Vulnerabilities and clinical manifestations in scorpion envenomations in Santarém, Pará, Brazil: a qualitative study*

* Extracted from the thesis: “Estudo clínicoepidemiológico, laboratorial e de vulnerabilidade dos acidentes escorpiônicos atendidos no Hospital Municipal de Santarém – Pará”, Faculdade de Medicina da Universidade de São Paulo, 2016. 1 Centro Avançado Avançado de Medicina Tropical, Santarém, PA, Brazil. 2 Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil. 3 Universidade de São Paulo, Faculdade de Medicina, Departamento de Doenças Infecciosas e Parasitárias, São Paulo, SP, Brazil. ABSTRACT Objective: To describe elements of vulnerabilities and clinical manifestations of the victims of scorpionism in Santarem-Pará. Method: Quantitative and qualitative study with a theoretical framework of Twenty-eight patients stung by scorpions were interviewed by applying a semi-structured instrument. Data were analyzed according to the technique of discourse analysis. Results: Seventeen patients (60.7%) were male and eight (28.6%) were illiterate. Twenty-two (78.5%) patients were small farmers. This study revealed that these patients had an important individual, social and programmatic vulnerability. Interviews revealed limited knowledge about prevention and first aid after the envenomation. Programmatic vulnerability is highlighted because there is difficulty in accessing health services due to the great geographical extension of the Amazon region and also a lack of experience of the health care workers in caring for scorpion sting victims. Conclusion: This research accurately reveals previously described neuromuscular and sensory nervous system disorders in these victims of scorpionism. As far as we know, this is the first study that addresses the vulnerability of scorpionism using qualitative methodology.


INTRODUCTION
Scorpionism is a health problem in Brazil and other regions of the world. There are approximately 1,800 species of scorpions worldwide. At least 34 of these are considered medically important. The species responsible for envenomations in South America belongs to the genus Tityus (1)(2)(3) . Globally, there are probably more than 1,200,000 scorpion stings and recent speculation suggests approximately 3,250 deaths per year. The annual incidence is 26.3 envenomations per 100,000 inhabitants and the mortality rate is 0.2% (2) . It has been a notifiable disease in Brazil since 1988. In 2017, 126,000 envenomations and 184 deaths were reported (4) .
More than 80% of scorpion envenomations are classified as mild. The severity of the systemic effects depends on venom composition and patient clinical condition. Children under ten and the elderly over 75 years old are generally more seriously affected. The vast majority of deaths have occurred in these ages (2) .
Scorpion venoms have at least one hundred different components, with activities in many ion channels. The most medically important scorpion venom toxins affect the Na + and K + channels and are also active on the chloride and calcium channels which are present in all cell membranes (5)(6)(7)(8)(9)(10) . This usually leads to membrane depolarization of muscles and nerves (sensory and autonomic nervous system) causing a massive release of neurotransmitters (epinephrine and acetylcholine) (5,9) .
Mild envenomations are characterized by immediate local pain. Systemic manifestations, when present, can occur within minutes of the envenoming. Moderate cases may present nausea, vomiting, abdominal pain, cramps, diarrhea, fever, sweating, and diaphoresis. Severe envenomations usually evolve with symptoms compatible to acute congestive heart failure due to increased vascular resistance and acute pulmonary edema that may manifest as tachypnea, dyspnea, hypoxia, hypotension, cardiac arrhythmia, bradycardia, and shock. Less frequently, nervous and/or muscular system such as psychomotor agitation, somnolence, tremors, mental confusion, seizures, and muscle contractions have been reported in some regions of the world (11)(12)(13)(14)(15)(16) . Antiarachnid/ scorpion or scorpion antivenom should be administered as early as possible in patients with systemic alterations with the dosage in according to the severity. Autonomic nervous system (ANS) manifestations observed in severe scorpion envenoming in some parts of the world are much less frequent in patients from the Santarém region of Brazil. The predominant manifestations in this region relate to acute cerebellar dysfunction and they present as electric shock sensations which can last hours. The vast majority of patients present a clinical manifestations compatible with acute cerebellar dysfunction which starts minutes afer envenoming and can last for up to two days (17)(18)(19) .
Previous publications have shown that the clinical manifestations observed in the Santarém region is completely different to any other scorpion envenoming in the world (1,12,20) . Given the novelty and peculiarity of clinical features currently and exclusively attributed to Tityus obscurus in this region of Pará State (Brazil), elements of vulnerability and aspects related to clinical symptomatology were evaluated by quantitative and qualitative approach (17)(18)(19) .

