Accepted Manuscript Ten years of snakebites in Iran Rouhullah Dehghani, Behrooz Fathi, DVM PhD Morteza Panjeh Shahi, Mehrdad Jazayeri PII:
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DOI:
10.1016/j.toxicon.2014.08.063
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TOXCON 4907
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Received Date: 11 May 2014 Revised Date:
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Accepted Date: 14 August 2014
Please cite this article as: Dehghani, R., Fathi, B., Shahi, M.P., Jazayeri, M., Ten years of snakebites in Iran, Toxicon (2014), doi: 10.1016/j.toxicon.2014.08.063. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Ten years of snakebites in Iran Rouhullah Dehghani, a Behrooz Fathi, b* Morteza Panjeh Shahi, c Mehrdad
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Jazayeri, c
a
Department of Environment Health and Social Determinants of Health (SDH)
b
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Research Center, Kashan University of Medical Sciences, Kashan, Iran
Department of Pharmacology, School of Veterinary Medicine, Ferdowsi
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University of Mashhad, Mashhad, Iran c
Health Center of Kashan University Medical Sciences and Health Services,
*
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Kashan, Iran
Correspondence to: Behrooz Fathi DVM PhD E-mail:
[email protected] AC C
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Tel.:09159765651
[email protected] ACCEPTED MANUSCRIPT
Ten years of snakebites in Iran
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Abstract
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important species which are responsible for the most snakebite incidents in Iran
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belong to the Viperidae family, including Vipera lebetina, Echis carinatus,
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Pseudocerastes persicus, Vipera albicornuta, and the Elapidae family, especially
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Naja naja oxiana. At least one kind of venomous snake is found in each of the 31
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Many species of venomous snakes are found in Iran. The most medically
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snakebite is a considerable health hazard in Iran, especially in the rural area of
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south and south-west of Iran. A retrospective, descriptive study of snakebite in
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Iran during 2002-2011 was carried out in order based on data collected from
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medical records of bite victims admitted to hospitals and health centers. From
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2002 to 2011, 53,787 cases of snake bites were reported by medical centers in
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provinces, and many provinces have more than one venomous species. As a result,
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to 9.1 during this decade and the number of recorded deaths were about 67 cases.
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The highest rate of snakebite was found in provinces of south and southwest of
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Iran. We suggest that people, especially in the rural areas, need to be trained and
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Iran. The annual incidence of snake bites in 100,000 of population varied from 4.5
educated about venomous snakes, their hazards, prevention of bite and the
18
importance of early hospital referral and treatment of victims. Also adequate
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antivenins as the main life saving medicine should be made available based on the
20
recorded numbers of victims in each area of the country.
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Keywords: Venomous snakes, Snakebite, Epidemiology, Iran
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Venomous snakes are distributed in most parts of the world and they are a serious
26
threat to public health especially in the areas where they are most abundant
27
(WHO, 2007; Warrell, 2010). It has been estimated that annual snakebite incidents
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1. Introduction
29
20,000 to 125,000 deaths (Chippaux, 1998; Kasturiratne et al., 2008). According
30
to the reported snakebites in Asia, it has been estimated that the prevalence of
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are 4 to 5 million around the world which caused about 400,000 amputations and
32
deaths annually (Mion and Olive, 1997). Lack of necessary knowledge about the
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snakebite in this part of the world is about four million, leading to about 100,000
risk of venomous snakes may lead to higher rate of snakebites especially in the
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rural areas (Hansdak et al., 1998; Alirol et al., 2010).
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species are non-venomous, 27 species are venomous and 11 species are semi-
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Iran has a variety of reptilian fauna including 83 species of snakes. Of these, 45
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including Hydrophis cyanocinctus and Hydrophis lapemoides, have been
39
recognized in waters of Iran; however, there is no report of sea snakebite
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venomous (Latifi, 2000). In addition, more than five species of sea snakes,
envenomations (Latifi, 2000; Rezaie-Atagholipour et al., 2012).
