Box Jelly Fish | Chironex | Irukandji Jelly Fish

Synopsis of Jellyfish Hazards
Two quite different types of dangerous box jellyfish occur throughout the world's oceans, particularly in the tropics. They are separated quite easily by the number of tentacles attached to each corner of the body, as well as by the type of sting they give. Not all box jellyfish are dangerous, but a good rule of thumb is to consider it as potentially dangerous until you know that it is safe.

1. Multi-tentacled Box Jellyfish
Square, box shaped body with a branched "arm" hanging from each corner, each with multiple tentacles (total up to 60 tentacles). There are at least two types of multi-tentacled box jellyfish in Thailand, one smaller with branches in a single row, and the other larger with branches in three dimensions. The Australian species Chironex fleckeri is an example of a multi-tentacled box jellyfish, and is widely considered the "world's most venomous animal", able to kill healthy adults and children in as little as 2 minutes through massive envenomation. As a general guideline, an adult multi-tentacled box jelly may have up to 120-180 metres of tentacle, requiring as little as 1.2 metres to kill a child, or 3-5 metres to kill an adult; some sort of barrier between the jellyfish and skin is an essential part of safety. Multi tentacled box jellyfish are generally found in shallow coastal environments, particularly on sandy beaches near mangroves and river mouths. They are found throughout the tropics of the world; they are commonest in the warmer months but may be found at any time of year in any conditions.

2. Single-tentacled Box Jellyfish
Rectangular box-shaped body with specimens from 1cm to 15cm tall (depending on species), with an unbranched "arm" hanging from each corner with one tentacle, each with a single tentacle only (total 4 tentacles). Throughout the world there are currently many types of single-tentacled box jellyfish that cause severe symptoms known as the "Irukandji syndrome", with more still being found; Carukia barnesi is a common Australian example. Irukandji syndrome has been confirmed throughout the recreational oceans and seas of the world, e.g. Australia, Thailand, Japan, Hawaii, Florida, Caribbean, Tahiti, India and others, as far north as North Wales in the UK and as far south as Melbourne in Australia. An initially minor skin sting results in severe symptoms after a delay in onset of about 5-40 minutes. The symptoms include: severe lower back pain, nausea, vomiting, profuse sweating, difficulty breathing, cramps, spasms, coughing and a feeling of "impending doom"; these are not usually deadly, but are severely distressing and may promote drowning. Some species can also cause severe hypertension (high blood pressure), which may be deadly to previously well patents, through stroke or heart attack. In Australia, Irukandji jellyfish are typically found along protected beaches, as well as reefs, islands and open ocean, particularly during periods of mild, onshore breezes. They are more abundant during warmer months, but may be found in any location, any time of year and in any conditions.

3. Other types of Jellyfish
Other types of jellyfish such as blue bottles, Portuguese man-o-war, blubbers, sea lice, lion's mane, sea nettles, mauve stingers and others are common in the Thai region but are of less serious medical concern than box jellyfish and Irukandjis, and are not generally considered life threatening in this region. However, it is not uncommon for people unfamiliar with jellyfish identification to fear all jellyfish; this can be easily overcome with education.

History of marine stinger knowledge in Thailand
A colleague (Dr John Williamson) visited Phuket, on the Andaman Sea, west Thailand, with Dr Robert Hartwick PhD, in August 1985. Exploration of the local coastline, fishing villages, and excursions with native fishermen in their boats revealed several jellyfish but no multi-tentacled box jellyfish (also called 'chirodropids') were seen. Local fisher folk immediately recognised photos of box jellyfish, and of human stings, and a village fisherman's wife proudly displayed leg scars from a sting 3 years previously which could have been a chirodropid. The fishermen knew the "summertime" chirodropids as "munga fi" (see case report below), which translated approximately info "fire jelly", and they associated hot, still weather and calm water with the risk of stings. Almost every fisherman admitted to "munga fi" stings at some time in his life. No deaths were known or admitted.

Later in Bangkok, at the Department of Dermatology, Siriraj Hospital, Dr. Williamson learned that the presentation of patients with mainly chronic scarring - almost definitely from "box-jellyfish" stings - sustained in the Bangkok area, was a regular occurrence. A senior Bangkok scuba diving instructor, Lieutenant Colonel (Ret.) A.B. "Dusty" Rhodes, continues to report jellyfish stings and sightings in the Gulf of Siam and in the Andaman Sea, including one night time sighting of a chirodropid in the Andaman Sea.

