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Original Article

Raúl Soriaa; Nayeli Velázquezb; Rashid Hernándezb.
aInosan Biopharma, S.A., Mexico City; bVeteria Labs, S.A. de C.V., Mexico City.
Corresponding Author: , . Tel: ; e-mail: raulsoria@protonmail.com

Citation: Raúl, Velázquez N, Hernández R. Update Regarding the Epidemiological Overview of Scorpion Stings in Mexico: 2017-2019.
Lat Am J Clin Sci Med Technol. 2021 Nov; 3: 166 - 178.
Received: August 27th, 2021.
Accepted: October 26th, 2021.
Published: November 16th, 2021.
Views: 92
Downloads: 2
ABSTRACT

Introduction. Scorpion sting envenomation (SSE) is a public health problem in Mexico. In 2013, Secretaría de Salud established an objective to reduce the incidence of SSE by 36% through strategies focused on medical care, biological control of scorpions and prevention. Objective. The main objective of this study was to evaluate the policy for the control of SSE in Mexico through an analysis of new cases and incidences to identify future challenges in the control of this acute medical condition. Material and Methods. This study used scorpion sting data obtained from the 2017-2019 Boletín Epidemiológico del Sistema Nacional de Vigilancia Epidemiológica from Secretaría de Salud. Results. Several inconsistencies were identified in the data regarding new cases of SSE in 2017-2019, with Durango, Puebla, Jalisco, and Guerrero being the states with the highest incidences. The five states with the most cases (i.e., Jalisco, Guanajuato, Guerrero, Morelos, and Michoacán) accounted for approximately 67.27% of all cases in Mexico. The results indicate that SSE has increased throughout the country. Discussion. It is essential to improve both the epidemiological surveillance of SSE and the access to information to publicly disclose all data reported. The goal of reducing the SSE incidence in México is far from being met. Thus, it is critical to review the latest strategy of increasing the availability of anti-scorpion fabotherapics in the country. Conclusions. The goals established in Plan Específico de Acción 2013 are far from being met. Estimates of new SSE cases were surpassed by almost 70,000 cases. The incidence has remained constant in the states considered priorities, which indicates that the policy for the control of SSE is disjointed. The decrease in mortality has had a double effect (i.e., results are successful) but diverts attention from the lack of strategies focused on prevention.

Keywords: epidemiología, alacranismo, picadura de alacrán, envenenamiento, antiveneno
RESUMEN

Introducción. La intoxicación por picadura de alacrán (IPPA) es un problema de salud pública en México. En 2013, la Secretaría de Salud estableció el objetivo de reducir la incidencia de IPPA en 36% mediante estrategias centradas en la atención médica, control biológico de alacranes y prevención. Objetivo. El objetivo principal del presente estudio fue evaluar la política para el control de IPPA en México mediante el análisis de nuevos casos e incidencias para identificar retos futuros en el control de esta condición médica aguda. Material y métodos. Este estudio utilizó datos de picadura de alacrán obtenidos del Boletín Epidemiológico del Sistema Nacional de Vigilancia Epidemiológica de la Secretaría de Salud entre 2017-2019. Resultados. Se identificaron varias inconsistencias en los datos de nuevos casos de IPPA entre 2017-2019. Durango, Puebla, Jalisco y Guerrero fueron las entidades con el mayor número de incidencias. Los estados con más casos (i.e. Jalisco, Guanajuato, Guerrero, Morelos y Michoacán) representaron aproximadamente 67.27% de todos los casos en México. Los resultados indican que la IPPA ha aumentado en todo el país. Discusión. Es fundamental mejorar tanto la vigilancia epidemiológica de la IPPA como el acceso a la información para divulgar públicamente todos los datos reportados. El objetivo de reducir la incidencia de la IPPA en México está lejos de cumplirse. Por tanto, es fundamental revisar la última estrategia para aumentar la disponibilidad de faboterapias contra la picadura de alacrán en el país. Conclusiones. Los objetivos establecidos en el Plan Específico de Acción 2013 están muy lejos de ser cumplidos. Se estima que los nuevos casos de IPPA han superado los 70,000. La incidencia se ha mantenido constante en las entidades que son consideradas prioritarias, lo cual indica que la política para el control de la IPPA está desarticulada. La disminución en la mortalidad ha tenido un doble efecto; es decir, los resultados son exitosos, pero desvía la atención acerca de la falta de estrategias centradas en la prevención.