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The 27 species of venomous snakes in Iran belong to the four Genera of Vipers,
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Crotalidaes, Elapids and Hydrophids, whereas 11species of semi-venomous
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snakes belong to the fifth Genera, the Colubrids (Farzanpaey, 1990; Latifi, 2000;
44
Dehghani, 2014). At least one kind of venomous snake is found in every
45
province of Iran; however, many provinces especially in the south of country
46
have more than one species of venomous snakes. In general, the most medically
47
important species which are responsible for the most snakebite incidents in Iran
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carinatus, Pseudocerastes persicus, Vipera albicornuta,
and the Elapidae
50
family, especially Naja naja oxiana (Fig. 2, 3) (Latifi, 2000; Firouz, 2005;
51
Vazirianzadeh et al., 2008).
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This retrospective, descriptive study of snakebite was conducted to collect
53
epidemiological data of snake bites in Iran from 2002 to 2011. The study was
54
carried out in order to aid the management of incidents, increase quality of
55
envenomation
of
promote
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government health policy and assist medical staff also to help people who are
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(Fig. 2, 3) belong to the Viperidae family, including Vipera lebetina, Echis
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increase
knowledge
researchers,
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treatment,
most at risk of snakebite and victims who have suffered envenoming.
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This is a retrospective, descriptive study of snakebite in Iran within a ten year
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period from March 2001 to March 2011. The data were collected in the form of
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designed questionnaire forms, from the medical records of 53787 snake-bite
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2. Methods and materials
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This study was carried out from an epidemiology viewpoint including: victims’
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gender, age, occupation and living place of the victims, along with their
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cases who were admitted to the health centers and hospitals all over the country.
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bitten part of the body, time of incident, offending snake, etc. The collected data
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symptoms and clinical conditions, antivenom therapy and other support cares,
were evaluated prospectively and statistically analyzed using Excel’s simple
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statistical functions, and then interpreted and presented in the form of tables and
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graphs.
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During 2002-2011, 53,787 snake bite victims were admitted to the health centres
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and hospitals of all provinces (Fig. 4). The results shows that the annual
93
incidence of snake bites in 100,000 of population were varied from 4.5 to 9.1
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3. Results
95
lowest in 2010 (4696), while the highest mortality occurred during 2005 (12) and
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the lowest in 2007 (3). Out of the 53,787 snake bite cases, there were 67 deaths
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(Fig. 5). The highest incidence of snake bite cases were in 2006 (6231) and the
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prevalence of snake bites and resulting deaths were recorded from Khuzestan and
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(0.12%) recorded (Fig. 6) (Table 1). Among the all provinces of Iran, the highest
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Baluchestan, Hormozgan, Fars and Kerman (Table 2). Although incidences of
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snakebites took place in many provinces, fatal cases were seen only
in
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Khuzestan (1), Hamadan (1), Hormozgan (1), Fars (1), Isfahan (1) and
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the lowest from Qum province. The next highest numbers were in Sistan and
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bites were not reported in North Khorasan province. The Ministry of Health and
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Medical Education reported that, the most victims of snake bites in 2011, were
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Charmahale Bakhtiyari (1) (Table 2). It should be noted that during 2011 snake
107
living place for rest (208/4%) of the cases were not reported. The reported gender
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people who lived in rural areas (3441/ 70%), and (1268/26%) in urban while, the
of victims was 3478 (70.7%) males and 1439 (29.3%) females in this year. Also
109
the highest rate of snake bites victims were in the 15-24 year old group (23 %),
110
followed by the group of 25-34 year old (21.7%) and 35-44 year old (14.1%),
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and the lowest rate of snake bites was reported among the victims less than
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5 years old (2.15%) (Fig. 7). One decade record, showed that most snake bites
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happened in summer, spring and fall season, with no reports of snakebite in
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(92.2%), followed by head and trunk 4.6%, and the rest of body (3.2%).
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weight, health condition, and also the offending snake, location of bite, amount of
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The recorded symptoms depend upon multiple factors including victims’ age,
119
different categories such as: local and systemic symptoms or mild, severe and
120
very severe symptoms etc., but in general the most common signs were recorded
121
as: pain at the site of bite, swelling, pain in lymphatic gland of bitten location,
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vomiting, headache, dizziness, diplopia, heavy eyelids, weakness, blister,
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injected venom and type of venom etc. The symptoms can be classified in
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been observed such as bruising and bleeding at the bite site, bleeding from
125
different part of the body like gums, subcutaneous bleeding, or spitting blood,
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hematuria, epistaxis and cerebral haemorrhage. Similar results were already
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reported in the smaller studies carried out by Besharat and Abbassi in 2008, 2009
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and Monzavi and colleagues in 2014 (Besharat et al., 2008; Besharat and Abbassi,
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2009; Monzavi et al., 2014). Although the precise identification of a snake which
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necrosis, and tachycardia. Related to Echis carinatus, some specific signs have
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that Echis carinatus to be responsible for the most mortality and morbidity cases
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is responsible for the most incidence of snakebites is difficult but it is believed
of snake bite in Iran.
