Scorpion Sting Research Articles

Mapping current and future risk of scorpion sting from a species with low medical concern, Mesobuthus phillipsii (Scorpiones: Buthidae) in Iran.

Scorpion stings are one of the most important health challenges and high priority research topic in public health. In this study, we aimed to model habitat suitability of the Mesobuthus phillipsii (Pocock 1889), a species with low medical concern, under current and future climatic conditions in Iran. We also identified vulnerable populations to scorpion stings in the country. Scorpion sting risk modeling was done using an ensemble approach by considering two species distribution modeling methods: MaxEnt and Random Forest methods. Distribution modeling was performed using the sdm R package. The results showed that due to climate change in 2070, the high-risk areas will increase from 20,839 to 79,212 km2. Habitats with a moderate risk of scorpion stings will also increase from 139,347 to 222,833 km2. Consequently, the number of villages in high-risk areas of scorpion stings will increase from 2,870 to 7,017, while this number will increase from 12,759 to 20,104 in the case of medium-risk villages. The results of this study can be used for scorpion stings management in Iran. This study can be used as an example for similar studies on scorpions with high medical emergency.

Toxicity Mechanism of Dangerous Scorpion Stings in Iran.

Considering the importance of scorpions and recognizing the mechanisms of toxicity caused by their medically important species in Iran and adopting the best therapeutic approach based on these mechanisms, this study was performed by reviewing the clinical manifestations of scorpion stings. The research was conducted by searching for articles and researches in related websites (PubMed, EMBASE, Scopus, Web of Science and CINAHL) and using domestic and international authoritative journals using the keywords of scorpion, clinical manifestations, in a review method. Finally, 104 qualified sources were selected and after reviewing and criticizing these studies, the author's point of view was presented. Clinical manifestations of Scorpion sting toxicity vary due to the existence of two toxic classes of neurotoxins and cytotoxins or hemotoxins in these arthropods in Iran. The number and distribution of species with neurotoxic venom are higher than the scorpions with cytotoxic venom and are reported throughout Iran. Scorpions with cytotoxic venom are mostly widespread in south and southwest of Iran. Treatment and prevention of scorpion stings in Iran and neighboring countries in the Middle East should be planned based on the mechanism of toxicity and the presence of toxic classes with neurotoxic or cytotoxic venoms.

Scorpion envenomation in the neotropical savannah: Environmental predictors and years of lost life

Scorpion stings envenomation (SSE) is a growing medical concern in Brazil, particularly in the state of Minas Gerais, which has recorded a significant number of incidents. This study aimed to investigate the potential predictors of scorpion sting incidence and evaluate the cost-effectiveness of interventions in Minas Gerais. Generalized Estimating Equations (GEE) models were constructed using socioeconomic and environmental variables as predictors and scorpion sting incidence as the response variable. The analysis revealed that mean annual temperature and major land use type were significant predictors of scorpion sting incidence, while precipitation and socioeconomic variables showed no relationship with incidence. The total number of cases and annual incidence of scorpion stings overlapped with regions experiencing higher forest conversion and agricultural land use, as well as higher temperatures. The estimated Disability-Adjusted Life Years (DALY) for scorpion sting incidents in Minas Gerais was substantial, indicating the need for effective prevention and treatment measures. The cost per DALY averted varied among municipalities, with some requiring minimal investment while others needing significant funding to address the scorpion risk. Mean annual temperature emerged as the main risk factor for scorpion stings, contributing to increased costs associated with antivenom treatment. These findings highlight the importance of considering environmental factors and implementing targeted interventions to mitigate scorpion sting incidents and reduce associated morbidity and mortality.

Anti-hyperglycaemic and selected organ protective effects of Ziziphus spina-christi hydroethanol leaf extract in alloxan induced diabetic rats