Palabras clave: epidemiology, scorpionism, scorpion sting, envenomation, antivenoms

INTRODUCTION

According to Secretaría de Salud (SSA [Ministry of Health]), “Scorpion sting envenomation [SSE] is a health problem of notable importance in Mexico”1, and ranks 15th among the most relevant conditions in the country.2

In Programa Específico de Acción para la Prevención y Control de la Intoxicación por Picadura de Alacrán 2013-2018 (Specific Action Program for the Prevention and Control of Scorpion Sting Envenomation), SSA identified four important aims for the management and control of this medical condition:

  1. To improve epidemiological information systems in the states to include updates regarding scorpion stings and the most affected regions.
  2. To formulate prevention strategies that consider the risk factors for each specific area of the country.
  3. To ameliorate housing conditions in priority areas.
  4. To reverse “[...] the annual increase in cases and maintaining the downward trend in deaths from SSE”.2

The high incidence of endemic scorpions has been acknowledged not only in epidemiological research; scorpion distribution studies have gained relevance in the last decade in environmental protection and taxonomy. Mexico accounts for 12% of scorpion species worldwide. Anyhow, the total number of scorpion species is not definitive. Riaño-Umbarilla3 et al. claim that Mexico has 280 species; Ponce Saavedra4 suggests the existence of 289 species, whereas Ureta, et al.5 state that the real number is 294. According to Ponce Saavedra, Francke, Quijano, and Cortés, the 32 states of Mexico have a registry of scorpions, including in total 38 genera.

The scorpions from the family Buthidae are considered medically important in Mexico, specifically the species Centruroides and Chaneke. In Jalisco, the state with the historically highest incidence of SSE, Centruroides elegans, Centruroides infamatus, Centruroides ornatus, and Centruroides tecumanus are the main species to cause envenomations.

Most of the literature on SSE6-9 emphasizes that the mortality rate due to scorpion sting since 2000 in Mexico has decreased considerably because of the use of fabotherapics, as the main therapeutic approach. Besides, it is commonly accepted that SSE is related to poverty conditions and certain weaknesses in the health system in Mexico; for example, the lack of hospital infrastructure in rural areas. In general, the network of public hospitals in the country —composed of various institutions such as Instituto Mexicano del Seguro Social (IMSS [Mexican Social Security Institute]), the different health services in each state, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE [Institute for Social Security and Services for State Workers]), among others— mainly deal with SSE cases.

Unlike envenomation caused by snakebites, SSE has drawn the attention of Mexican health authorities on such a way that they developed Norma Oficial Mexicana (Official Mexican Standard) NOM-033-SSA2-2011 for the surveillance, prevention, and control of scorpion sting envenomation. Likewise, from 2013 to 2018, a series of documents, such as the Specific Action Program and the Standardized Procedures Guidelines for Epidemiological Surveillance of SSE, was published, seeking to establish a framework of action to address this problem.1 In this context, with an active government infrastructure for the treatment of SSE nationwide, it is appropriate to evaluate the progress in the challenges and aims identified in 2013. For this purpose, it is relevant to analyze the official data regarding new cases of SSE and incidences reported by SSA from 2017 to 2019.

MATERIAL AND METHODS

Information regarding new SSE cases was obtained from Boletín Epidemiológico del Sistema Nacional de Vigilancia Epidemiológica from SSA. It provides weekly reports of SSE cases, which are classified in the non-communicable diseases section, specifically with the code CIE-10ª REV. T.63.2, X22. SSE data for the 52 weeks for 2017, 2018, and 2019 were collected.9

It is noteworthy to mention that the bulletin reports the state, the number of new cases per week, and a cumulative number that disaggregates the case information by sex.

