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Alonso LL, van Thiel J, Slagboom J, Dunstan N, Modahl CM, Jackson TNW, Samanipour S, Kool J. Studying Venom Toxin Variation Using Accurate Masses from Liquid Chromatography-Mass Spectrometry Coupled with Bioinformatic Tools. Toxins (Basel) 2024; 16:181. [PMID: 38668606 PMCID: PMC11053424 DOI: 10.3390/toxins16040181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
This study provides a new methodology for the rapid analysis of numerous venom samples in an automated fashion. Here, we use LC-MS (Liquid Chromatography-Mass Spectrometry) for venom separation and toxin analysis at the accurate mass level combined with new in-house written bioinformatic scripts to obtain high-throughput results. This analytical methodology was validated using 31 venoms from all members of a monophyletic clade of Australian elapids: brown snakes (Pseudonaja spp.) and taipans (Oxyuranus spp.). In a previous study, we revealed extensive venom variation within this clade, but the data was manually processed and MS peaks were integrated into a time-consuming and labour-intensive approach. By comparing the manual approach to our new automated approach, we now present a faster and more efficient pipeline for analysing venom variation. Pooled venom separations with post-column toxin fractionations were performed for subsequent high-throughput venomics to obtain toxin IDs correlating to accurate masses for all fractionated toxins. This workflow adds another dimension to the field of venom analysis by providing opportunities to rapidly perform in-depth studies on venom variation. Our pipeline opens new possibilities for studying animal venoms as evolutionary model systems and investigating venom variation to aid in the development of better antivenoms.
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Affiliation(s)
- Luis L. Alonso
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.L.A.); (J.S.)
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
| | - Jory van Thiel
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.L.A.); (J.S.)
- Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
- Naturalis Biodiversity Center, 2333 CR Leiden, The Netherlands
| | - Julien Slagboom
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.L.A.); (J.S.)
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
| | | | - Cassandra M. Modahl
- Centre for Snakebite Research & Interventions, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK;
| | - Timothy N. W. Jackson
- Australian Venom Research Unit, Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, VIC 3010, Australia;
| | - Saer Samanipour
- Van‘t Hof Institute for Molecular Sciences, University of Amsterdam, Science Park 904, 1098 XH Amsterdam, The Netherlands;
| | - Jeroen Kool
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (L.L.A.); (J.S.)
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
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Padidar S, Monadjem A, Litschka-Koen T, Thomas B, Shongwe N, Baker C, Mmema L, Sithole T, Murray J, Casewell NR, Pons J, Lalloo DG, Harrison RA, Stienstra Y, Dlamini WM. Snakebite epidemiology, outcomes and multi-cluster risk modelling in Eswatini. PLoS Negl Trop Dis 2023; 17:e0011732. [PMID: 37948462 PMCID: PMC10664941 DOI: 10.1371/journal.pntd.0011732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 11/22/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Halving snakebite morbidity and mortality by 2030 requires countries to develop both prevention and treatment strategies. The paucity of data on the global incidence and severity of snakebite envenoming causes challenges in prioritizing and mobilising resources for snakebite prevention and treatment. In line with the World Health Organisation's 2019 Snakebite Strategy, this study sought to investigate Eswatini's snakebite epidemiology and outcomes, and identify the socio-geographical factors associated with snakebite risk. METHODOLOGY Programmatic data from the Ministry of Health, Government of Eswatini 2019-2021, was used to assess the epidemiology and outcomes of snakebite in Eswatini. We developed a snake species richness map from the occurrence data of all venomous snakes of medical importance in Eswatini that was subjected to niche modelling. We formulated four risk indices using snake species richness, various geospatial datasets and reported snakebites. A multivariate cluster modelling approach using these indices was developed to estimate risk of snakebite and the outcomes of snakebite in Eswatini. PRINCIPAL FINDINGS An average of 466 snakebites was recorded annually in Eswatini. Bites were recorded across the entire country and peaked in the evening during summer months. Two cluster risk maps indicated areas of the country with a high probability of snakebite and a high probability of poor snakebite outcomes. The areas with the highest rate of snakebite risk were primarily in the rural and agricultural regions of the country. SIGNIFICANCE These models can be used to inform better snakebite prevention and treatment measures to enable Eswatini to meet the global goal of reducing snakebite morbidity and mortality by 50% by 2030. The supply chain challenges of antivenom affecting southern Africa and the high rates of snakebite identified in our study highlight the need for improved snakebite prevention and treatment tools that can be employed by health care workers stationed at rural, community clinics.
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Affiliation(s)
- Sara Padidar
- Department of Biological Sciences, University of Eswatini, Kwaluseni, Eswatini
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | - Ara Monadjem
- Department of Biological Sciences, University of Eswatini, Kwaluseni, Eswatini
- Mammal Research Institute, Department of Zoology & Entomology, University of Pretoria, Hatfield, Pretoria, South Africa
| | - Thea Litschka-Koen
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | - Brent Thomas
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nondusimo Shongwe
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | - Clare Baker
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lindelwa Mmema
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | | | - James Murray
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | - Nicholas R. Casewell
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jonathan Pons
- Eswatini Antivenom Foundation, Simunye, Eswatini
- Eswatini Snakebite Research and Intervention Centre, Simunye, Eswatini
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Robert A. Harrison
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ymkje Stienstra
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
| | - Wisdom M. Dlamini
- Department of Geography, Environmental Science and Planning, University of Eswatini, Kwaluseni, Eswatini
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van Thiel J, Alonso LL, Slagboom J, Dunstan N, Wouters RM, Modahl CM, Vonk FJ, Jackson TNW, Kool J. Highly Evolvable: Investigating Interspecific and Intraspecific Venom Variation in Taipans ( Oxyuranus spp.) and Brown Snakes ( Pseudonaja spp.). Toxins (Basel) 2023; 15:74. [PMID: 36668892 PMCID: PMC9864820 DOI: 10.3390/toxins15010074] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Snake venoms are complex mixtures of toxins that differ on interspecific (between species) and intraspecific (within species) levels. Whether venom variation within a group of closely related species is explained by the presence, absence and/or relative abundances of venom toxins remains largely unknown. Taipans (Oxyuranus spp.) and brown snakes (Pseudonaja spp.) represent medically relevant species of snakes across the Australasian region and provide an excellent model clade for studying interspecific and intraspecific venom variation. Using liquid chromatography with ultraviolet and mass spectrometry detection, we analyzed a total of 31 venoms covering all species of this monophyletic clade, including widespread localities. Our results reveal major interspecific and intraspecific venom variation in Oxyuranus and Pseudonaja species, partially corresponding with their geographical regions and phylogenetic relationships. This extensive venom variability is generated by a combination of the absence/presence and differential abundance of venom toxins. Our study highlights that venom systems can be highly dynamical on the interspecific and intraspecific levels and underscores that the rapid toxin evolvability potentially causes major impacts on neglected tropical snakebites.
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Affiliation(s)
- Jory van Thiel
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
- Naturalis Biodiversity Center, 2333 CR Leiden, The Netherlands
| | - Luis L. Alonso
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
| | - Julien Slagboom
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
| | | | - Roel M. Wouters
- Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
| | - Cassandra M. Modahl
- Centre for Snakebite Research & Interventions, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Freek J. Vonk
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Naturalis Biodiversity Center, 2333 CR Leiden, The Netherlands
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
| | - Timothy N. W. Jackson
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, VIC 3010, Australia
| | - Jeroen Kool
- Division of Bioanalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Sciences, Amsterdam Institute of Molecular and Life Sciences (AIMMS), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- Centre for Analytical Sciences Amsterdam (CASA), 1012 WX Amsterdam, The Netherlands
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Li Q, Zeng L, Deng H, Liang Q. Adverse reactions to four types of monovalent antivenom used in the treatment of snakebite envenoming in South China. Toxicon 2022; 219:106935. [DOI: 10.1016/j.toxicon.2022.106935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 10/31/2022]
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Liu CC, Wu CJ, Chou TY, Liaw GW, Hsiao YC, Chu LJ, Lee CH, Wang PJ, Hsieh CH, Chen CK, Yu JS. Development of a Monoclonal scFv against Cytotoxin to Neutralize Cytolytic Activity Induced by Naja atra Venom on Myoblast C2C12 Cells. Toxins (Basel) 2022; 14:toxins14070459. [PMID: 35878197 PMCID: PMC9320128 DOI: 10.3390/toxins14070459] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
The Taiwanese cobra, Naja atra, is a clinically significant species of snake observed in the wild in Taiwan. Victims bitten by N. atra usually experience severe pain and local tissue necrosis. Although antivenom is available for treatment of cobra envenomation, its neutralization potency against cobra-induced necrosis is weak, with more than 60% of cobra envenoming patients developing tissue necrosis after antivenom administration. The present study found that cytotoxin (CTX) is a key component of N. atra venom responsible for cytotoxicity against myoblast cells. Anti-CTX IgY was generated in hens, and the spleens of these hens were used to construct libraries for the development of single chain variable fragments (scFv). Two anti-CTX scFv, S1 and 2S7, were selected using phage display technology and biopanning. Both polyclonal IgY and monoclonal scFv S1 reacted specifically with CTX in cobra venom. In a cell model assay, the CTX-induced cytolytic effect was inhibited only by monoclonal scFv S1, not by polyclonal IgY. Moreover, the neutralization potency of scFv S1 was about 3.8 mg/mg, approximately three times higher than that of conventional freeze-dried neurotoxic antivenom (FNAV). Collectively, these results suggest that scFv S1 can effectively neutralize CTX-induced cytotoxicity and, when combined with currently available antivenom, can improve the potency of the latter, thereby preventing tissue damage induced by cobra envenoming.
