Temporal trend and epidemiological profile of accidents involving venomous animals in Brazil, 2007-2019

Tiago Cruz de Souza Beatrice Emeli Silva Farias Paulo Sérgio Bernarde Francisco Chiaravalotti Neto Djair Durand Ramalho Frade Andreia Fernandes Brilhante Leonardo Augusto Kohara Melchior About the authors

Abstract

Objective:

to analyze the temporal trend of accidents involving venomous animals in Brazil from 2007 to 2019.

Methods:

this was a cross-sectional study carried out with data from the Notifiable Health Conditions Information System (SINAN). Prais-Winsten linear regression was used for the temporal analysis. We calculated incidence rates according to sex and age group, relative risk and case fatality ratio.

Results:

during the study period there were 2,102,657 cases of accidents involving venomous animals. With the exception of snakebite, the remaining accidents showed a rising temporal trend in most regions of the country. Scorpion stings, snake bites and spider bites were responsible for 86% of accidents, mainly affecting male people of working age. Accidents involving snakes (0.4%) and bees (0.3%) had the highest case fatality ratios. Children were the main victims of accidents involving bees, caterpillars and "others".

Conclusion:

accidents involving venomous animals showed a rising temporal trend for most conditions, as well as different epidemiological profiles.

Keywords:
Snake Bites; Spatio-Temporal Analysis; Scorpions; Spider Bites; Health Information Systems

Study contributionsMain results

With the exception of snake bites, the remaining accidents involving venomous animals had a rising temporal trend in the majority of Brazilian regions. Scorpion stings (51.2%), snake bites (17.4%) and spider bites (17.3%) accounted for 86% of reported accidents

Implications for services

In forthcoming years, health services will note an increase in accidents involving venomous animals, except for snake bites and caterpillar stings in the North, Northeast and South.

Perspectives

Guidance for production and distribution of antivenom sera in the country’s Federative Units, in addition to directing efforts towards given risk groups or locations.

Introduction

Notification of accidents involving venomous animals is compulsory in Brazil, due to the magnitude of morbidity and mortality and their ability to produce temporary or permanent sequelae.11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
Between 2001 and 2019 there were almost 140,000 accidents per year, comprising a public health problem that mainly affects the most vulnerable populations of the country, with snakebite, in particular, being classified by the World Health Organization as a neglected tropical disease.11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...

2. Williams HF, Layfield HJ, Vallance T, Patel K, Bicknell AB, Trim SA, et al. The Urgent Need to Develop Novel Strategies for the Diagnosis and Treatment of Snakebites. Toxins (Basel). 2019;11(6):363p. doi: 10.3390/toxins11060363
https://doi.org/10.3390/toxins11060363...
-33. Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde. Acidente por animais peçonhentos - Notificações registradas no Sistema de Informação de Agravos de Notificação [Internet]. Brasília: Ministério da Saúde; 2022 [citado 2022 Maio 14]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinannet/cnv/animaisbr.def
http://tabnet.datasus.gov.br/cgi/deftoht...

Brazil is of continental size, has tropical and subtropical zones, six types of biomes and several species of poisonous and venomous animals.44. Instituto Brasileiro de Geografia e Estatística. Conheça o Brasil - Território. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; c2022 [citado 2021 Ago 27]. Disponível em: https://educa.ibge.gov.br/jovens/conheca-o-brasil/territorio/20591-introducao.html
https://educa.ibge.gov.br/jovens/conheca...
As such, the epidemiological profile of accidents caused by venomous animals in Brazil varies both in space, between its geographic macro-regions, and also in time. These variations are related not only to type of vegetation, climate or relief, but also to actions of humans, climate change, disorderly urban growth and the elimination of natural predators, among other factors.11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
,55. Ferreira A, Reis VPD, Boeno CN, Evangelista JR, Santana HM, Serrath SN, et al. Increase in the risk of snakebites incidence due to changes in humidity levels: A time series study in four municipalities of the state of Rondonia. Rev Soc Bras Med Trop. 2020;53:e20190377. doi: 10.1590/0037-8682-0377-2019
https://doi.org/10.1590/0037-8682-0377-2...

