- Open Access
The international view of envenoming in Brazil: myths and realities
© Bochner; licensee BioMed Central Ltd. 2013
- Received: 7 November 2013
- Accepted: 7 November 2013
- Published: 11 November 2013
Being distant from Brazil’s great natural diversity, from its long tradition in the study of snakebites and from the fact that it is one of the few countries which has a national information system for monitoring incidents involving venomous animals, non-Brazilian researchers face risks when estimating the incidence of these accidents in the country. The present work offers a critical review of the main estimates undertaken since 1954. It is interesting to note contradictions between textual and graphic information within the same article, variations over time in the work of a same researcher and differences among distinct authors, and that all these issues remain unmentioned or undiscussed. Comparison among such estimates and the data available at the Brazilian Information System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação – SINAN) creates an opportunity to identify the degree of imprecision present in those articles, and draws attention to the need for the production of studies at both the regional and national levels, based on concrete data collected at national, state and municipal levels, which has been available on the internet since 2001.
- Information systems
Brazil is a country of continental dimensions, encompassing 515,767,049 km2 divided into five regions, each presenting geographic, environmental, socioeconomic, cultural and political variations. Given this diversity, it is not difficult to understand the statement of some researchers: “Brazil is a country without standards”. How can one combine data from the extremes of Oiapoque in the north with data from Chuí in the south? How to mix data from Bahia with that from São Paulo? Regardless of the envenoming case studied, one cannot jump into calculations without taking into account the characteristics and diversity of this immense country.
The situation is even more serious when the object of study also depends on the distribution of animals throughout the length of the country, as is the case with accidents involving venomous animals.
Non-Brazilian researchers, then, being unaware of all this complexity, may be taking a risk in estimating the prevalence of envenomings by animals for Brazil as a whole, based solely on data from one or more states or even from a few municipalities. The results are impressive.
The first estimate of cases of, and deaths from, snakebite in the world was undertaken in 1954 by Swaroop and Grab . They presented a range between 30,000 and 40,000 annual deaths globally (without including the Soviet Bloc, China or the countries of Central Europe). Within this total, the largest figures were for Asia (25,000 to 35,000) and South America (3,000 to 4,000). For Africa, the authors explained that calculation was difficult and ended up estimating the number of deaths as between 400 and 1,000. In regard to the total number of global cases, they admitted that estimation was difficult, but hazarded an initial guess of around half a million people annually bitten by both poisonous and non-poisonous snakes.
In 1998, Chippaux  challenged Swaroop and Grab’s  figures, labeling them severe underestimations. According to him, the true incidence of snake envenoming in the world is in excess of five million cases annually, with 125,000 deaths . In 2000, White  estimated at more than three million the envenomings by snakes per year, leading to more than 150,000 deaths. In regard to Brazil, Chippaux  suggested an incidence between 350 and 450 per 100,000 (household survey), morbidity of 6.8 to 192 per 100,000 (hospital records), mortality of 0.4 per 100,000 (Southwest region) and of 0.4 to 5 (North region) and lethalness 0.4 to 6.5%. The sources of his data were six articles and a summary of a poster, none of which was based on national coverage. Four of the articles presented data from the state of São Paulo [10–13], one contained data from the state of Minas Gerais , the last used figures from the state of Acre  and the poster presented data from 24 municipalities in the state of Amazonas .
The limited number of country-wide studies was pointed out by Bochner and Struchiner , when they identified that only four were published in the 20th century: two in 1989 considered to be grey literature [18, 19], one in 1993  and one in 1998 . This last was published by the Brazilian Ministry of Health and consists of a manual for the diagnosis and treatment of attacks by venomous animals. It also contains national data for the years 1990 to 1993, despite having been published in 1998 and republished in 2001 . According to this manual, from January 1990 to December 1993 there were a total of 81,611 reported snakebite incidents, which represents an average of 20,000 cases per year for the country. The national rates per 100,000 inhabitants for the period from 1990 to 1993 were 13.78, 13.30, 14.08 and 13.94, respectively. The highest observed rates in this same period were found in the Center-West region: 34.75, 28.36, 37.98 and 32.13, respectively. As can be seen, the official national figures contradict the estimates offered by the aforementioned study .
In a study published in 2002, the same estimates of 1998 for Central and South America were maintained: 300,000 bites, of which close to 150,000 were envenomings, most of which were treated in hospitals [8, 27].
