q
https://sidra.ibge.gov.br/acervo#/S/Q... ^,1414. Hilbe JM. Negative binomial regression. 2nd ed. New York: Cambridge University Pres; 2011.

Based on the “forward” selection method, the independent variables were included in the multivariate model when they had a 95% confidence interval (95%CI), statistical significance of 5% (p-value<0.05) and a reduction in the value of the Akaike information criterion (AIC) after including new variables, as well as theoretical consistency according to the scientific literature, so as to avoid spurious association.¹⁵15. Heinze G, Wallisch C, Dunkler D. Variable selection: a review and recommendations for the practicing statistician. Biom J. 2018;60(3):431-49. doi: https://doi.org/10.1002/bimj.201700067.
https://doi.org/10.1002/bimj.201700067...

None of the variables selected for the final model were left out by the program used to perform the analysis, indicating that there was no multicollinearity. In addition, a correlation matrix with the multivariate regression coefficients was plotted to further check for multicollinearity. The factor used to identify multicollinearity was high correlation (≥0.9).¹⁶16. Wooldridge JM. Introductory econometrics: a modern approach. Boston: Cengage; 2020. Chapter 3, Multiple regression analysis estimation; p. 66-117.

The negative binomial regression model fit was checked using the Tukey-Pregibon goodness-of-link test, using linear squared predicted values (_hatsq), taken not to be statistically significant at a level of 5% (p-value>0.05).¹⁴14. Hilbe JM. Negative binomial regression. 2nd ed. New York: Cambridge University Pres; 2011. All steps described in the analysis of associated factors were processed using the Stata version 16.0 statistical program.

The research project was approved by the Federal University of Bahia Institute of Public Health Research Ethics Committee: Opinion No. 1.370.415/2015, issued on December 16^th 2015.

Results

According to the records held on the Notifiable Health Conditions Information System, between 2007 and 2019, there were 1,079,333 scorpion sting accidents in the 5,564 municipalities investigated, representing an average of 194.0 cases (standard deviation=1,017.9; minimum value=0 and maximum value=41,523) and cumulative incidence of 41.5/100,000 hab. per municipality. About 25%, 50% and 75% of the municipalities investigated recorded, respectively, a total of 5, 29 and 118 cases in this period, indicating a pattern of high scorpionism (outcome variable) case count dispersion.

Of the total number of accidents in the country, in the selected period (2007-2019), 46% (495,252) occurred in the Brazilian Northeast, 43% (459,819) in the Southeast, 5% (53,391) in the Midwest, 4% (44,475) in the North, and 2% (26,396) in the South. In the same period, a 311% increase was seen in the number of reported cases, rising from 37,347 in 2007 to 153,641 in 2019 (Figure 1).

The measures of central tendency and dispersion of the 17 variables of the investigated municipalities are described in Table 1. In the bivariate negative binomial regression analysis, 15 of these variables had significant association with the outcome. In the multivariate regression model, 10 independent variables remained strongly associated with the occurrence of scorpionism: (i) percentage of men working in the construction industry (IRR=0.90 - 95%CI 0.88;0.91); (ii) percentage of women working in the construction industry (IRR=1.65 - 95%CI 1.18;2.30); (iii) percentage of men working in domestic service (IRR=0.73 - 95%CI 0.69;0.77); (iv) percentage of women working in domestic service (IRR=1.21 - 95%CI 1.18;1.25); (v) percentage of men working in farming (IRR=0.93 - 95%CI 0.92;0.93); (vi) percentage of women working in farming (IRR=1.03 - 95%CI 1.02;1.04); (vii) percentage of households with refuse collection (IRR=0.99 - 95%CI 0.98;0.99); (viii) percentage of households with refuse left nearby (IRR=1.02 - 95%CI 1.01;1.02); (ix) expected number of years of schooling (IRR=0.88 - 95%CI 0.83;0.92); and (x) unemployment rate (IRR=1.07 - 95%CI 1.05;1.09) (Table 2).

According to the results of the matrix of correlation between the negative binomial regression coefficients (Table 3), no multicollinearity was identified between the variables of the adjusted model. The final model (AIC =58,766.11) showed a better data fit, compared to the bivariate model (AIC=59,978.13), formed by the outcome and the variable with the highest association in the bivariate analysis (percentage of women working in the construction industry). Additionally, the non-statistically significant result at the 5% level for the Tukey-Pregibon goodness-of-link test (hatsq=0.004 - p-value=0.707) indicated the good fit of the adjusted model to the negative binomial regression model.

