Sting-Related Deaths in Europe (1994–2016)

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This entry is adapted from the peer-reviewed paper 10.3390/biology11020282

Bees and wasps provide an important service to ecosystems, contributing to the improvement of biodiversity while helping to maintain ecological balance. Although not frequent, hornet, wasp, and bee stings may be life-threatening. With each sting, Hymenopterans inject a small amount of venom that can cause reactions of varying intensity: (i) normal local reactions (NLR), (ii) large local reactions (LLR), (iii) systemic anaphylactic reactions (SAR), (iv) systemic toxic reactions (STR) and (v) unusual reactions (UR). Hymenopteran stings have recently become a worldwide public health concern. However, this health problem can be underestimated despite the number of cases presented. With the expansion of non-native Hymenopteran species across Europe, allergists should be aware that their community’s exposures are continually changing.

Hymenoptera insect bee wasp hornet epidemiology fatalities venomous animals public health

1. Introduction

Anaphylaxis is an acute, life-threatening reaction that occurs shortly after contact with a trigger. It is classically defined as the most severe form of an allergic reaction, but it could also be induced by non-IgE-mediated pathways through the activation of mast cells and basophils through different mechanisms ^[1]. Common triggers of anaphylaxis include foods, drugs, venoms from insects, general anaesthetics, radiocontrast agents, and latex, among others, and their prevalence varies from region to region being different for each patient group ^[2].

The medically important groups of the Hymenoptera order in Europe are those of the genus Apis and Bombus (belonging to the family Apidae), and Vespula, Dolichovespula, Vespa and Polistes (family Vespidae) ^[3]. Social Apidae, Vespinae and Polistinae possess a large and comprehensive array of venom components ^[4]. Hymenoptera venoms are composed of a mixture of biologically active proteins and peptides, some of them common to different species such as phospholipases, hyaluronidase, phosphatase, α-glucosidase, serotonin, histamine, dopamine, noradrenaline, and adrenaline. Other proteins such as melittin, apamin, and the mast cell degranulating peptide are exclusive to bees, while mastoparan and bradykinin are only found in wasps ^[5]^[6]^[7]^[8]^[9]^[10]. As a rule, Hymenoptera species are not especially predisposed to attack humans; however, social hornets, wasps, and bees have developed a protective response to whatever risk the colony faces through stings.

With each sting, Hymenopterans inject a small amount of venom that can cause reactions of varying intensity: (i) normal local reactions (NLR), (ii) large local reactions (LLR), (iii) systemic anaphylactic reactions (SAR), (iv) systemic toxic reactions (STR) and (v) unusual reactions (UR) ^[11]. The local reaction is limited to the area of the sting and is usually small in size, with redness, swelling and intense pain. If a person has a reaction area of the sting of greater than 10 cm, it may mean that he or she has been sensitized, but, as a rule, it does not need any special action. SAR reactions are those that cause symptoms beyond the point of the sting and can range from skin lesions to respiratory problems, digestive symptoms or anaphylaxis. The prevalence of SAR in Europe due to Hymenoptera stings ranged between 0.3 and 7.5% in adults and is slightly lower in children (0.15–3.4%) ^[12]. STR occur due to multiple Hymenoptera stings because of the well-known toxic properties of their venoms. The symptomatology of UR differs from typical allergic reactions, and, in some cases, follow-up is required over many months ^[13].

Some authors indicated that 94.5% of humans are stung by Hymenoptera insects at some point in their lifetime ^[14]. Although most of these stings are not reported, general practitioners attend to a large number of patients with Hymenoptera stings, and a few of them require rapid assistant at emergency departments. Thus, in USA, it was estimated that 220,000 annual visits are made to the emergency department and nearly 60 deaths occur per year due to Hymenopteran stings ^[15]. In addition, an analysis of 4000 cases of anaphylaxis from Germany, Austria and Switzerland, show insect venom (n = 2074; 50.1%) as a common trigger of anaphylaxis ^[2]. For these reasons, researchers highlight that an effective and affordable treatment for anaphylaxis caused by these arthropods is critical.