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Affiliation(s)
- Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
| | - Tsai-Ying Chou
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
| | - Geng-Wang Liaw
- Department of Emergency Medicine, Yeezen General Hospital, Taoyuan 32645, Taiwan;
| | - Yung-Chin Hsiao
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Lichieh-Julie Chu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan;
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Chi-Hsin Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan;
- Ph.D. Program in Medical Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei 11042, Taiwan
| | - Po-Jung Wang
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
| | - Cheng-Hsien Hsieh
- Department of Emergency Medicine, En Chu Kong Hospital, New Taipei City 23741, Taiwan;
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan;
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan; (C.-C.L.); (Y.-C.H.); (L.-J.C.); (P.-J.W.)
- Liver Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33302, Taiwan
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- Correspondence: (C.-K.C.); (J.-S.Y.); Tel.: +88-63-2118800 (ext. 5171) (J.-S.Y.); Fax: +88-63-2118891 (J.-S.Y.)
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Hydrocortisone for Preventing Adverse Drug Reactions to Snake Antivenom: A Meta-Analysis. Emerg Med Int 2022; 2022:6151206. [PMID: 35498377 PMCID: PMC9054406 DOI: 10.1155/2022/6151206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Pretreatment with hydrocortisone (prehydrocortisone) has been used to protect against adverse drug reactions (ADRs) following antivenom administration after snakebite. However, controversial results have been reported in studies evaluating its efficacy. Herein, we conducted a meta-analysis to evaluate the effect of prehydrocortisone on the risk of ADRs. Methods We conducted a systematic search of PubMed, Embase, and Cochrane for relevant studies on the literature published up to December 6, 2020, with no language restrictions. Premedications, including hydrocortisone with or without other drugs, were compared with placebo or no premedication. Our primary end point was the risk of ADRs, which was reported as the number of patients who developed ADRs divided by the total number of snakebite patients administered with antivenom separately for the prehydrocortisone and control groups for each study. We evaluated pooled data using of a random-effects model. Results Among 831 identified studies, 4 were eligible and included in our analysis (N = 1348 participants). Upon combining all eight comparisons from the four selected studies, the overall pooled odds ratio (OR) for ADRs was 0.47 (95% CI 0.19, 1.17; p=0.11; I2 = 68%). When the analysis was restricted to only articles using hydrocortisone with other drugs, the pooled OR was 0.19 (95% CI 0.05, 0.75; p=0.02; I2 = 55%). The result was not statistically significant when the analysis was restricted to studies using prehydrocortisone alone, or randomized controlled designs, or cohorts. Our study was limited by heterogeneity, quality, and a paucity of data. Conclusions The findings in this study revealed that prehydrocortisone alone was ineffective. However, the substantial beneficial effect of prehydrocortisone combinations with premedications (injectable antihistamines or adrenaline) used against ADRs cannot be excluded. Therefore, the use of prehydrocortisone combinations with premedications (injectable antihistamines or adrenaline) as a prophylaxis may reduce the ADRs to antivenom.
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Lower levels of CXCL-8 and IL-2 on admission as predictors of early adverse reactions to Bothrops antivenom in the Brazilian Amazon. Cytokine 2022; 152:155825. [DOI: 10.1016/j.cyto.2022.155825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/25/2022] [Accepted: 02/06/2022] [Indexed: 12/13/2022]
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Gerardo CJ, Silvius E, Schobel S, Eppensteiner JC, McGowan LM, Elster EA, Kirk AD, Limkakeng AT. Association of a Network of Immunologic Response and Clinical Features With the Functional Recovery From Crotalinae Snakebite Envenoming. Front Immunol 2021; 12:628113. [PMID: 33790901 PMCID: PMC8006329 DOI: 10.3389/fimmu.2021.628113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background The immunologic pathways activated during snakebite envenoming (SBE) are poorly described, and their association with recovery is unclear. The immunologic response in SBE could inform a prognostic model to predict recovery. The purpose of this study was to develop pre- and post-antivenom prognostic models comprised of clinical features and immunologic cytokine data that are associated with recovery from SBE. Materials and Methods We performed a prospective cohort study in an academic medical center emergency department. We enrolled consecutive patients with Crotalinae SBE and obtained serum samples based on previously described criteria for the Surgical Critical Care Initiative (SC2i)(ClinicalTrials.gov Identifier: NCT02182180). We assessed a standard set of clinical variables and measured 35 unique cytokines using Luminex Cytokine 35-Plex Human Panel pre- and post-antivenom administration. The Patient-Specific Functional Scale (PSFS), a well-validated patient-reported outcome of functional recovery, was assessed at 0, 7, 14, 21 and 28 days and the area under the patient curve (PSFS AUPC) determined. We performed Bayesian Belief Network (BBN) modeling to represent relationships with a diagram composed of nodes and arcs. Each node represents a cytokine or clinical feature and each arc represents a joint-probability distribution (JPD). Results Twenty-eight SBE patients were enrolled. Preliminary results from 24 patients with clinical data, 9 patients with pre-antivenom and 11 patients with post-antivenom cytokine data are presented. The group was mostly female (82%) with a mean age of 38.1 (SD ± 9.8) years. In the pre-antivenom model, the variables most closely associated with the PSFS AUPC are predominantly clinical features. In the post-antivenom model, cytokines are more fully incorporated into the model. The variables most closely associated with the PSFS AUPC are age, antihistamines, white blood cell count (WBC), HGF, CCL5 and VEGF. The most influential variables are age, antihistamines and EGF. Both the pre- and post-antivenom models perform well with AUCs of 0.87 and 0.90 respectively. Discussion Pre- and post-antivenom networks of cytokines and clinical features were associated with functional recovery measured by the PSFS AUPC over 28 days. With additional data, we can identify prognostic models using immunologic and clinical variables to predict recovery from SBE.
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Affiliation(s)
| | | | - Seth Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | | - Lauren M McGowan
- Department of Surgery, Duke University, Durham, NC, United States
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, United States
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Mahmoudi GA, Ahadi M, Fouladvand A, Rezaei B, Bodagh Z, Astaraki P. Evaluation of Allergic Reactions Following Intravenous Infusion of Polyvalent Antivenom in Snakebite Patients. Antiinflamm Antiallergy Agents Med Chem 2021; 20:367-372. [PMID: 33563188 DOI: 10.2174/1871523020666210204143756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antivenom is a gold-standard treatment for snakebite envenoming. However, adverse reactions to snake antivenom are common in many parts. OBJECTIVE The aim of this study was to evaluate the allergic reactions following intravenous administration of antivenom sera. METHODS This was retrospective study, conducted snakebites patients referred to the Rahimi Hospital in Khorramabad. The files of these patients were accessed for demographic data, snakebite-related data, treatment provided, clinical presentation and allergic reaction status as a result of antivenom treatment. RESULTS 141 cases were investigated including 73.8% male and 26.2% female patients. The mean age of the patients was 38.1±17.1years. Age group 30-39 years accounted for highest number of snakebite cases (24.1%). A majority of victims (89.4%) were from the rural areas. Most of the patients (51.8%) were bitten in the spring and highest number of snakebite were reported in May (39.1%). The most common site of snakebite was lower extremities (50.4%) and upper extremities (44.7%). Among clinical feature of snakebite, pain was the most prevalent in 135 cases (95.7%) followed by swelling (83.7%). The mean antivenom vials used were 6.5±3.7 vials. Allergic reactions occurred in 6 patients (4.26%); reactions were mild in 5 patients and sever in 1patient. The commonest presentation was maculopapular rash (1.4%) and the least common were headache (0.71%), nausea (0.71%), fever (0.71) and hypotension (0.71%). CONCLUSION Snakebite is one of the significantlife-threatening environmental events.Immediate antivenom treatment can reduce mortality however, patients should be carefully monitored for adverse allergic reactions.
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Affiliation(s)
- Ghafar-Ali Mahmoudi
- Department of Internal Medicine, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad. Iran
| | - Maryam Ahadi
- Department of Internal Medicine, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad. Iran
| | - Ali Fouladvand
- Department of Pediatrics, School of Medicine, Lorestan University of Medical Sciences, Khorramabad. Iran
| | - Bareza Rezaei
- Department of Emergency Medicine, School of Medicine, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah. Iran
| | - Zahra Bodagh
- Student Research Committee, Lorestan University of Medical Sciences, Khorramabad. Iran
| | - Peyman Astaraki
- Department of Internal Medicine, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad. Iran
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Experience of Snakebite Envenomation by a Desert Viper in Qatar. J Toxicol 2020; 2020:8810741. [PMID: 33101406 PMCID: PMC7576367 DOI: 10.1155/2020/8810741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 11/25/2022] Open
Abstract
Crotaline and elapid snakebites are reported all over the world as well as in the Middle East and other countries around this region. However, data regarding snakebites and their treatment in Qatar are limited. This review paper is going to investigate the presentation and treatment of snakebite in Qatar. A good assessment helps to decide on the management of the snakebites envenomation. Antivenom and conservative management are the mainstays of treatment for crotaline snakebite. Point-of-care ultrasound (POCUS) has been suggested to do early diagnosis and treatment of soft tissue problems, such as edema and compartment syndrome, after a snakebite. The supporting data are not sufficient regarding the efficiency of POCUS in diagnosing the extent and severity of tissue involvement and its ultimate effect on the outcome. Further research is suggested in this case. Systemic complications, such as bleeding diathesis, can be managed by administering clotting factors and platelets.
