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Background  Despite recent deaths caused by box jellyfish envenomation occurring on the islands of Samui and Pha-ngan in the Gulf of Thailand, many people do not believe box jellyfish can kill humans and many people dismiss the problem as insignificant. More evidence has been requested from the communities in order to evaluate the need for and the implementation of sustainable prevention measures. We aimed to determine the magnitude of cases of severe stinging by box jellyfish and describe the characteristics of these cases on the islands of Samui and Pha-ngan in Surat Thani Province from 1997 to 2015.    Methods  Various strategies were integrated prospectively. Toxic jellyfish networks and surveillance system were established. Outbreak investigations were conducted retrospectively and prospectively from 2008 to 2015.    Results  There were 15 box jellyfish cases. A small majority of them were women (60.0) with a median age of 26.0 years (range 5.0–45.0 years). The highest incidence by month were August (33.3 %), September and October (20.0 %), and July (13.3 %). Eight cases occurred on Samui (53.3 %), 6 cases on Pha-ngan island (40.0 %), and one case on the boat. All cases developed symptoms and signs immediately after being stung. More than half of the cases were unconscious. There were six fatal cases (46.7 %). The wound characteristics had an appearance similar to caterpillar tracks or step ladder-like burn marks. Almost all cases involved Chirodropidae. One fatal case received fresh water and ice packs applied to the wounds (16.7 %). Among the cases with known first aid, only one out of six fatal cases had vinegar applied to the wounds (16.7 %), while haft of six surviving cases received the vinegar treatment.    Conclusions  The islands of Samui and Pha-ngan have the highest incidence of fatal and near fatal box jellyfish cases in Thailand. There is an urgent need for informed pre-clinical emergent care. Optimal pre-clinical care is an area of active research.

The magnitude of severe box jellyfish cases on Koh Samui and Koh Pha-ngan in the Gulf of Thailand