Hymenopteran stings have recently become a worldwide public health concern ^[16]^[17]. However, this health problem can be underestimated despite the number of cases presented. Realistic mortality epidemiological data are still lacking in some countries ^[18]. Information on the incidence of fatalities due Hymenoptera stings is crucial for an assessment of the problem, as well as to enhance medical assistance for patients and creating public policies aimed at decreasing the incidence of these events ^[19]^[20]. More than half of the people with fatal sting reactions had no preceding anaphylactic episodes ^[21]^[22].

According to chapter XX of the International Classification of Diseases and Related Health Problems 10th Revision (ICD-10) fatalities due to hornet, wasp and bee stings (including yellow jackets) are coded as X23 ^[23]. The worldwide incidence of insect-sting mortality ranged from 0.03 to 0.48 fatalities per 1,000,000 inhabitants per year, which is low but not negligible ^[21].

2. Hymenopteran Sting-Related Deaths

During 1994–2016, a total of 1691 deaths were officially registered in Europe with code X23. Fatalities were confirmed in 28 countries, with Germany (n = 327, 19.3%), France (n = 211, 12.5%) and Romania (n = 149, 8.8%) reporting the highest numbers (Table 1). A total of eleven countries (BG, FR, DE, EL, IT, PL, RO, RS, ES, CH and UK) report deaths every year. FR, DE, EL, PL and RO, had the minimum number of such deaths. At least one sting-related death occurred yearly in the following six countries: BG, IT, RS, ES, CH and UK. In the rest of the countries (n = 17), deaths due to stings of Hymenoptera insects are not always present. The maximum values of the number of annual deaths for the different countries, varied, ranking as: DE (32), FR (23), RO (16), CZ (14), HU (13); and AT, IT and FL (12). The range of deaths varies from country to country, at it is interesting to highlight the following: DE (range = 26); CZ, FR and RO (range = 14); HU (range = 13); AT (range = 12) and IT (range = 11).

Table 1. Descriptive statistics of fatalities due to hornet, wasp and bee stings by country (1994–2016).

Country ¹	Size	Sum	Minimum	Maximum	Range	Mode	Mean	Median	Standard Deviation	Variance
AT	15	73	0	12	12	5	4.87	5	3.27	10.7
BE	18	27	0	5	5	1	1.5	1	1.42	2.03
BG	9	26	1	6	5	2	2.89	2	1.62	2.61
HR	19	35	0	6	6	1	1.84	1	1.71	2.92
CZ	23	111	0	14	14	4	4.83	4	3.04	9.24
EE	17	14	0	3	3	0	0.82	1	1.01	1.03
FI	20	25	0	4	4	0	1.25	1	1.25	1.57
FR	15	211	9	23	14	14	14.07	14	4.15	17.21
DE	18	327	6	32	26	18	18.17	18	6.97	48.62
EL	2	9	4	5	1	4 & 5	4.5	4.5	0.71	0.5
HU	21	112	0	13	13	4	5.33	4	3.54	12.53
IE	8	2	0	1	1	0	0.25	0	0.46	0.21
IT	13	69	1	12	11	5 & 3	5.31	5	3.4	11.56
LV	9	9	0	2	2	2	1	1	1	1
LT	7	7	0	4	4	1 & 0	1	1	1.41	2
LU	7	1	0	1	1	0	0.14	0	0.38	0.14
NL	21	20	0	5	5	0	0.95	1	1.2	1.45
NO	20	19	0	3	3	1	0.95	1	0.76	0.58
PL	17	125	3	12	9	7 & 8 & 9	7.35	8	2.67	7.12
PT	13	9	0	4	4	0	0.69	0	1.32	1.73
RO	18	149	2	16	14	10	8.28	9	3.44	11.86
RS	18	53	1	6	5	3	2.94	3	1.43	2.06
SK	21	17	0	2	2	0	0.81	1	0.81	0.66
SI	19	21	0	4	4	0	1.11	1	1.37	1.88
ES	17	60	1	8	7	4 & 3	3.53	3	1.81	3.26
SE	20	44	0	6	6	1	2.2	2	1.61	2.59
CH	21	65	1	8	7	4	3.1	3	1.61	2.59
UK	15	51	1	7	6	2	3.4	4	1.84	3.4

¹ There are not registered deaths due to hornet, wasp and bee stings in: Iceland (1996–2016), Malta (1995–2004), Montenegro (1999–2004) and Bosnia and Herzegovina (2011).

