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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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]

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Tel.:09159765651

[email protected]

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Ten years of snakebites in Iran

1

Abstract

2

3

important species which are responsible for the most snakebite incidents in Iran

4

belong to the Viperidae family, including Vipera lebetina, Echis carinatus,

5

Pseudocerastes persicus, Vipera albicornuta, and the Elapidae family, especially

6

Naja naja oxiana. At least one kind of venomous snake is found in each of the 31

7

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Many species of venomous snakes are found in Iran. The most medically

8

snakebite is a considerable health hazard in Iran, especially in the rural area of

9

south and south-west of Iran. A retrospective, descriptive study of snakebite in

10

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

16

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

19

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.

21

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

28

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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

31

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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

33

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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

34

rural areas (Hansdak et al., 1998; Alirol et al., 2010).

35

36

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

38

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

43

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

48

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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).

52

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49

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

56

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

58

increase

knowledge

researchers,

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treatment,

most at risk of snakebite and victims who have suffered envenoming.

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67

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69

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This is a retrospective, descriptive study of snakebite in Iran within a ten year

71

period from March 2001 to March 2011. The data were collected in the form of

72

designed questionnaire forms, from the medical records of 53787 snake-bite

73

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2. Methods and materials

74

This study was carried out from an epidemiology viewpoint including: victims’

75

gender, age, occupation and living place of the victims, along with their

76

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cases who were admitted to the health centers and hospitals all over the country.

77

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

79

statistical functions, and then interpreted and presented in the form of tables and

80

graphs.

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87

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90

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During 2002-2011, 53,787 snake bite victims were admitted to the health centres

92

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

94

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3. Results

95

lowest in 2010 (4696), while the highest mortality occurred during 2005 (12) and

96

the lowest in 2007 (3). Out of the 53,787 snake bite cases, there were 67 deaths

97

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(Fig. 5). The highest incidence of snake bite cases were in 2006 (6231) and the

98

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

100

Baluchestan, Hormozgan, Fars and Kerman (Table 2). Although incidences of

101

snakebites took place in many provinces, fatal cases were seen only

in

102

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

104

bites were not reported in North Khorasan province. The Ministry of Health and

105

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

108

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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%),

111

and the lowest rate of snake bites was reported among the victims less than

112

5 years old (2.15%) (Fig. 7). One decade record, showed that most snake bites

113

happened in summer, spring and fall season, with no reports of snakebite in

114

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ACCEPTED MANUSCRIPT winter. Legs and hands were the most frequently bitten parts of the victims’ body

115

(92.2%), followed by head and trunk 4.6%, and the rest of body (3.2%).

116

117

weight, health condition, and also the offending snake, location of bite, amount of

118

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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,

122

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

124

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,

126

hematuria, epistaxis and cerebral haemorrhage. Similar results were already

127

reported in the smaller studies carried out by Besharat and Abbassi in 2008, 2009

128

and Monzavi and colleagues in 2014 (Besharat et al., 2008; Besharat and Abbassi,

129

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

131

that Echis carinatus to be responsible for the most mortality and morbidity cases

132

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is responsible for the most incidence of snakebites is difficult but it is believed

of snake bite in Iran.

133

In 2011, out of 4917 snake bites cases, 4911 cases (99.9%) recovered, and of this

134

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.

138

6

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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

143

envenomation.

144

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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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154 155

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156 157 158 159 160 161 162

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163

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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,

166

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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.

168

The present survey demonstrated that the frequency of snakebites in 100,000 of

169

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control or prevention of envenomation in this country. This study provides

170

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

172

Khuzestan province). This may be due to their hot and dry weather and also their

173

higher number of venomous snakes.

174

Most victims were males, likely this is because of their occupation like farming

175

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took place in South and Southwest provinces of Iran (the highest were seen in

176

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

180

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

185

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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

193

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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,

200

2007). Like many reports on snake bites (Tanen et al., 2001; Sharma et al., 2003;

201

Hon et al., 2004; Alirol et al., 2010; Rahman et al., 2010; Habib and Abubakar,

202

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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).

205

The findings suggest that people who working in the area where snakes are

206

common should wear appropriate protective clothing. This should significantly

207

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

9

210

polyvalent, are manufactured by the Razi Vaccine and Serum Research Institute.

211

The polyvalent product can neutralize the venom of six venomous snake species

212

including, Naja naja oxiana,Vipera lebetina, Echis carinatus, Vipera

213

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).

