Scorpionism in the State of Bahia,Brazil: A More Neglected Problem During the Pandemic?

Abstract

Introduction

During the confinement in the COVID-19 pandemic, there was an increase in the production of urban waste, increasing the risk of accidents caused by scorpions. We sought to determine the clinical and epidemiologic aspects of scorpionism records in the 7 mesoregions of the State of Bahia, Brazil, examining differences in periods before and during the pandemic.

Methods

Data were obtained from SINAN, Brazil's Notifiable Diseases Information System (January 2010–December 2021). Measures of morbidity (incidence and lethality) and mortality were evaluated, comparing the averages before (2018 and 2019) and during the pandemic (2020 and 2021). Sociodemographic data (ie, gender, age group, and race) and conditions of care (ie, time, classification, and evolution) were compared by mesoregion.

Results

A total of 159,982 cases of scorpionism were registered, with a higher proportion in the prepandemic period (P<0.05) and a higher average incidence in the Center South of Bahia (267.32; n=82,059; 51.29%). Most cases occurred in mixed-race individuals (61.73%), females (n=81,292; 51.22%), and individuals between 20 and 39 y of age (n=48,876; 30.55%) and most cases were classified as mild (n=136,816; 85.52%), were attended in <1 h (n=81,941; 51.22%), and progresses to cure (n=142,082; 88.81%). There were 263 deaths (0.16%), with a mortality rate of 1.77/100,000 inhabitants and a lethality of 0.16%.

Conclusion

It is suggested that during the COVID-19 pandemic, despite the upward curve of accidents, social isolation measures and collective fear may have decreased the search for medical care after a scorpion sting, reducing notifications of the condition in the State of Bahia.

Introduction

In Brazil, scorpionism is an important health problem, considering the significant increase in the number of cases and its high morbidity and mortality, especially in the Northeast region. ¹ Along with other accidents caused by arthropods, scorpion stings are responsible for the largest number of notifications in Brazil (67%). ² According to data from the Brazilian Ministry of Health, over the last 10 years, there has been a 149.3% increase in the number of notifications of envenomations caused by scorpionism, jumping from 64,162 in 2012, to 168,204 in 2019, 162,436 in 2020, and 159,934 in 2021. ³

Some postmodern factors may have contributed to this increase in scorpionism rates in Brazil, and this increase can be attributed to factors such as a more efficient notification system, the advance of deforestation, disorderly urban growth, and the rise in temperature and waste production. ⁴ In addition to these factors, although sexual reproduction is the norm in most scorpion families, some species within the Buthidae family reproduce by parthenogenesis, increasing the population of medically important scorpions that can come into contact with humans. ⁵

From an ecological point of view, urban ecosystems are totally dependent, but they have their own urban fauna. ⁶ It is therefore understood that scorpion envenomations occur mainly when their natural habitats are invaded, interrupted, or destroyed by humans. Urban spaces meet all the necessary conditions for the proliferation of these venomous synanthropes due to the existence of housing microclimates and the absence of natural predators. ⁷

Environmental changes resulting from human intervention have been occurring at levels incompatible with the support capacity of natural ecosystems. ⁸ Furthermore, the increase in population, along with accelerated urbanization and changes in the vegetation cover of natural areas, has resulted in the invasion of wild ecotopes and the devastation of ecosystems. Such actions cause an increase in the number of scorpionism records. ⁹ Scorpion accidents have been occurring for centuries, but the advancement of civilization and rapid urbanization have led to an increase in envenomation cases, particularly in rural areas, city outskirts, and even luxury condominiums in previously forested areas.^10,11

Since the declaration of the pandemic situation by the World Health Organization in 2020, there has been a change in the patterns of human societies, indicated by changes in behavioral, consumption, and mobility patterns. ¹² The changes in daily habits in the face of the COVID-19 pandemic are related to social isolation, and these changes, in turn, have translated into new environmental dynamics. The health crisis is also a humanitarian crisis resulting from the lack of basic conditions in some communities, related to difficulty in accessing water, sanitation, health, education, employment, and income. ¹³ Social isolation and the practice of teleworking, imposed in light of the emergence of the COVID-19 pandemic, promoted, among behavioral changes, an increase in the production of urban waste, ¹⁴ associated with the new habit of leaving shoes outside the home, making them a dark and safe refuge for scorpions, considering their ecological plasticity and general feeding habits. ¹⁵