Discussion

The results of this study demonstrate directly proportional association between scorpionism incidence in Brazil and the following municipal descriptors: percentage of households with refuse left nearby; unemployment rate; and percentage of women working in the construction industry, domestic service and farming. Inversely proportional association was observed between scorpionism incidence and the following municipal descriptors: expected number of years of schooling; percentage of households with refuse collection; and percentage of men working in the construction industry, in domestic service and in farming.

In Brazil, scorpion poisoning is reported with greater frequency in the home environment and the environment immediately surrounding the home, thus predisposing women working in domestic services to this health condition.¹⁷17. Lira-da-Silva RM, Amorim AM, Carvalho FM, Brazil TK. Acidentes por escorpião na cidade do Salvador, Bahia, Brasil (1982-2000). Gaz Med Bahia [Internet]. 2009 [acesso 21 nov. 2020];79(Supl 1):43-9. Disponível em: http://gmbahia.ufba.br/index.php/gmbahia/article/view/995/972
http://gmbahia.ufba.br/index.php/gmbahia... Due to historical and social influences, the role of women in society is still linked to doing domestic activities,¹⁸18. Motta AB. Emprego doméstico: revendo o novo. Cad CRH [Internet]. 1992 [acesso 19 nov. 2020];(16):31-49. Disponível em: https://repositorio.ufba.br/ri/bitstream/ri/2380/1/CadCRH-2007-362 s.pdf
https://repositorio.ufba.br/ri/bitstream... which have been related to scorpionism for more than 50 years in Brazil.¹⁷17. Lira-da-Silva RM, Amorim AM, Carvalho FM, Brazil TK. Acidentes por escorpião na cidade do Salvador, Bahia, Brasil (1982-2000). Gaz Med Bahia [Internet]. 2009 [acesso 21 nov. 2020];79(Supl 1):43-9. Disponível em: http://gmbahia.ufba.br/index.php/gmbahia/article/view/995/972
http://gmbahia.ufba.br/index.php/gmbahia... ^,1919. Bücherl W. Escorpionismo no Brasil. Mem Inst Butantan [Internet]. 1969 [acesso 19 nov. 2020];34:9-24. Disponível em: https://bibliotecadigital.butantan.gov.br/arquivos/66/PDF/3.pdf
https://bibliotecadigital.butantan.gov.b... However, this is the only study which has measured in an aggregated manner association between domestic service and scorpion poisoning.

The study showed that women were more vulnerable to scorpionism in all the Brazilian municipalities surveyed: an increase of 1% in the number of women working in domestic service was associated with a 21% increase in the incidence of scorpionism cases. The vulnerability of these workers has already been discussed in a study carried out in the city of Salvador, BA, based on scorpionism cases that occurred between 1982 and 2000.¹⁷17. Lira-da-Silva RM, Amorim AM, Carvalho FM, Brazil TK. Acidentes por escorpião na cidade do Salvador, Bahia, Brasil (1982-2000). Gaz Med Bahia [Internet]. 2009 [acesso 21 nov. 2020];79(Supl 1):43-9. Disponível em: http://gmbahia.ufba.br/index.php/gmbahia/article/view/995/972
http://gmbahia.ufba.br/index.php/gmbahia... Despite its frequently benign outcome in adults, this health condition leads to suffering, such as intense pain at the site of the sting, and can lead to clinical severity, especially in older adults or those with comorbidities, such as diabetes mellitus and hypertension.²⁰20. Santos MSV, Silva CGL, Silva Neto B, Grangeiro Júnior CRP, Lopes VHG, Teixeira Júnior AG, et al. Clinical and Epidemiological aspects of scorpionism in the world: a systematic review. Wilderness Environ Med. 2016;27(4):504-18. doi: https://doi.org/10.1016/j.wem.2016.08.003.
https://doi.org/10.1016/j.wem.2016.08.00... ^,2121. Albuquerque PLMM, Magalhães KN, Sales TC, Paiva JHHGL, Daher EF, Silva Junior GB. Acute kidney injury and pancreatitis due to scorpion sting: case report and literature review. Rev Inst Med Trop Sao Paulo. 2018;60:e30. doi: http://dx.doi.org/10.1590/S1678-9946201860030.
https://doi.org/10.1590/S1678-9946201860...