Ziziphus spina-christi has been traditionally used for the treatment of stomach pain, wounds, and hair loss, skin infections, diarrhoea, scorpion stings, and malaria. This study aims to investigate the anti-hyperglycaemic, anti-dyslipidaemic, liver and kidney protective effects of Ziziphus spina-christi ethanol leaf extract on diabetic rats. The experimental design comprises of five groups of albinos Wistar rats, with three rats per group. They are normal control group, normal and 150mg/kg bwt treatment with extract group, diabetic control group, diabetic and treatment with the 150mg/kg bwt extract group, and diabetic treated with Metformin as standard drug treated for 14 days. The results of the study indicated that there was a significant (P<0.05) reduction in the blood glucose level in the extract and reference drug administered groups as compared to the diabetic control. The levels of the serum alanine transaminase, serum aspartate transaminase and serum alkaline phosphatase activities were significantly (P<0.05) lower in the extract and standard drug treatment groups compared to the diabetic control group. In the diabetic control group, the creatinine and urea concentrations were significantly (P<0.05) higher compared with the extract and metformin treated groups. Also, the high-density lipoprotein and triacylglycerol levels were lower in the extract treated groups demonstrating a good lipid profile. In conclusion, Ziziphus spina-christi exhibits anti-hyperglycaemia, anti-dyslipidaemia and liver and kidney protective activities in diabetic model, and thus supporting its traditional usage in diabetes management.

A Novel Therapeutic Formulation for the Improved Treatment of Indian Red Scorpion (Mesobuthus tamulus) Venom-Induced Toxicity-Tested in Caenorhabditis elegans and Rodent Models.

Indian Red Scorpion (Mesobuthus tamulus) stings are a neglected public health problem in tropical and sub-tropical countries, including India. The drawbacks of conventional therapies using commercial anti-scorpion antivenom (ASA) and α1-adrenoreceptor antagonists (AAA) have prompted us to search for an adequate formulation to improve treatment against M. tamulus stings. Novel therapeutic drug formulations (TDF) of low doses of commercial ASA, AAA, and ascorbic acid have remarkably improved in neutralising the in vivo toxic effects of M. tamulus venom (MTV) tested in Caenorhabditis elegans and Wistar strain albino rats in vivo models. The neutralisation of MTV-induced production of free radicals, alteration of the mitochondrial transmembrane potential, and upregulated expression of genes involved in apoptosis, detoxification, and stress response in C. elegans by TDF surpassed the same effect shown by individual components of the TDF. Further, TDF efficiently neutralized the MTV-induced increase in blood glucose level within 30 to 60 min post-treatment, organ tissue damage, necrosis, and pulmonary oedema in Wistar rats, indicating its clinical application for effecting treating M. tamulus envenomation. This study demonstrates for the first time that C. elegans can be a model organism for screening the neutralization potency of the drug molecules against a neurotoxic scorpion venom.

A Retrospective Study on Patients Bitten or Stung by Arthropods Admitted to Major Hospitals in Jaffna District

Though a considerable number of arthropod stung or bitten patients seek medical assistance in Jaffna District, only few literatures are available. With this background, this retrospective study was designed to study the holistic pattern of arthropod stings or bites reported in Jaffna District. This institutional based retrospective descriptive study was carried out at major hospitals in Jaffna District. Basic demographic data, type of arthropods, site of bite and other recorded clinical manifestations were extracted to a data sheet from the BHTs for a period of one year. The data were analyzed using statistical software SPSS version 21. Ethical clearance was obtained from the Ethical Review Committee of the Faculty of Medicine, University of Jaffna. During the study period 1030 patients were reported to the Base Hospitals in the Jaffna District and the Teaching Hospital, Jaffna. Among them 57% were male and the age ranges from 1 to 86 years. Majority of them were from the MOH divisions of Chavakacheri (30%) and Tellipalai (22%) followed by PointPedro (18%). Most of them had unknown bite (36%) followed by wasp stings (23%) and white scorpion (15%) stings. Legs (36%) were the predominant site of bite followed by arm (31%) and head and neck (15)%. This study reveals 72% of the patients reported pain whereas 44% had swelling at the site of bite. Most of the patients (78%) stayed in the hospital for one day and others (22%) stayed for two days, and no fatality was recorded during the study period. In conclusion, arthropod stings or bites need not be neglected anymore and further in depth studies of arthropod biology and risk factors are paramount in order to help the health authorities in the primary prevention.