According to SSA, the data reported include all institutions of the national health system, which by January 2020 consisted of 20,005 public and private care units. The health units report cases based on Manual de Procedimientos Estandarizados para la Vigilancia Epidemiológica de la Intoxicación por Picadura de Alacrán (Standardized Procedures for Epidemiological Surveillance Booklet for Scorpion Sting Envenomation).

Each state is responsible for accounting the cases; the data are processed by a division of SSA (i.e. Dirección General de Epidemiología [General Directorate of Epidemiology], which is responsible for the final publication of Boletín Epidemiológico.

Data were revised for each state independently and aggregated in regions, using the regionalization proposed by Instituto Nacional de Estadística y Geografía, INEGI [National Institute of Statistics and Geography]), which divides Mexico into four regions: Central region, Central-western region, Northern region and Southeast region.

The information collected was processed using Microsoft Excel, version 16.45. The spatial representation of the incidence of scorpion stings in Mexico was processed in R Studio, version 1.4.11. Incidence and population data for each state were collected from the statistical yearbooks published by INEGI.

RESULTS

For the newly reported SSE cases in the 52 weeks of 2017, 2018, and 2019, there was a difference between the total number of cases calculated based on the total number of incidents reported weekly, and the total SSEs calculated; for example, the sum of the information disaggregated by the sex of the victims. Table 1 compiles the new SSE cases in Mexico from 2017-2019.

Table 1. New SSE cases in Mexico
State2017
NC*
2017
M+F**
∆***2018
NC*
2018
M+F**
∆***2019
NC*
2019
M+F**
∆***
Aguascalientes2,9152,91612,5962,586-102,6432,65411

Baja California868601181180147144-3

Baja California Sur53530666821031030

Campeche363603232045450

Coahuila15216311184214301951950

Colima11,40011,4222210,70510,7595410,67110,670-1

Chiapas166173716717693083146

Chihuahua288306183603943439741417

Ciudad de México37540631377408313773869

Durango3,4059,5546,1493,1148,9485,8343,3139,4826,169

Estado de México11,52511,5563111,09011,1425213,00613,116110

Guanajuato46,05346,29724440,50340,65114843,93644,341405

Guerrero40,90841,61570740,42141,18876743,98345,6901,707

Hidalgo2462537652224-42830531712

Jalisco49,76251,9572,19545,00947,8472,83844,88846,9882,100

Michoacán27,13727,73860126,57428,1751,60129,38230,4301,048

Morelos26,43127,8461,41525,24627,1331,88722,30525,9183,613

Nayarit13,65014,22657616,10616,63853216,36817,068700

Nuevo León121121085850122121-1

Oaxaca4,1635,0949313,4264,0616354,5204,834314

Puebla10,55913,3042,7458,59811,9703,37210,28113,0452,764

Querétaro3,8943,908144,1204,12554,7214,7265

Quintana Roo51543838859594-1

San Luis Potosí328328040841354604600

Sinaloa8,9569,2653099,93910,37443510,54810,791243

Sonora5,0635,7406774,9255,1822574,8745,163289

Tabasco394013738172731

Tamaulipas2972970338351133413410

Tlaxcala464825758174740

Veracruz304 30732222202270269-1

Yucatán434302425135350

Zacatecas5,3555,36494,7894,9141254,5664,58923

Total273,807290,51616,709260,371278,60518,234273,351292,89019,539

*NC refers to the total of new SSE cases taking into account weekly cases. **M+F refers to the total number of new SSE cases taking into account the cumulative cases by sex. “M” refers to male individuals and “F” to female individuals. ***∆ refers to the difference between “NC” and “M+F”.


Interestingly, in 2017, in seven out of the 32 states (Baja California, Baja California Sur, Campeche, Nuevo León, San Luis Potosí, Tamaulipas, and Yucatán) new SSE cases (both “NC” and “F+M”) were consistent. In 2018, Baja California, Coahuila, and Nuevo León reported equally consistent data. In 2019, Baja California Sur, Campeche, Coahuila, San Luis Potosí, Tamaulipas, Tlaxcala, and Yucatán did not report any difference between these two criteria.

Annually, by 2017, the total number of SSE cases nationwide —according to the “NC” column— was 273,807 cases. In contrast, taking into account the “F+M” data, the total number of cases was 290,516.