The author states that, in South America, the annual incidence is around 15 to 45 per 100,000 inhabitants, and this, therefore is based on Chippaux , Benítez et al. , Ribeiro et al.  and Silva et al. . However, in Figure 3 the map indicates a rate in excess of 100 per 100,000 inhabitants for the greater part of South America, thus contradicting the statements contained in accompanying text. For the state of Amazônia, the incidence is understood to be between 350 and 590 snakebites per 100,000 inhabitants, with a mortality rate that may reach five per 1000,000 inhabitants. These results were based on Chippaux et al. , Kerrigan  and Pierini et al. . It is important to emphasize that, among the group of seven articles cited by Chippaux  on which his estimates were based, three refer to data from Brazil, one being from the state of São Paulo , one from a small region of the state of Minas Gerais  and one from the state of Acre . Such data are limited to generate a solid estimate of the national incidence of snakebites.
The high discrepancy in the incidence attributed to Brazil in Figure 3 may be seen when the value (> 100/100,000) is compared to the 13.8 cases per 100,000 for the country as a whole, and the 52.6 per 100,000 for the North region, where the greatest incidence is observed. These data were published in 2009 by the Ministry of Health in its guide for epidemiological surveillance .
In 2008 Kasturiratne et al.  commented on the work of Swaroop and Grab , Chippaux  and White . They observed that the study by Swaroop and Grab  was based mainly on hospital data, and for this reason its figures on mortality were underestimated, while the works of Chippaux  and White  did not informed the methodology used to find their estimates. Given that, Kasturiratne et al.  justified a new estimate of the global burden of snakebite with the application of a more rigorous and repeatable methodology. They grouped 227 countries into 21 geographical regions, following the classification used for the Global Burden of Disease (GBD) project  in 2005.
These authors used three strategies to gather primary data: electronic searching for publications about snakebites, selection of specific data on mortality in the relevant countries from databases maintained by United Nations organizations, and identification of grey literature from discussions with key informants. In their results they presented an estimate of maximum and minimum for the number of cases and for the incidence of snakebite per 100,000 inhabitants. For Brazil, which makes up almost exclusively the classification “Latin America, Tropical”, the number of snakebites for the year 2007 was estimated as being between 29,636 and 31,895. The incidence per 100,000 was in the range from 14.97 to 16.12, these values being very different from those presented in Figure 3[28–31].
Kasturiratne et al.  also estimated for the same region “Latin America, Tropical” the number of deaths as being between 100 and 299, and the mortality rate was given as ranging from 0.051 to 0.151 per 100,000 people. Amongst the sources used by these authors to generate their estimates there are only one article and a book chapter that contain data about Brazil [23, 39]. The book chapter is more comprehensive, since it deals with the clinical toxicology of snakebite incidents in South America. The article, on the other hand, has a restricted focus, dealing with snakebites in the urban area of Cuiabá. Judging by the research methodology employed, it apperars that Portuguese-language publications were not included, which might explain the lack of national and regional studies that could minimally represent each region of Brazil. It should be noted, however, that the study of Carvalho and Nogueira  is in Portuguese.
In 2010 Warrell  analyzed the work Swaroop and Grab , Chippaux  and Kasturiratne et al.  and considered them incomplete, faulty, or lacking information about their data-gathering methods, which undermines their extrapolations. He thought that the global estimate of deaths produced by Swaroop and Grab  were low, as they were based solely on hospital data and did not took into account the Soviet Bloc, China or the countries of Central Europe. According to Warrel , Chippaux’s work  extrapolated individual cases that occurred in specific locations within countries when estimating annual global cases. The study carried out by Kasturiratne et al.  was considered as lacking the essential heterogeneity of the incidence of snakebites within and between countries, and as generalizing this incidence across adjacent territories, thus producing unexpected results (the Caribbean and West Pacific Islands), given that its annual estimates were overly broad.
In 2008 Chippaux  had already presented an evaluation similar to that of Warrel . The study suggested that the estimates of Swaroop and Grab  were low because of the lack of relevant information and the work of Kasturiratne et al.  had limitations attributable to its sources and uncertainties about the primary data, which contributed to the creation of overly wide ranges. It also considered that although another research , based on a greater number of publications, was more reliable; it presented gaps in information, including the issue of representativeness of local studies within the general epidemiological field.
It is important to point out that Brazil, in contrast to various other countries, possesses national information systems designed to record incidents involving venomous animals. The most important of these is the System on Diseases of Compulsory Declaration (Sistema de Informação de Agravos de Notificação – SINAN), as it has a specific module for recording that type of incident, which makes the information more detailed and appropriate for epidemiological analysis of this health issue [42, 43].