The historical vulnerability of Brazil’s Northeastern states, such as Bahia, brings to light an even more challenging reality in times of pandemic. ¹⁶ Scorpionism must be discussed from the perspective of social factors that contribute to promoting the human-scorpion encounter. Socioeconomic disparities between Bahia's mesoregions can directly contribute to the high prevalence of scorpionism, and for this reason, identifying risk areas can improve our understanding of scorpionism patterns in the state. Thus, this study provides a comparative analysis of scorpionism in the mesoregions of the State of Bahia before and during the COVID-19 pandemic.

Methods

Ethical Aspects

Ethical and professional aspects were followed, maintained, and respected, as established by National Health Council Resolution No. 466, of December 12, 2012, which recommends that research involving only secondary data in the public and unrestricted domain, without nominal identification of research participants, does not require analysis by a research ethics committee.

Study Area

Bahia is a state in the northeast of Brazil and is made up of 417 municipalities, population of 14,136,417 inhabitants, with more than 71% of them residing in urban areas. ¹⁷ Bahia is the largest of the Northeastern states, with a territory covering an area of 564,760,427 km² (36.334% of the total area of the Northeast region). The state is divided into 7 mesoregions: Extremo Oeste Baiano (EOB), Vale São-Franciscano (VSF), Centro Norte Baiano (CNB), Centro Sul Baiano (CSB), Nordeste Baiano (NB), Metropolitana de Salvador (MS), and South Bahia (SB). Bahia has many different climates, but based on the Köppen-Geiger classification, the most predominant are tropical savannah climate (Aw) and hot semiarid climate (BSh). ¹⁸

Study Method and Data Source

A retrospective descriptive cross-sectional epidemiologic study of the clinical-epidemiologic and sociodemographic characteristics of cases of scorpionism registered between 2010 and 2021 was carried out using secondary data available on the Notifiable Diseases Information System (SINAN) platform of the SUS Informatic Department (DATASUS, http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinannet/animaisp/bases/animaisbrnet.def). The units of analysis were the 7 mesoregions of the State of Bahia, and the outcome variable was the number of cases of scorpionism. The other unit of analysis used refers to aggregate data relating to accidents and deaths caused by scorpionism. The following variables were used: exposure data (ie, municipality, area of occurrence, and time elapsed between the accident and care) and clinical characteristics of the patient (ie, presence of clinical manifestations, staging, use of serum therapy, and clinical evolution). Demographic and population variables were obtained using the Demographic Census database, made available by the Brazilian Institute of Geography and Statistics (IBGE).

Data Analysis

The ecological analytic design was used as an epidemiologic method of analysis, evaluating the association between the average level of exposure (sociodemographic variables) and the incidence of scorpionism in delimited geographic areas: mesoregions of the State of Bahia, comparing accidents in the period before and during the COVID-19 pandemic.

Descriptive Analysis

The data were compiled to determine the simple frequencies (n) and relative frequencies (%) of the variables referring to the injured individual and the accident (eg, gender, age group, municipality, severity, time until care, and clinical evolution). All data were tabulated into spreadsheets and presented in the form of contingency tables and graphs prepared in the Excel program on Windows version 10 (Microsoft Corp, Redmond, WA). This stage also consisted of estimating measures of morbidity (incidence and lethality) and mortality for each mesoregion, from comparisons of the incidence averages from the prepandemic period (2018 and 2019) with those of the pandemic period (2020 and 2021) using the proportion test, with a significance level of 5%.