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Sasa M, Segura Cano SE. New insights into snakebite epidemiology in Costa Rica: A retrospective evaluation of medical records. Toxicon X 2020; 7:100055. [PMID: 32776004 PMCID: PMC7398977 DOI: 10.1016/j.toxcx.2020.100055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 11/19/2022] Open
Abstract
Continuous monitoring of the snakebite envenoming allows elucidating factors that affect its incidence at spatial and temporal scales, and is a great tool to evaluate the proper management of snakebite in health centers. To determine if there have been changes over time in snakebite epidemiology in Costa Rica, we conducted a retrospective study using medical records from six hospitals for the years 2012-2013. A total of 475 snakebite patients were treated at the selected hospital during this period. Most bites occurred during the rainy season and primarily affected young men, mainly farm workers and schoolchildren. About 55% of bites occur in peri-domiciliary environments, although its prevalence varies geographically. Bothrops asper generates the vast majority of envenoming in the country, which is why the main local symptoms registered are edema, pain, and bleeding disorders. The time elapsed until treatment did not explain the degree of severity at admission. However, complications were observed more frequently in patients who took longer to receive treatment. The primary complications were bacterial infections, whereas kidney failure and compartment syndrome documented at very low frequencies. Only one death was recorded, reflecting the low fatality rate exhibited in the country. Hospital treatment included the rapid administration of antivenom and complementary treatment of antibiotics, analgesics, and antihistamines. The application of the latter as prophylactic does not seem to prevent the appearance of mild early adverse reactions, registered in 22.5% of the cases. Morbidity and mortality rates from snakebite have continued to decrease in the country, as a result of the efforts that Costa Rica has made to improve its public health system. Among those efforts, the creation of primary care centers (EBAIS) has reduced the time to treatment in many regions of the country. The Costa Rican experience of using antivenom in primary health care centers and maintaining good medical records could be considered for application in other countries where snakebite is a major health problem.
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Affiliation(s)
- Mahmood Sasa
- Instituto Clodomiro Picado, Universidad de Costa Rica, San José, Costa Rica
- Museo de Zoología, Escuela de Biología, Universidad de Costa Rica, San José, Costa Rica
| | - Sofía E. Segura Cano
- Departamento de Farmacología y Toxicología, Escuela de Medicina, Universidad de Costa Rica, San José, Costa Rica
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12
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Shim JS, Kang H, Cho Y, Shin H, Lee H. Adverse Reactions after Administration of Antivenom in Korea. Toxins (Basel) 2020; 12:E507. [PMID: 32781766 PMCID: PMC7472312 DOI: 10.3390/toxins12080507] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 11/16/2022] Open
Abstract
Kovax® antivenom is the main treatment for toxins produced by the Gloydius species. However, research on adverse reactions after Kovax® antivenom administration is scarce. We aimed to identify the incidence and characteristics of adverse reactions after Kovax® antivenom administration. We conducted a retrospective review of the medical records of snakebite patients in Korea between January 2008 and September 2019. We identified the frequency, characteristics, and treatments of adverse reactions to Kovax® antivenom. There were 150 patients with snakebites, of whom 121 (80.7%) patients received Kovax® antivenom. Adverse reactions occurred in five patients (4.1%). Acute adverse reactions within 24 h of antivenom administration occurred in two patients (1.7%). The symptoms of patients with acute adverse reactions were nausea, diaphoresis, dizziness, and hypotension. Delayed adverse reactions that occurred 24 h after antivenom administration were reported in three patients (2.5%). One patient had a skin rash after 10 days, and two patients had fever 37 and 48 h after antivenom use. In conclusion, most patients were managed safely after Kovax® antivenom, and the incidence of adverse reactions was low. Severe adverse reactions occurred in a small percentage of patients, and there were no deaths.
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Affiliation(s)
- Jin Seok Shim
- Department of Emergency Medicine, College of Medicine, Hanyang University Hospital, Hanyang University, 04763 Seoul, Korea; (J.S.S.); (H.L.)
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University Hospital, Hanyang University, 04763 Seoul, Korea; (J.S.S.); (H.L.)
| | - Yongil Cho
- Department of Emergency Medicine, College of Medicine, Hanyang University Hospital, Hanyang University, 04763 Seoul, Korea; (J.S.S.); (H.L.)
| | - Hyungoo Shin
- Department of Emergency Medicine, College of Medicine, Hanyang University Guri Hospital, Hanyang University, 11923 Guri, Korea;
| | - Heekyung Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University Hospital, Hanyang University, 04763 Seoul, Korea; (J.S.S.); (H.L.)
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13
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Jain A, Kumar A, Shikhi M, Kumar A, Nair DT, Salunke DM. The structure of MP-4 from Mucuna pruriens at 2.22 Å resolution. Acta Crystallogr F Struct Biol Commun 2020; 76:47-57. [PMID: 32039885 PMCID: PMC7010354 DOI: 10.1107/s2053230x20000199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/08/2020] [Indexed: 11/10/2022] Open
Abstract
The structure of the MP-4 protein was previously determined at a resolution of 2.8 Å. Owing to the unavailability of gene-sequence information at the time, the side-chain assignment was carried out on the basis of a partial sequence available through Edman degradation, sequence homology to orthologs and electron density. The structure of MP-4 has now been determined at a higher resolution (2.22 Å) in another space group and all of the structural inferences that were presented in the previous report of the structure were validated. In addition, the present data allowed an improved assignment of side chains and enabled further analysis of the MP-4 structure, and the accuracy of the assignment was confirmed by the recently available gene sequence. The study reinforces the traditional concept that conservative interpretations of relatively low-resolution structures remain correct even with the availability of high-resolution data.
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Affiliation(s)
- Abha Jain
- Regional Centre for Biotechnology, NCR Biotech Science Cluster, 3rd Milestone, Faridabad–Gurgaon Expressway, Faridabad 121 001, India
| | - Amit Kumar
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Aruna Asaf Ali Marg, New Delhi 110 067, India
| | - Meha Shikhi
- Regional Centre for Biotechnology, NCR Biotech Science Cluster, 3rd Milestone, Faridabad–Gurgaon Expressway, Faridabad 121 001, India
- Kalinga Institute of Industrial Technology, Bhubaneswar, Odisha 751 024, India
| | - Ashish Kumar
- Regional Centre for Biotechnology, NCR Biotech Science Cluster, 3rd Milestone, Faridabad–Gurgaon Expressway, Faridabad 121 001, India
| | - Deepak T. Nair
- Regional Centre for Biotechnology, NCR Biotech Science Cluster, 3rd Milestone, Faridabad–Gurgaon Expressway, Faridabad 121 001, India
| | - Dinakar M. Salunke
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Aruna Asaf Ali Marg, New Delhi 110 067, India
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14
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Benjamin JM, Abo BN, Brandehoff N. Review Article: Snake Envenomation in Africa. CURRENT TROPICAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40475-020-00198-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Schaper A, de Haro L, Deters M, Hermanns-Clausen M, Ebbecke M. Vergiftungen durch exotische Haustiere. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1332-1335. [DOI: 10.1007/s00103-019-03025-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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16
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Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom. J Trop Med 2019; 2019:2689171. [PMID: 31205473 PMCID: PMC6530221 DOI: 10.1155/2019/2689171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/07/2019] [Accepted: 03/25/2019] [Indexed: 11/18/2022] Open
Abstract
Diagnosing and treating acute severe and recurrent antivenom-related anaphylaxis (ARA) is challenging and reported experience is limited. Herein, we describe our experience of severe ARA in patients with neurotoxic snakebite envenoming in Nepal. Patients were enrolled in a randomised, double-blind trial of high vs. low dose antivenom, given by intravenous (IV) push, followed by infusion. Training in ARA management emphasised stopping antivenom and giving intramuscular (IM) adrenaline, IV hydrocortisone, and IV chlorphenamine at the first sign/s of ARA. Later, IV adrenaline infusion (IVAI) was introduced for patients with antecedent ARA requiring additional antivenom infusions. Preantivenom subcutaneous adrenaline (SCAd) was introduced in the second study year (2012). Of 155 envenomed patients who received ≥ 1 antivenom dose, 13 (8.4%), three children (aged 5−11 years) and 10 adults (18−52 years), developed clinical features consistent with severe ARA, including six with overlapping signs of severe envenoming. Four and nine patients received low and high dose antivenom, respectively, and six had received SCAd. Principal signs of severe ARA were dyspnoea alone (n=5 patients), dyspnoea with wheezing (n=3), hypotension (n=3), shock (n=3), restlessness (n=3), respiratory/cardiorespiratory arrest (n=7), and early (n=1) and late laryngeal oedema (n=1); rash was associated with severe ARA in 10 patients. Four patients were given IVAI. Of the 8 (5.1%) deaths, three occurred in transit to hospital. Severe ARA was common and recurrent and had overlapping signs with severe neurotoxic envenoming. Optimising the management of ARA at different healthy system levels needs more research. This trial is registered with NCT01284855.