Studies in Thailand suggest that a locally occurring plant "phakbung-thale" (Ipomoea pes-caprae (L.) Roth) which is found in abundance along the warmer seashores of both hemispheres, and which has been and is used by Thai fisherman to both prevent and treat jellyfish stings (Wasuwat 1970; Applied Scientific Research Institute of Thailand 1977), may have a valid pharmacological basis (Pongprayoon et al 1991)

Human Fatalities
A review of Thai literature dealing with jellyfish stings in the Gulf of Siam and Andaman Sea revealed anecdotal reports of a few deaths following jelly fish stings (Siriraj Hospital Gazette 1985 and J. Nakorn Rachasema Hospital 1991 - in Thai and not listed in Medline).

In December 1995, two deaths were described after jellyfish envenomation at Langkawi Island, on the west coast of Malaysia on its border with Thailand (Fenner & Williamson 1996). The victims; rapid demise and the characteristic skin markings suggested that the causative jellyfish was a multi-tentacled box jellyfish.

1999
A 26 year old British tourist was swimming off Chaweng Beach on the Thai Island of Koh Samui on October 20, 1999. It was early evening and the sea was calm. He suddenly came out of the water and was observed by his friends waling unsteady and asking for water to drink. He then, within minutes, collapsed, stopped breathing and was pulseless with dilated non reactive pupils on arrival at a nearby local hospital. The physician, one of the reporters, noted extensive welts across his neck, chest and back with the typical appearance of recent jelly fish stings. Efforts of resuscitation were not successful.

2002
A 25 year old male from Australia and a 23 year old female, from Switzerland died in August after being stung in waters of Koh Pha Ngan, officials said. The 25 year old (male) died on 9 August 2002 after receiving massive stings to his legs while swimming of the islands Hat Rin Nok beach. He died before arriving at a beach-side clinic, a hospital official said. Late afternoon wading in waist-deep water he was stung on both legs, stopped breathing - pulseless within 5 minutes. Resuscitation commenced immediately asystolic ECG on arrival at the local hospital 15 minutes later.

Bangkok Pater Report:

Island warns of deadly jellyfish after tourist deaths - Wed Aug 21 12.33 2002 AM ET
BANGKOK, Thailand - Officials on a popular resort island in southern Thailand have laid nets in the sea to prevent poisonous jellyfish from nearing the shore after two foreign tourists were fatally stung while swimming.

Sean Tyrrel, 25 of Australia and Mounya Den, 23, of Switzerland died earlier this month after being stung in waters off Koh Pha Ngan, officials said Wednesday.

Tyrrell died on Aug. 9 after receiving massive stings to his legs while swimming off the island's Hat Rin Beach. He died before arriving at a beachside clinic a hospital official said.

A day later, Dena died from similar stings to her legs after being taken by speedboat to Ban Don Inter Hospital on the nearby island of Koh Samui.

The victims' hometowns were not immediately available.

The deaths on the island, which is known for hosting all-night rave parties, have prompted local authorities to warn tourists against swimming in the sea during the monsoon season, when the deadly jellyfish are frequently washed toward the beach by rough seas.

"We have set up a sign board on the beach warning tourists to refrain from swimming where the jellyfish are rampant, and laid nets in the areas to prevent the lethal jellyfish from coming close to the beach," Hat Rin local administrator Prasob Tauychareon told The Associated Press.

The victims were the first to die from jellyfish stings in several decades, he said.

3 April 2008 (Thursday), Klong Dao beach, Koh Lanta, Southwest Thailand.
11 year old girl dies after being stung by jellyfish while paddling on lilo about 20m out from the beach in the morning around 10 am. Later that day a sign was erected on the beach saying: Watch out for Jellyfish, be careful when you are swimming.

History of marine stinger knowledge in Australia
Whilst deaths and life threatening stings from marine stingers have been known and tracked in Australia since 1884, two issues have been pivotal.