Sociodemographic Analysis

Sociodemographic data (ie, gender, age group, and race) and case-management conditions (ie, time of care, classification, and evolution) were compared by mesoregion using Pearson's χ² test, significance of 5%, evaluating the association, or dependence, between the observed variables and the number of cases. The unit of analysis was the mesoregions of Bahia, and the outcome variable was the number of cases of scorpionism (P≤5%). For statistical analysis, the R-Project software version 3.6.2 (R Core Team, Vienna, Austria) was used. For numerical variables, measures of central tendency and dispersion were used, and for demographic variables and scorpionism, the Fisher exact test was used.

Mapping of Risk Areas (Hotspots)

For the analysis, a matrix was produced that indicates for each pair of mesoregions whether they can be considered equal or different in relation to the incidence of scorpionism. Thus, a georelational database was created through the connection between tabular data and geospatial features (QGIS 3.18) to create kernel density maps using the georelational database and the vector files (shapefiles) database available at the National Semi-Arid Institute/Brazilian Semi-Arid Information and Knowledge Management System and IBGE. Using geoprocessing techniques, spatial analyses were carried out to visualize the distribution/concentration of the phenomenon.

Results

Between 2010 and 2021, a total of 159,982 cases of scorpionism were recorded in the State of Bahia, with clusters of municipalities showing a higher average incidence in the CSB (n=82,059 cases), which is equivalent to 51.29% of total accidents, followed by the CNB, with 26,760 cases (16.73%) and the EOB, with 14,110 cases (8.82%) (Figure 1).

Figure 1.

Incidence of scorpionism by mesoregion of the State of Bahia (2010–2021). CNB, Centro Norte Baiano; CSB, Centro Sul Baiano; EOB, Extremo Oeste Baiano; MS, Metropolitana de Salvador; NB, Nordeste Baiano; SB, Sul Baiano; VSF, São-Franciscano (VSF).

The average incidence of scorpionism cases, distributed according to each mesoregion of the state, in the period studied (Table 1) showed that the years 2018 and 2019 presented the highest values, especially in the CSB (267.32/100,000) and the EOB (186.54/100,000), with mortality and lethality rates of 0.45 and 0.30, respectively. However, lethality was higher in the VSF (0.35) and SB (0.24) mesoregions.

Table 1.

Epidemiologic variables of registered cases of scorpionism in the mesoregions of State of Bahia (2010–2021).

	Mesoregions (incidence a/year)
Year	CNB (n=26,760; 16.73%)	CSB (n=82,059; 51.29%)	EOB (n=14,110; 8.82%)	MS (n=8416; 5.26%)	NB (n=7160; 4.48%)	SB (n=15,073; 9.42%)	VSF (n=6404; 4%)
2010	61.38	213.06	91.98	10.19	8.05	28.32	28.34
2011	67.92	245.88	111.67	14.92	12.10	34.49	39.95
2012	56.02	200.90	127.94	13.35	18.34	33.78	31.61
2013	68.57	205.38	184.39	11.58	25.24	38.93	45.90
2014	64.63	238.86	191.96	14.76	24.52	46.96	42.52
2015	73.09	189.79	154.56	13.63	21.31	38.95	39.50
2016	62.17	171.32	142.78	13.06	26.21	36.13	32.86
2017	89.59	252.64	172.08	24.05	42.38	63.72	57.09
2018	150.51	400.94	283.64	21.56	65.34	72.36	87.04
2019	155.45	414.09	293.79	17.84	87.33	55.69	95.73
2020	147.45	365.13	244.20	15.22	64.03	67.33	72.38
2021	128.67	309.86	239.49	14.43	53.14	70.93	46.33
Incidence	93.79	267.32	186.54	15.38	37.33	48.97	51.6
Mortality	0.11	0.45	0.30	0.02	0.06	0.10	0.13
Lethality (%)	0.12	0.19	0.16	0.17	0.15	0.24	0.35

CNB, Centro Norte Baiano; CSB, Centro Sul Baiano; EOB, Extremo Oeste Baiano; MS, Metropolitana de Salvador; NB, Nordeste Baiano; SB, Sul Baiano; VSF, Vale São-Franciscano.