216

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

225

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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,

227

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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ACCEPTED MANUSCRIPT 234 235

Alirol, E., Sharma, S.K., Bawaskar, H.S., Kuch, U., Chappuis, F., 2010. Snake

236

Bite in South Asia: A Review. PLoS Negl Trop Dis. 4(1): e603. doi:10.1371/

237

journal.pntd.0000603

238

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References:

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from Andhra Pradesh using immunoanalytical approach. Indian J Med Res.

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Brunda, G., Sashidhar, R.B., 2007. Epidemiological profile of snake-bite cases

125(5): 661-668.

241

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series of 100 cases of snake bites in Loghman Hospital between 2000-2005.

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Pajoohandeh Journal 13 (4): 315-320. In Persian.

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Besharat, M., Abbasi, F., 2009. Snake bite in Iran: diagnosis,

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prevention, treatment. Journal of Medical Council of Islamic

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Republic of Iran 27 (1): 63-76. In Persian.

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Chen, A.C., Winkel, K., 2001. Call for global snake-bite control and

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procurement funding. Lancet 357(9262): 1132 p.

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Chippaux, J.P., 1998. Snake-bites: appraisal of the global situation. Bull World

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Besharat, M., Vahdani, P., Abbasi, F., Korooni Fardkhani, S., 2008. Reporting a

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Dehghani, R., Mehrpour, O., Panjeh Shahi, M., Jazayeri, M., Karrari, P., Keyler,

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D., Zamani, N., 2014. Epidemiology of venomous and semi-venomous

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snakebites (Ophidia: Viperidae, Colubridae) in the Kashan city of the Isfahan

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province in Central Iran. JRMS_423_12R6_OA (In press)

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Incidence of snake bites in Kashan, Iran during an Eight - year period (2004 -

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2011). Archives of Trauma Research 1, 67- 71.

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Farzanpey, R., 1990. Ophiology. Tehran: Central University Publications No.

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Dehghani, R., Panjeh Shahi, M., Jazayeri, M., Sabahi Bidgoli, M., 2012.

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Firouz, E., 2005. The complete fauna of Iran. London: I. B. Tauris.

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Habib, A.G., Abubakar, S.B., 2011. Factors affecting snake bite mortality in

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Hansdak, S.G., Lallar, K.S., Pokharel P., Shyangwa, P., Karki, P., Koirala, S.,

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1998. A clinico- epidemiolog ical study of snake bite in Nepal. Trop Doct.

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28(4): 223– 226.

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Hon, K.L., Kwok, L.W., Leung, T.F., 2004. Snakebites in children in the

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densely populated city of Hong Kong: a 10-year survey. Acta Paediatr. 93(2):

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Kassiri, H., Naghibzadeh, R., Kavosi-Asl, P., 2012. An epidemiological study of

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Kasturiratne, A., Wickremasinghe, A.R., de Silva, N., et al., 2008. The global

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burden of snakebite: a literature analysis and modeling based on regional

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estimates of envenoming and deaths. PLoS Med. 5(11), e218.

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Latifi M. 2000. The Snakes of Iran. Published by Environment Protection

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organization, Tehran, 478 pp. (in Persian, with Latin index).

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Mion, G., Olive, F., 1997. Les envenimations par vipéridés en Afrique Noire.

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In: Saissy JM, ed. Réanimation tropicale. Paris: Arnette, 349–366.

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Molyneux, D.H., 2010. Neglected tropical diseases--beyond the tipping point?

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Med. 26(1): 36-38.

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course of rattlesnake envenomations cared for at a tertiary referral center in

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India. 11(2): 497-500.

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Warrell, D. A., 2010. Snake bite. Lancet 375: 77–88.

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neglected public health issue: Report of a consultative meeting. Geneva:

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Available: http://www.who i n t/blood products/animals_sera/Rabies

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World Health Organization (WHO), 2007. Rabies and envenomings. A

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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

AC C

16

EP

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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1552

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EP

TE D

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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

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TE D

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

SC

2

AC C

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TE D

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

SC

2

2002

AC C

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TE D

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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TE D

Fig. 7.

25-34

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0 less than 5

342

SC

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]

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Ethical statement The study did not need ethical approval.

Ten years of snakebites in Iran.

Many species of venomous snakes are found in Iran. The most medically important species which are responsible for the most snakebite incidents in Iran...
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