In 2018, there was a total of 260,371 “NC” SSE cases; however, when the information was disaggregated by sex, this number increased to 278,605 cases. This phenomenon was also observed in 2019, when the total number of "NC" SSE cases was 273,351, while the "M+F" SSE cases were 292,890.

If only considering the “NC” columns, it would be possible to affirm that, from 2017 to 2019, SSE cases did not increase in Estado de México and that, in 2018, there was a decrease in the number of cases. In contrast, when considering the total number of “M+F” SSE cases, the cases increased during 2017-2019.

When analyzing the columns, indicating the differences between “NC” and “M+F” SSE cases (∆), the differences are not the same in all states. In 2017, the five states with the highest incidences were Durango (∆ 6,149), Puebla (∆ 2,745), Jalisco (∆2,195), Morelos (∆ 1,415), and Oaxaca (∆931).

In 2018, the five states with the highest incidences were Durango (∆ 5,842), Puebla (∆ 3,422), Jalisco (∆ 2,848), Morelos (∆ 1,988), and Michoacán (∆1,692).

In 2019, Durango remained the state with the highest incidence (∆ 6,169), followed by Puebla (∆ 2,764), Morelos (∆ 3,613), Jalisco (∆ 2,100), and Guerrero (∆ 1,707).

The availability of weekly data allowed identifying the weeks with the highest number of registered incidents (see Graphic 1 and Table 2). In 2017, week 32 (August 7-13) had the highest incidence of cases nationwide, with 1,917 cases, followed by week 30 (July 24 -30), with 1,526 cases. In 2018, week 33 (August 13-19) registered the highest incidence of cases (11,362), followed by week 32 (August 6-12), which according to Boletín there were 11,599 fewer “M+F” cases, compared to the number of new cases per week.

Tabla 2. Weeks with the highest incidence of SSE cases in Mexico, 2017-2019
Position201720182019
Week# IncidencesWeek# IncidencesWeek# Incidences
1321,9173311,362325,530

2301,52632-10,599281,491

3201,268361,442301,250

4241,052351,384361,190

511792441,36420941

641743271,18542803

7447171978522742

8406901673419721

9255525258527713

1095403854248593

Interestingly, week 32 is the only week (out of the ten) with the highest number of cases repeated in 2017, 2018, and 2019.

Regarding the discrepancies in the weekly accounting of new SSE cases, it is also pertinent to use accumulated total cases by sex of the victims. Table 3 shows the SSE cases in ascending order.

Table 3. New SSE cases by state in 2017, 2018, and 2019
PositionState2017State2018State2019
1Jalisco51,957Jalisco47,847Jalisco46,988

