EVALUATION OF SCORPION STING INCIDENCE IN TURKEY

Scorpion stings are common in Turkey due to its geographical location, climate and socioeconomic structure. Scorpion envenomation cases are a considerable public health problem in all regions of the country. Important healththreatening scorpions in Turkey are Androctonus crassicauda, Leiurus quinquestriatus, Mesobuthus gibbosus and M. eupeus, all of which belong to the Buthidae family. They are described to be potentially dangerous to humans. So far, there is no study about scorpion sting incidence covering all geographical regions of Turkey; therefore, in this study, we analyzed the frequency of scorpion sting cases in the country. A total of 24,261 scorpion sting cases were reported during 2005. Most of which (about 80%) occurred in the Southeastern Anatolia (30.4%), Mediterranean Sea (24.9%) and Aegean regions (23.5%), where medically important scorpion species are found. The sting cases mostly occurred during the summer period. Our results suggest that scorpion stings are an important problem in Turkey. This simple descriptive study will help develop interventions to prevent scorpion stings, which should take local sting cases into consideration.

In spite of the epidemiological and clinical data limitations, this simple descriptive study will help develop interventions to prevent scorpion stings, which should take into consideration local sting cases.In this study, we analyzed data based on the number of scorpion stings associated with previously designed studies on scorpion sting cases in Turkey during the year of 2005, aimed at providing data to develop national policies and activities in risky regions of Turkey.

Location of Turkey
Turkey (36º-42ºW; 26º-45ºE), with a total area of 779 45 km², lies between Europe and Asia and is surrounded by the Black Sea, Bulgaria and Greece on the north, the Aegean Sea on the west, the Mediterranean Sea, Syria and Iraq on the south, Iran on the east, and Armenia and Georgia on the northeast (The Turkish State

Data on Scorpion Sting
Data on scorpion stings included 81 cities from the seven regions of Turkey.We used data of scorpion stings on humans, which have been reported by provincial, local hospitals or primary health centers to the Ministry of Health during 2005.

Population Data
We obtained population data from the 2000 census of Turkish Statistical Institute.

Statistical Analysis
All data were analyzed using SPSS software and the Pearson's Chi-Square method.
Results were considered significant when the p value was less than 0.01.

RESULTS
Our study analyzed 24,261 scorpion sting cases reported by health centers to the Ministry of Health during 2005.No data on scorpion sting was provided by the following nine (11%) provinces: Agri, Ardahan, Balikesir, Bartin, Bayburt, Bolu, Canakkale, Istanbul and Manisa (Figure 1), whereas data were obtained from 72 (89%) provinces.Sting cases occurred in all regions.The largest numbers of cases were reported in the Southeastern Anatolia region (30.4%; Figure 2), followed by the Mediterranean Sea region (24.9%; Figure 3), the Aegean region (23.5%; Figure 4), the Central Anatolia region (11.4%) and the East Anatolia region (5.5%).
No death due to scorpion stings was reported during the study period.The ratio between scorpion stings and populations in the regions (Table 1) was statistically significant (p<0.001).The highest morbidity ratios were determined in the Southeastern Anatolia and Mediterranean Sea regions, whereas the lowest morbidity ratios were determined in the Black Sea and Marmara regions of Turkey (Table 1).
Seasonal distribution of the scorpion sting cases is shown in Figure 5.In the summer period, 12,985 (53.5%) out of 24,621 sting cases were reported; the following seasonal distribution was observed: autumn (22.1%), spring (19.9%), and winter (4.5%).In the Marmara region, most sting cases were seen in the spring, whereas in other regions it was noticed in the summer period.Analysis of data showed that scorpion sting cases increased during the spring and summer seasons in the Southeastern Anatolia, Aegean and East Anatolia regions.The cases increased during the summer and autumn periods in the Mediterranean and Central Anatolia regions (Figure 5).There was a statistically significant association between scorpion sting incidence and seasons (p<0.001).stated that child patients showed signs of local and autonomic nervous system failures but no lethality occurred in these cases.
Similarly to these clinical studies, in our study most of the scorpion stings (30.4%) were seen in the Southeastern Anatolia region of Turkey.A larger number of scorpion stings were recorded in the provinces of Sanliurfa (22.6%),Adiyaman (19.9%),Mardin (18%), Gaziantep (13.9%), and Batman (13%) than in the other provinces of this region (Figure 2).The current study indicates that scorpion stings are still a major public health problem in this region which has the most dangerous scorpion species.
Mesobuthus gibbosus is also a common species from the Aegean region of Central Anatolia to the middle of East Anatolia (12,15,21,23,31).In a study in the Aegean region, Suzek et al. (38) 4).
On the other hand, in a study in Antalya, a province of the Mediterranean Sea region, Dayar et al. (10) presented a case of a five-year-old girl that was stung by a scorpion and admitted to the hospital with generalized muscle contraction, pulmonary edema, tachypnea, serious arrhythmia, tachycardia, abnormal electrocardiography findings and increased cardiac enzymes.The authors notified that the patient died due to myocardial ischemia.In our investigation, analysis of scorpion sting data of the Mediterranean Sea region (Figure 3) showed that the majority of cases were notified in Antalya (30.5%).
In one of the clinical studies in Central Anatolia, Kekec et al. (24) recorded that scorpion stings were the most common cases (43%) in all animal-originated envenomation cases applied to the Medical School Department of the Emergency Service, Erciyes University of Kayseri, between January and December 1999.In our study, a larger number of scorpion sting cases were recorded in Konya and Kirikkale Provinces than in the other provinces of this region.
With regard to Eastern Anatolia, Karakurt and Kocak (20) reported two cases of children who suffered from myocarditis and pulmonary edema after scorpion stings in Malatya Province.In the current study, the majority of scorpion stings (49%) were recorded in Malatya Province.