^a

Incidences (cases/population × 100,000) and mortality rates (deaths/population × 100,000) expressed per 100,000 inhabitants and lethality (total deaths/total cases × 100) expressed as a percentage.

Source: Notifiable Diseases Information System (SINAN, 2022).

Females were the most affected by scorpionism in Bahia (51.22%), but with no significant difference between the sexes (Table 2). However, the results of the χ² test indicated dependence between the sexes in the SB mesoregion, with the male population (n=9834) being more affected than the female population (n=5232), whereas in the CNB mesoregion, the female population (n=14,863) was more affected by scorpionism than the male population (n=11,887).

Table 2.

Sociodemographic data of registered cases of scorpionism in the State of Bahia (2010 to 2021).

Variable		N	%
Sex a
Male		78,630	49.15
Female		81,292	50.81
	Total	159,922	99.96
Age range (y)
<1		3571	2.23
1–4		8143	5.09
5–9		11,886	7.43
10–14		14,943	9.34
15–19		48,876	30.55
20–39		38,639	24.15
40–59		10,611	6.63
60–64		7169	4.48
65–69		5762	3.60
70–79		7137	4.46
≥80		3076	1.92
	Total	159,813	100
Race
Asian		1358	0.85
White		18,751	11.72
Brazilian Indigenous		826.00	0.52
Latino		98,761	61.73
Black		15,834	9.90
Ignored		24,452	15.28
	Total	159,982	100

^a

Uninformed data were removed from the calculation.

Source: Notifiable Diseases Information System (SINAN, 2022).

The age groups most affected by scorpionism in Bahia were aged between 20 and 39 y (30.55%) and between 40 and 59 y (24.15%). Age dependency was found in the NB mesoregion, with children (aged 1–14 y) and young people (aged 15–19 y) being the most affected groups, with 2285 and 2361 cases, respectively. The adult population (aged 20–64 y) was most affected in the MS mesoregion (n=5899), whereas the elderly (aged >65 y) were most affected in the CSB mesoregion (n=9242).

Sociodemographic data on scorpionism in the period studied revealed that the most affected ethnic groups were mixed race with 61.73% of accidents, whites (11.72%) and Blacks (9.9%), highlighting the large number of cases where race was ignored (15.28%). White individuals were most affected in the CSB mesoregion (n=12,691), Black individuals in the MS (n=1567), Asian individuals (n=621) and mixed-race individuals (n=50,079) in the EOB, and Indigenous individuals in the SB (n=320).

Epidemiologic data on patient care time in the State of Bahia revealed that 51.22% of cases required 1 h or less to be seen, and 26.46% were seen between 1 and 3 h after an accident (Table 3). However, the CS mesoregion presented the highest number of visits within 3 h after the accident (n=66,845) and the SB mesoregion from 3 to 12 h (n=2137), whereas the NB (n=420) and SB (n=817) mesoregions had a longer time to assist an injured person (>12 h).

Table 3.

Epidemiologic data of scorpionism in the State of Bahia, Brazil (2010–2021).

Variable		n	%
Time from sting until assistance (h)
Unknown		15,578	9.74
0–1		81,941	51.22
1–3		42,331	26.46
3–6		3236	2.02
6–12		2057	1.29
12–24		10,330	6.46
≥24		4509	2.82
	Total	144,404	100
Case evolution
Unknown		17,615	11.01
Cured		142,082	88.81
Death due to the notified condition		263.00	0.16
Death due to another condition		22.00	0.01
	Total	159,982	100
Classification of case
Unknown		7683	4.8
Mild		1331	0.83
Moderate		136,816	85.52
Severe		14,152	8.85
	Total	159,982	100

Source: Notifiable Diseases Information System (SINAN, 2022) and Mortality Information System (SIM, 2022).