Temporal trend analyses of accidents involving venomous animals are excellent strategies for analyzing how these phenomena oscillate in nature, allowing us to verify whether their incidence is falling, rising or stationary, in a given place.66. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saude. 2015;24(3):565-76. doi: 10.5123/s1679-49742015000300024
https://doi.org/10.5123/s1679-4974201500...

Although the literature contains several studies analyzing the epidemiological profile of venomous animal accidents in Brazil,11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
,55. Ferreira A, Reis VPD, Boeno CN, Evangelista JR, Santana HM, Serrath SN, et al. Increase in the risk of snakebites incidence due to changes in humidity levels: A time series study in four municipalities of the state of Rondonia. Rev Soc Bras Med Trop. 2020;53:e20190377. doi: 10.1590/0037-8682-0377-2019
https://doi.org/10.1590/0037-8682-0377-2...
,77. Almeida TS, Fook SM, Franca FO, Monteiro TM, Silva EL, Gomes LC, et al. Spatial distribution of scorpions according to the socioeconomic conditions in Campina Grande, State of Paraiba, Brazil. Rev Soc Bras Med Trop. 2016;49(4):477-85. doi: 10.1590/0037-8682-0128-2016
https://doi.org/10.1590/0037-8682-0128-2...
at the time this report was completed, there were no up-to-date studies comparing temporal trends in the Brazilian geographic macro-regions.

Knowledge of the epidemiological profile is necessary both for guiding prevention policies for this type of accident and also for guiding the production and distribution of antivenom sera between the country’s Federative Units, in order to direct efforts towards given risk groups or locations.77. Almeida TS, Fook SM, Franca FO, Monteiro TM, Silva EL, Gomes LC, et al. Spatial distribution of scorpions according to the socioeconomic conditions in Campina Grande, State of Paraiba, Brazil. Rev Soc Bras Med Trop. 2016;49(4):477-85. doi: 10.1590/0037-8682-0128-2016
https://doi.org/10.1590/0037-8682-0128-2...

The objective of this study was to analyze the temporal trend of accidents involving venomous animals in Brazil from 2007 to 2019.

Methods

This was an ecological study, taking the Brazilian geographic macro-regions as its units of analysis. Brazil has approximately 213 million inhabitants and covers an area measuring 8.5 million km2.88. Instituto Brasileiro de Geografia e Estatística. IBGE divulga estimativa da população dos municípios para 2021. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2021 [citado 2021 Ago 27]. Disponível em: https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/31461-ibge-divulga-estimativa-da-populacao-dos-municipios-para-2021
https://agenciadenoticias.ibge.gov.br/ag...
As one of the largest and most populous countries in the world, Brazil has great biodiversity with regard to fauna and flora.44. Instituto Brasileiro de Geografia e Estatística. Conheça o Brasil - Território. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; c2022 [citado 2021 Ago 27]. Disponível em: https://educa.ibge.gov.br/jovens/conheca-o-brasil/territorio/20591-introducao.html
https://educa.ibge.gov.br/jovens/conheca...
The Brazilian Federation is comprised of 27 Federative Units, distributed between five geographic macro-regions: North (7), Northeast (9), Southeast (4), South (3) and Midwest (4). The national territory has five climate zones, defined as Equatorial, Temperate, Tropical - Central Brazil, Tropical - Eastern Northeast and Tropical - Equatorial Zone; and six classes of biomes, namely, Amazon, Atlantic Forest, Cerrado, Caatinga, Pampas and Pantanal.44. Instituto Brasileiro de Geografia e Estatística. Conheça o Brasil - Território. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; c2022 [citado 2021 Ago 27]. Disponível em: https://educa.ibge.gov.br/jovens/conheca-o-brasil/territorio/20591-introducao.html
https://educa.ibge.gov.br/jovens/conheca...

This study was performed on cases of accidents involving venomous animals in Brazil, recorded on the compulsory notification forms of the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN) between 2007 and 2019. The data on these cases were extracted from TABNET, a system available through the Brazilian National Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde - DATASUS), accessed on May 14, 2021.33. Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde. Acidente por animais peçonhentos - Notificações registradas no Sistema de Informação de Agravos de Notificação [Internet]. Brasília: Ministério da Saúde; 2022 [citado 2022 Maio 14]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinannet/cnv/animaisbr.def
http://tabnet.datasus.gov.br/cgi/deftoht...