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17
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Zdenek CN, Hay C, Arbuckle K, Jackson TNW, Bos MHA, Op den Brouw B, Debono J, Allen L, Dunstan N, Morley T, Herrera M, Gutiérrez JM, Williams DJ, Fry BG. Coagulotoxic effects by brown snake (Pseudonaja) and taipan (Oxyuranus) venoms, and the efficacy of a new antivenom. Toxicol In Vitro 2019; 58:97-109. [PMID: 30910521 DOI: 10.1016/j.tiv.2019.03.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 03/12/2019] [Accepted: 03/21/2019] [Indexed: 01/03/2023]
Abstract
Snakebite is a neglected tropical disease that disproportionately affects the poor. Antivenom is the only specific and effective treatment for snakebite, but its distribution is severely limited by several factors, including the prohibitive cost of some products. Papua New Guinea (PNG) is a snakebite hotspot but the high costs of Australian antivenoms (thousands of dollars per treatment) makes it unaffordable in PNG. A more economical taipan antivenom has recently been developed at the Instituto Clodomiro Picado (ICP) in Costa Rica for PNG and is currently undergoing clinical trials for the treatment of envenomations by coastal taipans (Oxyuranus scutellatus). In addition to potentially having the capacity to neutralise the effects of envenomations of non-PNG taipans, this antivenom may have the capacity to neutralise coagulotoxins in venom from closely related brown snakes (Pseudonaja spp.) also found in PNG. Consequently, we investigated the cross-reactivity of taipan antivenom across the venoms of all Oxyuranus and Pseudonaja species. In addition, to ascertain differences in venom biochemistry that influence variation in antivenom efficacy, we tested for relative cofactor dependence. We found that the new ICP taipan antivenom exhibited high selectivity for Oxyuranus venoms and only low to moderate cross-reactivity with any Pseudonaja venoms. Consistent with this genus level distinction in antivenom efficacy were fundamental differences in the venom biochemistry. Not only were the Pseudonaja venoms significantly more procoagulant, but they were also much less dependent upon the cofactors calcium and phospholipid. There was a strong correlation between antivenom efficacy, clotting time and cofactor dependence. This study sheds light on the structure-function relationships of the procoagulant toxins within these venoms and may have important clinical implications including for the design of next-generation antivenoms.
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Affiliation(s)
- Christina N Zdenek
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
| | - Chris Hay
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia; Reptile Kingdom Australia, Carrara, QLD, Australia
| | - Kevin Arbuckle
- Department of Biosciences, College of Science, Swansea University, SA2 8PP, United Kingdom
| | - Timothy N W Jackson
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, 3010, VIC, Australia
| | - Mettine H A Bos
- Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Bianca Op den Brouw
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
| | - Jordan Debono
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia
| | - Luke Allen
- Venom Supplies Pty Ltd, Stonewell Rd, Tanunda, SA 5352, Australia
| | - Nathan Dunstan
- Venom Supplies Pty Ltd, Stonewell Rd, Tanunda, SA 5352, Australia
| | | | - María Herrera
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica
| | - José M Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica
| | - David J Williams
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, 3010, VIC, Australia; Charles Campbell Toxinology Centre, School of Medicine and Health Sciences, University of Papua New Guinea, Boroko 121, National Capital District, Papua New Guinea
| | - Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia.
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18
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Panda S, Kumari L. Anti-Ophidian Properties of Herbal Medicinal Plants: Could it be a Remedy for Snake Bite Envenomation? Curr Drug Discov Technol 2018; 16:319-329. [PMID: 30019647 DOI: 10.2174/1570163815666180718095655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 01/09/2023]
Abstract
Snake bite envenoming causes high rates of morbidity and mortality and is one of the serious health-related concerns all over the globe. Around 3200 species of snakes have been discovered till date. Amid these species, about 1300 species of snakes are venomous. On account of its severity, World Health Organization (WHO) recently included snakebite envenoming in the list of neglected tropical diseases. Immunotherapy has partially solved the issues related to snakebite envenomation. However, it is associated with numerous adverse effects, due to which alternative treatment strategies are required for the treatment of snakebite. Traditionally, a large repository of herbal medicinal plants is known to possess activity against snake venom. An exploration of the therapeutic benefits of these medicinal plants used for the treatment of snakebites reveals the presence of various potential phytochemicals. The aim of the present review is to provide an outline regarding poisonous snakes all over the world, various compositions of snake venom, adverse effects related to anti-snake venom and numerous medicinal plants used for the anti-ophidian activity.
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Affiliation(s)
- Subhamay Panda
- Department of Pharmacy, Gupta College of Technological Sciences, Ashram More, Asansol-713301, India.,Indian Institute of Human and Social Sciences (IIHSS), Sitarampur, Asansol-713359, India
| | - Leena Kumari
- Department of Pharmaceutical Technology, Jadavpur University, Kolkata-700032, India
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19
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The snakebite problem and antivenom crisis from a health-economic perspective. Toxicon 2018; 150:115-123. [PMID: 29782952 DOI: 10.1016/j.toxicon.2018.05.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 05/08/2018] [Accepted: 05/14/2018] [Indexed: 11/22/2022]
Abstract
The scourge of snakebite has been well documented but largely ignored by the global health community for several decades, especially the role that economics has played in causing and exacerbating this crisis. Every year millions of people in low and middle-income countries face death, disability and disadvantage from snakebite envenoming (SBE) without access to appropriate treatment. Health-economic factors pervade every aspect of this neglected problem. A multitude of financial and commercial factors helped to cause, and now perpetuate, shortages of high quality, affordable and region-appropriate antivenom in areas where they are most needed. Alongside the death, physical disability and psychological anguish from SBE is a debilitating financial toll, which includes both direct costs of treatment and indirect costs from lost income. SBE is a problem that disproportionately affects poor, rural and agrarian communities, with most victims being young and industrious subsistence workers. The burden of envenoming is often felt by families and communities that can least afford it, and negatively impacts local and national productivity. The lack of long-term investment in health systems to properly manage SBE has led to insufficient funding for antivenom development, procurement, quality control and distribution, despite highly favourable cost effectiveness of some antivenoms. This has contributed to market failures that have seen antivenom output fall and become inaccessible to most victims. Solutions to these problems exist and are achievable, however the challenge for advocates is to appreciate the importance of health-economics and ensure that strategies to redress the economic causes and consequences of SBE are themselves cost-effective and financially sustainable.
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20
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Fry BG. Snakebite: When the Human Touch Becomes a Bad Touch. Toxins (Basel) 2018; 10:E170. [PMID: 29690533 PMCID: PMC5923336 DOI: 10.3390/toxins10040170] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 01/08/2023] Open
Abstract
Many issues and complications in treating snakebite are a result of poor human social, economic and clinical intervention and management. As such, there is scope for significant improvements for reducing incidence and increasing patient outcomes. Snakes do not target humans as prey, but as our dwellings and farms expand ever farther and climate change increases snake activity periods, accidental encounters with snakes seeking water and prey increase drastically. Despite its long history, the snakebite crisis is neglected, ignored, underestimated and fundamentally misunderstood. Tens of thousands of lives are lost to snakebites each year and hundreds of thousands of people will survive with some form of permanent damage and reduced work capacity. These numbers are well recognized as being gross underestimations due to poor to non-existent record keeping in some of the most affected areas. These underestimations complicate achieving the proper recognition of snakebite’s socioeconomic impact and thus securing foreign aid to help alleviate this global crisis. Antivenoms are expensive and hospitals are few and far between, leaving people to seek help from traditional healers or use other forms of ineffective treatment. In some cases, cheaper, inappropriately manufactured antivenom from other regions is used despite no evidence for their efficacy, with often robust data demonstrating they are woefully ineffective in neutralizing many venoms for which they are marketed for. Inappropriate first-aid and treatments include cutting the wound, tourniquets, electrical shock, immersion in ice water, and use of ineffective herbal remedies by traditional healers. Even in the developed world, there are fundamental controversies including fasciotomy, pressure bandages, antivenom dosage, premedication such as adrenalin, and lack of antivenom for exotic snakebites in the pet trade. This review explores the myriad of human-origin factors that influence the trajectory of global snakebite causes and treatment failures and illustrate that snakebite is as much a sociological and economic problem as it is a medical one. Reducing the incidence and frequency of such controllable factors are therefore realistic targets to help alleviate the global snakebite burden as incremental improvements across several areas will have a strong cumulative effect.
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Affiliation(s)
- Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St. Lucia, QLD 4072, Australia.
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21
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Ochola FO, Okumu MO, Muchemi GM, Mbaria JM, Gikunju JK. Epidemiology of snake bites in selected areas of Kenya. Pan Afr Med J 2018; 29:217. [PMID: 30100971 PMCID: PMC6080980 DOI: 10.11604/pamj.2018.29.217.15366] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 03/28/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction Snake bites are a silent public health problem in Kenya. Previous studies on snake bites in the country have mainly focused on identifying offending snake species, assessing the severity of envenomation and testing the efficacy of antivenom. Factors associated with snake
bites in the country are yet to be fully understood. The aim of this work was to determine pharmaco-epidemiological factors associated with snake bites in areas of Kenya where incidence, severity and species responsible for snake bites have been reported. Methods Kakamega provincial hospital, Kabarnet, Kapenguria and, Makueni district hospitals were selected as study sites based on previous findings on incidence, severity and species responsible for snake bites in catchment areas of these hospitals. Persistent newspaper reports of snake bites in these areas and distribution of snakes in Kenya were also considered. Cases of snake bites reported between 2007-2009 were retrospectively reviewed and data on incidence, age, site of the bites, time of bite and antivenom use was collected. Results 176 bites were captured, 91 of which occurred in 2009. Individual incidence was between 2.7/100,000/year and 6.7/100,000/year. Bites peaked in the 1-15 year age group while 132/176 bites were in the lower limb area and 49/176 victims received antivenom. Most bites occurred during the dry season, in the bush and in the evening. Overall mortality was 2.27%. Conclusion There is a need to sensitize the Kenyan public and healthcare personnel on preventive measures, first aid and treatment of snake bites.