Of the total number of accidents recorded, 142,082 cases (88.81%) occurred in the warmer months of the year and resulted in a cure, with no dependence observed in any of the state's mesoregions. Regarding the final classification, most patients presented with mild clinical signs (85.52%), whereas severe cases totaled 1331 (0.83%). Mild cases were more dependent in the CNB mesoregion (n=23,872) and moderate (n=1827) and severe (n=242) cases in the EOB. Deaths from scorpion stings in the State of Bahia totaled 263 cases (0.16%), and of these, 41.8% (n=110) underwent serum therapy, and 58.2% (n=64) were aged between 1 and 9 y, demonstrating a greater risk of this envenomation for young individuals.

Although the data show a growth trend curve for the State of Bahia over the years, when comparing the average incidences of the period between the prepandemic (2018 and 2019) and the COVID-19 pandemic (2020 and 2021), there was a higher proportion of scorpion accidents in the prepandemic period (P<0.05) (Figure 2).

Figure 2.

Total number of cases of scorpionism in Bahia (2010–2021) and trend line (blue) calculated from a linear model, with error range (gray area), from the 95% confidence interval.

When applying the kernel density technique, the optimized hotspot analysis tool showed a heterogeneous geographic distribution, with spatial clusters with high incidence values of scorpionism in the most central areas of Bahia, mainly in the central coastal areas, contrasting with less frequent records of envenomations in areas to the north and east of the etate (Figures 3 and 4). Temporal analysis showed a growth trend in cases, with a peak in 2019 (before the COVID-19 pandemic) and a sharp reduction in notifications in 2020 (the height of the COVID-19 pandemic), with growth resuming in 2021 (Figure 4).

Figure 3.

Kernel density estimate of scorpionism cases in the State of Bahia (2010–2015). Radius parameter of 100 km, pixel of 1000 m, quartic method.

Figure 4.

Kernel density estimate of scorpionism cases in the State of Bahia (2016–2021). Radius parameter of 100 km, pixel of 1000 m, quartic method.

Discussion

The annual rates of accidents caused by venomous animals have grown over time in Brazil, with almost double the number of accidents from 2007 to 2021. ¹⁹ During the period studied, there was a large increase in the incidence of scorpionism in the State of Bahia, especially between 2018 and 2021 in the CSB, CNB, and EOB mesoregions. Previous study attributed this growth to the improvement of the notification system and the greater search for hospital care, ¹⁵ but it also represents the high plasticity of some species of scorpions in anthropically altered environments.^20,21

Climate change, chaotic urban expansion, rapid industrial development, the unsustainable use of natural resources, the expansion of agricultural frontiers, the elimination of natural predators, and the imbalance in ecosystems are factors that can help the expansion of scorpions in the environment. ¹⁹ As a result, the areas occupied by humans and scorpions tend to overlap. As the human population grows and urban areas expand, the original habitats of scorpions are often lost, altered, or fragmented. In this study, the population distribution data in Bahia precisely overlap with the incidence data of scorpionism, confirming their synanthropic nature. Generally, the coastal areas of Bahia are more industrially active, populated, and developed, whereas the Caatinga biome regions are socioeconomically more deprived. ²²

Brazil has a continental dimension and marked social inequalities, with millions of Brazilians living in precarious socioeconomic conditions. ²³ Bahia is the largest state in the Northeast region, and despite having one of the largest gross domestic products in Brazil, it occupies position 21 in the Brazilian ranking of the Human Development Index. These data reveal that despite economic growth in the state, many people still live in precarious conditions with restricted access to education and healthcare. ²⁴ The State of Bahia has the highest absolute number of notifications of accidents caused by venomous animals in the Northeast region, with an average incidence of 98 cases per 100,000 inhabitants per year. There is a direct and proportional association between the incidence of scorpionism cases in Brazil and territories with healthcare weaknesses. ²⁵

It is common sense that when cities grow, the number of households increases, and so does the production of domestic waste, which can be an important factor in the increase in cases of scorpionism. However, the 2022 Census revealed that Bahia, despite being the fourth most populous state in Brazil, showed below-average growth (0.9%), which did not impact the growth in cases of scorpion accidents. ¹⁷ A recent study showed a high incidence of scorpion envenomation in socially vulnerable municipalities and, paradoxically, in those with better sanitation and garbage collection, which means that other factors must influence the increase in cases. ²³