Using the TABNET platform, the data were filtered according to:

  1. year of notification (2007-2019);

  2. sex (male; female);

  3. age, stratified in age groups (in years: 0-4; 5-9; 10-14; 15-19; 20-39; 40-59; 60-69; 70-79; ≥ 80);

  4. region of residence (North; Northeast; Southeast; South; Midwest); and

  5. type of accident (caused by snakes, spiders, scorpions, caterpillars, bees and other creatures).

The "other" category refers to accidents caused by venomous animals that have less repercussion on people’s health, such as hymenopterans (ants and wasps), coleopterans (beetles), chilopodans (centipedes), diverse types of fish, cnidarians (jellyfish and Portuguese man-of-war); while "unknown" refers to accidents in which the animal that caused them is unknown. The latter category was not included in this study.

In order to calculate the incidence rate, demographic data were extracted from TABNET using filters for sex and age group.99. Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde. População Residente [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2021 Out 07]. Disponível em: https://datasus.saude.gov.br/populacao-residente
https://datasus.saude.gov.br/populacao-r...
The incidence rates were obtained by dividing the number of new cases of each type of accident by the number of people at risk, according to the "sex" and "age group" variables. The ratio obtained was multiplied by 100,000 to arrive at the number of cases per 100,000 inhabitants.

Incidence rate association with sex was analyzed using relative risk (RR) calculations, taking male incidence as the numerator and female incidence as the denominator. The 95% confidence intervals (95%CI) for each RR were also calculated by Brazilian macro-region.

The case fatality ratio was estimated by dividing the number of deaths according to the type of accident reported (filtered from the TABNET system using the "case progression" variable) by the total number of reported accidents of the same type, multiplied by 100.

The Prais-Winsten linear regression method was used in the temporal trend analyses, taking the years evaluated, i.e. 2007 to 2019, as independent variables, when calculating annual percentage change (APC) and respective 95%CI. The venomous animal accident incidence rates were converted to the logarithmic scale (base-10).

Temporal trend was taken to be falling when the 95%CI values were negative; rising when the 95%CI values were positive; and stationary when the 95%CI included the value zero. A 5% significance level was adopted.66. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saude. 2015;24(3):565-76. doi: 10.5123/s1679-49742015000300024
https://doi.org/10.5123/s1679-4974201500...
The analyses were performed using STATA 13.

As this study was based on public domain data about people who are not identified in any way, it did not need to be submitted to a Research Ethics Committee for approval.

Results

A total of 2,102,657 cases of accidents involving venomous animals were reported in Brazil between 2007 and 2019, with an annual average of 175,222. The most frequently occurring accident was scorpion sting (51.2%), followed by snakebite (17.4%) and spider bite (17.3%), accounting for 86% of cases.

Some of these accidents were more frequent in certain regions of the country (Table 1). Scorpion stings were most frequent in the Northeast (68.6/100,000 inhab.), followed by the Southeast (41.2/100,000 inhab.) and the Midwest (26.5/100,000 inhab.), while snake bites predominated in the North (53.1/100,000 inhab.) and Midwest (19.0/100,000 inhab.) regions. The most predominant types of accident in the South were spider bites (61.3/100,000 inhab.), bee stings (9.2/100,000 inhab.) and caterpillar stings (6.3/100,000 inhab.). Accidents categorized as "other" were more frequent in the North (6.6/100,000 inhab.).

Table 1
Distribution of number of cases of accidents involving venomous animals (n), percentage of cases (%), annual mean (mean), number of deaths, case fatality ratio and incidence rate, by type of accident and national macro-region, Brazil, 2007-2019

There was also variation in the case fatality ratio. It was higher for snakebite accidents (0.40%) and bee sting accidents (0.29%), in the Midwest and North regions, respectively (Table 1).

Risk magnitude differed in space and time, as shown in Figure 1, in which it is evident, that in some regions the time series lines did not cross each other, e.g. scorpion stings in the Northeast, snake bites in the North, and spider bites and caterpillar stings in the South.

