J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 193 http://jad.tums.ac.ir Published Online: June 30, 2020 Original Article Epidemiological Characteristics of Scorpionism in West Azerbaijan Province, Northwest of Iran Samira Firooziyan 1,2 ; Ali Sadaghianifar 2 ; Javad Rafinejad 1 ; Hassan Vatandoost 1,3 ; *Mulood Mohammadi Bavani 4 1 Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2 Urmia Health Center, Disease Control Unit, Urmia University of Medical Sciences, Urmia, Iran 3Department of Chemical Pollutants and pesticides, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran 4 Department of Medical Entomology and Vector Control, School of Public Health, Urmia University of Medical Sciences, Urmia, Iran (Received 26 Oct 2019; accepted 22 May 2020) Abstract Background: There are four medically important scorpion species (Mesobuthus eupeus, Mesobuthus caucasicus, An- droctonus crassicauda and Hottentotta saulcyi) in the West Azerbaijan Province, northwestern Iran. scorpionism is con- sidered as a health problem in this region, because there is no information about scorpion envenomation, this study was designed to study epidemiological characteristics of scorpionism to optimize prevention and treatment of scorpion sting in northwest of Iran. Methods: All the data from epidemiological surveys completed in West Azerbaijan hospitals over four years (2014– 2017) for scorpion victims were collected. This information includes the number of victims, sex, age, signs and symp - toms, site of sting, body parts of victims, history of previous sting, the condition of the patient in terms of recovery and death, and the time to receive anti venom, all data were analyzed by the Excel software. Results: A total of 2718 cases of scorpionism were reported from March 2014 to March 2017 in the study area. The most cases occur in both sexes in the age groups of 25 to 34 years old. In urban areas 40.3% of people and in rural areas 59.7% of them have suffered. The Poldasht and Chaldoran cities, had the most and least incidence respectively. Conclusion: In this study, the high risk areas in the case of scorpion stings were identified. Results of this study can be used to design preventive programs to educate more people about dangerous areas to prevent scorpion sting and even death. Keywords: Scorpion; Scorpionism; West azerbaijan Introduction So far 64 species of scorpions have been re- ported from Iran belonging to Buthidae (86%), Hemiscorpiidae (9.5%), and Scorpionidae fam- ilies (4.5%) (1). Scorpions are venomous animals that can sting people and cause public health problems and sometimes can be fatal (2). The medical- ly important scorpion species in Iran belong to two families of Buthidae and Hemiscorpiidae (2). From the Buthidae family the species of Mesobuthus eupeus, Mesobuthus phillipsii, Mes- obuthus caucasicus, Odontobuthus doriae, Odontobuthus bidentatus, Orthochirus iranus, Buthacus macrocentrus, Apistobuthus susanae, Compsobuthus matthiesseni, Hottentotta saul- cyi, Hottentotta zagrosensis and Hottentotta jayakari are the most medically relevant scor- pion in Iran (2-8). From Hemiscorpiidae the Hemiscorpius lepturus and Hemiscorpius acan- thocercus species are considered as dangerous and deadly scorpion in Iran (7, 9). Buthidae is the largest family in Iran (2). Most medically important scorpion species have been reported from south and south western provinces of *Corresponding author: Dr Mulood Mohammadi- Bavani, E-mail: mulud.muhammady@yahoo.com J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 194 http://jad.tums.ac.ir Published Online: June 30, 2020 Iran, among which Khuzestan is regarded as high risk area (2, 10). Buthidae species have mostly neurotoxic effect, but Hemiscorpiidae such as H. lepturus (local name: Gadim), causes cell death with hemolytic effect cause more death in the coun- try (11-13). In Iran for scorpion sting treatment poly- valent antivenom is used. This antivenom is prepared by Razi institute against six medi- cally relevant scorpion species: M. eupeus, A. crassicauda, O. doriae, H. saulcyi, H. zagro- sensis and H. lepturus (2, 3). There are four medically important scorpion species: M. eupeus, M. caucasicus, A. crassi- cauda and H. saulcyi: in West Azerbaijan Prov- ince, northwestern Iran, among which M. eupeus is the most prevalence and Androctonus crassi- cauda is the deadliest (3, 14). The people most affected by scorpion stings usually live in poor communities where med- ical resources are often sparse. Scorpion sting is a common health problem all over the world, including Iran. Nearly 50000 cases of