Scorpion Stings in Minas Gerais (Brazil): A Monocentric Retrospective Study Evaluating All Envenoming Cases of Local Scorpionism

We aim to provide better insights into the demographic, epidemiological, and seasonal characteristics of scorpion envenomation reported in the Rio Doce Valley, Brazil. We conducted this monocentric retrospective descriptive study with data on Investigation Forms of Accidents by Venomous Animals, only envenoming cases of scorpion stings, between January 1, 2017 and December 31, 2020, belonging to the compulsory notification system of the Municipal Hospital of Governador Valadares. There were 3032 accidents, and the male-to-female ratio was 1.17:1 (male, 54%; females, 46%). Accidents occurred every month, but there was an increase in June, July, and October to January. In most cases, the time between the scorpion sting and medical care was between 1 and 3 h (n=1304; 43%). The most frequent clinical and systemic manifestations were pain at the bite site (94%) and vagal symptoms (7%). Cases were mild (n=2750, 91%), moderate (n=221, 7%), and severe (n=56, 2%). Children younger than 10 y constituted the most cases, 522 (17%). There was a significant difference between clinical severity and age (P<0.01). Ten patients developed acute pulmonary edema. Two 4-y-old children died. All severely envenomated patients as well as 74% and 2% of mild and moderately envenomated patients, respectively, received specific scorpion antivenoms. Scorpion envenomation is of greater severity in children aged <10 y. The clinical presentation includes mainly local pain associated with vagal symptoms. Accidents occur every month, but there was an increase in June, July, and October to January.

Clinical assessment of scorpion sting victims in Minia government upper Egypt Abstract

Clinical assessment of scorpion sting victims in Minia government upper Egypt Abstract

Epidemiology of Scorpion Sting in Southwestern Iran Over Five Years

Background: Scorpionism is a considerable public health problem worldwide in tropical and subtropical regions. It is one of the major health problems and the leading cause of death in the western and southern parts of Iran. Objectives: This study was performed with the aim of investigating the epidemiological features of scorpion stings in Shoushtar city. Methods: This cross-sectional study was performed on 5479 cases in Shoushtar city, Khuzestan province, Iran, from January 1, 2014 until December 31, 2018. First, the incidence rate of scorpion stings was calculated for the study years; then, the bites frequency distribution chart was drawn by month. The t-test and Fisher exact test were used for data analysis using SPSS 22. Results: The average incidence rate of scorpion stinging during the study period was 579.55 per 100000. There was a gradual decrease in the incidence rate over the study period. The incidence of scorpionism was lower in winter, especially in January and February. The most prone body parts of sting were arms and legs (76%); the stings were more common in men than women and more in urban areas than rural areas. Household women had the highest frequency of stings, so almost 1 of every 3 victims was household women; most stings happened indoors. There was a significant association between gender and location, so it was 13 times more in women than men in an indoor location (P = 0.001, OR = 0.076). Conclusions: Shoushtar is a city with a high incidence rate of scorpion sting in the country, especially in the warm seasons. Most cases of stings occur in Housekeepers and in indoor environments. It seems renovation of residential areas, using chemical controls in roofed areas, and enhancing people's knowledge regarding the advantage of using gloves and boots can be vital in the reduction of sting incidences.

Even a Scorpion Sting Hurts Just as Much: A Sobering Look at Men as Victims of Intimate Partner Abuse and Violence

The subject of intimate violence and abuse has piqued the interest of different groups of people, including psychologists, scholars, and human rights activists over the past 45 years. Even though the epidemiological literature has consistently shown that at least one out of every three people who experience intimate partner violence is a male partner, current initiatives have chosen to ignore this fact. Instead, the phenomenon has been described by most of its advocates as a gender-cockeyed social issue, with a man penned in an “offender”position and a woman in that of a “helpless victim”. Consequently, the exploited man and the abusing woman have been overly overlooked in the therapeutic processes, academic research, and legislative domain. This analytical paper, therefore, is an attempt to counter this position by showing how abuse and violence to intimate male partners happen and the milieu that gave rise to the misconceptions which have led to this unfortunate standpoint. Findings demonstrate that intimate male partners from all walks of life and backgrounds experience abuse and violence of some sort, particularly those relating to non-physical, unlike most women. The paper recommends abnegating the current unilateral narrative and rhetoric of domestic abuse and violence.

Scorpion sting complicated by ischemic stroke in a child

Scorpionic envenomations (SE) are a public health problem, especially in Morocco where they rank first, causing high morbidity and mortality.