Data from the Brazilian Association of Public Cleaning and Special Waste Companies (ABRELPE) reveal that quarantine and social isolation during the COVID-19 pandemic generated a 15 to 25% increase in the amount of residential waste in Brazil. ²⁶ Not only did the increase in waste production contribute to the increase in the number of scorpion accidents, but also another new habit that emerged with the pandemic, that of leaving shoes outside the house, making this accessory a dark and safe refuge for scorpions. ²⁷ Although the Brazilian Association of Public Cleaning and Special Waste Companies data show that the conditions established during the pandemic would be conducive to the growth of scorpionism, the number of cases in Bahia during this period did not follow this trend. This may indicate that accident victims avoided medical care after the accident, leading to a reduction in case reports.

Our study did not show a significant difference in the number of cases of scorpionism between men and women in Bahia, corroborating the previous study that showed that in Brazil, unlike what happens with snakebites, which occur mostly in men in the agricultural sector, scorpionism occur proportionally in both sexes. ²⁸ The male:female ratio may vary according to the type of occupation of each group. Several studies have shown a higher incidence of scorpionism among women employed in domestic services,^29–31 as observed in the CNB mesoregion. ³² However, other studies have found that most scorpionism cases occur in men, as observed in the SB mesoregion. This indicates that the occupational environment can directly influence the profile of affected individuals. ²⁸ Therefore, it is suggested that considering that the North, Northeast, and Central-West regions have a considerable proportion of rural municipalities, this favors the risk of contact between field workers and venomous animals, regardless of sex. ²¹

The age groups most affected by scorpion accidents in Bahia were between 20 and 59 y of age, totaling 54.7% of registered cases. These numbers corroborate previous studies for Bahia and the Northeast region.^19,33 A previous study showed that there was an upward trend in cases of scorpionism in Brazil regardless of age group. ¹⁹ The notification of scorpionism cases may be associated with several local factors, such as the biology and natural behavior of animals, related to geographic distribution, climatic conditions, and the availability of habitats favorable to scorpions. ²⁸

According to data from the 2022 National Household Sample Survey of the Brazilian Institute of Geography and Statistics, it is estimated that 42.8% of Brazilians declare their race as white, 45.3% as Latino, 10.3% as Black, and 1.6% as Asian or Brazilian Indigenous. Our study showed that in Bahia, Latino people seem to be the group most affected by scorpionism (61.73%), a constant trend over the years. This higher incidence in the Latino population may be related to factors such as greater social vulnerability, resulting in worse housing, sanitation, and waste-management conditions, exposing this group to venomous synanthropic animals such as scorpions.^28,29

Chronic anthropogenic disturbance, unlike acute disturbance, which promotes immediate habitat replacement, results in severe alteration of the phylogenetic and functional diversity of species.^5,33 Habitat degradation can negatively affect the distribution of scorpion species. Changes in landscape configuration influence the composition of scorpions but not species richness, which indicates that there is greater species turnover in anthropically disturbed environments.^34,35 The discussion of anthropogenic disturbances, although not directly analyzed in our results, provides a broader context for understanding environmental impacts on scorpion populations. These disturbances can alter habitats, potentially affecting scorpion behavior and human interaction rates.

Of the 4 species of scorpions of medical importance in Brazil, the distribution of 3 species is related to population density. This factor, associated with investments in public health and distances and accessibility to health centers, shows the North and Northeast regions of Brazil to have the highest priority for investment in prevention and mortality caused by scorpionism. ²⁰ In the SB and VSF mesoregions, among the main taxa of medical importance we find Tityus stigmuros (Thorel, 1876) and Tityus serrulatus (Lutz & Mello, 1922), the latter being responsible for the highest lethality rate considering the high toxicity of its venom, its ecological plasticity, its generalist feeding habits, and its parthenogenetic form of reproduction. ²⁸