scorpi- on stings have been reported annually from Iran (3, 15). Some studies on scorpionism in Iran shows: the most cases of scorpion stings occurred in rural area in summer season (16- 20). The age groups of 10–24 and 25–44 years old are more at risk (17, 20-22). Foot and hand are more frequent bitten by scorpions (16, 20, 22-25). Scorpion venoms, which are especially le- thal in young children, release autonomic nerv- ous system mediators causing myocardial dam- age, cardiac arrhythmias, pulmonary edema, shock, paralysis, muscle spasms and pancrea- titis (26). Early administration of anti-venom is highly effective, together with intensive care support in severe cases. However, the rapid tissue distribution of scorpion venom toxins and their ability to cause early death especial- ly in young children, demands early treatment with anti-venom and full cardio-respiratory support (27). The true incidence of scorpion sting enven- oming is not known because many cases do not seek medical attention. However, it has been estimated that there are approximately 1 mil- lion stings per year in the world. In Northern Africa, the Middle East (notably Iran), India and Latin America scorpion stings are an emer- gent health problem, due to the adaptation of some scorpion species to the urban environ- ment (15). Since over the past 4 years, deaths from scorpion sting have been reported from West Azerbaijan province and Scorpion sting is a public health problem in this region of Iran. There is no information about epidemiologi- cal characteristics of scorpionism in this area. Therefore, this study was designed to describe epidemiological characteristics of scorpion en- venomation in West Azerbaijan Province, north- west of Iran to optimize prevention and treat- ment through community awareness. Materials and Methods Study area West Azerbaijan Province is located in the northwest of Iran (Fig. 1), bordering Turkey, Iraq and Azerbaijan's Nakhchivan Autonomous Republic, as well as the provinces of East Azer- baijan, Zanjan and Kurdistan. It is separated from Armenia by Turkey's short border with the Azerbaijan Republic. This province covers an area of 39,487km², or 43,660 km² including Lake Urmia, between 37.5528° N and 45.0759° E. In 2012 the province had a population of about 3 million (estimate). The capital and larg- est city of the province is Urmia. The people of this province are active in agriculture and animal husbandry. For this reason, the province has been selected to examine the status of scor- pion sting and important medical species. Data collection The data from epidemiological surveys com- pleted in West Azerbaijan hospitals over four years for scorpion victims were collected. This information includes the number of victims, sex, age, signs and symptoms, body parts of victims, time of sting, history of previous sting, https://en.wikipedia.org/wiki/Azerbaijan_(Iran) https://en.wikipedia.org/wiki/Turkey https://en.wikipedia.org/wiki/Iraq https://en.wikipedia.org/wiki/Azerbaijan https://en.wikipedia.org/wiki/Nakhchivan_Autonomous_Republic https://en.wikipedia.org/wiki/Nakhchivan_Autonomous_Republic https://en.wikipedia.org/wiki/East_Azerbaijan_Province https://en.wikipedia.org/wiki/East_Azerbaijan_Province https://en.wikipedia.org/wiki/Zanjan_Province https://en.wikipedia.org/wiki/Kurdistan_Province https://en.wikipedia.org/wiki/Armenia https://en.wikipedia.org/wiki/Azerbaijan_Republic https://en.wikipedia.org/wiki/Lake_Urmia https://en.wikipedia.org/wiki/Urmia J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 195 http://jad.tums.ac.ir Published Online: June 30, 2020 the condition of the patient in terms of recov- ery and death and the time to receive anti ven- om. The above information was analyzed by the Excel software. A spatial distribution map of scorpionism was introduced using GIS 4.2. Results From March 2014 to March 2017, a total of 2718 cases of scorpion sting from West Azer- baijan Province were recorded. The largest num- ber (821 cases) was in 2014 and the lowest (548 cases) in 2015 (Fig. 2). Many scorpion stings occurred during the hot months of May to September with a peak in August (Fig. 2). In these four years, 53.6% of cases oc- curred in men and 46.4% in women. In males, the most cases were in the age group of 25 to 34 years old and the least cases were in the age group of 5 to 9 years old (Table 1), while in the females, the highest number of victims was in the age group of 25 to 34 years, and the smallest in the age group of 0–4 years old (Table 2). Therefore, the most cases of scor- pion sting in both sexes were in the age group of 25 to 34 years old. 40.3% of stung people in urban areas and 59.7% in rural areas were reported. Among 2718 patients, in 80 cases (2.9%) the head and neck, in 1364 cases (50.2%) the hands, in 1069 cases (39.3%) the leg and in 205 cases the trunk were bitten (Table 3). In this study, the most cases of scorpion stings including 1263 cases (46%) occurred: at 00:00 to 6:00AM and the lowest cases in- cluding 456 cases (16.8%) occurred at 12:00 AM to 6:00PM (Table 4). 