Figure 1
Time series of the incidence rate of accidents involving venomous animals (cases/100,000 inhab.), per national macro-region, Brazil, 2007-2019

Of all the accident types observed, snake bites only had a falling temporal trend in the South; while in the remaining regions the trend was stationary. Caterpillar stings had a stationary trend in the North, Southeast and South. The remaining venomous animal accidents - including those classified as "other" - had a rising temporal trend (Table 2).

Table 2
Temporal trend of incidence of accidents involving venomous animals, by type of accident and national macro-region, Brazil, 2007-2019

Scorpion stings, snake bites and spider bites occurred mostly among individuals of working age. The behavior of caterpillar stings was the opposite, with greater incidence among young and elderly people. On the other hand, risk of bee stings and "other" accidents was greater as age decreased, occurring more among young people and less among the elderly; the exception was the Northern region, where risk was higher among individuals of working age (Figure 2).

Figure 2
Incidence rate of accidents involving venomous animals (cases/100,000 inhab.), by age group and national macro-region, Brazil, 2007-2019

In the study period, we found higher incidence of all types of accidents with venomous animals among males, especially snake bites, the risk of which among males in Brazil as a whole was 3.47 times higher than among females (Table 3). In the Northeast, being male proved to be a protective factor against scorpion stings (RR = 0.8).

Table 3
Incidence of accidents involving venomous animals, by sex, relative risk and 95% confidence interval, according to type of accident and national macro-region, Brazil, 2007-2019

Discussion

Scorpion stings had the highest incidence among accidents caused by venomous animals in Brazil, in the period studied;11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
and had a rising trend in the number of cases in all the country’s macro-regions.

Tityus serrulatus, also known as the Yellow Scorpion, is the species most commonly associated with this type of accident1010. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Manual de controle de escorpiões 2009. Série B. Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2009. [citado 2021 out 07]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_controle_escorpioes.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
and its spatial distribution has increased in all Brazilian regions, given its ease of adaptability to urban environments and rapid proliferation: T. serrulatus reproduces without needing to mate, adapts to different temperature zones and survives long periods without food or water.1111. Pimenta RJG, Brandao-Dias PFP, Leal HG, Carmo AOD, Oliveira-Mendes BBR, Chavez-Olortegui C, et al. Selected to survive and kill: Tityus serrulatus, the Brazilian yellow scorpion. PLoS One. 2019;14(4):e0214075. doi: 10.1371/journal.pone.0214075
https://doi.org/10.1371/journal.pone.021...
Attempts to control this scorpion species in Brazil have not been significantly successful.1111. Pimenta RJG, Brandao-Dias PFP, Leal HG, Carmo AOD, Oliveira-Mendes BBR, Chavez-Olortegui C, et al. Selected to survive and kill: Tityus serrulatus, the Brazilian yellow scorpion. PLoS One. 2019;14(4):e0214075. doi: 10.1371/journal.pone.0214075
https://doi.org/10.1371/journal.pone.021...

The Northeast region stood out as having the highest incidence of scorpion stings, and its victims were mostly female.1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
This finding of our study is probably due to occupational and behavioral factors that can be found in the domestic environment, where females are more exposed.1313. Barros RM, Pasquino JA, Peixoto LR, Targino IT, Sousa JA, Leite RS, et al. Clinical and epidemiological aspects of scorpion stings in the northeast region of Brazil. Cien Saude Colet. 2014;19(4):1275-82. doi: 10.1590/1413-81232014194.01602013
https://doi.org/10.1590/1413-81232014194...

Scorpion stings occurred mostly among older individuals still of working age, demonstrating possible association of the home environment as a risk site for scorpion stings. Most of the victims of this type of accident were identified by another study as students, housewives, and retirees/pensioners.1414. Taniele-Silva J, Martins LG, Sousa MB, Souza LM, Cardoso RMB, Velasco SRU, et al. Retrospective clinical and epidemiological analysis of scorpionism at a referral hospital for the treatment of accidents by venomous animals in Alagoas State, Northeast Brazil, 2007-2017. Rev Inst Med Trop Sao Paulo. 2020;62:e26. doi: 10.1590/s1678-9946202062026
https://doi.org/10.1590/s1678-9946202062...

