J Arthropod-Borne Dis, June 2013, 7(1): 66–70 S Rafizadeh et al.: Epidemiology of… http://jad.tums.ac.ir Published Online: April 10, 2013 Original Article Epidemiology of Scorpionism in Iran during 2009 Sina Rafizadeh 1, Javad Rafinejad 2, *Yavar Rassi 2 1Department of Deputy of Strategic Planning, Reference Health Laboratories Research Center, Deputy of Treatment, Ministry of Health and Medical education of Health, Tehran, Iran 2Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran (Received 20 Nov 2012; accepted 19 Dec 2012) Abstract Background: Scorpion sting is a major health problem in Iran. The aim of current study was to measure the inci- dence rates of scorpion stings, mortality, recovery, and affected age groups. The results of treatment with and with- out anti venom also were considered in the entire country during 2009. Methods: All the data were collected from emergency section of different hospitals and then were analyzed by re- lated software. The responsibility of such data collection and surveillance is related to the Department of Violence and Injury, Ministry of Health and Medical Education of Iran. Results: A total incidence of 59.5/100000 was found for the 12-month period. During the study period the most and the least cases were reported from Khuzestan and Mazandaran Provinces with incidence of 541 and 0 per 100000 respectively. Totally 40220 anti venom vials were used, i.e., the ratio of 91 vial/ 100 affected cases. The stings occur mainly in rural areas (57.7%). Young people with the age group of 15–24 years old were the most victims of stings. The mortality and recovery rates of cases who had received anti venom less than 6 h of stings were calculated as 0.01% and 99.9% respectively. Conclusion: The high incidence of scorpion stings in Iran especially in Khuzestan suggests the necessity of preven- tive programmes for decreasing the incidence. Such programmes could start by community educating in the high prevalent areas. In addition prompt and local treatment is particularly important for infants and pre-school children. Keywords: Epidemiology, Scorpion, Iran Introduction Scorpions are venomous arthropods, mem- bers of the class Arachnida. These animals are found in all continents except Antarctica, and are known to cause problems in tropical and subtropical regions. Scorpion stings and their consequences represent an important cause of emergency, in particular pediatric, in many countries (Chippauxa et al. 2008). The epidemiology of the scorpionism in the world is poorly investigated. Accidents caused by scorpion stings are a relatively common event in subtropical and tropical countries and can cause lethal envenomation in humans, es- pecially in children (Ismail 1995). The clinical symptoms in scorpion sting are typically varied, depending on factors such as scorpion’s species, amount of injected venom, season, age and physical conditions of injured patient that may be weak as brief local responses or as dangerous as severely physiological changes that are led to death (Magurie 2001, Solegland et al. 2004). The Iranian scorpion fauna consists of over 44 named species from 23 genera in two families, Buthidae and Scorpionidae. In Iran, similar to other parts of the world, there are a few known species of scorpions respon- sible for severe envenoming. At least seven *Corresponding author: Prof Yavar Rassi, E-mail: rassiy@tums.ac.ir 66 J Arthropod-Borne Dis, June 2013, 7(1): 66–70 S Rafizadeh et al.: Epidemiology of… http://jad.tums.ac.ir Published Online: April 10, 2013 species have been implicated in envenoming of humans and considered medically important. Hemiscorpius lepturus (Hemiscorpionidae), is the most medically important scorpion in Iran (Zarei et al. 2009). Even though scorpions are abundant in many parts of Iran, envenomation arising from scorpion stings is not fully defined from the clinical signs, symptoms and epidemi- ological aspects. So the aim of this study was to appraisal these aspects of the topic. Materials and Methods The initial data including age, sex, signs and symptoms, site of biting, and final out- come of the patients were derived and rec- orded in a previously prepared questionnaire by emergency section of hospitals of 42 uni- versities of Medical Sciences from the whole parts of Iran and then were analyzed by re- lated software, Excell 2009, Excell Maritime Carriers Ltd, USA. Results All together, 44366 cases of scorpionism were recorded during 2009. Of these, 42.3 % was related to urban and remaining in rural districts. The males with 51.8 % were the most affected gender. The age group of 15– 24 years was by far the most commonly af- fected group (21.8%), however, the least num- ber of patients with 5.1% belonged to the age group of more than 65 years. Table 1 shows age and sex distribution of patients stung by scorpion in Iran in 2009. Of 44336 scorpion stung, 8998 (19.2%) observed on head and trunk, 18898 (40.3%) on hand and 18991(40.5%) on leg areas (Table 2). The average incidence of scorpionism was esti- mated 59.5 per 100000, however, the highest and the lowest affected cases were observed in Khuzestan and Mazandaran provinces with incidences of 541 and 0 per 100000 in- dividuals, respectively. Other four provinces including Hormozghan, Sistan and Baluchi- stan, Boshehr and Ilam with incidences of 153.9, 136.1, 127 