8 percent of the cases (n= 217) had previous history of sting and 2.2% (n= 61) had used previous scorpion anti venom in the past four years. The time of treatment between sting and anti-venom injection in 70.3% of patients were less than 6 hours, in 8% of patients were 6 to 12 hours, in 6.4% of patients lasted more than 12 hours and 15.3% of patients did not re- ceive anti venom (Table 5). The percentage of recovered cases were 99.93% and the deaths due to scorpion sting were 0.07% (2 out of 2718 cases), of which two deaths were observed in the last two years (one case in 2016 and an- other in 2017). The average incidence of scor- pionism per 1000 people was calculated and Poldasht and Chaldoran counties had the most and least incidence (Table 6, Fig. 3). Table 1. Stung persons classified by age group (males) Total >65 55–64 45–54 35–44 25–34 15–24 10–14 5–9 0–4 Years 305 313 262 380 1260 100 19 12 15 20 66 5.2 28 20 13 26 87 6.9 41 42 46 56 185 14.7 57 55 46 66 224 17.8 68 76 61 93 298 23.6 56 61 48 83 248 19.7 17 20 13 16 66 5.2 6 19 8 13 46 3.7 13 8 12 7 40 3.2 2017 2016 2015 2014 Total % Table 2. Stung persons classified by age group (females) Total >65 55–64 45–54 35–44 25–34 15–24 10–14 5–9 0–4 Years 356 375 286 441 1458 100 18 17 15 22 72 4.9 20 22 10 22 74 5.1 34 41 44 45 164 11.2 66 58 47 90 261 17.9 82 96 77 111 366 25.1 77 82 54 103 316 21.7 20 27 14 18 79 5.4 15 19 12 11 57 4 24 13 13 19 69 4.7 2017 2016 2015 2014 Totally % J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 196 http://jad.tums.ac.ir Published Online: June 30, 2020 Table 3. Stung persons according to body part Total Trunk Leg Hand Head and neck Years 661 688 548 821 2718 100 56 43 47 59 205 7.5 258 286 228 297 1069 39.3 330 344 254 436 1364 50.2 17 15 19 29 80 3 2017 2016 2015 2014 Total % Table 4. Time of scorpion stings in stung persons Total 18–24 12–18 6–12 0–6 Years 661 688 548 821 2718 100 142 152 123 83 500 18.4 163 122 106 65 456 16.8 153 166 115 65 499 18.3 203 248 204 608 1263 46.5 2017 2016 2015 2014 Totally % Table 5. Time of anti-venom injection after sting Total >12 6–12 <6 Without Years 661 688 548 821 2718 100 61 44 34 36 175 6.4 48 65 31 74 218 8.0 480 501 338 591 1910 70.3 72 78 145 120 415 15.3 2017 2016 2015 2014 totally % Table 6. The average incidence of scorpionism per 1000 people in different areas Years 2017 2016 2015 2014 Totally % per1000 Naghadeh 16 17 14 44 91 3.35 0.71 Miandoab 3 10 12 36 61 2.24 0.22 Mahabad 43 47 31 46 167 6.14 0.71 Maku 38 63 33 73 207 7.62 2.18 Shoot 50 8 0 7 65 2.39 1.17 Shahin dej 21 26 29 44 1120 4.42 1.30 Salmas 48 103 91 66 308 11.33 1.57 Sardasht 64 35 27 54 180 6.62 1.51 Khoy 15 28 11 22 76 2.80 0.22 Chaldoran 1 0 5 0 6 0.22 0.13 Chaipareh 6 1 8 3 18 0.66 0.40 Takab 51 48 14 58 171 6.29 2.12 Piranshahr 7 18 5 3 33 1.21 0.24 Poldasht 74 107 92 46 319 11.74 7.56 Bukan 21 19 23 38 101 3.72 0.40 Oshnavieh 23 4 4 10 41 1.51 0.55 Urmia 180 154 149 271 754 27.74 0.72 Total 661 688 548 821 2718 100 0.83 J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 197 http://jad.tums.ac.ir Published Online: June 30, 2020 Fig. 1. The status of study area, West Azerbaijan Province in Iran 0 50 100 150 200 250 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 2015 2016 2017 Fig. 2. Monthly scorpion sting cases, West Azerbaijan, northwest of Iran, 2014–2017 (X: Month, Y: Scorpion sting cases) J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 198 http://jad.tums.ac.ir Published Online: June 30, 2020 Fig. 3. Spatial distribution of incidence of scorpion sting from West Azerbaijan of Iran, 2014–2017 Discussion Scorpion stings are considered as one of the most medically important problem in Iran. There are 64 species of scorpions belonging to tree families (Buthidae, Hemiscorpiidae and Scorpionidae) in Iran (1). Four medically important species of scor- pions including: M. eupeus, M. caucasicus, A. crassicauda and H. saulcyi have been re- ported from West Azerbaijan Province and cause public health problems in this region. M. eupeus has been captured in the most parts of northwest corner of Iran (3). Scorpionism is a common health prob- lem all over