In the environment outside the household, other occupations related to scorpionism have been identified, such as the construction industry and rural work.²²22. Brites-Neto J, Brasil J. Estratégias de controle do escorpionismo no município de Americana, SP. Bol Epidemiol Paul [Internet]. 2012 [acesso 19 nov. 2020];9(101):4-15. Disponível em: http://periodicos.ses.sp.bvs.br/scielo.php?script=sci_arttext&pid=S1806-42722012000500001&lng=pt
http://periodicos.ses.sp.bvs.br/scielo.p... ^,2323. Carmo EA, Nery AA, Nascimento Sobrinho CL, Casotti CA. Clinical and epidemiological aspects of scorpionism in the interior of the state of Bahia, Brazil: retrospective epidemiological study. Sao Paulo Med J. 2019;137(2):162-8. doi: https://doi.org/10.1590/1516-3180.2018.0388070219.
https://doi.org/10.1590/1516-3180.2018.0... In this study, the ‘percentage of women working in the construction industry’ variable showed direct association with cumulative incidence of scorpionism cases in the Brazilian municipalities. The same was not found for the ‘percentage of men working in the construction industry’, which showed an inverse relationship.

Presence of rubble on building sites is constant, and workers in this sector are susceptible to the presence of scorpions that use this waste material for shelter.²⁴24. Khatony A, Abdi A, Fatahpour T, Towhidi F. The epidemiology of scorpion stings in tropical areas of Kermanshah province, Iran, during 2008 and 2009. J Venom Anim Toxins Incl Trop Dis. 2015;21:45. doi: http://dx.doi.org/10.1186/s40409-015-0045-4.
https://doi.org/10.1186/s40409-015-0045-... Historically, the construction industry labor market has been dominated by men, preserving the socially inherited influence of the ways of working destined to each gender. Despite women entering the construction industry, they tend to do jobs such as cleaning and catering, when they do not have the qualifications necessary for more prestigious professions such as engineering and architecture.²⁵25. Romcy D, Brites JG. As mulheres na construção civil: algumas notas a partir de um trabalho de campo. Rev Vernaculo. 2014;(36):137-64. doi: http://dx.doi.org/10.5380/rv.v0i36.37827.
https://doi.org/10.5380/rv.v0i36.37827... It is to be expected that women will be closer to piles of building waste, which scorpions use as shelter.

In certain regions, such as in the state of Amazonas, scorpionism is more frequently reported in rural areas.²⁶26. Costa CLSO, Fé NF, Sampaio IC, Tadei WP. A profile of scorpionism, including the species of scorpions involved, in the State of Amazonas, Brazil. Rev Soc Bras Med Trop. 2016;49(3):376-9. doi: http://dx.doi.org/10.1590/0037-8682-0377-2015.
https://doi.org/10.1590/0037-8682-0377-2... The rural environment is also favorable to the proliferation of scorpions when there are places for them to shelter (e.g., piles of organic matter, debris, garbage, warehouses and stores) and food (e.g., cockroaches, termites, crickets, insect larvae and spiders).⁶6. Ministério da Saúde (BR). Manual de controle de escorpiões [Internet]. Brasília, DF: MS; 2009 [cited 19 nov. 2020]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
https://bvsms.saude.gov.br/bvs/publicaco... Closeness to these places and failure to use personal protective equipment can result in rural workers being at risk of accidents involving scorpions. In the case of female rural workers, risk of these accidents is expected to be greater, given their increased exposure resulting from doing both agricultural and domestic activities.²⁷27. Boris E. Produção e reprodução, casa e trabalho [tradução]. Tempo Soc. 2014;26(1):101-21. doi: https://doi.org/10.1590/S0103-20702014000100008.
https://doi.org/10.1590/S0103-2070201400...

Socioeconomic and infrastructure/sanitation factors also need to be considered and incorporated into scorpion poisoning protection strategies in Brazilian municipalities. According to the findings of this investigation, adding one year to the ‘expected number of years of schooling’ of the municipal population was associated with a 12% reduction in the incidence of scorpion stings.

The relationship between scorpion poisoning and educational aspects has been mentioned in other studies, according to which scorpionism was directly related to illiteracy - in the accidents that occurred in Brazil between 2001 and 2012 - or was more frequent in individuals with less education - also in the cases that occurred in Brazil between 2001 and 2012.⁵5. Reckziegel GC, Pinto V. Scorpionism in Brazil in the years 2000 to 2012. J Venom Anim Toxins Incl Trop Dis. 2014;20:2-8. doi: https://doi.org/10.1186/1678-9199-20-46.
https://doi.org/10.1186/1678-9199-20-46... ^,77. Chippaux J-P. Epidemiology of envenomations by terrestrial venomous animals in Brazil based on case reporting: from obvious facts to contingencies. J Venom Anim Toxins Incl Trop Dis. 2015;21:13 doi: https://doi.org/10.1186/s40409-015-0011-1.
https://doi.org/10.1186/s40409-015-0011-...

Education is a social determinant of health that contributes to the improvement of living conditions because, indirectly, it facilitates having better paid jobs, thus ensuring access to quality health services and housing with good infrastructure/sanitation.¹³13. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: debates, policy and practice, case studies [Internet]. Geneva: WHO; 2010 [acesso 19 nov. 2020]. Disponível em: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
https://www.who.int/sdhconference/resour...