Epidemiologic profile of scorpion sting accidents in the duodecennial between 2011 and 2022 in the southeastern region of Brazil

Scorpion sting accidents have a significant impact in Brazil, leading to increased hospitalizations and healthcare costs, especially in regions with high scorpion populations. The present study aimed to perform an epidemiological analysis of these accidents in Southeastern Brazil. It is an epidemiological, ecological, and mixed-design study. The methodological strategy involved the analysis of epidemiological bulletins provided by the Sistema de Informação de Agravos de Notificação (Sinan) from 2011 to 2022. The data revealed that 613,385 cases of accidental scorpion bites were reported. Minas Gerais had the highest number of cases (50.44%). Males, Caucasians, between 20 and 59 years old, with a low level of education, are the most affected. Victims sought medical attention within 3 hours of the bite, and 27.34% were on the fingers. About 89.7% of the cases were classified as mild, 95.33% were cured, and 0.78% died from the reported disease. The results highlight the urgent need for targeted prevention strategies, improved medical management, and community awareness campaigns to reduce the impact of scorpion stings in the southeastern region of Brazil.

Therapeutic potential and industrial applications of Terminalia arjuna bark.

Terminalia arjuna (Roxb. ex DC.) Wight & Arnot (Combretaceae) is one of the most frequently used medicinal trees in Indian traditional medicinal systems. It is used for the treatment of a variety of diseases including cardiovascular disorders. The purpose of this review was to provide a comprehensive overview of the phytochemistry, medicinal uses, toxicity, and industrial applications of T. arjuna bark (BTA), as well as to identify gaps in research and applications of this important tree. It also aimed to analyze trends and future research paths to utilize the full potential of this tree. Extensive bibliographic research on the T. arjuna tree was carried out using scientific research engines and databases such as Google Scholar, PubMed, and Web of Science, covering all relevant English-language articles. The database "World Flora Online (WFO)" (http://www.worldfloraonline.org) was used to confirm plant taxonomy. To date, BTA has been traditionally employed for several disorders such as snakebites, scorpion stings, gleets, earaches, dysentery, sexual disorders, and urinary tract infections along with the cardioprotective activity. About 38 phytocompounds were identified from BTA and were classified as triterpenoids, tannins, flavonoids, and glycosides. A wide range of in vitro and in vivo pharmacological effects of BTA were reported such as anti-cancer, antimicrobial, antiviral, anti-inflammatory, antioxidant, hepatoprotective, anti-allergic, anti-diabetic, and wound healing activities. The oral administration of BTA (500mg/kg) per day did not result in any toxicity in humans. The in vivo acute and sub-acute toxicity analysis of the methanol extract of BTA and one of its major compounds, 7-methyl gallate, did not produce any adverse effects up to a dose of 1000mg/kg. This comprehensive review highlights various aspects of traditional knowledge, phytochemicals, and pharmacological significance of BTA. The review covered safety information on employing BTA in pharmaceutical dosage forms. Despite its long history of medicinal benefit, more studies are needed to understand the molecular mechanisms, structure-activity relationship, and potential synergistic and antagonistic effects of its phytocompounds, drug administration, drug-drug interactions, and toxicological effects.

Scorpion Envenomation: The Cause of Inadequate Subarachnoid Block - A Case Series

Background: Failure of neuraxial or regional anaesthesia can result from factors such as drug errors, technical inefficiencies, and poor patient positioning. While these causes are well-known, resistance to local anaesthetic action due to mutations in sodium channels or scorpion sting is a lesser-known contributor to block failure. In India, a tropical country with a significant number of patients presenting for surgical procedures, a history of scorpion bites is not uncommon. Case: We observed seven cases of failed regional anesthesia who had history of scorpion sting. All the patients received intrathecal bupivacaine by experienced anesthesiologists, of seven patients five patients did not develop sensory or motor block. One patient had delayed successful subarachnoid block after second attempt and one patient had successful block at first attempt. Conclusion: Our observations revealed instances of failed spinal blocks, despite adequate drug dosages and experienced anesthesiologists performing the procedures, in patients with a history of scorpion envenomation. Accordingly, our study concludes that obtaining a thorough scorpion sting history during pre-anesthesia check-ups, particularly in endemic areas, can effectively prevent unnecessary repeated pinpricks, escalating dosages, patient and surgeon discomfort, and skepticism towards the skills of anesthesiologists.

Production of recombinant scorpion antivenoms in E. coli: current state and perspectives.