In the face of all these estimates made by non-Brazilian researchers, the following question arises: what does SINAN have to offer with respect to these figures? By way of comparison, the data on snakebites recorded by SINAN for the year 2007 were gathered. The system recorded 27,030 cases and 125 deaths, suggesting an incidence of 14.28 per 100,000 inhabitants and a mortality rate of 0.066 .
It can be noted that the estimates of minimum and maximum figures given by Kasturiratne et al.  for the year 2007 contain the values indicated by SINAN for cases, deaths, incidence and mortality rate, despite the fact that the maps displayed values that widely differed from the reality in Brazil. Once again, the relevance and pertinence of these maps should be questioned.
In 2008 Bochner and Fiszon , two Brazilian researchers, using the data from SINAN for the period from 2001 to 2006, developed a profile of incidents involving venomous animals in Brazil, taking into account regional variations. In that study, snakebite morbidity for the country was defined as 14 per 100,000 inhabitants, with the highest observed value being in the North region, at 49 per 100,000 inhabitants.
In 2010, a group of four researchers, formed by three non-Brazilians and one Brazilian, published an article in which they indicated that, in Brazil, health statistics related to venomous animals were satisfactory . This group mentioned the work of Oliveira et al. , which covers the epidemiology of animal envenoming in Brazil, based on data collected by the Ministry of Health by means of SINAN from 2000 to 2007.
The map presented in Figure 6 contains a few mistakes, the most general of which is the fact that there is no way to represent any incidence rate greater than 10 and less than, or equal to, 100. In the case of Brazil, the SINAN data from 2006 shows that the North region of the country does not have the same incidence as the Northeast. Furthermore, even the Northeast, with the highest national incidence, does not exceed the figure of 100. Neither of the states in this region, Pernambuco or Alagoas, shows an incidence over 100, thus leaving hanging the question of where exactly is the location whose incidence exceeds 1,000, as indicated on the map.
According to Figure 7, the highest rates of scorpion stings in Brazil are found in all the states of the Southeast and South regions, and part of the North (Roraima, Amapá and parts of Amazonas and Pará), the Northeast (a small area in Bahia) and Center-West (Mato Grosso do Sul, Goiás and part of Mato Grosso). The data from SINAN offer a different picture of the distribution of scorpion stings in Brazil. The rate does not exceed 100 per 100,000 in any state. The region with the highest rate is the Northeast, followed by the Southwest, North, Center-West, and finally by the South [44, 45].
The estimates of the incidence of snake and scorpion envenoming in Brazil made by foreigners have shown themselves to be unsatisfactory and not a faithful reflection of the reality in the country.
Very often, due to the fact that data are presented in maps, the discrepancies have gone unnoticed and have been reproduced over time in various publications.
The methodology of developing indicators based on different regional studies is highly sensitive to the choice of works to be included in the sample. In many cases the estimates are based on very heterogeneous data collected from highly specific locations, which generates unrepresentative and untrustworthy information. It is thus very necessary to be familiar with the peculiarities of Brazil, which is not an easy task, even for a native.
Brazil has a long tradition in the production, control and distribution of antivenom serum, as well as in the free treatment of victims. A concern in regard to information about envenoming has been present in Brazil ever since the first ampoule of serum was delivered to the populace by Vital Brazil in 1901 .
Currently, the duty of reporting poisoning occurrences has changed from being obligatory to being compulsory . The records of these reports are the basis of the Information System on Diseases of Compulsory Declaration (SINAN), and, despite the possibility of underreporting in some geographic areas; these records constitute the best picture of the Brazilian reality in regard to envenoming. Thus, the best course is to leave estimates to one side and to undertake research at national and regional levels, based on concrete data from the country as a whole, its states and municipalities. Such data have been available on the Internet since 2001.