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In 2011, out of 4917 snake bites cases, 4911 cases (99.9%) recovered, and of this
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96.4% by using antivenom and 3.6% without antivenom therapy and there were 6
135
deaths (0.1%) recorded. Because most of the time, victims were unable to
136
correctly identify the offending snake, medical staff used the antivenom based on
137
the snake fauna of the region or polyvalent antivenoms.
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intramuscular (IM) injection for 8.6%. The interval between bite and injection
140
antivenom was recorded as: for survival cases 61.8 % after 0-6 h, 21.3% after 6-
141
12 h and 13.3% after more than 12 h. All of the six fatal cases received snake
142
antivenom, five of them between 6 to 12 h and one of them more than 12 h post
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envenomation.
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The administration routes were intravenous (IV) injection for 91.4% of cases and
145
inflammatory, analgesics, fluid therapy and blood transfusion if necessary, steroid
146
therapy (Hydrocortizone) and Chlorpheramine for prevention of possible allergic
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Other supportive treatments for patients included: Antihistamine, Anti-
reaction. Wide spectrum antibiotics therapy such as cefazoline+ aminoglycoside
148
or, cefazoline+ clyndamycine or a mixture of ceftazidim+ clyndamycin and
149
aminoglycoside. Moreover, artificial ventilation was applied in patients with
150
difficulty breathing and fasciotomy in patients with extreme swelling.
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especially in South Asia (WHO, 2009; Molyneux, 2010). In spite of existence of
165
snakebite issue in most parts of Iran, there is no center for surveillance, record,
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Snakebite is a serious but neglected health issue in many tropical countries,
167
evidence that snake bite is a common problem in Iran, especially in rural areas.
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The present survey demonstrated that the frequency of snakebites in 100,000 of
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control or prevention of envenomation in this country. This study provides
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in ten years per 100,000 populations was 7.42. The highest rate of snakebites
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population was 4.5 to 9.1 during 2002 to 2011. The mean incidence of snakebites
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Khuzestan province). This may be due to their hot and dry weather and also their
173
higher number of venomous snakes.
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Most victims were males, likely this is because of their occupation like farming
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took place in South and Southwest provinces of Iran (the highest were seen in
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The high numbers of male victims suggest an amplified hazard from outside
177
activities (Tanen et al., 2001).
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and other outdoor activities which cause them to be more at risk of snakebite.
In this study, most cases of snakebite were in a group of 15-24 year age followed
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by 25-34 and 35 to 44 year old. In contrast, the least number of snakebites took
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place in children less than 5 years old and this was in agreement with the results
181
of earlier studies (Mal, 1994; Brunda and Sashidhar, 2007; Kassiri et al., 2012).
182
The results of our study showed that the peak occurrence of snake bite incidents
183
was in hot weather like the summer season. This is similar to findings of studies
184
in the Indian subcontinent, where reports indicated that between 50 to 94 percent
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Sashidhar, 2007). This may be because of more movements and activities of
187
reptiles and humans during hot weather than cold. Snakebites have a cyclic
188
model and frequently happen during the warmer months of the year. Therefore
189
raising people’s awareness in high risk areas by local media, training the rural
190
people in community places like mosques, schools and also by trusted people,
191
having a prevention plan by authority etc., during this time can improve the
192
situation and considerably decrease the risk of snakebites or possible mortality
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of snakebites occurred during the hot season (Srihari et al., 2001; Brunda and
194
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and also cost of treatment.
195
with studies in India (Chen and Winkel, 2001). They were bitten in agricultural
196
fields whereas working and while sleeping in the open air (Sharma et al., 2005).