Supporting the findings for education, the incidence of scorpion accidents in Brazilian municipalities was shown to be directly associated with the municipal unemployment rate. Being employed is an important source of income, implies access to the minimum necessities for survival, and can impact health and nutrition conditions.¹³13. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: debates, policy and practice, case studies [Internet]. Geneva: WHO; 2010 [acesso 19 nov. 2020]. Disponível em: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
https://www.who.int/sdhconference/resour... Difficulty in obtaining consumer goods and services is often related to housing with precarious infrastructure/sanitation services, this being a favorable scenario for scorpions.¹³13. Solar O, Irwin A. A conceptual framework for action on the social determinants of health: debates, policy and practice, case studies [Internet]. Geneva: WHO; 2010 [acesso 19 nov. 2020]. Disponível em: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
https://www.who.int/sdhconference/resour... ^,2828. Lakhkar BB, Patil MM, Patil SV. Scorpion Sting Envenomation. J Nepal Paediatr Soc. 2016;36(3):284-7. doi: https://doi.org/10.3126/jnps.v36i3.14875.
https://doi.org/10.3126/jnps.v36i3.14875... It is well known that parental unemployment can influence child malnutrition and increased incidence of low weight for age, this being one of the determinants of the occurrence of severe scorpionism symptoms and mortality among children.²⁸28. Lakhkar BB, Patil MM, Patil SV. Scorpion Sting Envenomation. J Nepal Paediatr Soc. 2016;36(3):284-7. doi: https://doi.org/10.3126/jnps.v36i3.14875.
https://doi.org/10.3126/jnps.v36i3.14875... ^,2929. Pieters J, Rawlings S. Parental unemployment and child health in China. Rev Econ Househ. 2020;18:207-37. doi: https://doi.org/10.1007/s11150-019-09457-y.
https://doi.org/10.1007/s11150-019-09457...

Disposal of household refuse in the municipal environment was related to the occurrence of scorpionism. Accumulation of refuse favors the appearance of scorpions, as it provides food and shelter.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... Cockroaches and other small insects are part of the main diet of scorpions, and are found in abundance in places with periodic accumulation of organic waste, as usually occurs in areas with poor infrastructure/sanitation.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... ^,66. Ministério da Saúde (BR). Manual de controle de escorpiões [Internet]. Brasília, DF: MS; 2009 [cited 19 nov. 2020]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
https://bvsms.saude.gov.br/bvs/publicaco... Establishing environments with good bio-sanitary conditions, free from food and water sources for insects, can be an important strategy for reducing the proliferation of the medically important species T. serrulatus, which also figures as an urban pest in Brazil.²2. Chávez-Haro AL, Ortiz E. Scorpionism and Dangerous Species of Mexico. In: Gopalakrishnakone P, Possani LD, Schwartz EF, Rodrígues de La Vega RC. Scorpion Venoms. Berlim: Springer; 2015. p. 201-324. doi: https://doi.org/10.1007/978-94-007-6404-0.
https://doi.org/10.1007/978-94-007-6404-... ^,3030. Pimenta RJG, Brandão-Dias PFP, Leal HG, Carmo AO, Oliveira-Mendes BBR, Chávez-Olórtegui C, et al. Selected to survive and kill: Tityus serrulatus, the Brazilian yellow scorpion. PLoS One. 2019;14(4):e0214075. doi: https://doi.org/10.1371/journal.pone.0214075.
https://doi.org/10.1371/journal.pone.021...

This research was conducted using secondary data from the Notifiable Health Conditions Information System, which is known to be prone to data completion errors, as well as reporting problems. However, there are advantages in using secondary data, such as lower cost and studies being conducted more quickly. The ecological study design, adopted in this investigation, prevents causal inferences from being made in relation to the associated factors identified. However, its exploratory nature allows the formulation of hypotheses to be investigated. Furthermore, because this is an ecological study that used existing data, lack of availability of relevant information from secondary sources limited the analysis, making it impossible to explore other factors, such as the spatial distribution, richness, and abundance of scorpion species, which could influence scorpionism being recorded.

We conclude that addressing the occurrence of scorpion sting accidents - which have been increasing in recent years - demands improvements in infrastructure/sanitation conditions, in education indicators, and in the availability of jobs that indirectly facilitate access to good bio-sanitary conditions in households. This study also brings evidence that scorpion sting accidents could be related to the type of work/occupation that women do.

This set of information should be used in municipal service management, as a demand in relation to health, as well as in agendas related to education and economic development, because it appears to be intrinsically linked to the occurrence of scorpion poisoning.

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