First, multi-tentacled box jellyfish were originally identified in Australia in the 1940's, and linked as the causal agent to fatalities in 1955. However, it wasn't until the 1960's that Jack Barnes, a physician in Cairns, began advising the public to wear protective clothing to minimise their exposure to risk. For decades, this protective clothing was pantyhose; in the early 1980's, lycra body suits were introduced. Both work well (see below for more information). However, protective clothing was, in general, not popular with beach-goers. In 1982, a company called UniNet began installing 'stinger nets', in response to request from the tourism industry. Today, about 30 stinger nets are installed at popular beaches throughout northern Queensland where Chironex occur. There has never been a life threatening multi-tentacled box jellyfish sting inside the nets; in addition, the nets provide a safer place to swim than in unprotected areas, and they act as a positive, reassuring education device to the recreational public. Indeed, deaths in Queensland have reduced from 1 per 4 years before the nets to 1 per 12 years since the nets, whereas in Northern Territory where nets are not used, deaths have increased from 1 in 4 years to 1 in 3 years. Because of the nets, Chironex have been considered well managed in Queensland for over 20 years, allowing the tourism industry to flourish.

Second, the symptoms of Irukandji syndrome were first identified in Australia in the 1940's, but were not linked to species of jellyfish as the causal agent until 1961. However, the general public and tourism industry was not widely aware of Irukandjis and the illness they cause until 2002, following two highly publicised tourist fatalities in North Queensland. The negative publicity resulting from the fatalities caused a conservatively-estimated loss to tourism of about $65 Million. In response, the state government initiated the Queensland Government Irukandji Task Force, for the purpose of overseeing research and public safety. Through the Task Force, excellent contributions to the scientific knowledge and management strategies were produced toward reducing risk from marine stingers. As an outgrowth of the Task Force, the Whitsunday region assembled a local Marine Stinger Management Committee in 2005; in two years of pro-active effort at raising awareness about the utility of protective clothing, life threatening stings reduced from a historical average of 30-ish per year to 7 per year to 4 per year!

Best Practice Prediction
In general, multi-tentacled box jellyfish are commonest in the warmer months (November to May in Australia), particularly along shallow, sandy beaches near mangroves and river mouths, and particularly along the southern ends of bays. However, they have been found all months and in just about all tropical regions.

Multi-tentacled box jellyfish often swarm in shallow, protected conditions, e.g. calm, early morning seas. Presence of schools of small prawns and fish often coincide with Box Jellyfish swarms, because multi-tentacled box jellyfish follow their food. Whilst "early season" box jellies are typically too small to be a health threat (they become deadly at about 8cm body size), it is important to keep in mind that large specimens are often found with small specimens, so the detection of a high risk condition is based on presence of box jellyfish, not presence of large box jellyfish.

In general, single-tentacled box jellyfish typically swarm on flat-calm days with a mild, 5-10 know onshore breeze. In Australia, we typically see swarms of Irukandjis between between Christmas and New Year, and somewhat lesser swarms around Easter time, but usually only for 1-2 days in any given location. However, it is important to note that even when swarms are not present, occasional stings do occur in all conditions.

It has been demonstrated by many different researchers over the past 50 years that a very strong correlation exists between Irukandjis and 'salps and jelly buttons'. Salps are a type of colonial invertebrate that are easily recognised as chains of jellyfish, with the individuals stuck together in a herringbone pattern. Jelly buttons are any of a number of types of small clear jellyfish that produce a 'sea lice' type of nuisance sting. Both salps and jelly buttons are more numerous than Irukandjis, and may be effectively used as predictors of the relative risk of Irukandjis. On the highest risk Irukandji days, it is common to see salps and jelly buttons washing up at the tide line, and also to feel a higher than usual "sea lice" sort of stinging irritation feeling to the skin.

Best Practice Prevention
The primary strategy for prevention of life-threatening jellyfish stings in Australia is providing a barrier between jellyfish and human skin. For multi-tentacled box jellyfish, the most successful method currently in use is stinger nets; for single-tentacled box jellyfish, the most successful method currently in use is protective clothing. It should be noted, however, that protective clothing works equally well for all types of jellyfish sting prevention. The reason for the different strategies is that multi-tentacled box jellyfish are more of a 'beach problem', where Irukandjis are a 'reef, island and beach problem'/ Thus, the nets work well for beaches, but not so well for reefs and island; but whereas divers and snorkelers do not mind wearing protective clothing, beach-goers tend to be less willing. Thus, the biggest challenge in the Queensland marine stinger problem is currently beach Irukandji stings.