3. Specific Locations where Hymenopteran Sting-Related Deaths Occurred

The X23 code extension to four-digit is fully available for most of the countries, with a total of 18 reporting case details. Conversely, three countries (FI, LV and SI) report all deaths without the four-digit extension. In seven countries (BE, BG, EE, LT, RS, SK and SE) both the X23 code with and without an extension to four-digit are used. All countries register the highest number of deaths with the code X23.9 (unspecified place), except for Hungary, and Austria, where the code X23.0 (home) harbours the highest number of Hymenopteran sting-related death events. In general, the pattern observed for most countries, with a few exceptions is X23.9 > X23.0 > X23.8 >X23.4 > X23.7; with no recorded deaths labelled as X23.5 (trade and service area). Very little used codes are: (i) 1 death coded as X23.3 (sports and athletics area) and 1 death coded as X23.6 (industrial and construction area), both having place in Romania; and (ii) seven deaths coded as X23.2 (school, other institution and public administrative area) in Belgium (1), Czechia (1), Hungary (3), Poland (1) and Spain (1); and 8 deaths coded as X23.1 (residential institution) in Austria (1), Belgium (1), Czechia (3), Norway (1) and Poland (2).

4. Age Distribution of Hymenopteran Sting-Related Deaths

Adults (25–64 years) were the most common age group to be fatally injured by Hymenopteran stings. Lithuania is the only exception, with an equal rate of adults and seniors (65 years and older) Hymenopteran sting-related deaths, a total of three. Only adult deaths were found in the following two countries: Ireland and Luxembourg. Children (0–14 years) fatalities were recorded in six countries: FR (2), RO (2), AT (1), HR (1), PT (1), and SK (1). A total of 22 victims in the youth group (15–24 years) were recorded in 12 countries with the following distribution: RO (6), AT (3), HU (2) and CH (2), and CZ, FR, DE, IT, LT, PL, RS and SI with only one death.

5. Hymenopteran Sting-Related Deaths by Gender

The majority of deaths (n = 1691) in Europe occurred in males. In fact, there are four countries with only male deaths, specifically, Greece and Portugal with nine male victims each; and Ireland and Luxembourg with two and one male victims, respectively. The X23 gender ratio (X23GR) of mortality varied from a min value of 1.4 for Norway to a maximum value of 20 for Slovenia, with a range of 18.6 for the whole dataset of countries. Obtained values for the calculated X23 gender differential (X23GD) varied between countries, being over 100 in Germany, France and Romania, with values of 157, 113 and 111, respectively.

6. Hymenopteran Sting-Related Deaths Features by Region: Eastern, Northern, Southern and Western Europe

Fatalities mostly occurred in Western (42.8%), Eastern (31.9%), Southern (15.1%) and Northern Europe (10.1%). Both X23GR and X23GD varied for the four regions, as follows: X23GD [Western Europe (366), Eastern Europe (310), Southern Europe (190) and Northern Europe (83)] and X23GR [Southern Europe (6.8), Eastern Europe (3.7), Western Europe (3.0) and Northern Europe (2.9)] (Table 2). Results show that eight and twenty-one fatalities were recorded in children (0–14 years) and the youth group (15–24 years), respectively. Adults (25–64 years) and seniors (65 years and older) were the most common age groups to be fatally injured with a total of 1128 victims (66.7%) and 520 victims (30.8%), respectively (Table 2). Fatal stings occurred mainly at home (29.4%) and at other specified places (11.2%), followed by on the street and highway (3.2%) and at farms (1.5%). However, 44.2% of the fatalities, a total of 748, are recorded at an “unspecified place”. The ranked order of the place of ocurrence was: X23.9 (unspecified place) > X23.0 (home) > X23.8 (other specified places) for Europe and Northern Europe; X23.0 (home) > X23.9 (unspecified place) > X23.8 (other specified places) for Eastern Europe; and X23.9 (unspecified place) > X23.8 (other specified places) > X23.0 (home) for Southern Europe.