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Affiliation(s)
- Francis Okumu Ochola
- Department of Pharmacology and Toxicology, School of Medicine, Moi University, Eldoret, Kenya
| | - Mitchel Otieno Okumu
- Department of Pharmacy, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya.,Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - Gerald Mwangi Muchemi
- Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - James Mucunu Mbaria
- Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - Joseph Kangangi Gikunju
- Department of Medical Laboratory Science, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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22
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Wilkins D, Burns DS, Wilson D, Warrell DA, Lamb LEM. Snakebites in Africa and Europe: a military perspective and update for contemporary operations. J ROY ARMY MED CORPS 2018; 164:370-379. [PMID: 29626137 DOI: 10.1136/jramc-2017-000883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/20/2017] [Indexed: 11/04/2022]
Abstract
Snakebite envenoming is rare among military patients, with few cases reported in recent years. Increasingly, however, military operations are taking place in remote parts of Africa, which are inhabited by numerous species of venomous snake, and in Europe, where dangerous species exist but are less common. Bites from a venomous snake may prove fatal, and therefore military medics must be adequately prepared to manage them. This paper reviews the most medically significant species of venomous snake present in Africa and Europe, before suggesting an evidence-based approach to snakebite prevention and management, including possible changes to the UK's Clinical Guidelines for Operations.
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Affiliation(s)
- Daniel Wilkins
- Royal Army Medical Corps, 3 Medical Regiment, Preston, UK
| | - D S Burns
- Department of Infection and Tropical Medicine, Heartlands Hospital, Birmingham, UK.,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Wilson
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Respiratory Medicine, University Hospital Birmingham, Birmingham, UK
| | - D A Warrell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - L E M Lamb
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
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23
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Morais V. Antivenom therapy: efficacy of premedication for the prevention of adverse reactions. J Venom Anim Toxins Incl Trop Dis 2018; 24:7. [PMID: 29507580 PMCID: PMC5831611 DOI: 10.1186/s40409-018-0144-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/07/2018] [Indexed: 11/29/2022] Open
Abstract
Antivenoms or antitoxins have been effectively used for more than a century. During this time, these products have always proven to be highly effective in the treatment of infections and envenomations. However, antivenoms did not exhibit good safety results in their initial applications. After many improvements, antivenoms have substantially better safety profiles but still have some side effects. Due to the occurrence of adverse reactions, the practice of using premedication with the intent to decrease side effects has become accepted or mandatory in many countries. The drugs used for premedication belong to the histamine H1 antagonist, glucocorticoid and catecholamine groups. Currently, this practice is being questioned due to low or controversial efficacies in clinical assays. In this article, we discuss the causes of adverse reactions, the mechanisms of drugs that block the undesired effects and the results obtained in clinical trials. Although these three families of drugs could have positive effects on reducing adverse reactions, only adrenaline has demonstrated positive results in clinical assays.
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Affiliation(s)
- Victor Morais
- Department of Biotechnology, Institute of Hygiene, Faculty of Medicine, University of the Republic, Uruguay, Av. Alfredo Navarro, 3051 Montevideo, Uruguay
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24
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Allergic reactions to antivenom in a patient bitten twice by the same snake within a month: A rare case report and literature review. Chin J Traumatol 2017; 20:299-302. [PMID: 28988729 PMCID: PMC5831231 DOI: 10.1016/j.cjtee.2016.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 02/04/2023] Open
Abstract
Antivenom is the most effective method currently available for the treatment of poisonous snake bite. Allergic reactions to antivenom have been reported in the past. Here we shared a case of allergic reactions to antivenom in an old male patient who was bitten twice by the same snake (probably same one) at the same biting site within a month whereas the patient did not show any allergic disorder in the first bitten. Envenomations twice in a short period time by the same kind of snake are very rare. Physician should be alert to the occurrence of allergic reactions in treating this type of patients with antivenom. The skin allergy test has a certain value in predicting the allergic response before the second use of antivenom. Desensitization may reduce the incidence of allergic reactions, but this is insufficient. Rather than non-IgE-mediated immediate hypersensitivity, patients receiving the second treatment of antivenom may develop IgE-mediated immediate hypersensitivity. Once happened, the antivenom treatment should be stopped promptly and anti-allergy treatment should be given immediately.
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Mong R, Ng VCH, Tse ML. Safety profile of snake antivenom (use) in Hong Kong - a review of 191 cases from 2008 to 2015. Clin Toxicol (Phila) 2017; 55:1066-1071. [PMID: 28657429 DOI: 10.1080/15563650.2017.1334916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The mainstay of treatment for significant envenoming from snakebites is antivenom. However, there is insufficient data regarding the safety of antivenom used in Hong Kong. We describe the incidence of hypersensitivity reactions from antivenom use and review the frequency and reasons for intensive care unit (ICU) admission. METHODS The Hong Kong Poisons Information Centre database was reviewed. All patients given snake antivenom between 2008 and 2015 were included. Patient demographics, species of snake involved, details of antivenom used, treatment location, use of pre-treatment, reasons for ICU admission (where applicable) and details of early and late antivenom reactions were extracted. RESULTS There were 191 patients who received snake antivenom. Most (93%) were treated with either the green pit viper antivenom from Thailand or the Agkistrodon halys antivenom from China. The incidences of early hypersensitivity reactions to green pit viper antivenom and Agkistrodon Halys antivenom were 4.7% and 1.4%, respectively. Most patients (69%) were managed in the ED observation ward or general ward. There were 59 patients managed in ICU, most (90%) of whom were admitted for close monitoring during antivenom administration. There were no cases of significant morbidity from antivenom administration. Eight patients (5.6%) had features suggestive of mild serum sickness. CONCLUSIONS The incidence of immediate hypersensitivity reaction to antivenom commonly used in Hong Kong is low. Majority of patients were managed safely in the emergency department observation ward or general ward. Serum sickness appears to be uncommon and possible cases presented with mild features.
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Affiliation(s)
- Rupeng Mong
- a Hong Kong Poison Information Centre , United Christian Hospital , Kwun Tong, Kowloon , Hong Kong
| | - Vember C H Ng
- a Hong Kong Poison Information Centre , United Christian Hospital , Kwun Tong, Kowloon , Hong Kong
| | - Man Li Tse
- a Hong Kong Poison Information Centre , United Christian Hospital , Kwun Tong, Kowloon , Hong Kong
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Herrera M, Sánchez M, Machado A, Ramírez N, Vargas M, Villalta M, Sánchez A, Segura Á, Gómez A, Solano G, Gutiérrez JM, León G. Effect of premedication with subcutaneous adrenaline on the pharmacokinetics and immunogenicity of equine whole IgG antivenom in a rabbit model. Biomed Pharmacother 2017; 90:740-743. [PMID: 28419970 DOI: 10.1016/j.biopha.2017.04.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022] Open
Abstract
Subcutaneous administration of a low dose of adrenaline is used to prevent the early adverse reactions (EARs) induced by snake antivenoms. We used a rabbit model to study the effect of premedication with adrenaline on the potential of antivenoms to exert therapeutic effects and to induce late adverse reactions. We found that premedication with adrenaline did not change the heart rate or blood pressure of normal rabbits, but reduced the rise in temperature in rabbits previously sensitized with antivenom. Pharmacokinetic studies suggest that premedication with adrenaline does not affect the ability of the antivenom to exert the initial control of envenomation nor the susceptibility of rabbits to develop recurrence of antigenemia and envenomation. Our results also indicate that it is unlikely that premedication with adrenaline decreases the incidence of late reactions induced by the antivenom administration, although it reduces the extent of early reactions.
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Affiliation(s)
- María Herrera
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica; Sección de Química Analítica, Escuela de Química, Universidad de Costa Rica, San José, Costa Rica
| | - Melvin Sánchez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | | | - Nils Ramírez
- Instituto de Investigaciones Farmacéuticas, Facultad de Farmacia, Universidad de Costa Rica, San José, Costa Rica
| | - Mariángela Vargas
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Mauren Villalta
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Andrés Sánchez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Álvaro Segura
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Aarón Gómez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Gabriela Solano
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Guillermo León
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.