Quite simply, Irukandjis most frequently sting the chest and upper arms, because they swim at the surface and most swimmers and bathers bob at the surface; multi-tentacled box jellies typically sting the legs, because they swim near the bottom. A full-body lycra suit covers up about 75-80% of the body's skin surface, but also serves to cover the parts most frequently stung. Furthermore, lycra suits provide excellent sun protection, and can be removed at the end of the day, leaving the wearer and the corals with less greasiness from sunscreen.

Numerous types of "jellyfish repellents" have been marketed throughout the years. There is insufficient evidence that these actually work to prevent a life threatening envenomation. In general, jellyfish stinging cells operate on a hair-trigger mechanism. Therefore, a chemical means of repelling a jellyfish may be ineffective because one it touches the skin, the sting still occurs; similarly, inhibiting the hair trigger may be ineffective because it is a mechanical process. Thus the only method considered safe by marine stinger safety experts is providing a physical barrier between the jellyfish and human skin.

Best Practice First Aid Treatment
Like all first aid treatment, the highest priority is saving human life. With multi-tentacled box jellyfish stings, loss of consciousness and cardiac standstill may occur in as little as 2 minutes, so it is of the utmost importance to stay with the person, get help on the way, and commence CPR (Cardiopulmonary resuscitation) if necessary. With single-tentacled box jellyfish, the initial sting will often seem quite minor, but severe systemic symptoms develop after a delay of 5-40 minutes. Thus, the priority for multi-tentacled box jellyfish stings is to maintain life; stopping additional envenomation with vinegar is a secondary priority; with single-tentacled box jellyfish, there is ample time to see if symptoms develop, and early vinegar can make a huge difference. Vinegar stops the stinging cells that haven't fired yet from firing; this inhibition process is permanent and instant, and works with any type of undiluted household vinegar. Hot water or ice should NOT be used; freshwater causes massive discharge of stinging cells, thus increasing envenomation, and heat dilates capillaries, thus potentially worsening the effect of the sting by increasing the amount and speed of venom uptake.

FIRST AID TREATMENT FOR MULTI-TENTACLED BOX JELLYFISH STINGS (e.g. Chironex)

1. Remove from water, if necessary
2. Send others for help; do not leave the victim
3. If the patient is unconscious, commence CPR (cardiopulmonary resuscitation) immediately
4. If the patient is conscious, douse stung area liberally with vinegar for 39 seconds
5. Check consciousness regularly - victims will often scream with pain - if they become quiet they may be going unconscious.
6. Be prepared to give CPR if necessary
7. Get to medical aid as quickly as possible.

FIRST AID TREATMENT FOR SINGLE-TENTACLED BOX JELLYFISH STINGS (e.g. Irukandji)

Importance of Research in prediction, prevention & treatment
Many important advancements have been made in recent years toward improvements and insights in prediction, prevention and treatment of marine stingers and their stings. This research is very active in Australia, and a strong collaborative research program is now up and running between Thailand and Australia

The most active areas of research at this time in Australia are into the ecology of the Cjorpmex and Irukandjis, in order to refine our understanding of their prediction, and on developing better offshore treatments for Irukandji stings (e.g., dive operators, island resorts)

In Thailand, the current research focus is on identification of the species present, and on understanding their ecology, i.e. being able to predict and detect them with greater accuracy. There is an excellent chance that the antivenom used in Australia for Chironex-type box jellyfish will also be effective for Thailand box jellyfish, and that the magnesium treatment used by hospitals for Irukandji envenomation will also be effective for Thai Irukandjis. However, it must be cautioned for Chironex-type box jellyfish that death typically happens faster than antivenom can be delivered to the victim; thus prevention remains the primary focus.

Box Jelly Fish | Chironex | Irukandji Jelly Fish

BOX JELLYFISH INFORMATION Information supplied by Phuket Aquarium (Phuket, Thailand), written by Prof. Peter Fenner and Dr Lisa-Ann Gershwin.

BOX JELLYFISH INFORMATION
Information supplied by Phuket Aquarium (Phuket, Thailand), written by Prof. Peter Fenner and Dr Lisa-Ann Gershwin.