The data on time of care, evolution of the case, and severity of the scorpion envenomation showed that most patients were treated within 1 h of the sting and progressed to cure, and the cases were classified as mild. However, the NB and SB mesoregions had a longer time to assist injured people. Studies indicate that age and timely to arrival at specialized care are critical factors in the prognosis of scorpionism. Younger children, particularly those up to 9 y of age, are at higher risk due to higher venom concentrations relative to their smaller body size, and timely treatment is crucial for improving outcomes.^32,35

The data from the kernel maps revealed that the main area affected by scorpion accidents is the region that encompasses the microregions of SB and CSB, where we found that a kind of dispersal corridor. Scorpions are low-dispersal animals, but factors such as habitat complexity and the level of anthropogenic disturbance can determine species richness and abundance patterns.^33,36 It appears that the two mesoregions (SB and CSB) had more male victims, predominantly from the Indigenous population, and a higher average incidence of scorpionism, especially among the elderly, respectively. These mesoregions may act as dispersal corridors, as indicated by the kernel map. Although scorpions are animals with low-dispersal capabilities, factors such as habitat complexity and anthropogenic disturbances can influence species richness and abundance patterns, potentially contributing to the higher fatality rate observed.

The State of Bahia accounts for ∼30% of notifications in the Northeast region and has the highest mortality rate from scorpionism. ³³ However, the number of reported scorpion incidents decreased during the COVID-19 pandemic not only in the State of Bahia, as shown in our study, but throughout Brazil, including cases involving other venomous animals. ³⁷ Therefore, the pandemic significantly impacted data on notifiable diseases. Health authorities prioritized hospital care for COVID-19 patients, which led to overwhelmed healthcare systems due to the surge in patients and limited resources. This, in turn, affected the treatment of scorpionism patients.^27,38 Additionally, there is a direct correlation between socioeconomic factors and incidents involving venomous animals. Areas with significant inequalities often have poorer living conditions, inadequate sanitation, substandard housing, overcrowding, and limited access to healthcare services.

Limitations

Among the limitations of our study, we can highlight the problem of underreporting of cases of scorpion stings, which have already been documented even in periods before and after the COVID-19 pandemic; possible recording or typing errors in secondary data from SINAN; incomplete forms; and the lack of training of health teams. However, in addition to the problems with the notification form, SINAN does not provide information on the species of scorpions involved in cases of envenomation and death, as is the case with other venomous animals, such as snakes and spiders. Thus, these forms are collected in total and cannot be checked individually due to obvious logistics.

Since most accidents in Brazil involve scorpions of the genus Tytius, there is only one type of scorpion antivenom applied, and for this reason, there is no identification of the animal's species. However, accumulated data have indicated that the available antivenom is inadequately effective in treating accidents involving species such as T. obscurus, T. apiacas, and T. strandi. Furthermore, some species, such as Rhopalurus amazonicus, are emerging as clinically significant in Brazil. These realities emphasize the increasing attention and effort to identify species responsible for envenomation cases, seeking to establish evidence-based species-specific medical risk profiles as well as to determine which of them cannot be treated effectively with currently available antivenoms.

The lack of species identification at the time of care is a problem that has reduced the quality of evidence in the literature on clinical toxinology, thus impacting future patient management. This also prevents more accurate epidemiologic studies on the regional distribution of cases, according to the scorpion species involved. In addition, it is difficult to obtain updated data on social vulnerability factors, especially in 2020, when the Brazilian Census was not conducted by IBGE. Therefore, it is necessary to implement improvements in compulsory reporting practices and expand healthcare in cases of scorpion stings.

Conclusion

The study showed an increasing trend in the number of cases of scorpionism in Bahia, with the CSB and SB mesoregions being most affected. It is suggested that during the COVID-19 pandemic, the social isolation measures adopted in 2020, combined with the prioritization of hospitals for treating COVID-19 patients and various socioeconomic factors, potentially played a significant role in reducing scorpion sting notifications. Scorpionism is a complex problem, which makes socioenvironmental design associated with more efficient health surveillance actions difficult. Given this, our findings highlight the need to monitor scorpionism through epidemiologic surveillance in the State of Bahia.