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Schutzbach M, Vonderhagen S, Jäger M. Antiserumtherapie bei Schlangenbiss durch Schwarze Mamba. Unfallchirurg 2016; 119:1053-1056. [DOI: 10.1007/s00113-016-0241-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hamza M, Idris MA, Maiyaki MB, Lamorde M, Chippaux JP, Warrell DA, Kuznik A, Habib AG. Cost-Effectiveness of Antivenoms for Snakebite Envenoming in 16 Countries in West Africa. PLoS Negl Trop Dis 2016; 10:e0004568. [PMID: 27027633 PMCID: PMC4814077 DOI: 10.1371/journal.pntd.0004568] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 03/02/2016] [Indexed: 12/02/2022] Open
Abstract
Background Snakebite poisoning is a significant medical problem in agricultural societies in Sub Saharan Africa. Antivenom (AV) is the standard treatment, and we assessed the cost-effectiveness of making it available in 16 countries in West Africa. Methods We determined the cost-effectiveness of AV based on a decision-tree model from a public payer perspective. Specific AVs included in the model were Antivipmyn, FAV Afrique, EchiTab-G and EchiTab-Plus. We derived inputs from the literature which included: type of snakes causing bites (carpet viper (Echis species)/non-carpet viper), AV effectiveness against death, mortality without AV, probability of Early Adverse Reactions (EAR), likelihood of death from EAR, average age at envenomation in years, anticipated remaining life span and likelihood of amputation. Costs incurred by the victims include: costs of confirming and evaluating envenomation, AV acquisition, routine care, AV transportation logistics, hospital admission and related transportation costs, management of AV EAR compared to the alternative of free snakebite care with ineffective or no AV. Incremental Cost Effectiveness Ratios (ICERs) were assessed as the cost per death averted and the cost per Disability-Adjusted-Life-Years (DALY) averted. Probabilistic Sensitivity Analyses (PSA) using Monte Carlo simulations were used to obtain 95% Confidence Intervals of ICERs. Results The cost/death averted for the 16 countries of interest ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra Leone. The cost/DALY averted ranged from $83 (95% Confidence Interval: $36-$240) for Benin Republic to $281 ($159–457) for Sierra-Leone. In all cases, the base-case cost/DALY averted estimate fell below the commonly accepted threshold of one time per capita GDP, suggesting that AV is highly cost-effective for the treatment of snakebite in all 16 WA countries. The findings were consistent even with variations of inputs in 1—way sensitivity analyses. In addition, the PSA showed that in the majority of iterations ranging from 97.3% in Liberia to 100% in Cameroun, Guinea Bissau, Mali, Nigeria and Senegal, our model results yielded an ICER that fell below the threshold of one time per capita GDP, thus, indicating a high degree of confidence in our results. Conclusions Therapy for SBE with AV in countries of WA is highly cost-effective at commonly accepted thresholds. Broadening access to effective AVs in rural communities in West Africa is a priority. Antivenom is the main intervention against snakebite poisoning but is relatively scarce, unaffordable and the situation has been compounded further by the recent cessation of production of effective antivenoms and marketing of inappropriate products. Given this crisis, we assessed the cost effectiveness of providing antivenoms in West Africa by comparing costs associated with antivenom treatment against their health benefits in decreasing mortality. In the most comprehensive analyses ever conducted, it was observed the incremental cost effectiveness ratio of providing antivenom ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra-Leone per death averted while cost per Disability Adjusted Life Year (DALY) averted ranged from $83 for Benin Republic to $281 for Sierra-Leone. There is probability of 97.3–100% that antivenoms are very cost-effective in the analyses. These demonstrate antivenom is highly cost-effective and compares favorably to other commonly funded healthcare interventions. Providing and broadening antivenom access throughout areas at risk in rural West Africa should be prioritized given the considerable reduction in deaths and DALYs that could be derived at a relatively small cost.
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Affiliation(s)
- Muhammad Hamza
- College of Health of Sciences, Bayero University, Kano, Nigeria
| | - Maryam A. Idris
- College of Health of Sciences, Bayero University, Kano, Nigeria
| | - Musa B. Maiyaki
- College of Health of Sciences, Bayero University, Kano, Nigeria
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jean-Philippe Chippaux
- Institut de Recherche pour le Development, Cotonou, Benin Republic and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Paris, France
| | - David A. Warrell
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Kuznik
- College of Health of Sciences, Bayero University, Kano, Nigeria
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Celgene Corporation, Warren, New Jersey, United States of America
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de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment. Br J Clin Pharmacol 2016; 81:446-52. [PMID: 26256124 PMCID: PMC4767202 DOI: 10.1111/bcp.12739] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/31/2015] [Accepted: 08/04/2015] [Indexed: 01/04/2023] Open
Abstract
Antivenom is the mainstay of treatment of snakebite envenoming. However, adverse reactions to snake antivenom that is available are common in many parts of the world where snakebite is prevalent. Both acute (anaphylactic or pyrogenic) and delayed (serum sickness type) reactions occur. Acute reactions are usually mild but severe systemic anaphylaxis may develop, often within an hour or so of exposure to antivenom. Serum sickness after antivenom has a delayed onset between 5 and 14 days after its administration. Ultimately, the prevention reactions will depend mainly on improving the quality of antivenom. Until these overdue improvements take place, doctors will have to depend on pharmacological prophylaxis, where the search for the best prophylactic agent is still on-going, as well as careful observation of patients receiving antivenom in preparation for prompt management of acute as well as delayed reactions when they occur.
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Affiliation(s)
- H. Asita de Silva
- Clinical Trials Unit, Faculty of MedicineUniversity of KelaniyaRagamaSri Lanka
| | - Nicole M. Ryan
- Clinical Toxicology Research Group, School of Medicine and Public HealthThe University of NewcastleNewcastleNSWAustralia
| | - H. Janaka de Silva
- Clinical Trials Unit, Faculty of MedicineUniversity of KelaniyaRagamaSri Lanka
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Dixit R, Herz J, Dalton R, Booy R. Benefits of using heterologous polyclonal antibodies and potential applications to new and undertreated infectious pathogens. Vaccine 2016; 34:1152-61. [PMID: 26802604 PMCID: PMC7131169 DOI: 10.1016/j.vaccine.2016.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 01/06/2016] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Passive immunotherapy using polyclonal antibodies (immunoglobulins) has been used for over a century in the treatment and post-exposure prophylaxis of various infections and toxins. Heterologous polyclonal antibodies are obtained from animals hyperimmunised with a pathogen or toxin. AIMS The aims of this review are to examine the history of animal polyclonal antibody therapy use, their development into safe and effective products and the potential application to humans for emerging and neglected infectious diseases. METHODS A literature search of OVID Medline and OVID Embase databases was undertaken to identify articles on the safety, efficacy and ongoing development of polyclonal antibodies. The search contained database-specific MeSH and EMTREE terms in combination with pertinent text-words: polyclonal antibodies and rare/neglected diseases, antivenins, immunoglobulins, serum sickness, anaphylaxis, drug safety, post marketing surveillance, rabies, human influenza, Dengue, West Nile, Nipah, Hendra, Marburg, MERS, Hemorrhagic Fever Virus, and Crimean-Congo. No language limits were applied. The final search was completed on 20.06.2015. Of 1960 articles, title searches excluded many irrelevant articles, yielding 303 articles read in full. Of these, 179 are referenced in this study. RESULTS Serum therapy was first used in the 1890s against diphtheria. Early preparation techniques yielded products contaminated with reactogenic animal proteins. The introduction of enzymatic digestion, and purification techniques substantially improved their safety profile. The removal of the Fc fragment of antibodies further reduces hypersensitivity reactions. Clinical studies have demonstrated the efficacy of polyclonal antibodies against various infections, toxins and venoms. Products are being developed against infections for which prophylactic and therapeutic options are currently limited, such as avian influenza, Ebola and other zoonotic viruses. CONCLUSIONS Polyclonal antibodies have been successfully applied to rabies, envenomation and intoxication. Polyclonal production provides an exciting opportunity to revolutionise the prognosis of both longstanding neglected tropical diseases as well as emerging infectious threats to humans.
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Affiliation(s)
- Rashmi Dixit
- The Children's Hospital, Westmead, Sydney, Australia.
| | | | | | - Robert Booy
- The Children's Hospital, Westmead, Sydney, Australia
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Habib AG, Lamorde M, Dalhat MM, Habib ZG, Kuznik A. Cost-effectiveness of antivenoms for snakebite envenoming in Nigeria. PLoS Negl Trop Dis 2015; 9:e3381. [PMID: 25569252 PMCID: PMC4287484 DOI: 10.1371/journal.pntd.0003381] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 10/28/2014] [Indexed: 11/18/2022] Open
Abstract
Background Snakebite envenoming is a major public health problem throughout the rural tropics. Antivenom is effective in reducing mortality and remains the mainstay of therapy. This study aimed to determine the cost-effectiveness of using effective antivenoms for Snakebite envenoming in Nigeria. Methodology Economic analysis was conducted from a public healthcare system perspective. Estimates of model inputs were obtained from the literature. Incremental Cost Effectiveness Ratios (ICERs) were quantified as deaths and Disability-Adjusted-Life-Years (DALY) averted from antivenom therapy. A decision analytic model was developed and analyzed with the following model base-case parameter estimates: type of snakes causing bites, antivenom effectiveness to prevent death, untreated mortality, risk of Early Adverse Reactions (EAR), mortality risk from EAR, mean age at bite and remaining life expectancy, and disability risk (amputation). End-user costs applied included: costs of diagnosing and monitoring envenoming, antivenom drug cost, supportive care, shipping/freezing antivenom, transportation to-and-from hospital and feeding costs while on admission, management of antivenom EAR and free alternative snakebite care for ineffective antivenom. Principal Findings We calculated a cost/death averted of ($2330.16) and cost/DALY averted of $99.61 discounted and $56.88 undiscounted. Varying antivenom effectiveness through the 95% confidence interval from 55% to 86% yield a cost/DALY averted of $137.02 to $86.61 respectively. Similarly, varying the prevalence of envenoming caused by carpet viper from 0% to 96% yield a cost/DALY averted of $254.18 to $78.25 respectively. More effective antivenoms and carpet viper envenoming rather than non-carpet viper envenoming were associated with lower cost/DALY averted. Conclusions/Significance Treatment of snakebite envenoming in Nigeria is cost-effective with a cost/death averted of $2330.16 and cost/DALY averted of $99.61 discounted, lower than the country's gross domestic product per capita of $1555 (2013). Expanding access to effective antivenoms to larger segments of the Nigerian population should be a considered a priority. Snake bite is a major public health problem throughout rural communities in West Africa and leads to a significant number of deaths and disabilities per year. Even though effective antivenoms exist against the locally prevalent carpet viper and other poisonous snakes, they are generally not available in community settings, possibly because of their high acquisition cost. We evaluated the cost-effectiveness of making antivenom more broadly available in Nigeria by comparing the treatment costs associated with antivenom therapy against their medical benefit in reducing the risk of mortality. We find that the incremental cost effectiveness ratio (ICER) associated with making antivenom available in Nigeria was $2,330 per death averted and $100 per disability adjusted life year (DALY) averted. Both of these suggest that snakebite antivenom is highly cost-effective in Nigeria and they also compare very favorably against other commonly funded health interventions for which similar estimates exist. Since a substantial reduction in mortality and DALYs could be achieved at a relatively modest upfront cost, expanding access to antivenom to broader parts of the population should be a priority consideration for future investments in healthcare.