and 123 per 100000 per- sons were the next important scorpionism priority within the country respectively. The times elapsed between sting and in- jection of anti venom were less than 6 hour for 56.6% of cases, 6–12 hour for 21% of cases, more than 12 hours for 11% of cases and the rest of individuals had not received any anti venom. Totally 40220 anti venom vial were used, indicates the coverage of 91 vial/100 affect- ed cases. The yellow scorpion was easily identified by the patients (54.6%). Moreo- ver, stings were occurred during the night. The mortality and recovery rates of cases with and without anti venom, was evaluated (0.03, 99.97%) and (0.11, 99.89%) respec- tively. According to results, the mortality rate of affected cases was 0.04% (19/44366). Table 1. Epidemiological characteristics of cases stung by scorpions in Iran, 2009 Age (yr) Male Female Totally % 0–4 1656 1296 2952 6.7 5–9 1756 1428 3184 7.2 10–14 1830 1675 3505 7.9 15–24 4899 4770 9669 21.8 25–34 4788 4659 9443 21.3 35–44 3360 3211 6571 14.8 45–54 1868 1743 3611 8.1 55–64 1654 1500 3154 7.1 >65 1153 1120 2273 5.1 Totally 22064 21402 44366 100 67 J Arthropod-Borne Dis, June 2013, 7(1): 66–70 S Rafizadeh et al.: Epidemiology of… http://jad.tums.ac.ir Published Online: April 10, 2013 TAI* (hours) Patients (n) % recovery (n) % Mortality (n) % <6 25052 56.47 25048 56.46 4 0.009 6-12 8690 19.58 8686 19.57 4 0.009 >12 5248 11.84 5243 11.83 5 0.010 WAI** 5376 12.11 5370 12.10 6 0.012 Totally 44366 100 44347 99.96 19 0.04 *Time of anti venom injection after stung **Without anti venom injection Table 2. Features of scorpion stings among the studied cases in Iran, 2009 Characteristics Patients (n) % Sting site Head and trunk 6477 14.6 Hand 18898 42.6 Leg 18991 42.8 Discussion Envenomings by scorpion stings are also an important, yet neglected, health issue in many parts of the world, particularly in the extreme Northern and Southern parts of Af- rica, the Middle East, Southern states of USA, Mexico and parts of South America, and the Indian sub-continent. The true incidence of scorpion sting en- venoming is not known because many cases do not seek medical attention. However, it has been estimated that there are approximately 1 million stings per year. In Mexico alone, 250,000 scorpion stings are reported yearly, but fatalities have declined from 2,000 to less than 50 per year following widespread distribution of antivenoms (WHO 2007). In Tunisia 40,000 stings, 1,000 hospital admis- sions and 100 deaths are reported each year. There is a high incidence in other parts of Northern Africa, the Middle East (notably Iran), India and Latin America (WHO 2007). In this study 44366 scorpion stings were registered in 2009 and in comparison with 2002 (37535 cases), we observed notably increasing on incidence of scorpion sting in Iran. Different studies have shown varied age distribution for scorpion stings. Children from 9 to 15 years old were more frequently affected (54.1%) than other age groups (38.8% for 3 to 8 years old, and 7.1% for 0 to 2 years) (Adiguzel et al. 2007). This result was not the similar with our study. The age groups of 15–24 years were by far the most commonly affected. In the present study, male victims pre- dominated over females (51.8% versus 48.2%). Several authors assign similar results to more activity displayed by boys than by girls (Hernandez 1997). However, there was no dif- ference in severe cases between the sexes. Other studies indicated that males, with their outdoor activities had more contact with scor- pions than females (16–18), while other re- ports indicated that females accounted for the majority of victims (Bergman 1997, For- rester 2004, Ozkan 2006). In the current study, hands and legs were the most affected parts of the body (85.4 %), a frequency that is not very different from those reported by other authors who showed that hands, arms, feet and legs were more frequently stung than other body parts (Farghly 1999, Gordillo 2000, Silva et al. 2000, Al-Sadoon 2003, de Roodt et al. 2003). Table 1. Countinued… 68 J Arthropod-Borne Dis, June 2013, 7(1): 66–70 S Rafizadeh et al.: Epidemiology of… http://jad.tums.ac.ir Published Online: April 10, 2013 Our study also showed that the majority of scorpion stings occur in July and August, during the hot season of the year. This is in accordance with data from the medical liter- ature (Abroug 1994, Touloun 2001, Soulay- mani 2004). Conclusion The present paper is the first comprehen- sive epidemiological study on injuries relat- ed to scorpions’ sting in Iran. The high inci- dence of scorpion stings in Iran especially in Khuzestan suggests the necessity of preven- tive programmes for decreasing the incidence. Such programmes could start by educating those affected by scorpion stings on how to avoid further stings. In addition early and local treatment is particularly important for infants and preschool children. Works on behaviour of scorpions in the region and dif- ferent control measure are also recommended. Acknowledgements The authors are grateful to staffs of emer- gency section of hospitals of 42 Univesities of Medical Sciences from the whole parts of Iran for their contribution and help in regis- tration and sending of data. The authors de- clare that there is no conflict of interest. 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