A study conducted in the state of Paraíba found no association between the socioeconomic factors analyzed and the geographic location of scorpion stinging; however, it is expected that higher rates of scorpion stinging will be found where housing conditions are poorer.77. Almeida TS, Fook SM, Franca FO, Monteiro TM, Silva EL, Gomes LC, et al. Spatial distribution of scorpions according to the socioeconomic conditions in Campina Grande, State of Paraiba, Brazil. Rev Soc Bras Med Trop. 2016;49(4):477-85. doi: 10.1590/0037-8682-0128-2016
https://doi.org/10.1590/0037-8682-0128-2...

The scorpion sting case fatality ratio in Brazil was 0.09% in the period studied, this being lower than that reported in other research, which found a 0.13% case fatality ratio in Brazil between 2009 and 2013.1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
Although scorpion stings are frequent and generally only result in local clinical presentations, this is not the case regarding systemic manifestations, for which 5% of reported cases are severe and of these, 0.3% are fatal.1515. Godoy DA, Badenes R, Seifi S, Salehi S, Seifi A. Neurological and Systemic Manifestations of Severe Scorpion Envenomation. Cureus. 2021;13(4):e14715. doi: 10.7759/cureus.14715
https://doi.org/10.7759/cureus.14715...
The Northern region had a higher presented case fatality ratio for scorpion stings (0.17%), in relation to the other regions of the country. The fatal cases were found in the Amazon region, mainly following Tityus metuendus and Tityus obscurus stings.1616. Queiroz AM, Sampaio VS, Mendonca I, Fé NF, Sachett J, Ferreira LC, et al. Severity of Scorpion Stings in the Western Brazilian Amazon: A Case-Control Study. PLoS One. 2015;10(6):e0128819. doi: 10.1371/journal.pone.0128819
https://doi.org/10.1371/journal.pone.012...

Regarding snake bites, the highest frequency of these accidents in the period studied was reported in the Northern region, thus corroborating the results of other studies.1717. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de Vigilância em Saúde. [Internet]. Brasília: Ministério da Saúde; 2019. [citado 2021 out 07]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
,1818. Feitosa ES, Sampaio V, Sachett J, Castro DB, Noronha M, Lozano JL, et al. Snakebites as a largely neglected problem in the Brazilian Amazon: highlights of the epidemiological trends in the State of Amazonas. Rev Soc Bras Med Trop. 2015;48 (Suppl 1):34-41. doi: 10.1590/0037-8682-0105-2013
https://doi.org/10.1590/0037-8682-0105-2...
It is also noteworthy that the number of cases may be higher than found in this study, due to underreporting in the region, especially in relation to cases occurring in remote places.1818. Feitosa ES, Sampaio V, Sachett J, Castro DB, Noronha M, Lozano JL, et al. Snakebites as a largely neglected problem in the Brazilian Amazon: highlights of the epidemiological trends in the State of Amazonas. Rev Soc Bras Med Trop. 2015;48 (Suppl 1):34-41. doi: 10.1590/0037-8682-0105-2013
https://doi.org/10.1590/0037-8682-0105-2...

Regarding the profile of snakebite victims in Brazil, our study showed that most of the victims were male and of working age. This suggests occupational risk.1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
,1717. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de Vigilância em Saúde. [Internet]. Brasília: Ministério da Saúde; 2019. [citado 2021 out 07]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
Similar results were reported by another study, according to which males and rural workers are the most affected.1919. Moreno E, Queiroz-Andrade M, Lira-da-Silva RM, Tavares-Neto J. Características clínicoepidemiológicas dos acidentes ofídicos em Rio Branco, Acre. Rev Soc Bras Med Trop. 2005;38(1):15-21. doi: 10.1590/s0037-86822005000100004
https://doi.org/10.1590/s0037-8682200500...
Snakebite has also been described as an environmental risk accident for traditional population groups living in communities far from urban centers, such as nomads, indigenous people, hunters and gatherers.2020. Gutierrez JM, Calvete JJ, Habib AG, Harrison RA, Williams DJ, Warrell DA, et al. Snakebite envenoming. Nat Rev Dis Primers. 2017;3:17063. doi: 10.1038/nrdp.2017.63
https://doi.org/10.1038/nrdp.2017.63...
Still with regard to snake bites, they had a stationary temporal trend in almost all regions of the country; the only falling trend occurred in the Southern region.