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Affiliation(s)
- Abdulrazaq G. Habib
- Infectious & Tropical Diseases Unit, College of Health Sciences, Bayero University Kano, Nigeria
- * E-mail:
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Mahmood M. Dalhat
- Infectious & Tropical Diseases Unit, College of Health Sciences, Bayero University Kano, Nigeria
| | - Zaiyad G. Habib
- Infectious & Tropical Diseases Unit, College of Health Sciences, Bayero University Kano, Nigeria
| | - Andreas Kuznik
- Infectious & Tropical Diseases Unit, College of Health Sciences, Bayero University Kano, Nigeria
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
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De-Simone SG, Napoleão-Pêgo P, Teixeira-Pinto LA, Melgarejo AR, Aguiar AS, Provance DW. IgE and IgG epitope mapping by microarray peptide-immunoassay reveals the importance and diversity of the immune response to the IgG3 equine immunoglobulin. Toxicon 2014; 78:83-93. [DOI: 10.1016/j.toxicon.2013.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 11/29/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
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Faioli CN, Domingos TFS, de Oliveira EC, Sanchez EF, Ribeiro S, Muricy G, Fuly AL. Appraisal of antiophidic potential of marine sponges against Bothrops jararaca and Lachesis muta venom. Toxins (Basel) 2013; 5:1799-813. [PMID: 24141284 PMCID: PMC3813912 DOI: 10.3390/toxins5101799] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/08/2013] [Accepted: 10/11/2013] [Indexed: 01/10/2023] Open
Abstract
Snakebites are a health problem in many countries due to the high incidence of such accidents. Antivenom treatment has regularly been used for more than a century, however, this does not neutralize tissue damage and may even increase the severity and morbidity of accidents. Thus, it has been relevant to search for new strategies to improve antiserum therapy, and a variety of molecules from natural sources with antiophidian properties have been reported. In this paper, we analyzed the ability of ten extracts from marine sponges (Amphimedon viridis, Aplysina fulva, Chondrosia collectrix, Desmapsamma anchorata, Dysidea etheria, Hymeniacidon heliophila, Mycale angulosa, Petromica citrina, Polymastia janeirensis, and Tedania ignis) to inhibit the effects caused by Bothrops jararaca and Lachesis muta venom. All sponge extracts inhibited proteolysis and hemolysis induced by both snake venoms, except H. heliophila, which failed to inhibit any biological activity. P. citrina inhibited lethality, hemorrhage, plasma clotting, and hemolysis induced by B. jararaca or L. muta. Moreover, other sponges inhibited hemorrhage induced only by B. jararaca. We conclude that Brazilian sponges may be a useful aid in the treatment of snakebites caused by L. muta and B. jararaca and therefore have potential for the discovery of molecules with antiophidian properties.
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Affiliation(s)
- Camila Nunes Faioli
- Department of Molecular and Cellular Biology, Institute of Biology, Federal Fluminense University, Niteroi 24020-141, RJ, Brazil; E-Mails: (C.N.F.); (T.F.S.D.); (E.C.O.)
| | - Thaisa Francielle Souza Domingos
- Department of Molecular and Cellular Biology, Institute of Biology, Federal Fluminense University, Niteroi 24020-141, RJ, Brazil; E-Mails: (C.N.F.); (T.F.S.D.); (E.C.O.)
- Department of Marine Biology, Institute of Biology, Federal Fluminense University, Niteroi 24020-141, RJ, Brazil
| | - Eduardo Coriolano de Oliveira
- Department of Molecular and Cellular Biology, Institute of Biology, Federal Fluminense University, Niteroi 24020-141, RJ, Brazil; E-Mails: (C.N.F.); (T.F.S.D.); (E.C.O.)
| | | | - Suzi Ribeiro
- Department of Invertebrates, Federal University of Rio de Janeiro, National Museum 20940-040, RJ, Brazil; E-Mails: (S.R.); (G.M.)
| | - Guilherme Muricy
- Department of Invertebrates, Federal University of Rio de Janeiro, National Museum 20940-040, RJ, Brazil; E-Mails: (S.R.); (G.M.)
| | - Andre Lopes Fuly
- Department of Molecular and Cellular Biology, Institute of Biology, Federal Fluminense University, Niteroi 24020-141, RJ, Brazil; E-Mails: (C.N.F.); (T.F.S.D.); (E.C.O.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +55-21-2629-2294; Fax: +55-21-2629-2376
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León G, Herrera M, Segura Á, Villalta M, Vargas M, Gutiérrez JM. Pathogenic mechanisms underlying adverse reactions induced by intravenous administration of snake antivenoms. Toxicon 2013; 76:63-76. [PMID: 24055551 DOI: 10.1016/j.toxicon.2013.09.010] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/01/2013] [Accepted: 09/11/2013] [Indexed: 11/28/2022]
Abstract
Snake antivenoms are formulations of immunoglobulins, or immunoglobulin fragments, purified from the plasma of animals immunized with snake venoms. Their therapeutic success lies in their ability to mitigate the progress of toxic effects induced by snake venom components, when administered intravenously. However, due to diverse factors, such as deficient manufacturing practices, physicochemical characteristics of formulations, or inherent properties of heterologous immunoglobulins, antivenoms can induce undesirable adverse reactions. Based on the time lapse between antivenom administration and the onset of clinical manifestations, the World Health Organization has classified these adverse reactions as: 1 - Early reactions, if they occur within the first hours after antivenom infusion, or 2 - late reactions, when occurring between 5 and 20 days after treatment. While all late reactions are mediated by IgM or IgG antibodies raised in the patient against antivenom proteins, and the consequent formation of immune complexes, several mechanisms may be responsible for the early reactions, such as pyrogenic reactions, IgE-mediated reactions, or non IgE-mediated reactions. This work reviews the hypotheses that have been proposed to explain the mechanisms involved in these adverse reactions to antivenoms. The understanding of these pathogenic mechanisms is necessary for the development of safer products and for the improvement of snakebite envenomation treatment.
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Affiliation(s)
- Guillermo León
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.
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Deshpande RP, Motghare VM, Padwal SL, Pore RR, Bhamare CG, Deshmukh VS, Pise HN. Adverse drug reaction profile of anti-snake venom in a rural tertiary care teaching hospital. J Young Pharm 2013; 5:41-5. [PMID: 24396245 PMCID: PMC3828666 DOI: 10.1016/j.jyp.2013.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/19/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES The study was carried out with the aim of evaluation of the adverse drug reaction profile of anti-snake venom serum (ASV) in a rural tertiary care hospital. METHODS An observational study was conducted in SRTR Medical College, Ambajogai, Maharashtra, India. A total number of 296 indoor case papers of snake bite from February to September 2011 and June to August 2012 were retrieved from the record section and the antivenom reactions were assessed. In addition, basic epidemiological data and prescribing practices of ASV were also analyzed. RESULTS Vasculotoxic snake bites were more common (50.61%) than neuroparalytic ones (22.56%). Mild envenomation was the commonest presentation. A total of 92 (56.10%) patients who received ASV suffered from antivenom reactions. The most common nature of reaction was chills, rigors (69.56%) followed by nausea and vomiting (34.8%). 10-15% patients suffered from moderate to severe reactions like hypotension and sudden respiratory arrest. We did not find any dose response relationship of ASV to risk of reactions (odds ratio 0.37). Intradermal sensitivity test was performed in about 72% cases. CONCLUSION Our study showed a higher incidence of reactions to ASV at our institute.
