651 Corresponding author: Drª Jacqueline de Almeida Gonçalves Sachett. e-mail: jacenfermagem@hotmail.com Received 26 December 2017 Accepted 8 August 2018 Rev Soc Bras Med Trop 51(5):651-659, Sep-Oct, 2018 doi: 10.1590/0037-8682-0356-2017 Major Article Delayed healthcare and secondary infections following freshwater stingray injuries: risk factors for a poorly understood health issue in the Amazon Jacqueline de Almeida Gonçalves Sachett [1],[2] , Vanderson Souza Sampaio [1],[3] , Iran Mendonça Silva [1],[2] , Akemi Shibuya [4] , Fábio Francesconi Vale [1],[5] , Fabiano Peixoto Costa [2] , Pedro Pereira de Oliveira Pardal [6] , Marcus Vinícius Guimarães Lacerda [1],[2],[7] and Wuelton Marcelo Monteiro [1],[2] [1]. Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil. [2]. Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, AM, Brasil. [3]. Sala de Análise de Situação em Saúde, Fundação de Vigilância em Saúde do Amazonas, Manaus, AM, Brasil. [4]. Coordenação de Biodiversidade, Instituto Nacional de Pesquisas da Amazônia, Manaus, AM, Brasil. [5]. Faculdade de Medicina, Universidade Federal do Amazonas, Manaus, AM, Brasil. [6]. Centro de Ciências da Saúde, Universidade Federal do Pará, Belém, PA, Brasil. [7]. Instituto de Pesquisas Leônidas & Maria Deane, Fundação Oswaldo Cruz, Manaus, AM, Brasil. Abstract Introduction: This study aimed to describe the profle of freshwater stingray injuries in the State of Amazonas, Brazilian Amazon, and to identify the associated risk factors for secondary infections. Methods: This cross-sectional study used surveillance data from 2007 to 2014 to identify factors associated with secondary infections from stingray injuries. Results: A total of 476 freshwater stingray injuries were recorded, with an incidence rate of 1.7 cases/100,000 person/year. The majority of injuries were reported from rural areas (73.8%) and 26.1% were related to work activities. A total of 74.5% of patients received medical assistance within the frst 3 hours of injury. Secondary infections and necrosis were observed in 8.9% and 3.8%, respectively. Work-related injuries [odds ratio (OR) 4.1, confdence interval (CI); 1.87-9.13] and >24 hours from a sting until receiving medical care (OR; 15.5, CI; 6.77-35.40) were independently associated with the risk of secondary bacterial infection. Conclusions: In this study, work-related injuries and >24 hours from being stung until receiving medical care were independently and signifcantly associated with the risk of secondary infection. The frequency of infection following sting injuries was 9%. The major factor associated with the risk of secondary bacterial infection was a time period of >24 hours from being stung until receiving medical care. Keywords: Wound infection. Epidemiology. Risk factors. Venomous animals. INTRODUCTION Both traumatic and toxic components are involved in stingray injuries from marine or freshwater stingray punctures, and are common in coastal regions globally 1,2 . In Brazil, from 2007 to 2013, most of the 4,118 injuries from aquatic animals were due to stingrays (69%) in marine and freshwater environments 3 . Freshwater stingray injuries are common in the Brazilian Amazon, representing 88.4% of aquatic animal injuries reported from this region 3 . The number of cases detected offcially in the Amazon is likely to be considerably lower than the actual number, as a result of underreporting, given the diffculties faced by riverine and indigenous populations living in remote areas to reach health centers. One survey from the State of Acre, in Brazil, found stingray injuries were common, with 18% of rubber tappers and 23% of Amerindians affected at least once in their lifetime 4 . Moreover, delays in patient care, along with the use of homemade remedies may impair healing of the wound site and lead to a high frequency of local complications, such as secondary bacterial infections 5,6 . To assess the health burden due to stingray injuries through population- and hospital-based feld studies it is essential to understand the extent of complications following this poorly understood health problem 6 . In the Central and Western Brazilian Amazon, freshwater stingrays from the Potamotrygonidae family are more frequent, comprising four genera, Potamotrygon, Paratrygon, Plesiotrygon, and Heliotrygon, and 28 recognized species. Some species are widely distributed, such as Paratrygon aiereba,