197
In addition, the chance of snakebite may be increased by the tendency of mice,
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The high prevalence of snake bites (82%) in people of rural areas was consistent
199
warehouse of workplaces or farms especially grain farms (Brunda and Sashidhar,
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2007). Like many reports on snake bites (Tanen et al., 2001; Sharma et al., 2003;
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Hon et al., 2004; Alirol et al., 2010; Rahman et al., 2010; Habib and Abubakar,
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rats, lizards etc, to residential areas such as ruined or unfinished buildings and
2011) the majority of victims (92.2%) were bitten in the extremities like legs and
203
hands. In contrast, Plowman reported that two third of victims were bitten in
204
upper limbs (Plowman et al., 1995).
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The findings suggest that people who working in the area where snakes are
206
common should wear appropriate protective clothing. This should significantly
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reduce the number of snakebite cases. In general, most snake bite cases in Iran
208
were treated with antivenin which is the basis for treatment of envenomation. In
209
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polyvalent, are manufactured by the Razi Vaccine and Serum Research Institute.
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The polyvalent product can neutralize the venom of six venomous snake species
212
including, Naja naja oxiana,Vipera lebetina, Echis carinatus, Vipera
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albicornata, Pseudocerastes persicus, Agkistrodon halys. However it is much
214
better if the offending snake is identified and a more effective specific
215
monovalent antivenom applied (Dehghani et al., 2012).
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The accessibility of antivenom would be improved by increasing the production
217
of antivenoms, and the correct use of them in the care centers should be taught to
218
staff. The local health centers should be prepared and their staff should be
219
properly trained in diagnosis and treatment of snakebite envenoming. In addition,
220
understanding of the issue by collaboration among practitioners, epidemiologists,
221
and toxicologists should be increased (Warrell, 2010).
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Iran, three types of antivenoms (equine type), including mono-, tetra- and
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critical situation of snakebite, victim and other related issues. A health
224
information system should be established to improve the management of
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Training programs for people of rural area would help them to understand the
snakebite issue.
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In conclusion, epidemiology of snakebite in Iran is similar to other regions,
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especially in Asia. Since there is not a systematic organization to record all
228
aspects of snakebite in the whole country, therefore the snakebite consequences
229
may be higher than the documented records in this study. Therefore, our findings
230
may not reflect all aspects of snakebite during the study period. However, there is
231
no other comprehensive information in the literature about snakebite in all parts
232
of Iran.
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Alirol, E., Sharma, S.K., Bawaskar, H.S., Kuch, U., Chappuis, F., 2010. Snake
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Bite in South Asia: A Review. PLoS Negl Trop Dis. 4(1): e603. doi:10.1371/
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journal.pntd.0000603
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Table 1 Number of snake bites and resulting deaths in 100,000 of population in Iran
Year
2002
2003
2004
2005
2006
2007
2008
2009
Number
5609
5968
5791
5714
6231
4912
4777
5172
Incidence in
8.4
9.1
8.6
8.3
9
6.9
6.6
6.6
7
4
population 6
12
6
3
9
7
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Mortality
2010
2011
Total
Average
4696
4917
53787
5378.7
6.2
4.5
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100,000 of
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during 2002-2012.
7
6
67
7.42
6.7
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Table 2 Number of snake bites, during March 2011 to March 2012, in each province of Iran Grade Province
Urban Rural Total %
Deaths %
Khuzestan
275
651
926
18.8 1
16.7
2
Sistan and Baluchestan
212
290
502
10.2 -
-
3
Hormozgan
159
307
466
9.47 1
16.7
4
Fars
159
229
388
8.2
1
16.7
5
Kerman
119
210
329
6.9
-
-
6
Busher
144
173
317
6.7
-
7
Kermanshah
8
Lorestan
9
East Azerbaijan
10
Kohkiloye and
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187
223
4.7
-
35
166
201
4.2
-
39
150
189
4
-
-
3.7
-
-
47
-
131
178
20
124
144
3
-
-
35
96
131
2.7
-
-
21
101
122
2.5
-
-
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Boyerahmad
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1
Zanjan
12
Gilan
13
Golestan
14
West Azerbaijan
27
90
117
2.4
-
-
15
Kurdestan
26
81
107
2.2
1
16.7
Mazanderan
35
46
81
1.7
-
-
Ghazvin
34
45
79
1.6
-
-
Ardebil
6
42
48
1
-
-
19
Ilam
11
35
46
0.97 -
-
20
Isfahan
17
26
43
0.91 1
16.7
21
Razavi Khorasan
11
31
42
0.89 -
-
22
Charmahal e, Bakhtiyari
10
31
41
0.86 -
-
23
Tehran
10
29
39
0.82 -
-
17 18
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16
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11
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Hamadan
10
25
35
0.74 1
16.7
25
South Khorasan
9
21
30
0.63 -
-
26
Markazi
7
20
27
0.57 -
-
27
Yazd
13
13
26
0.55 -
-
28
Alborz
13
2
15
0.31 -
-
29
Semnan
4
9
13
0.27 -
-
30
Qum
8
4
12
0.25 -
-
31
North Khorasan
0
0
0
0.00 -
-
3365 4917 100
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Total
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24
6
100
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Captions:
Fig. 1. Distribution of snakebites in Iran.