Study deSign
This is a hermeneutic, qualitative, observational, descriptive and prospective study. It is based on the theoretical framework of vulnerability, aiming to understand that a scorpion sting is not limited to an individual's exposure to the animal, but results from situations and contexts that involve the person's life, work activity, access to health services, knowledge about the envenomations and other factors that will determine envenomation occurrence, progression, and severity.
The conceptual basis allowed us to process the reading and interpretation of these accidents from a vulnerability viewpoint to broaden our understanding of these envenomations and support proposals to better meet patient needs, program actions, and health policies.
The concept of vulnerability, according to Ayres et al (21) , integrates the following dimensions: individual, social and programmatic. Individual Vulnerability refers to the degree and quality of information that individuals have about health problems, and how they elaborate and apply this information in practice; Social Vulnerability assess information acquisition, access to the media, the availability of cognitive and material resources, and the power to participate in policy decisions and institutions; and Programmatic Vulnerability refers to the program evaluation and how it responds to the health problem control; besides it refers to the degree and quality of an institution's commitment, resources, management and monitoring of programs at different levels of (21) .

Scenario
Santarém Municipal Hospital (MHS) is the main medical center in the northwest region of Pará State. This is a frontline medical centre for almost 1,200,000 people that live in Santarem and nearby. This town, the second most important in Pará, is located on the bank of the Tapajos River with an estimated population of 302,667 (22) . The city has extensive deforestation due to soybean plantations.

data collection
Patients admitted and hospitalized at MHS, from February 2013 to January 2014, were interviewed. Twentyeight patients treated for scorpion envenoming at the Hospital during this time were included in the study.
Interviews were guided by an instrument consisted of two parts: Part One was structured in closed questions to obtain social, demographic, and epidemiological data; Part Two: semi-structured to understand elements of vulnerability and symptomathology by allowing patients free expression in answering the following questions: "Tell me how the accident occurred?"; "What should be done after a scorpion sting?"; "Why did you seek help at the hospital?"; "What is the treatment for a scorpion sting?"; "Do you know how to identify a venomous scorpion?"; and "Do you have any way to avoid being stung by scorpions"?
All interviews were recorded at the hospital or at patients'homes by the researcher who had no prior relationship with patients thus ensuring their freedom of expression. Patient privacy was always a foremost concern. data analySiS and proceSSing Data related to the semi-structured part of the study were fully transcribed and analyzed according to the technique of discourse analysis proposed by Fiorin and Savioli and adapted by Car and Bertolozzi (23) based on the Theory of Greimás: the Construction of Meaning Making, whose themes and figures are extracted from testimonials. Systematic reading of the statements was performed and then concepts and thematic categories were identified (23)(24) . To ensure the anonymity of the participants of this research, each interview was coded.
Analysis was performed by one of the researchers with expertise in qualitative research. Analysis validation was performed by the interviewer and results discussed together with the other authors.
The analysis generated analytical categories -perception about: the situation in which the accident occurred; the animal; clinical manifestations; procedures after the accident; treatment in the health service; and prevention actions. We complied with qualitative research review guidelines -RATS (25) .

ethical aSpectS
The study was approved by University of Sao Paulo Research Ethics Committee (CAPPesq number: 1128/07 and 0153/07). All patients gave their free and informed consent.
All precautions related to interview confidentiality were adopted.

