Short Communication |
Corresponding author: Will K. Reeves ( wkreeves@gmail.com ) Academic editor: Jack Neff
© 2016 Jameson D. Voss, Richard Kugblenu, Khabira Salter, Lucas Johnson, Will K. Reeves.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Voss JD, Kugblenu R, Salter K, Johnson L, Reeves WK (2016) Case series of 23 deaths from Hymenoptera stings among United States Air Force populations. Journal of Hymenoptera Research 48: 95-99. https://doi.org/10.3897/JHR.48.7905
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Medical conditions arising from hymenopteran sting allergy or mass envenomation are a serious health concern, particularly in austere environments. Both practicing allergists and entomological pest control personnel should consider the relevance of stinging insects when responding to problems with Hymenoptera. Recent occupational reviews of civilian deaths from insect bites and stings prompted our review of the US Air Force Mortality Registry to determine the relevance of insect stings and bites as a cause of death in the US Air Force. After reviewing over 40 years of death records we identified 23 death records, among US Air Force Active duty, guard, or retirees that arose directly from hymenopteran stings.
Hymenoptera , bees, wasps, stings, mortality, military, Air Force Mortality Registry
Public health aspects of pest control have substantially improved since the days when flea-infested rats helped transmit the Black Death that decimated medieval Europe (
In modern times, this legacy of fleas, mosquitoes, and stray dog control makes it easy to overlook another threat envenomation from Hymenoptera (i.e., bees, wasps, and ants) or possibly other insects such as certain Lepidopteran caterpillars. While hymenopteran stings are known to cause allergic reactions, their medical importance is underestimated because their venom is often more irritating than lethal and they are not known as a vector for any infectious diseases.
Despite having a lower historical priority, there is growing evidence for the medical importance of ants, bees, and wasps. A recent review of mortality among workers in the United States found there were 52 occupational deaths from bees, 11 deaths from wasp stings, 4 from ant stings, and an additional 16 from spiders or other unknown insects from 2003–2010 and thousands of non-fatal lost work days attributable to insect stings (
We evaluated the Air Force Mortality Registry (AFMR), which is the largest mortality registry within the Department of Defense. In the late 1990s, the Air Force began to compile death records from any member who died in the Active, Reserve, and Guard components of the Air Force and any retiree from these components. These records are still being collected from current times and now date back to 1970. There are over 350,000 deaths already registered within this database. The Air Force is the only service to assemble a long-term database of mortality records among retirees.
Within AFMR, deaths are classified by International Classification of Diseases (ICD) –10 codes based on the death certificate, casualty reports, ICD–10 codes obtained from the National Death Index, or a combination of sources. We defined cases as those having an ICD–10 of T63.4, which is the standardized coded designation for hymenoptera stings. All death certificates were reviewed individually to evaluate whether the individual died at home, on arrival, or after arrival to a medical facility.
There were 23 deaths due to Hymenoptera stings representing <0.7 per 10,000 of all registered deaths within AFMR. A death certificate was available for 15 of the 23 identified cases. The number of stings was not reported so we could not determine if these were death from a single sting or mass envenomation. There is a significant difference between death from anaphylaxis or heart attack and massive toxin exposure. Eight individuals died after arrival to the emergency room, but before admission to an inpatient setting, and three died after being admitted to an inpatient setting. Thus, 11/15 deaths (73%) occurred after arrival to an emergency department.
Aggregate demographics are provided in Table
Summary Characteristics of 23 Hymenoptera Death Cases in the US Air Force 1977–2013.
Age | average 59.0; range 38–86 |
Sex | 22 males; 1 female |
Status | 20 retirees; 1 each from Active, Reserve, and Guard components |
Clinical allergists could potentially play a role in secondary prevention of death or serious allergic reactions, such as screening individuals at risk for Hymenoptera sensitivity including at the time of retirement or separation from military service. Once identified, these individuals could carry medical countermeasures as recommended by their medical provider. Immunologic testing (e.g., specific IgE tests, basophil activation test, horseradish peroxidase, etc.) may help with identification and immunotherapy may provide therapeutic and quality of life benefits (
While a comprehensive approach to Hymenoptera control offers hope that these deaths are modifiable, these benefits have not yet materialized. In fact, despite the broad-based progress in mitigating medical effects of numerous pests, trends in occupational Hymenoptera deaths are fairly stable over the past decade (
The authors have no conflicts of interest to disclose. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University, United States Air Force, United States Navy, Department of Defense, or the U.S. Government. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW–2015-1032, 11 March 2015.