- Swaroop S, Grab B: Snakebite mortality in the world. Bull World Health Organ 1954, 10(1):35–76.PubMed CentralPubMedGoogle Scholar
- Chippaux JP: Les complications locales des morsures de serpents. Med Trop 1982, 42(2):177–183.Google Scholar
- Sawai Y: Snake bites in Asia. Snake 1973, 5(1):29–39.Google Scholar
- Russell FE: Snake venom poisoning. Philadelphia: JB Lippincott Company; 1980:562.Google Scholar
- Reid HA: Bites by foreign venomous snakes in Britain. Br Med J 1978, 1(6127):1598–1600. 10.1136/bmj.1.6127.1598PubMed CentralView ArticlePubMedGoogle Scholar
- Reid HA: Antivenom reactions and efficacy. Lancet 1980, 1(8176):1024.View ArticlePubMedGoogle Scholar
- World Health Organization: Progress in the characterization of venoms and standardization of antivenoms. 58th edition. Geneva: WHO Offset Publication; 1981.Google Scholar
- Chippaux JP: Snake-bites: appraisal of the global situation. Bull World Health Organ 1998, 76(5):515–524.PubMed CentralPubMedGoogle Scholar
- White J: Bites and stings from venomous animals: a global overview. Ther Drug Monit 2000, 22(1):65–68. 10.1097/00007691-200002000-00014View ArticlePubMedGoogle Scholar
- Cardoso JLC: Hospital Vital Brazil: 50 years of clinical experience at lnstituto Butantan, São Paulo. Toxicon 1996, 34(2):158.View ArticleGoogle Scholar
- Jorge MT, Ribeiro LA: Epidemiologia e quadro clínico do acidente por cascavel sul-americana (Crotalus durissus). Rev Inst Med Trop São Paulo 1992, 34(4):347–354. 10.1590/S0036-46651992000400013View ArticlePubMedGoogle Scholar
- Lebrão ML, Ribeiro LA, Jorge MT: Evaluation of deaths by accidents with venomous snakes in the State of São Paulo, 1988/1989. Rev Assoc Med Bras 1995, 41(5):343–347.PubMedGoogle Scholar
- Ribeiro LA, De Campos VAF, Albuquerque MJ, Takaoka NY: Acidente ofídico no Estado de São Paulo. Rev Ass Med Bras 1993, 39(1):4–7.Google Scholar
- Magalhães O: Campanha antiofídica em Minas Gerais. Mem Inst Oswaldo Cruz 1958, 56(2):291–371.PubMedGoogle Scholar
- Pierini SV, Warrell DA, De Paulo A, Theakston RD: High incidence of bites and stings by snakes and other animals among rubber tappers and Amazonian Indians of the Juruá Valley, Acre State, Brazil. Toxicon 1996, 34(2):225–236. 10.1016/0041-0101(95)00125-5View ArticlePubMedGoogle Scholar
- Cruz-Rocha MA, Borges CC, Verçosa-Dias A, Boechat AL, Loureiro JAES, Borja AG, Paiva CS, Melo CS, Maciel FS, Bindá LW, Barros ACS, Sadahiro A, Dos Santos MC: Incidence of accidents caused by poisonous snakes in twenty four municipal districts of Amazonas state. J Venom Anim Toxins 1997, 3(1):253.Google Scholar
- Bochner R, Struchiner CJ: Epidemiologia dos acidentes ofídicos nos últimos 100 anos no Brasil: uma revisão. Cad Saúde Pública 2003, 19(1):7–16.View ArticlePubMedGoogle Scholar
- Secretaria Nacional de Ações Básicas de Saúde: Acidentes ofídicos. Contribuição ao estudo da morbidade. Brasília: Ministério da Saúde; 1989.Google Scholar
- Resende CC, Araújo FAA, Sallenave RNUR: Análise epidemiológica dos acidentes ofídicos. Brasília: Secretaria Nacional de Ações Básicas de Saúde; 1989.Google Scholar
- Barraviera B: Estudo clínico dos acidentes ofídicos: revisão. J Bras Med 1993, 65(4):209–250.Google Scholar
- Fundação Nacional de Saúde: Manual de diagnóstico e tratamento de acidentes por animais peçonhentos. Brasília: Ministério da Saúde; 1998:131.Google Scholar
- Fundação Nacional de Saúde: Manual de diagnóstico e tratamento de acidentes por animais peçonhentos. 2º ed rev edition. Brasília: Ministério da Saúde; 2001:120.Google Scholar
- Fan HW, Cardoso JL: Clinical toxicology of snakebite in South America. In Handbook of clinical toxicology of animal venoms and poisons. Edited by: Meier J, White J. Boca Raton (Florida): CRC Press; 1995:667–688.Google Scholar