2Guanajuato46,297Guerrero41,188Guerrero45,690

3Guerrero41,615Guanajuato40,651Guanajuato44,341

4Morelos27,846Michoacán28,175Michoacán30,430

5Michoacán27,738Morelos27,133Morelos25,918

6Nayarit14,226Nayarit16,638Nayarit17,068

7Puebla13,304Puebla11,970Estado de México13,116

8Estado de México11,556Estado de México11,142Puebla13,045

9Colima11,422Colima10,759Sinaloa10,791

10Durango9,554Sinaloa10,374Colima10,670

11Sinaloa9,265Durango8,948Durango9,482

12Sonora5,740Sonora5,182Sonora5,163

13Zacatecas5,364Zacatecas4,914Oaxaca4,834

14Oaxaca5,094Querétaro4,125Querétaro4,726

15Querétaro3,908Oaxaca4,061Zacatecas4,589

16Aguascalientes2,916Aguascalientes2,586Aguascalientes2,654

17Ciudad de México406San Luis Potosí413San Luis Potosí460

18San Luis Potosí328Ciudad de México408Chihuahua414

19Veracruz307Chihuahua394Ciudad de México386

20Chihuahua306Tamaulipas351Tamaulipas341

21Tamaulipas297Hidalgo224Hidalgo317

22Hidalgo253Veracruz220Chiapas314

23Chiapas173Coahuila214Veracruz269

24Coahuila163Chiapas176Coahuila195

25Nuevo León121Baja California118Baja California144

26Baja California86Quintana Roo88Nuevo León121

27Quintana Roo54Nuevo León85Baja California Sur103

28Baja California Sur53Baja California Sur68Quintana Roo94

29Tlaxcala48Tlaxcala58Tlaxcala74

30Yucatán43Tabasco38Tabasco73

31Tabasco40Campeche32Campeche45

32Campeche36Yucatán25Yucatán35

Total290,516278,605292,890

In 2017, Jalisco topped the list (51,975 cases), followed by Guanajuato (46,297 cases), Guerrero (41,615 cases), Morelos (27,846 cases), and Michoacán (27,738 cases).

In 2018, Jalisco remained in the first position, with 4,110 fewer cases reported. Guerrero moved to second place, with 41,188 cases (+427), followed by Guanajuato, with 40,651 (-5,646), Michoacán, with 28,175 (+437), and Morelos, with 27,133 cases (-713).

Between 2017 and 2018, nine out of the 32 Mexican states (Jalisco, Nayarit, Puebla, Mexico, Colima, Sonora, Zacatecas, Baja California Sur, and Tlaxcala) kept their position in the list of SSE cases. Notably, in 2017, the five states with the most cases accounted for 67.27% of the total SSE cases; in 2018, they accounted for 66.4%; and in 2019, they accounted for 66%. In the three years analyzed, in 17 out of 32 states, there were fewer than 1,000 SSE cases annually. Graphic 2 shows the distribution of SSE cases in Mexico.

From 2018 to 2019, 53% of the states maintained their position in the list concerning the previous year. Although Jalisco reported a decrease of 859 cases in 2019, it remained on top of the list with 46,988 SSE cases, followed by Guerrero for the second year in a row, with 45,690 (+4,502) cases, Guanajuato, with 44,341 cases, Michoacán, with 30,430 cases, and Morelos, with 25,518 cases.

Regarding the incidence of cases in 2017, the five states that reported the highest number of SSE cases per 100,000 inhabitants in Mexico were (see Table 4) Colima (1552.42), Morelos (1433.11), Guerrero (1159.75), Nayarit (1141.54), and Guanajuato (789.510) (see Table 4).

Tabla 4. SSE incidence in Mexico, 2017, 2018, and 2019
StatePopulation
201710
Incidence
2017
Population
201810
Incidence
2018
Population
201910
Incidence
2019
Aguascalientes1,304,744223.4921,337,792193.30361,415,421187.506