Snake bites had the highest case fatality ratio among all accidents involving venomous animals in Brazil, with the Midwest and Northern regions standing out, this being where the Pantanal and Amazon biomes are located, respectively. These results were similar to those found by another study that analyzed venomous animal accidents in Brazil from 2007 to 2013.1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
Several factors may be related to the snakebite case fatality ratio, such as the time elapsed between the accident and receiving health care, as well as difficulty in accessing a health service. In addition, other studies found that some victims or their legal guardians chose inadequate treatment measures, capable of making the case worse before getting to a health service, such as the use of homemade infusions, incision and/or application of substances at the site of the bite, tourniquet procedure, seeking help from a witch doctor, among others.1919. Moreno E, Queiroz-Andrade M, Lira-da-Silva RM, Tavares-Neto J. Características clínicoepidemiológicas dos acidentes ofídicos em Rio Branco, Acre. Rev Soc Bras Med Trop. 2005;38(1):15-21. doi: 10.1590/s0037-86822005000100004
https://doi.org/10.1590/s0037-8682200500...
,2121. Silva AM, Colombini M, Moura-da-Silva AM, Souza RM, Monteiro WM, Bernarde PS, et al. Ethno-knowledge and attitudes regarding snakebites in the Alto Jurua region, Western Brazilian Amazonia. Toxicon. 2019;171:66-77. doi: 10.1016/j.toxicon.2019.10.238
https://doi.org/10.1016/j.toxicon.2019.1...

Worldwide, snakebite affects about 2.7 million people, between 80,000 and 140,000 of whom die, mostly in India (50,000), followed by Pakistan (8,000) and Bangladesh (6,000). In the Americas, however, snakebite deaths are estimated in hundreds rather than thousands; in Brazil, there are 119 deaths per year.22. Williams HF, Layfield HJ, Vallance T, Patel K, Bicknell AB, Trim SA, et al. The Urgent Need to Develop Novel Strategies for the Diagnosis and Treatment of Snakebites. Toxins (Basel). 2019;11(6):363p. doi: 10.3390/toxins11060363
https://doi.org/10.3390/toxins11060363...
,1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
Some 87% of snakebite accidents in Brazil are related to vipers of the Bothrops genus.2222. Matos RR, Ignotti E. Incidence of venomous snakebite accidents by snake species in Brazilian biomes. Cien Saude Colet. 2020;25(7):2837-46. doi: 10.1590/1413-81232020257.31462018.
https://doi.org/10.1590/1413-81232020257...

Spider bites had a rising temporal trend in the five Brazilian national macro-regions and accounted for 17.3% of notifications, with the Southern region standing out. Another study indicates that spider bite incidence in the South is ten times higher than in the other regions of Brazil:11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
in Southern Brazil, the probability of spider bite does not appear to differ between sexes. This fact may possibly be related to its more frequent occurrence in urban areas and in households;1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...
spider bite in Southern Brazil mainly affects people of working age, while in the other regions of the country slightly higher relative risk is found for males.

The spider bite case fatality ratio in Brazil as a whole was 0.05%, with the Northeast (0.28%) and Midwest (0.22%) regions standing out as accounting for the highest rates during the 13 years analyzed.11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
,1212. Silva AMD, Bernarde PS, Abreu LC. Accidents with Poisonous Animals in Brazil by Age and Sex. Rev Bras Crescimento Desenvolv Hum. 2015;25(1). doi: 10.7322/jhgd.96768
https://doi.org/10.7322/jhgd.96768...