Up: Echis carinatus (left), Vipera lebetina (right).
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Fig. 2. The most venomous snakes of Iran (author’s personal collection).
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Down: Pseudocerastes persicus (left), Naja naja oxiana (right).
Fig. 3. (A, B, C, D, E, and F) Distribution maps of six species of medically important snakes in Iran.
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Fig. 4. Number of snakebites in Iran during 2002-2011.
Fig. 5. Incidence of snakebites in 100.000 of population in Iran during 20022011.
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Fig. 6. Mortality rate of snakebites in Iran during 2002-2011.
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Fig. 7. Frequency of snakebites according to age groups in Iran during 2011.
ACCEPTED MANUSCRIPT Ardebil East Azerbaijan
Caspian Sea
West Azerbaijan
Hamadan
Semnan
Qum
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Kermanshah
Median Khorasan
Markazi Lorestan
Isfahan
South Khorasan Yazd
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Khuzestan
Kerman Charmahal e, Bakhtiyari
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Fars
Kohkiloye Boyerahmad
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Oman Sea
Fig. 1.
increase
Gilan Golestan Zanjan Ghazvin Mazanderan Kurdestan Alborz Tehran
North Khorasan
Sistan va Baluchestan
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Fig. 2.
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Caspian Sea
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Iran
Oman Sea
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A. Distribution of Macrovipera or Vipera lebetina in Iran
B. Distribution of Echis carinatus in Iran
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C. Distribution of Pseudocerstes persicus in Iran
D. Distribution of Naja naja oxiana in Iran
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E. Distribution of Vipera albicornuta in Iran
F. Distribution of Akistrodon halys in Iran
Fig. 3.
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7000 6231
5968 5791
6000
5714
5172
5609
4912
4917 4777
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5000 4696
4000
3000
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2000
0
0
2002
2003
2004
2005
2006
AC C
EP
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Fig. 4.
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1000
2007
2008
2009
2010
2011
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9
9 8.6
8.4
8.3
8 6.9 6.6
7
6.6 6.2
6 4.5
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5 4 3
1 0 2003
2004
2005
2006
2007
2008
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2002
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2
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Fig. 5.
2009
2010
2011
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12
10
7
7 6
6
6
6 4
4
3
0 2004
2005
2006
2007
2008
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2003
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2
2002
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Fig. 6.
7
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8
9
2009
2010
2011
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1200
1128 1070
800 694 573 538
600
371
200
106
5 to 14
15-24
35-44
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Fig. 7.
25-34
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0 less than 5
342
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400
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1000
45-54
55-64
195
more than unknown 64
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The manuscript highlights. 1-We report, for the first time the snake bite problem during one decade in Iran. 2- We show the prevalence of snake bite and resulting deaths in all provinces
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4- We show the main offending snake species in Iran
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3- The study develop guidelines for the management of snakebite in Iran
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Authors declaration: conflicts of interest statement
On behalf of Co-authors, I wish to confirm that there are no known conflicts of interest associated with this publication and also we declare that this study has
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been supported by fund from Kashan University of Health-IRAN. As corresponding author, I confirm that the manuscript has been read and
approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. I further confirm that the order of
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authors listed here and in the cover sheet has been approved by all of us.
On behalf of other authors, the corresponding author is the only contact for the
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Editorial process. I am responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address as follow:
Sincerely yours
Behrooz Fathi,
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Corresponding Author:
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second author;
[email protected] &
[email protected] First author Rouhullah Dehghani,
[email protected] Third author Morteza Panjeh Shahi,
[email protected] Forth author Mehrdad Jazayeri,
[email protected] ACCEPTED MANUSCRIPT
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Ethical statement The study did not need ethical approval.