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Affiliation(s)
- Rushikesh Prabhakar Deshpande
- Department of Pharmacology, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Beed, Maharashtra 431517, India
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Abstract
Snake envenomation is a global public health problem, with highest incidence in Southeast Asia. Inadequate health services, difficult transportation and consequent delay in antisnake venom administration are the main reasons for high mortality. Adverse drug reactions and inadequate storage conditions limit the use of antisnake venom. The medicinal plants, available locally and used widely by traditional healers, therefore need attention. A wide array of plants and their active principles have been evaluated for pharmacological properties. However, numerous unexplored plants claimed to be antidotes in folklore medicine need to be studied. The present article reviews the current status of various medicinal plants for the management of snake bite.
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Affiliation(s)
- Y K Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi - 110029, India
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Otero-Patiño R, Segura Á, Herrera M, Angulo Y, León G, Gutiérrez JM, Barona J, Estrada S, Pereañez A, Quintana JC, Vargas LJ, Gómez JP, Díaz A, Suárez AM, Fernández J, Ramírez P, Fabra P, Perea M, Fernández D, Arroyo Y, Betancur D, Pupo L, Córdoba EA, Ramírez CE, Arrieta AB, Rivero A, Mosquera DC, Conrado NL, Ortiz R. Comparative study of the efficacy and safety of two polyvalent, caprylic acid fractionated [IgG and F(ab′)2] antivenoms, in Bothrops asper bites in Colombia. Toxicon 2012; 59:344-55. [DOI: 10.1016/j.toxicon.2011.11.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 11/17/2011] [Accepted: 11/22/2011] [Indexed: 11/15/2022]
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Morais V, Berasain P, Ifrán S, Carreira S, Tortorella MN, Negrín A, Massaldi H. Humoral immune responses to venom and antivenom of patients bitten by Bothrops snakes. Toxicon 2012; 59:315-9. [DOI: 10.1016/j.toxicon.2011.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 11/24/2011] [Accepted: 12/08/2011] [Indexed: 11/24/2022]
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Habib AG. Effect of Pre-Medication on Early Adverse Reactions Following Antivenom Use in Snakebite. Drug Saf 2011; 34:869-80. [DOI: 10.2165/11592050-000000000-00000] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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de Silva HA, Pathmeswaran A, Ranasinha CD, Jayamanne S, Samarakoon SB, Hittharage A, Kalupahana R, Ratnatilaka GA, Uluwatthage W, Aronson JK, Armitage JM, Lalloo DG, de Silva HJ. Low-dose adrenaline, promethazine, and hydrocortisone in the prevention of acute adverse reactions to antivenom following snakebite: a randomised, double-blind, placebo-controlled trial. PLoS Med 2011; 8:e1000435. [PMID: 21572992 PMCID: PMC3091849 DOI: 10.1371/journal.pmed.1000435] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 03/31/2011] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Envenoming from snakebites is most effectively treated by antivenom. However, the antivenom available in South Asian countries commonly causes acute allergic reactions, anaphylactic reactions being particularly serious. We investigated whether adrenaline, promethazine, and hydrocortisone prevent such reactions in secondary referral hospitals in Sri Lanka by conducting a randomised, double-blind placebo-controlled trial. METHODS AND FINDINGS In total, 1,007 patients were randomized, using a 2 × 2 × 2 factorial design, in a double-blind, placebo-controlled trial of adrenaline (0.25 ml of a 1∶1,000 solution subcutaneously), promethazine (25 mg intravenously), and hydrocortisone (200 mg intravenously), each alone and in all possible combinations. The interventions, or matching placebo, were given immediately before infusion of antivenom. Patients were monitored for mild, moderate, or severe adverse reactions for at least 96 h. The prespecified primary end point was the effect of the interventions on the incidence of severe reactions up to and including 48 h after antivenom administration. In total, 752 (75%) patients had acute reactions to antivenom: 9% mild, 48% moderate, and 43% severe; 89% of the reactions occurred within 1 h; and 40% of all patients were given rescue medication (adrenaline, promethazine, and hydrocortisone) during the first hour. Compared with placebo, adrenaline significantly reduced severe reactions to antivenom by 43% (95% CI 25-67) at 1 h and by 38% (95% CI 26-49) up to and including 48 h after antivenom administration; hydrocortisone and promethazine did not. Adding hydrocortisone negated the benefit of adrenaline. CONCLUSIONS Pretreatment with low-dose adrenaline was safe and reduced the risk of acute severe reactions to snake antivenom. This may be of particular importance in countries where adverse reactions to antivenom are common, although the need to improve the quality of available antivenom cannot be overemphasized.
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Affiliation(s)
- H Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
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Estrada R, Herrera M, Segura Á, Araya J, Boschini C, Gutiérrez JM, León G. Intravenous administration of equine-derived whole IgG antivenom does not induce early adverse reactions in non-envenomed horses and cows. Biologicals 2010; 38:664-9. [DOI: 10.1016/j.biologicals.2010.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 07/20/2010] [Accepted: 08/11/2010] [Indexed: 11/15/2022] Open
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Methodology of clinical studies dealing with the treatment of envenomation. Toxicon 2010; 55:1195-212. [DOI: 10.1016/j.toxicon.2010.02.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 02/05/2010] [Accepted: 02/18/2010] [Indexed: 01/22/2023]
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Management of snake bites in the tropics - based on the example of Papua New Guinea. Wien Klin Wochenschr 2009; 121 Suppl 3:53-6. [PMID: 19915819 DOI: 10.1007/s00508-009-1243-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Snake bites by venomous snakes are a widely neglected topic despite the fact that they may cause severe tissue damages and lead to life threatening situations resulting in death mostly due to the lack of adequate medical help. Papua New Guinea hosts one of the most venomous snakes worldwide - the taipan. Medical facilities are limited, the one and only real hospital being located in Port Moresby. Transport facilities for patients are rare and comparably slow, the roads bad except the so-called highway which is in a mint condition. Besides first aid measures (compression and immobilization) the application of (specific) antivenom is the (life-saving) treatment of choice. This product is extremely expensive therefore there is only a very limited supply (mostly by products which have already passed the expiry date). Since in addition these products must be kept in a fridge vast areas lacking energy supply don't have storage facilities. Conclusions drawn from the experience in Port Moresby therefore cannot be extended to the rest of the country.
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Apparent marked reduction in early antivenom reactions compared to historical controls: Was it prophylaxis or method of administration? Toxicon 2009; 54:779-83. [DOI: 10.1016/j.toxicon.2009.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/31/2009] [Accepted: 06/02/2009] [Indexed: 11/20/2022]
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Schaper A, Desel H, Ebbecke M, De Haro L, Deters M, Hentschel H, Hermanns-Clausen M, Langer C. Bites and stings by exotic pets in Europe: an 11 year analysis of 404 cases from Northeastern Germany and Southeastern France. Clin Toxicol (Phila) 2009; 47:39-43. [PMID: 18608301 DOI: 10.1080/15563650801954875] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The presence of exotic, and sometimes venomous, pets in European homes is becoming more common. This phenomenon is the basis of a French-German cooperative evaluation of the species causing the injuries and the circumstances, severity, and treatment of the envenomations METHODS A retrospective, descriptive, cross-sectional, case series of data from 1996 to 2006. The study sample consists of all cases of bites and stings by exotic pets that were registered at four poisons European poisons centers. The inclusion criteria were bites and stings of human beings. RESULTS From 1996 to 2006 four poisons centers in Europe were consulted on 404 bites and stings by exotic pets. The average age of the patients was 36 (2 to 75) years and 73% of the patients were male. The severity of the envenomations, according to the Poisoning Severity Score, was as follows: 29 severe (7.1%), 55 moderate (14.2%) and 320 minor (78.7%). There were no fatalities in this case series. Exotic snakebites from rattlesnakes, cobras, mambas, and other venomous snakes caused 39% of envenomations, aquatic animals (mostly lionfish of the Pterois genus and stingrays) caused 30% of envenomations and arthropods (tarantulas and scorpions) caused 27% of envenomations. All severe envenomations were caused by venomous snakes. CONCLUSIONS European healthcare professionals may encounter patients bitten or stung by exotic pets. Poisons center consultation can help manage these unusual presentations and help obtain rarely used antivenoms.
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León G, Segura Á, Herrera M, Otero R, de Siqueira França FO, Barbaro KC, Cardoso JLC, Wen FH, de Medeiros CR, Prado JCL, Malaque CMS, Lomonte B, Gutiérrez JM. Human heterophilic antibodies against equine immunoglobulins: assessment of their role in the early adverse reactions to antivenom administration. Trans R Soc Trop Med Hyg 2008; 102:1115-9. [DOI: 10.1016/j.trstmh.2008.04.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 04/25/2008] [Accepted: 04/25/2008] [Indexed: 10/21/2022] Open
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Isbister GK, Brown SG, MacDonald E, White J, Currie BJ. Current use of Australian snake antivenoms and frequency of immediate‐type hypersensitivity reactions and anaphylaxis. Med J Aust 2008; 188:473-6. [DOI: 10.5694/j.1326-5377.2008.tb01721.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 11/29/2007] [Indexed: 11/17/2022]
Affiliation(s)
- Geoffrey K Isbister
- Menzies School of Health Research, Charles Darwin University, Darwin, NT
- Calvary Mater Hospital, Newcastle, NSW
| | - Simon G Brown
- Fremantle Hospital, Fremantle, WA
- University of Western Australia, Perth, WA
| | | | - Julian White
- Women's and Children's Hospital, Adelaide, SA
- Adelaide University, Adelaide, SA
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, NT
- Northern Territory Clinical School, Flinders University, Royal Darwin Hospital, Darwin, NT
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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