Table 2. Absolute and relative frequency of the deaths due to hornet, wasp and bee stings in Europe and by European region: counts, X23 gender ratio of mortality (X23GR), X23 gender differential in mortality (X23GD), by age distribution and by place of occurrence.

Items	Items	Eastern Europe ¹ 1994–2016	Northern Europe ² 1996–2016	Southern Europe ³ 1995–2015	Western Europe ⁴ 1995–2016	Europe 1994–2016
Deaths	Total	540	171	256	724	1691
	Men	425 (78.7%)	127 (74.3%)	223 (87.1%)	545 (75.3%)	1320 (78.1%)
	Woman	115 (21.3%)	44 (25.7%)	33 (12.9%)	179 (24.7%)	371 (21.9%)
Ratio	X23GR	3.7	2.9	6.8	3	3.6
	X23GD	310	83	190	366	949
Age	≤14 years	3 (0.6%)	-	2 (0.8%)	3 (0.4%)	8 (0.5%)
	15–24 years	10 (1.9%)	1 (0.6%)	3 (1.2%)	7 (1%)	21 (1.2%)
	25–64 years	418 (77.4%)	101 (59.1%)	169 (66%)	440 (60.8%)	1128 (66.7%)
	≥65 years	109 (20.2%)	55 (32.2%)	82 (32%)	274 (37.8%)	520 (30.8%)
Place	Not reported	33 (6.1%)	52 (30.4%)	73 (28.5%)	1 (0.1%)	159 (9.4%)
	X23 code extension to four-digit reported ⁵	507 (93.9%)	119 (69.6%)	183 (71.5%)	723 (99.9%)	1532 (90.6%)
	X23.0 (home)	241 (44.6%)	35 (20.5%)	19 (7.4%)	202 (27.9%)	497 (29.4%)
	X23.1 (residential institution)	5 (0.9%)	1 (0.6%)	-	2 (0.3%)	8 (0.5%)
	X23.2 (school, other institution and public administrative area)	5 (0.9%)	-	1 (0.4%)	1 (0.1%)	7 (0.4%)
	X23.3 (sports and athletics area)	1 (0.2%)	-	-	-	1 (0.1%)
	X23.4 (street and highway)	17 (3.1%)	1 (0.6%)	6 (2.3%)	30 (4.1%)	54 (3.2%)
	X23.5 (trade and service area)	-	-	-	-	-
	X23.6 (industrial and construction area)	1 (0.2%)	-	-	-	1 (0.1%)
	X23.7 (farm)	18 (3.3%)	1 (0.6%)	6 (2.3%)	1 (0.1%)	26 (1.5%)
	X23.8 (other specified place)	48 (8.9%)	9 (5.3%)	21 (8.2%)	112 (15.5%)	190 (11.2%)
	X23.9 (unspecified place)	171 (31.7%)	72 (42.1%)	130 (50.8%)	375 (51.8%)	748 (44.2%)

¹ Eastern Europe (n = 6): BG, CZ, HU, PL, RO and SK. ² Northern Europe (n = 9): EE, FI, IS, IE, LV, LT, NO, SE and UK. ³ Southern Europe (n = 10): BA, HR, EL, IT, MT, ME, PT, RS, SI and ES. ⁴ Western Europe (n = 7): AT, BE, FR, DE, LU, NL, and CH. ⁵

7. Hymenopteran Sting-Related Deaths, X23 Mortality Rates (X23MR)

The mortality rates (X23MR) were calculated based on the population size of each country, the obtained results ranged from 0 to 2.24 with an average of 0.26. The country with the highest mean X23MR was Estonia (0.61) followed by Austria and Slovenia (0.6 and 0.55, respectively). The countries with the lowest X23MR values were Ireland (0.05), United Kingdom (0.06) and the Netherlands (0.06). The highest rates were recorded in countries from Eastern Europe (X23MR = 0.35) followed by Western (X23MR = 0.28), Northern (X23MR = 0.23) and Southern (X23MR = 0.2) Europe (Figure 1).

Figure 1. Map of Europe showing the average Hymenopteran sting-related mortality rates (X23MR) during the studied period (1994–2016). The X23MR are expressed in terms of annual rates (i.e., per year) and per 1,000,000 inhabitants, based in the dataset range for each country.

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