The Northeast and South had the highest bee sting incidence rates; it should also be noted that all Brazilian regions showed a rising temporal trend. This problem has been recorded in the Brazil since 1956, after the accidental release of Africanized bees that spread throughout the Americas and became a public health problem in the countries where they formed colonies.2323. Pucca MB, Cerni FA, Oliveira IS, Jenkins TP, Argemi L, Sorensen CV, et al. Bee Updated: Current Knowledge on Bee Venom and Bee Envenoming Therapy. Front Immunol. 2019;(10):2090. doi: 10.3389/fimmu.2019.02090
https://doi.org/10.3389/fimmu.2019.02090...
Africanized honey bees are significantly more defensive than other bees, attack with little provocation, attack in greater numbers, pursue their victim for longer periods, and apparently release greater amounts of venom.2323. Pucca MB, Cerni FA, Oliveira IS, Jenkins TP, Argemi L, Sorensen CV, et al. Bee Updated: Current Knowledge on Bee Venom and Bee Envenoming Therapy. Front Immunol. 2019;(10):2090. doi: 10.3389/fimmu.2019.02090
https://doi.org/10.3389/fimmu.2019.02090...

Individuals aged 0 to 9 years old and males were the most affected by bee stinging. In all regions of the country, the data suggest no causality between this type of accident and the economically active population. A study carried out in a city in Northeast Brazil indicated that most bee sting cases occurred in urban areas and were unrelated to work.2424. Linard ATS, Barros RM, Sousa JA, Leite RS. Epidemiology of bee stings in Campina Grande, Paraíba state, Northeastern Brazil. J Venom Anim Toxins incl Tropl Dis. 2014;20:1-6. doi: doi:10.1186/1678-9199-20-13
https://doi.org/doi:10.1186/1678-9199-20...

The bee sting case fatality ratio in Brazil as a whole was 0.29%, with higher ratios being found in the Midwest (0.41%) and Northern (0.35%) regions in the period studied. A study covering the period from 2001 to 2012 found case fatality ratios ranging from 0.3% to 0.4% in all regions, pointing to the severity of outcomes associated with the large amount of venom injected as a result of multiple stings. This can result in anaphylactic reaction.11. Chippaux JP. 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):ecollection2015. doi: 10.1186/s40409-015-0011-1
https://doi.org/10.1186/s40409-015-0011-...
Another study found that bee stings increased by more than 200% in the ten years between 2009 and 2019, with case fatality being higher in older people and people living in the Northeast region.2525. Kono IS, Freire RL, Caldart ET, Rodrigues FS, Santos JA, Freire LGD, et al. Bee stings in Brazil: Epidemiological aspects in humans. Toxicon. 2021;201:59-65. doi: 10.1016/j.toxicon.2021.08.014
https://doi.org/10.1016/j.toxicon.2021.0...

Bee stings are expected to be less fatal than snake bites or scorpion stings. However, the bee sting case fatality ratios found in this study indicate similar or even higher values than the snakebite and scorpion sting case fatality ratios in several Brazilian regions. One possible hypothesis for this evidence is the higher frequency of notification of the most severe bee stings (involving multiple stings and allergic individuals), as well as underreporting of mild cases in which the victim does not seek medical care, thus directly affecting the case fatality ratio calculation.

Caterpillar stings showed a stationary temporal trend in the North, Southeast and Southern regions, and a rising trend in the Midwest and Northeast regions. According to other studies, in the future, caterpillar stings will have greater incidence and broader geographic distribution, given (i) global warming, (ii) destruction of their natural habitat, forcing caterpillars to live in other areas, especially in trees located in urban surroundings, and (iii) the killing of natural predators due to extensive pesticide use.2626. Seldeslachts A, Peigneur S, Tytgat J. Caterpillar Venom: A Health Hazard of the 21st Century. Biomedicines. 2020;8(6):143. doi: 10.3390/biomedicines8060143
https://doi.org/10.3390/biomedicines8060...

Caterpillar stings had the lowest incidence in relation to the other accidents involving venomous animals analyzed in this study. However, although underreported, this is perhaps the most common accident involving venomous animals, especially in tropical climates, not only through direct contact but also through indirect contact (airborne), and can result in diversified clinical pictures.2626. Seldeslachts A, Peigneur S, Tytgat J. Caterpillar Venom: A Health Hazard of the 21st Century. Biomedicines. 2020;8(6):143. doi: 10.3390/biomedicines8060143
https://doi.org/10.3390/biomedicines8060...