the world, yet neglected. The true incidence of scorpion sting envenoming is not known because many cases do not seek medical attention. However, it has been esti- mated that there are approximately 1 million stings per year. In Mexico, Tunisia, Brazil and Khuzestan, south-west Iran, 250000, 40000, 37000 and 25000 stings were reported in 2005 (15). About 37535 scorpion stings were registered in 2009 and in comparison with cases of 2002, we observed notably in- creasing on incidence of scorpion sting in Iran (6, 18). Although scorpion sting is a public health problem in the West Azerbaijan Prov- ince but there is a big gap of information on scorpionism in this region. Our results showed that over four last years (2014–2017), a total of 2718 cases of scorpi- on stings have been recorded from West Azer- baijan. In this region, the age group of 25 to 39 is more at risk and the health system in community education should address this age group, while some studies have suggested that most of the victims of scorpionism are young- er than 25 years old (18, 19, 28). Results of some studies like our results shows that the age of the most of stung per- sons are more than 25 years old (17, 21, 22). This age group is more active in farming, ranching and gardening. Because of their great- er activity, they are more likely to be contacted by scorpions. The health system in community education should address this age group. Our results showed that 53.6% of cases occurred in men and 46.4% in women that scorpion sting among males sex were 7.2% more than in females. According to reports from the World Health Organization and some studies, the same result was reported (15, 29, 30). While in some other studies unlike our results scorpion stings in females were more than in males (22, 31, 32). However, in West Azerbaijan Province, because men are more active than women and most of the farming and gardening work is done by men so they are more at risk in the case of scorpion stings, therefore men should be given more training in order to prevent fur- ther scorpion sting. In this study, similar to some other stud- ies, hand, leg, trunk, head and neck, respec- tively, are more likely to be stung by scor- J Arthropod-Borne Dis, June 2020, 14(2): 193–201 S Firooziyan et al.: Epidemiological Characteristics of … 199 http://jad.tums.ac.ir Published Online: June 30, 2020 pions (18, 29, 33-36). Like our results in some studies foot and hand have been more fre- quent bitten by scorpions (16, 20, 22-25). This may be because most people do not take pro- tective measures like using gloves and boots while working in the fields and gardens. There- fore, these organs are easily exposed to scor- pion sting. We have to educate people to care- fully examine shoes before wearing them and to use gloves and safety shoes when work- ing in an open environment and do not move stones for no reason. In this study, about 15.3% of the victims didn’t receive antivenin. As most cases oc- cur in the village (60%), the villagers should be informed that antivenin is available in hos- pitals and health centers. because more sting occur per day, they can easily get antivenin from the health center for free. Our results showed that many scorpion stings occurred during the hot months of May to September with a peak in August. The re- sults of some studies on scorpion enven- omation in Iran, in this case are similar to our results that the peak of scorpion stings occurs in hot month of the year (16-20). This can be for two reasons: In the hot months of the year the scorpions are more active and also peo- ple's activities such as agriculture, gardening and other activities are increasing. These makes people more likely to encounter scorpions and bitten by them. In our study 99.93% of stung people were recovered and 0.07% of them died. Because the species M. eupeus has a wide distribution in this area (3). Likely this species caused the most scorpion stings in this region. Androcto- nus crassicauda is regarded as a deadly scor- pion in Iran (2), and this species has been re- ported from this area (3). This black species is probably responsible for the death from the scorpion sting in this corner of Iran. Conclusion In this study, the high risk areas of the province were identified as scorpion sting by using spatial distribution. The results of this study can be used to design preventive pro- grams, to educate more people about the im- portant areas of the province's area at the risk of scorpion sting, and the prevention of scorpion sting and even death. 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