Baja California3,534,6882.4333,533,7723.33923,578,5614.024

Baja California Sur786,8646.736832,8278.1650788,11913.069

Campeche921,5173.907948,4593.3739984,0464.573

Coahuila2,995,3745.4423,063,6626.98513,175,6436.140

Colima735,7241,552.484759,6861,416.2430772,8421,380.619

Chiapas5,317,9603.2535,445,2333.23225,647,5325.560

Chihuahua3,746,2818.1683,816,86510.32263,765,32510.995

Ciudad de México8,833,4164.5968,788,1414.64269,031,2134.274

Durango1,782,205536.0771,815,966492.74051,852,952511.724

Estado de México17,118,52567.50617,604,61963.290217,245,55176.054

Guanajuato5,864,016789.5105,952,087682.97056,173,643718.231

Guerrero3,588,2551,159.7563,625,0401,136.20823,643,9741,253.851

Hidalgo2,913,1528.6852,980,5327.51543,050,72010.391

Jalisco8,022,181647.6678,197,483583.67928,325,800564.366

Michoacán4,627,902599.3644,687,211601.10374,791,977635.020

Morelos1,943,0441,433.1121,987,5961,365.11652,022,5681,281.440

Nayarit1,246,2021,141.5481,290,5191,289.24871,270,6461,343.254

Nuevo León5,157,7802.3465,300,6191.60365,533,1472.187

Oaxaca4,037,357126.1724,084,67499.42044,120,741117.309

Puebla6,254,597212.7086,371,381187.87146,542,484199.389

Querétaro2,034,030192.1312,091,823197.19642,239,112211.066

Quintana Roo1,619,7623.3341,709,4795.14781,684,5415.580

San Luis Potosí2,777,99511.8072,824,97614.61962,845,95916.163

Sinaloa3,009,952307.8123,059,322339.09473,131,012344.649

Sonora2,972,580193.0983,050,473169.87533,037,752169.961

Tabasco2,407,8601.6612,454,2951.54832,544,3722.869

Tamaulipas3,583,2958.2883,661,1629.58713,620,9109.418

Tlaxcala1,295,7813.7041,330,1434.36041,364,1475.425

Veracruz8,106,1383.7878,220,3222.67638,488,4473.169

Yucatán2,145,8782.0042,199,6181.13662,233,8661.567

Zacatecas1,588,418337.6941,612,014304.83612,233,866205.429

In 2018, Colima topped the list, with 1416.24 cases per 100,000 inhabitants, followed by Morelos (1365.11), Nayarit (1289.24), Guerrero (1136.20), and Guanajuato (682.97). Overall, 40% of the states of Mexico reported a decrease in cases, compared to the previous year. In 2019, the five states with the highest incidence of SSE cases were Colima (1380.61), Nayarit (1343.25), Morelos (1281.440), Guerrero (1253.85), and Guanajuato (718.23).

Graphic 3 displays the variation in the incidence of SSE cases in the 32 states of the country. Table 5 compiles the total SSE cases by region.

Table 5. 2017-2019 SSE cases in the different regions of Mexico
Region2017%2018%2019%
Central region
(Ciudad de México, Guerrero, Hidalgo, Estado de Mexico, Morelos, Puebla, Tlaxcala, and Oaxaca)
100,12234.4696,18434.52103,38035.30

Central-western region
(Aguascalientes, Colima, Guanajuato, Jalisco, Michoacán de Ocampo, Nayarit, Querétaro, San Luis Potosí, and Zacatecas)
164,15656.50156,10856.03161,92655.29

Northern region
(Baja California, Baja California Sur, Chihuahua, Coahuila, Durango, Nuevo León, Sinaloa, Sonora, and Tamaulipas)
25,5858.8125,7349.2426,7549.13

Southeast region (Campeche, Chiapas, Quintana Roo, Tabasco, Veracruz de Ignacio de la Llave, and Yucatán)6530.225790.218300.28

Total290,516100%278,605100%292,890100%

In 2017, the nine states that compose the Central-western region (Aguascalientes, Colima, Guanajuato, Jalisco, Michoacán, Nayarit, Querétaro, San Luis Potosí, and Zacatecas), accounted for 56.5% of all cases in the country, followed by the Central region (34.4%), North region (25.5%), and Southeast region (0.22%).

Between 2018 and 2019, the Central-western and North regions reported a slight decrease in cases, while the other regions showed a slight increase.

Out of the 290,516 SSE cases recorded in 2017, 48% (138,606 SSE) were men, and 52% (150,910) were women. In 2018, 49% of SSE cases were men, and 51% were women. In 2019, out of the 292,890 cases, 48% were men, and 52% were women. Although the global aggregate was constant in the years analyzed, the disaggregated SSE and states data revealed differences (see Graphic 4).

In Jalisco and Zacatecas, the proportion of SSE cases was 50% for men and women. In 29 out of the 32 states, most of the cases were women; in Colima, Querétaro, and Yucatán, the cases indicated a higher percentage of male cases (Figure 1).

DISCUSSION

Programa Específico de Acción para la Prevención y Control de la Intoxicación por Picadura de Alacrán 2013-2018 from SSA defined two main objectives: “to promote prevention and self-care of health among the population to avoid SSE cases” and “to provide specific and timely treatment to reduce mortality”.1

The same document presented four strategies to control SSE. The first one involved improving the epidemiological surveillance system to include SSE and areas with an endemic presence of scorpions. The second strategy sought to improve housing in the most vulnerable areas by installing protective screens on doors and windows, encouraging the use of mosquito nets, and identifying refuge sites for scorpions in homes and residential areas. The third strategy is the chemical control (insecticides) of scorpions inside and outside houses. The fourth strategy, mainly spread, proposed expanding access to health services, particularly increasing the number of anti-scorpion fabotherapics, and establishing that the treatment of SSE should be carried out in health units along with first and second levels of care.