- Gutierrez JM: Clinical toxicology of snakebite in Central America. In Handbook of clinical toxicology of animal venoms and poisons. Edited by: Meier J, White J. Boca Raton (Florida): CRC; 1995:645–665.Google Scholar
- Bolaños R: Serpientes, venenos y ofidismo en Centroamérica. San Jose: Universidad de Costa Rica; 1984.Google Scholar
- Russell FE, Walter FG, Bey TA, Fernandez MC: Snakes and snakebite in Central America. Toxicon 1997, 35(10):1469–1522. 10.1016/S0041-0101(96)00209-7View ArticlePubMedGoogle Scholar
- Chippaux JP: Morsures et envenimations ophidiennes. Rev Fr Lab 2002, 2002(342):55–60.Google Scholar
- Chippaux JP, Goyffon M: Envenimations et intoxications par les animaux venimeux ou vénéneux: I.Généralités. Med Trop 2006, 66(3):215–220.Google Scholar
- Chippaux JP: Incidence et mortalité par animaux venimeux dans les pays tropicaux. Med Trop 2008, 68(4):334–339.Google Scholar
- Chippaux JP: La crise actuelle de la sérothérapie antivenimeuse et ses solutions. Biofutur 2008, 27(292):45–48.Google Scholar
- Chippaux JP: Incidence mondiale et prise en charge des envenimations ophidiennes et scorpioniques Global incidence of snake and scorpion envenoming. Med Sci 2009, 25(2):197–200.Google Scholar
- Benítez JA, Rifakis PM, Vargas JA, Cabaniel G, Rodríguez-Morales AJ: Trends in fatal snakebites in Venezuela, 1995–2002. Wild Environ Med 2007, 18(3):209–213. 10.1580/06-WEME-BR-076R.1View ArticleGoogle Scholar
- Da Silva CJ, Jorge MT, Ribeiro LA: Epidemiology of snakebite in a central region of Brazil. Toxicon 2003, 41(2):251–255. 10.1016/S0041-0101(02)00287-8View ArticlePubMedGoogle Scholar
- Chippaux JP, Galtier J, Lefait JF: Epidémiologie des envenimations en Guyane française. B Soc Pathol Exot 1984, 77(2):206–215.Google Scholar
- Kerrigan KR: Venomous snakebite in eastern Ecuador. Am J Trop Med Hyg 1991, 44(1):93–99.PubMedGoogle Scholar
- Secretaria de Vigilância em Saúde: Guia de vigilância epidemiológica. Normas e manuais técnicos. Série A. 7ª Edição edition. Brasília: Ministério da Saúde; 2009:816.Google Scholar
- Kasturiratne A, Wickremasinghe AR, De Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, Savioli L, Lalloo DG, Silva HJ: The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008, 5(11):e218. 10.1371/journal.pmed.0050218PubMed CentralView ArticlePubMedGoogle Scholar
- Mathers CD, Ezzati M, Lopez AD: Measuring the burden of neglected tropical diseases: the global burden of disease framework. PLoS Negl Trop Dis 2007, 1(2):e114. 10.1371/journal.pntd.0000114PubMed CentralView ArticlePubMedGoogle Scholar
- Carvalho MA, Nogueira F: Serpentes da área urbana de Cuiabá, Mato Grosso: aspectos ecológicos e acidentes ofídicos associados. Cad Saúde Pública 1998, 14(4):753–763. 10.1590/S0102-311X1998000400017View ArticlePubMedGoogle Scholar
- Warrell DA: Snake bite. Lancet 2010, 375(9708):77–88. 10.1016/S0140-6736(09)61754-2View ArticlePubMedGoogle Scholar
- Chippaux JP: Estimating the global burden of snakebite can help to improve management. PLoS Med 2008, 5(11):e221. 10.1371/journal.pmed.0050221PubMed CentralView ArticlePubMedGoogle Scholar
- Bochner R, Struchiner CJ: Acidentes por animais peçonhentos e sistemas nacionais de informação. Cad Saúde Pública 2002, 18(3):735–746. 10.1590/S0102-311X2002000300022View ArticlePubMedGoogle Scholar
- Bochner R: Sistemas nacionais de informação de acidentes por animais peçonhentos. Gaz Méd Bahia 2012, 82(Supl 1):64–77.Google Scholar
- Sistema de Informação de Agravos de Notificação: Tabulação de dados. 2001 a 2006 e a partir de 2007. Acidente por animais peçonhentos. http://dtr2004.saude.gov.br/sinanweb/