reSultS
According to Table 1, 28 patients (17 males: 60.7%) were included; ages ranged from 1 to 70 years; the highest accident rate was in the 21-30 years age group (32.1%); the prevailing schooling range was between 1 and 3 years completed (46.4%); eight patients were illiterate (28.6%). The majority of envenomations occurred while at work 26 (92.9%). The most important occupation was smallholdings farmer 22 (78.5%), the others worked in wood extraction. The majorities of patients had no occupational qualification (24: 85.7%) and they were not registered in the National Employment Record Booklet; 22 (78.6%) patients worked 40 hours or more per week (Table 1).
Over 60% of those interviewed lived with at least 7 people and 35% in wooden houses with palm leaf rooves. The majority of patients were owner (78.6%), housing conditions were very poor, none lived in residences with a sewage system; 57% had running water, and only 46% had regular garbage collections. Paradoxically, two-thirds (60.7%) of the population reported that their living resources were sufficient and that they depended on public transport (82.1%) ( Table 2).      After the bite, we put a black stone. ...There are people who tie the animal to the sting site; they say it is to stop the venom spreading through the body (P22, P28).
Preserving the scorpion in alcohol and drinking this liquid is an antidote against the scorpion sting; the local sucking …reduces venom absorption (P26).

about hoSpital care
There was no antivenom at the Hospital for treatment (P7) but patients reported that they were well treated by health professionals (P9, P10).