Although SSE is not a recent health issue, the interest in treating it varies depending on the interests of each current administration. The president-centered nature of the policy aimed at controlling SSE changed direction after Ernesto Zedillo's administration. It had personal expertise with SSE, and promoted the development of a strategy for controlling and treating this acute condition.13

Certain common challenges have been identified in most of the literature on the epidemiology of SSE; for example, epidemiological surveillance7 and the vulnerability of specific population groups such as infants and adults, and care outside hospitals with home remedies.

A study by Dhaesa-Dávila, who addressed the pharmacological management of SSE in Mexico in the late 1980s, reported that clinical records on scorpion stings were deficient and, in many cases, nonexistent. This observation suggests that the population in regions with the highest incidence of poisonous scorpions has only oral traditions regarding scorpions and prevention and treatment measures.14

A study by Celis that analyzed mortality due to scorpion stings proposed improving nonfatal attack records and emphasizing treatment measures in the child population because 68% of recorded deaths by SSE are infants younger than 5 years old.7

Castillo-Pérez stated that the public health measures implemented in Guanajuato have been exclusively therapeutic; that is, the availability of fabotherapics has been ensured.8

Thus, the study points out that no efforts were made to create prevention strategies in this state.8

Chowell, Díaz, Saldaña and Aleman found that most of the health units attached to the health services of Colima do not have personnel trained for the administration of fabotherapics. Likewise, they reported that the long periods between stings and the initiation of treatment is one of the main problems to be addressed in the state.15

Thus, this research's main objective was to compare the goals and strategies for the control of SSE with the epidemiological data for SSE in 2017, 2018, and 2019. Therefore, the first issue to address will be improving the epidemiological surveillance of SSE.

Based on an comprehensive review of the data regarding new SSE cases, there was a remarkable difference between the total number of cases reported weekly and the total number of SSE cases disaggregated by sex of the victims. This discrepancy was especially apparent in some states of Mexico, for example, in Durango and Puebla. In Durango, the number of cases exceeded 6,000 each year analyzed, reflecting profound deficiencies in the methodology used for SSE reporting SSE in these states and in the dissemination of information received by the administration.

In 26 out of the 32 states in Mexico, the annual cases number was less than 1,000; however, it concerns that the states with the highest incidences are those with the highest number of annual cases. Furthermore, there is a lack of data to conduct a more in-depth analysis of the epidemiology of SSE. Information on the municipalities where incidents are reported, the age of victims and the victim's occupation would be relevant data for future analyses.

Although there have been studies like Castillo-Pérez's, including information on SSE disaggregated by the municipality, these data are not available to the public. Specifically, Castillo-Pérez stated that the data used in his research came from the Unified Updated Epidemiological Surveillance System of Guanajuato; but, after reviewing the Ministry of Health of Guanajuato's website, it was not possible to locate the data. Direct references to this system refer to the national epidemiological surveillance system platform, whose access is limited to SSA staff.8 One possible way to obtain this information is disclosure. Instituto Nacional de Transparencia, Acceso a la Información y Protección de Datos Personales (INAI [National Institute of Transparency, Access to Information]) makes this information public and it would be useful for future research on SSE in Mexico.

In Plan Específico de Acción 2013, SSA stated that the main goal was to reduce the incidence of SSE cases by 36.5% by 2018. It was estimated that it was necessary to have fewer than 208,838 cases in 2017 or fewer than 198,396 cases in 2018 to achieve that goal .

The results of this research show that this goal was far from being met. In 2017, there were 69,767 more SSE cases than estimated, and in 2018, there were 94,494 more SSE cases than estimated.

Thus, the government’s strategy for reducing mortality has had a double effect. On the one hand, positive results (decreased mortality) justified the monetary investment in fabotherapics, but on the other, focusing on mortality detracts from the importance of morbidity and, therefore, diverts attention from the failure and abandonment of prevention policies, such as improving housing in areas with higher risk.