- Bochner R, Fiszon JT: Profil des accidents par des animaux venimeux au Brésil, 2001 à 2006. In Toxines et fonctions cholinergiques neuronales et non neuronales. France: Collection Rencontres en Toxinologie, Publication de la SFET; 2008:119–122. 16Google Scholar
- Gutiérrez JM, Williams D, Fan HW, Warrell DA: Snakebite envenoming from a global perspective: towards an integrated approach. Toxicon 2010, 56(7):1223–1235. 10.1016/j.toxicon.2009.11.020View ArticlePubMedGoogle Scholar
- De Oliveira RC, Wen FH, Sifuentes DN: Epidemiologia dos acidentes por animais peçonhentos. In Animais peçonhentos no Brasil: biologia, clínica e terapêutica dos acidentes. Edited by: Cardoso JL, França FOS, Fan HW, Malaque CMS, Haddad-Jr V. São Paulo: Sarvier; 2009:6–21.Google Scholar
- Chippaux JP, Goyffon M: Epidemiology of scorpionism: a global appraisal. Acta Trop 2008, 107(2):71–79. 10.1016/j.actatropica.2008.05.021View ArticlePubMedGoogle Scholar
- Chippaux JP: Epidemiology of accidents by venomous animals. Niterói, Rio de Janeiro: Lecture at: 1st International Conference Vital para o Brasil; 2013.Google Scholar
- Amorim AM, Carvalho FM, Lira-da-Silva RM, Brazil TK: Acidentes por escorpião em uma área do Nordeste de Amaralina, Salvador, Bahia, Brasil. Rev Soc Bras Med Trop 2003, 36(1):51–56.View ArticlePubMedGoogle Scholar
- Biondi-de-Queiroz I: Scorpion envenoming in the State of Bahia: epidemiological and clinical study of the envenomings treated at the Center for Antivenom Information (CIAVE) between 1995 and 1997. J Venom Anim Toxins 2001, 7(2):314–315.Google Scholar
- Lira-da-Silva RM, Amorim AM, Brazil TK: Envenenamento por Tityus stigmurus (Scorpiones; Buthidae) no Estado da Bahia, Brasil. Rev Soc Bras Med Trop 2000, 33(3):239–245.View ArticlePubMedGoogle Scholar
- Bucaretchi F, Baracat EC, Nogueira RJ, Chaves A, Zambrone FA, Fonseca MR, Tourinho FS: A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus. Rev Inst Med Trop São Paulo 1995, 37(4):331–336. 10.1590/S0036-46651995000400008View ArticlePubMedGoogle Scholar
- Von Eickstedt VRD, Ribeiro LA, Candido DM, Albuquerque MJ, Jorge MT: Evolution of scorpionism by Tityus bahiensis (Perty) and Tityus serrulatus Lutz and Mello and geographical distribution of the two species in the state of São Paulo – Brazil. J Venom Anim Toxins 1996, 2(2):92–105.Google Scholar
- Nunes CS, Bevilacqua PD, Jardim CCG: Aspectos demográficos e espaciais dos acidentes escorpiônicos no Distrito Sanitário Noroeste, Município de Belo Horizonte, Minas Gerais, 1993 a 1996. Cad Saúde Pública 2000, 16(1):213–223. 10.1590/S0102-311X2000000100022View ArticlePubMedGoogle Scholar
- Soares MRM, Azevedo CS, De Maria M: Escorpionismo em Belo Horizonte, MG: um estudo retrospectivo. Rev Soc Bras Med Trop 2002, 35(4):359–363.View ArticlePubMedGoogle Scholar
- Pardal PPO, Castro LC, Jennings E, Pardal JSO, Monteiro MRCC: Aspectos epidemiológicos e clínicos do escorpionismo na região de Santarém, Estado do Pará, Brasil. Rev Soc Bras Med Trop 2003, 36(3):349–353. 10.1590/S0037-86822003000300006View ArticlePubMedGoogle Scholar
- Lourenço WR, Cloudsley-Thompson JL, Cuellar O, Von Eickstedt VRD, Barraviera B, Knox MB: The evolution of scorpionism in Brazil in recent years. J Venom Anim Toxins 1996, 2(2):121–134.View ArticleGoogle Scholar
- Lourenço WR: Peut-on parler d’une biogéographie du scorpionisme? C R Seances Soc Biogéogr 1988, 64(4):137–143.Google Scholar
- Brazil V: A defesa contra o ophidismo: um verdadeiro descortino para o Brasil da época. In A defesa contra o ophisismo: 100 anos depois: comentários. Niterói: Instituto Vital Brazil; 2011:41–46.Google Scholar
- Ministério da Saúde: Portaria N° 2.472, de 31 de agosto de. Brasília; 2010. http://portal.saude.gov.br/portal/arquivos/pdf/6_portaria_2472.pdfGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.