Scorpion envenomation is a serious health problem in tropical and subtropical zones. The access to scorpion antivenom is sometimes limited in availability and specificity. The classical production process is cumbersome, from the hyper-immunization of the horses to the IgG digestion and purification of the F(ab)'2 antibody fragments. The production of recombinant antibody fragments in Escherichia coli is a popular trend due to the ability of this microbial host to produce correctly folded proteins. Small recombinant antibody fragments, such as single-chain variable fragments (scFv) and nanobodies (VHH), have been constructed to recognize and neutralize the neurotoxins responsible for the envenomation symptoms in humans. They are the focus of interest of the most recent studies and are proposed as potentially new generation of pharmaceuticals for their use in immunotherapy against scorpion stings of the Buthidae family. This literature review comprises the current status on the scorpion antivenom market and the analyses of cross-reactivity of commercial scorpion anti-serum against non-specific scorpion venoms. Recent studies on the production of new recombinant scFv and nanobodies will be presented, with a focus on the Androctonus and Centruroides scorpion species. Protein engineering-based technology could be the key to obtaining the next generation of therapeutics capable of neutralizing and cross-reacting against several types of scorpion venoms. KEY POINTS: • Commercial antivenoms consist of predominantly purified equine F(ab)'2fragments. • Nanobody-based antivenom can neutralize Androctonus venoms and have a low immunogenicity. • Affinity maturation and directed evolution are used to obtain potent scFv families against Centruroides scorpions.

N°349 – Guillain-Barré syndrome following scorpion sting: A case report

N°349 – Guillain-Barré syndrome following scorpion sting: A case report

Modeling the time series of Scorpion sting in Southwestern Iran

Scorpion stings pose a significant public health concern in Iran, resulting in approximately 45,000-50,000 cases and 19 deaths annually. Scorpions, belonging to the Arachnida class, are venomous arthropods found in all continents except Antarctica. They are of particular concern in tropical and subtropical regions. The Khuzestan and Hormozgan provinces have the highest reported incidence, with an estimated 36,000 cases each year. This study focused on modeling the time series data of scorpion stings specifically in Shoushtar city from 2017 to 2022. Our objective was to investigate the presence of seasonality and long-term trends in the incidence of scorpion stings by utilizing advanced analytical techniques such as the Autoregressive Integrated Moving Average (ARIMA) model. We applied the Seasonal ARIMA model to fit a univariate time series of scorpion sting incidence. This study revealed a significant seasonal trend and an overall increase and decrease in scorpion sting cases during the study period. The best-fitting model for the available data was a seasonal ARIMA model in the form of ARIMA (0,0,1) (1,1,1)12. This model can forecast the frequency of scorpion sting cases in Southwestern Iran over the next two years. As a result, Time series analysis can provide valuable insights into the patterns and trends of Scorpion sting incidents, allowing for better planning and allocation of healthcare resources. By understanding the seasonal variations, proactive measures can be implemented to address the growing issue of Scorpion stings in Iran effectively.

The use of chloroquine with or without adjuncts in the effective management of scorpion sting in the tropics: case reports.

Patients presented with pain emanating from the right big toe and medial arch, respectively. The said pain had same manifestation and intensity in both patients and followed same course but radiated higher in up to the ipsilateral flank in the first patient but was limited to the ipsilateral iliac region of the second patient. The sites showed signs of inflammation with pain being most prominent. Diagnosis of scorpion envenomation were made based on the given history. The pain was eliminated using chloroquine given intramuscularly at the site of scorpion sting. Scorpion sting can occur at any time in the tropic and lidocaine only cannot alleviate pain. Chloroquine can be used in managing scorpion sting as it also has many other benefits that can make it more preferred to the other conventional approaches used.

Occurrence of scorpion sting and associated factors in a highly marginalized municipality in Guerrero, Mexico: A cross-sectional study.