Regarding this latter, the initiative of replacing earth floors with concrete floors was abandoned. The work by Silva-Domínguez is especially interesting because it states that the factors increase the risk of SSE, i.e., keeping ducks in the house, the lack of concrete roofs and floors, and child labor.16 Additionally, the future Plan Específico de Acción should also consider the environmental and climatic factors associated to the increase of SSE. Almaraz-Lira et al. demonstrated that high temperatures and heavy rain affect the incidence of scorpion stings.17

Finally, it is critical to review the latest strategy of increasing the availability of anti-scorpion fabotherapics in the country. During 2013-2018, different health agencies around the country purchased drugs. Thus, the only publicly available information was found in the IMSS' transparency portal, which reports that in 2018, the Institute bought approximately 194,885 units of anti-scorpion fabotherapics for $182.00 MNX per unit. 18

Since 2018, this transparency platform has been dismantled due to the new unified purchasing strategy promoted by the federal government. The main problem with IMSS data is that the headquarters made the purchases; therefore, it is not possible to determine how the units were distributed to the states.

CONCLUSIONS

This study analyzed the data on new SSE cases and incidences between 2017 and 2019 to discuss some relevant aspects of SSE control policy, such as objectives and results.

Even though SSE is a condition of significant medical relevance (as some states report as one of the leading causes of medical care), policies aimed at controlling SSE in Mexico in recent years have been disjointed and inefficient in preventing the occurrence of new cases.

Health authorities emphasize that the decrease in mortality due to SSE is a sign of success; however, the strategies implemented do not solve the structural problem. So far, there are no data to analyze the availability of anti-scorpion fabotherapics nationwide; therefore, it is difficult to investigate the availability of treatment.

Health authorities have systematically ignored several demands such as improving SSE morbidity data, increasing training for medical personnel of the national health system regarding the correct application of treatments, and implementing prevention policies.

In future research, it is necessary to review the effect of preventive measures, such as improvements in housing (for example, replacing dirt floors with concrete or installing protective barriers on doors and windows) on the occurrence of SSE.

CONFLICT OF INTEREST

Raul Soria is the current Chief Operations Officer (COO) at Inosan Biopharma Group, a company dedicated to researching antivenoms; however, none of the stakeholders influenced this research. The Inosan Biopharma Group is committed to research and open access to knowledge.

Nayeli Velazquez and Rashid Hernandez currently work at Veteria Labs S.A de C.V, part of the Inosan Group firm. Like, Eng. Soria, none of the above co-authors were influenced in any form by the stakeholders of Inosan Biopharma or Veteria Labs.

REFERENCES

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All Rights Reserved® 2019

Latin American Journal of Clinical Sciences and Medical Technology,
Año 1, No. 1, octubre, 2019 es una publicación contínua editada por Vesalio S.C.; http://www.lajclinsci.com/    Editor responsable: Gilberto Castañeda Hernández.    Reserva de Derechos al Uso Exclusivo: 04-2019-062013242000-203; ISSN: 2683-2291; ambos otorgados por el Instituto Nacional del Derecho de Autor.    Responsable de la última actualización de este número, Web Master Hunahpú Velázquez Martínez,
Calle San Luis Potosí #182-1, Col. Roma, Alcaldía Cuauhtémoc, C.P. 06700, Ciudad de México; teléfono: 55 64 40 41    Fecha de última modificación, 30 de marzo de 2020.
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All Rights Reserved® 2019

Latin American Journal of Clinical Sciences and Medical Technology,
Año 1, No. 1, octubre, 2019 es una publicación contínua editada por Vesalio S.C.; http://www.lajclinsci.com/    Editor responsable: Gilberto Castañeda Hernández.    Reserva de Derechos al Uso Exclusivo: 04-2019-062013242000-203; ISSN: 2683-2291; ambos otorgados por el Instituto Nacional del Derecho de Autor.    Responsable de la última actualización de este número, Web Master Hunahpú Velázquez Martínez,
Calle San Luis Potosí #182-1, Col. Roma, Alcaldía Cuauhtémoc, C.P. 06700, Ciudad de México; teléfono: 55 64 40 41    Fecha de última modificación, 30 de marzo de 2020.