The Southern region accounted for the highest caterpillar sting incidence rates. This result has also been found in other studies. It is possible that changes caused by humans to land use have led to the decrease of tree hosts and have consequently led to the need for their adaptation and migration to new host environments, such as orchards close to urban areas.2727. Azevedo TSD. Distribuição biogeográfica da ocorrência de acidentes provocados por lagartas do gênero lonomia, no Brasil, no período de 2000 a 2007. Hygeia. 2011;[citado 2022 Set 19];7:13. Disponível em: https://seer.ufu.br/index.php/hygeia/article/view/17041
https://seer.ufu.br/index.php/hygeia/art...

There was little difference in caterpillar sting incidence between the sexes. In effect, incidence was higher among children, regardless of the region of the country, and a possible explanation for this result could be the fact that the younger age groups are more exposed, driven by curiosity to catch or touch caterpillars. Among adults, it is possible that these accidents are related to occupations that result in contact or proximity to plants and take place outdoors.2828. Bragg BSG, Bradley N. Caterpillar and Moth Bites. Treasure Island: Caterpillar and Moth Bites; StatPearls Publishing; 2022 [cited 2021 Aug 3]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539851/
https://www.ncbi.nlm.nih.gov/books/NBK53...

Accidents recorded as "other" on the SINAN system, caused by hymenopterans, coleopterans, chilopodans, cnidarians, diverse types of fish and other creatures, had a rising temporal trend in all the regions of the country, but accounted for less than 5% of reported cases. In the North, their highest incidence related to male, suggesting occupational accidents; in the other regions, there was little distinction between the sexes; children under 5 years of age were the most affected, probably because they are more defenseless in relation to ants, wasps, beetles and centipedes, among others. It is assumed that cases classified as "other" occur in the home environment. Incidentally, the scarcity of studies dedicated to interpreting this type of data is noteworthy.

Based on the results of this study’s temporal analysis, an annual increase in all accidents caused by venomous animals, to be cared for in health services, is projected for the coming years. The exceptions to this forecast are snakebite; and caterpillar stinging in the North, Northeast and Southern regions of the country.

In order to mitigate this type of health problem, whether in urban or rural environments,taking into account that many accidents result from occupational risk and are therefore preventable, it is recommended that special attention be paid to the use of personal protective equipment (PPE) in certain work activities. In order to reduce household accidents, fumigation of domestic environments, constant cleaning of households and elimination of possible venomous animal hiding places are recommended.1717. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Guia de Vigilância em Saúde. [Internet]. Brasília: Ministério da Saúde; 2019. [citado 2021 out 07]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

Research with smaller-scale geographic units, such as states and municipalities, is also recommended, since it may demonstrate patterns different from those found at the macro-regional level.

We conclude that there was a rising temporal trend for most accidents with venomous animals during the study period. The spatial distribution of these accidents occurred heterogeneously and showed distinct epidemiological patterns

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    Linard ATS, Barros RM, Sousa JA, Leite RS. Epidemiology of bee stings in Campina Grande, Paraíba state, Northeastern Brazil. J Venom Anim Toxins incl Tropl Dis. 2014;20:1-6. doi: doi:10.1186/1678-9199-20-13
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    » https://doi.org/10.1016/j.toxicon.2021.08.014
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    » https://doi.org/10.3390/biomedicines8060143
  • 27
    Azevedo TSD. Distribuição biogeográfica da ocorrência de acidentes provocados por lagartas do gênero lonomia, no Brasil, no período de 2000 a 2007. Hygeia. 2011;[citado 2022 Set 19];7:13. Disponível em: https://seer.ufu.br/index.php/hygeia/article/view/17041
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    » https://www.ncbi.nlm.nih.gov/books/NBK539851

  • Associate academic work

    Master’s Degree dissertation entitled Spatial and temporal distribution of accidents involving venomous animals in Brazil, 2007-2019, defended by Tiago Cruz de Souza at the Universidade Federal do Acre Postgraduate Program on Health Sciences in the Western Amazon, on August 31, 2021.

Publication Dates

  • Publication in this collection
    04 Nov 2022
  • Date of issue
    2022

History

  • Received
    09 Feb 2022
  • Accepted
    09 Sept 2022
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com