Scorpion sting is a neglected public health problem, despite a global estimate of 1.2 million scorpion stings and some 3,250 deaths annually. This cross-sectional study estimates the occurrence of scorpion stings and identifies associated factors in seven communities in the highly marginalized municipality of Chilapa, in the Mexican state of Guerrero. After informed consent, 1,144 households provided information on 4,985 residents. The questionnaire collated sociodemographic data, characteristics of the dwelling, efforts to avoid scorpion stings, and individual information of scorpion stings suffered in the last year. Cluster-adjusted (acl), bivariate and multivariate analysis relied on the Mantel-Haenszel procedure. The overall period prevalence of scorpion stings in the year prior to the study was 4.4% (218/4985), 5.4% in men (126/2320), and 3.5% in women (92/2665), p<0.01. The majority occurred at home 68.3% (149/218), followed by agricultural fields 26.6% (58/218), street 2.8% (6/218), and work 2.3% (5/218). Factors associated with scorpion sting were carrying firewood (OR 2.1; CI95%acl 1.40-3.09), keeping free-range hens around of the home (OR 1.9; CI95%acl 1.19-2.85), residing in a rural area (OR 1.7; CI95%acl 1.04-2.78), being male (OR 1.6; CI95%acl 1.18-2.28), and helping with housework (OR 1.6; CI95%acl 1.04-2.40). This study confirms scorpion bites are a public health problem in these marginalized communities in Guerrero State, with risk factors related to living conditions and the work process at home and in the fields. Almost all risk factors identified could be reduced with low-cost interventions implemented by the communities themselves.

Approach to Scorpion Stings in our General Intensive Care Unit in Şanlıurfa

Amaç: Akrep sokmalarına bağlı olarak oluşan zehirlenmeler ve getirdiği sonuçlar dünyada güncelliğini koruyan sağlık problemlerindendir. Akrep sokmaları bölgemizde, özellikle ilimiz ve çevresinde yaygın olarak görülmektedir. Dünyada tanımlanmış olan 1500’den fazla akrep türünün sadece birkaç tanesi çok zehirlidir ve Türkiye’de 15 tür akrep bulunduğu tahmin edilmektedir. Bu çalışmada akrep sokması nedeniyle hastanemiz yoğun bakım ünitesi (YBÜ)’de takip ettiğimiz hastaların demografik verileri, epidemiyolojik, klinik özellikleri ve sonuçları değerlendirildi. Materyal ve metod: Etik kurul onayı (HRÜ/23.03.11) alındıktan sonra Ocak 2013- Ocak 2023 tarihleri arasında Harran Üniversitesi Hastanesinde akrep sokması ön tanısıyla takip ve tedavi edilen hastaların arşiv verileri değerlendirildi. Sistemik belirti gösteren ve özellik arz eden erişkin hastalarla ilgili genel YBÜ’ deki tedavi yaklaşımları, epidemiyolojik ve klinik sonuçlar değerlendirildi. Bulgular: Çalışmamıza dahil edilen, akrep sokması tanısıyla hastanemizde tedavi gören 1493 hastanın 910’u &amp;gt;17 yaş hastalardı. Bunların da 74’ü üçüncü seviye YBÜ’ de tedavi gören hastalardı. Erişkin YBÜ’ de tedavi gören hastaların %25,7’si (n= 19) erkek, %74,3’ü (n=55) kadındı. Hastaların yaşı 18 ile 88 arasında değişmekteydi. Kadın hastaların %43,6’sı (n=24) gebeydi. En sık görülen semptom, lokal ağrı (%98,6, n=73) idi. Çoğunlukla alt (%52,7) ve üst (%44,6) ekstremitelerin etkilendiği görüldü. Hastaların %70,3’ü (n=52) profilaktik amaçlı tetanoz antiserum, %56,8’si (n=42) anti-venom tedavisi aldı. Gebe hastalara ağrı kesici olarak intravenöz parasetamol uygulandı. Gebe hastalara hastaneye yatışta ve taburculuk öncesi obstetrik USG yapılmış olup herhangi bir komplikasyona rastlanılmadan şifayla taburcu edildi. Hastaların tamamının şifayla taburcu edildiği görüldü. Sonuç: Akrep sokmasına bağlı sistemik belirtileri olan ve gebelik gibi özellik arz eden durumu olan hastaların, YBÜ’de yakın takip ve tedavisi, ölüm oranlarının azaltılmasına katkı sağlayabilir. Akrep sokmalarına kırsal bölgelerde özellikle kadın hastalarda ve gebelerde sıklıkla rastlanılmaktadır. Bunun, bölgemizdeki tarım alanlarında çoğunlukla 15-49 yaş kadınların çalışmasına bağlı olabileceğini düşünmekteyiz. Bu sonuçların, yapılacak daha geniş kapsamlı halk sağlığı çalışmalarıyla desteklenmesi gerektiğini düşünmekteyiz.