Figure 1 .
Figure 1.Distribution of scorpion stings according to the provinces of Turkey.The risk of scorpionism was assessed based on the sting frequency/population ratio.

Figure 2 .
Figure 2. The Southeastern Anatolia region with its provinces according to occurrence of the highest morbidity ratios.

Figure 3 .
Figure 3.The majority of scorpion stings were seen in Antalya, Kahramanmaras, Icel, and Hatay Provinces of the Mediterranean Sea region.

Figure 4 .
Figure 4. Scorpion stings are responsible for significant morbidity in Mugla, Aydın and Denizli Provinces of the Aegean region.

Figure 5 .
Figure 5. Seasonal distribution of the scorpion stings in Turkey.Except for the Marmara region, most stings were seen in the summer period.
(14,16,34,36,40) of the Black Sea region, Mocan et al.(26)presented a case of a 28-year-old man admitted to the Faculty of Medicine, Black Sea Technical University, with a history of right leg pain, vomiting, diarrhea, agitation, restlessness, blurred vision, peripheral cyanosis, increased lachrymation and salivation, and oliguria following a scorpion sting which had occurred two days before.Thus, the authors suggested that scorpion stings should be added to the ever-growing list of O. Ozkan et al.EVALUATION OF SCORPION STING INCIDENCE IN TURKEY.J. Venom.Anim.incl.Trop.Dis., 2008, 14, 1, p. 136 causes of hemolytic-uremic syndrome.They also stated that Euscorpius carpaticus, E. germanus and E. italicus are known as nonlethal scorpion species in this region.Our analysis showed that scorpion sting cases were mostly seen in the provinces of Corum (28.7%),Rize (15%), Ordu (10%) and Tokat (9.2%) in this region.Turkey has a subtropical, semi-arid climate with extreme temperatures.In the east, summers are hot and dry; winters are cold, rainy and snowy.Along the coastal area, the Mediterranean climate is dominant with long, hot, dry summers and short, mild, rainy winters.Rainfall shows great differences from one region to another in Turkey (www.meteor.gov.tr).Similarly, most scorpion sting cases were seen during the summer period in Brazil, Saudi Arabia, Egypt, Morocco and Iran(14,16,34,36,40)when compared to the other months, which agrees with the findings of our study.On the other hand, most sting cases were seen at spring time in the Marmara region.In the other regions, the largest numbers of cases were reported in the summer period.Analysis of the data on sting cases showed a difference due to the incidence of scorpion stings in the various seasons depending on the region climate, indicating that the scorpion activities are related to the climate.For example, scorpion activities increased during the spring and the summer in Southeastern Anatolia, Aegean and Hakkari) regions, according to the analyses of geographical data of scorpion stings.These regions present scorpion species which are known as medically important.Scorpion stings are responsible for significant morbidity; therefore, our results suggest that scorpion stings are an important health problem in Turkey, especially in the Southeastern Anatolia, Mediterranean Sea and Aegean regions.In conclusion, to decrease both scorpion stings and possible envenomations of humans, (a) the population should be aware of scorpions; (b) antivenom must be continuously supplied to the health centers of the regions which have high incidence of scorpion stings -the beginning of the scorpion activities in geographical regions O. Ozkan et al.EVALUATION OF SCORPION STING IN TURKEY.J. Venom.Anim.Toxins incl.Trop.Dis., 2008, 14, 1, p. 137 must be considered for antivenom supplying; (c) medical professionals from risky regions should be informed about medically important scorpion species and their knowledge about scorpionism treatment should be kept up-to-date; (d) the children's careless behaviors such as walking barefoot, lifting stones and playing with scorpion nests can increase the number of scorpion stings; therefore, training brochures should be prepared and exhibited at schools.