DISCUSSION
The social context in the amazonic region are characterized by: growing social inequality, low human development index, low-income population, disorderly urban growth, land conflict, increase in deforestation (mainly caused by fire), difficulty in accessing health services in remote areas, reduced number of health professionals, limited resources, weak social control, poor access to health education and particularly to health policies, among others elements of vulnerability.
The study highlights the particular characteristics of scorpionism in Santarém and the most important aspects of vulnerability and symptomatology for these patients. Poor schooling and poor access to information may limit adequate post envenomation management and delay admission to the health service indirectly revealing the presence of individual and social vulnerability. Data that suggest important individual and social vulnerabilities may have influenced the occurrence of the envenomations, based in Table 1 and Table 2.
Although these animals are extraordinarily adaptive with a wide natural distribution capacity, the envenomations in this study were predominantly from rural areas. Northern region alone accounts for about two thirds of all rural area envenomations in Brazil and some in peri-urban areas by scorpions. In contrast, scorpionism is predominantly an urban envenomation over the country as a whole (61.6%) (1,26) . In this study scorpionism occurred, most of the time, when the patient was working, cutting wood or harvesting açai palm fruit.
Although the recognition of the animal is usual among the population, it is necessary to identify the species, since there are several genera of scorpions with wide distribution www.scielo.br/reeusp Rev Esc Enferm USP · 2020;54:e03579 in the region, but apparently only the genus Tityus has medical importance. We should enphasied that the clinical manifestations observed in this study appear to be related only to Tityus obscurus. Weakness (hypotonia) and difficulty in "feeling" objects while manipulating them are the consequence of abnormalities observed in tactile perception. Sensations of numbness and electric shock are related to proprioceptive function impairment as reported by patient P8. It is important to stress that these manifestations occurred simultaneously to many patients.
Soon after being stung, patients reported pain, which could be intense and spreading, commonly feeling numbness or local electrical shock that could become more generalized. Patients also complained of other local and regional manifestations that indicated muscle strength impairment. In fact, pain is the most frequent local manifestation; it is often intense and can last for several hours as scorpion toxins activate nociceptors, producing pain by dramatically slowing inactivation of sodium channels (27) . The "electric shock sensation" generally appears within 15 minutes of the sting and occurs in nearly all cases (17) . P17 revealed gustatory alteration compatible with impairment of the VII cranial pair. Taste disturbance (... the tongue tastes like mud) may be due to changes in tongue sensitivity.
Some interviewees reported to drool, difficulty swallowing, speaking and hypotonia (dragging legs). All these manifestations are compatible with motor coordination dysfunction, which is dependent on the cerebellum (17)(18)(19) .
Probably, the patient 22 witnessed dark colored urine which could correspond to myoglobinuria. Renal impairment is extremely rare in scorpionism; however, an earlier study described two cases in the Santarém region with renal injury presumably caused by T. obscurus (17) .
Many patients ingested or applied substances locally, only afterwards seeking medical attention because of no clinical improvement.
The Government's Health Department discourages any home treatments such as: drinking alcohol, blowing tobacco smoke on the site, or using a tourniquet, as they do not provide any benefits (28) . It recommends taking the victim to a medical reference unit as soon as possible (1) . However, such advice does not seem to be widely disseminated in the study region, which shows elements of individual and social vulnerability as well as a clear deficiency in the implementation of the National Program for the Control of Accidents by Venomous Animals.
Scorpionism interventions such as tourniquet, sucking the wound, local incision, and use of contaminated topical substances, although rare can lead to local complications; again, revealing individual, social, and programmatic vulnerability.
Patient could present a better prognosis if pre-hospital care (conduct soon after the envenomation) and adequate pre-hospital procedures are performed. It is essential that patients are quickly to the Health Service. Decentralization of specific antivenom distribution in the region and an increase of health professionals in difficult to access communities are essential for improving assistance in venomous animal accidents.
The Hospital was found to have no serum; in one case serum was only administered 17 hours after admission (P7) which indicates programmatic vulnerability. However, patients said they were well treated in the Hospital and that the doctor evaluated them regularly (P9, P10).
Using personal protection equipment such as closed footwear, long boots, leather gloves, especially when handling construction materials or transporting firewood, wood and stones, are effective measures to avoid scorpionism (1) .
These facts reveal that most of the patients were individually and socially vulnerable. The population should have access to information on how to correctly identify and avoid 'dangerous scorpions'.
We identified the following elements of individual and social vulnerability: socio-demographic characteristics, such as low levels of education (together with some illiteracy), low professional skills, poor housing conditions, and a lack of adequate information regarding the measures to be taken after a scorpion injury. These conditions could demonstrate inequality and social exclusion.
This study confirms previous publications that in the Santarém region occurs unique clinical manifestations of scorpionism. In summary reveals that these envenomations compromise acute cerebellar function as evidenced by ataxia, dysarthria, dysmetry; peripheral motor nervous system exemplified by fasciculations, myoclonus, hypertonia, spasms and even hypotonia. In relation to the Sensory Peripheral Nervous System, patients reported pain and abnormalities in tactile perception, numbness, and electric shocks in the body. Perhaps this venom concentrates its activities in other ion channel families (Na + , K + ) found in cell membranes expressed in cerebellar neurons beyond autonomic nervous system (29)(30) . These findings were only possible thanks to the qualitative approach that enabled the emergence of perceptions and representations about scorpionism (31) .

CONCLUSION
To the best of our knowledge this is the first qualitative study that identifies and evaluates clinical symptoms and vulnerabilities after scorpion stings. It describes with greater precision previously reported neuromuscular manifestations (mainly cerebellar) and reveals other abnormalities that have not previously been described as nervous system abnormalities: sensitivity, neuromuscular, cranial pair abnormalities such as gustatory and speech-related disorders, and renal irregularities in hospitalized scorpion sting patients from the Santarém region.
The qualitative approach decisively contributes to the detection of clinical manifestations and demonstrated that the population describes in its own way characteristics and aspects that are barely discernible in exclusively quantitative studies, such as paraesthesia epitomized by the "sensation of electric shock".

DESCRIPTORES
Picaduras de Escorpión; Vulnerabilidad en Salud; Enfermería en Salud Pública; Investigación Cualitativa. health professional training, including nurses, as well as improving access to the reference hospitals.
Programmatic vulnerability emerges when there is difficulty in accessing health services and a lack of knowledge among professionals in Basic Health Units and hospitals, probably due to limited access to continuing education. Eventually, there is a lack of antivenom at the only reference center in the area, reinforcing the need for the National Program for the Control of Accidents by Poisonous Animals to improve its public policies and actions.