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Tsai TS, Tsai IH, Qiu JL, Chan YY, Chiang YW. Comparative analysis of Deinagkistrodon acutus venom from Taiwan and China utilizing chromatographic, electrophoretic, and bioinformatic approaches, along with ELISA employing a monospecific antivenom. Toxicon 2024; 241:107663. [PMID: 38423218 DOI: 10.1016/j.toxicon.2024.107663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/12/2024] [Accepted: 02/27/2024] [Indexed: 03/02/2024]
Abstract
Deinagkistrodon acutus is a medically important pitviper inhabiting mainly South China and Taiwan. The hemorrhagic effects of its envenoming are compatible to its venom, which is abundant in metalloproteases (svMPs) and C-type lectin-like proteins. In this study, we investigated geographic variations in the venom of D. acutus collected from Taiwan and four Mainland Chinese provinces: Fujian, Jiangxi, Anhui, and Hunan. The variations were assessed through high-performance liquid chromatography, non-metric multidimensional scaling analysis, gel electrophoresis, and enzyme-linked immunosorbent assay (ELISA) with a monospecific antivenom (DaMAV) generated against the Taiwanese D. acutus venom, and discussed based on venom-protein sequences in databases and literature related to D. acutus venom. Additionally, the cross-reactivity of DaMAV against Crotalus horridus and Calloselasma rhodostoma venoms was investigated. We noted differential abundances of D. acutus venom metalloproteases, C-type lectin-like proteins, and phospholipase A2, along with point mutations and selective expression of serine protease isoforms. The ELISA results revealed that the venom from Taiwan was more reactive toward Taiwanese DaMAV than the four Mainland Chinese venoms, consistent with chromatographic profile differences, whereas C. horridus venom presented moderate cross-reactivity with DaMAV. The observed immunoreactivities of these venom with DaMAV can be attributed to the high prevalence of their PIII-svMPs, which are the dominant antigens, and the conservation of PIII-svMP epitopes.
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Affiliation(s)
- Tein-Shun Tsai
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, No. 1, Shuefu Road, Pingtung, 912301, Taiwan.
| | - Inn-Ho Tsai
- Institute of Biological Chemistry, Academia Sinica, No. 128, Academia Road Sec. 2, Taipei, 115, Taiwan; Institute of Biochemical Sciences, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, 106319, Taiwan
| | - Jing-Lin Qiu
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, No. 1, Shuefu Road, Pingtung, 912301, Taiwan
| | - Yuen-Ying Chan
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, No. 1, Shuefu Road, Pingtung, 912301, Taiwan
| | - Yu-Wei Chiang
- Department of Medical Research, Taipei Veterans General Hospital, No. 322, Sec. 2, Shipai Rd., Taipei, 112062, Taiwan; Department of Biology and Anatomy, National Defense Medical Centre, No. 161, Sec. 6, Minquan E. Rd., Taipei, 11490, Taiwan
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Larréché S, Bousquet A, Chevillard L, Gahoual R, Jourdi G, Dupart AL, Bachelot-Loza C, Gaussem P, Siguret V, Chippaux JP, Mégarbane B. Bothrops atrox and Bothrops lanceolatus Venoms In Vitro Investigation: Composition, Procoagulant Effects, Co-Factor Dependency, and Correction Using Antivenoms. Toxins (Basel) 2023; 15:614. [PMID: 37888645 PMCID: PMC10611193 DOI: 10.3390/toxins15100614] [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: 09/13/2023] [Revised: 10/05/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Bothrops venoms are rich in enzymes acting on platelets and coagulation. This action is dependent on two major co-factors, i.e., calcium and phospholipids, while antivenoms variably neutralize venom-related coagulopathy effects. Our aims were (i) to describe the composition of B. atrox and B. lanceolatus venoms; (ii) to study their activity on the whole blood using rotational thromboelastometry (ROTEM); (iii) to evaluate the contribution of calcium and phospholipids in their activity; and (iv) to compare the effectiveness of four antivenoms (Bothrofav™, Inoserp™ South America, Antivipmyn™ TRI, and PoliVal-ICP™) on the procoagulant activity of these two venoms. Venom composition was comparable. Both venoms exhibited hypercoagulant effects. B. lanceolatus venom was completely dependent on calcium but less dependent on phospholipids than B. atrox venom to induce in vitro coagulation. The four antivenoms neutralized the procoagulant activity of the two venoms; however, with quantitative differences. Bothrofav™ was more effective against both venoms than the three other antivenoms. The relatively similar venom-induced effects in vitro were unexpected considering the opposite clinical manifestations resulting from envenomation (i.e., systemic bleeding with B. atrox and thrombosis with B. lanceolatus). In vivo studies are warranted to better understand the pathophysiology of systemic bleeding and thrombosis associated with Bothrops bites.
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Affiliation(s)
- Sébastien Larréché
- Inserm, UMRS-1144, Université Paris Cité, F-75006 Paris, France;
- Department of Medical Biology, Bégin Military Teaching Hospital, F-94160 Saint-Mandé, France; (A.B.); (A.-L.D.)
| | - Aurore Bousquet
- Department of Medical Biology, Bégin Military Teaching Hospital, F-94160 Saint-Mandé, France; (A.B.); (A.-L.D.)
| | - Lucie Chevillard
- Inserm, UMRS-1144, Université Paris Cité, F-75006 Paris, France;
| | - Rabah Gahoual
- Chemical and Biological Technologies for Health Unit, CNRS UMR 8258, Inserm, Université Paris Cité, F-75006 Paris, France;
| | - Georges Jourdi
- Innovative Therapies in Hemostasis, Inserm, Université Paris Cité, F-75006 Paris, France; (G.J.); (C.B.-L.); (P.G.); (V.S.)
- Department of Biological Hematology, Lariboisière Hospital, Assistance Publique–Hôpitaux de Paris, F-75010 Paris, France
| | - Anne-Laure Dupart
- Department of Medical Biology, Bégin Military Teaching Hospital, F-94160 Saint-Mandé, France; (A.B.); (A.-L.D.)
| | - Christilla Bachelot-Loza
- Innovative Therapies in Hemostasis, Inserm, Université Paris Cité, F-75006 Paris, France; (G.J.); (C.B.-L.); (P.G.); (V.S.)
| | - Pascale Gaussem
- Innovative Therapies in Hemostasis, Inserm, Université Paris Cité, F-75006 Paris, France; (G.J.); (C.B.-L.); (P.G.); (V.S.)
- Department of Hematology, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris, F-75015 Paris, France
| | - Virginie Siguret
- Innovative Therapies in Hemostasis, Inserm, Université Paris Cité, F-75006 Paris, France; (G.J.); (C.B.-L.); (P.G.); (V.S.)
- Department of Biological Hematology, Lariboisière Hospital, Assistance Publique–Hôpitaux de Paris, F-75010 Paris, France
| | - Jean-Philippe Chippaux
- French National Research Institute for Sustainable Development, Université Paris Cité, F-75006 Paris, France;
| | - Bruno Mégarbane
- Inserm, UMRS-1144, Université Paris Cité, F-75006 Paris, France;
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, Assistance Publique–Hôpitaux de Paris, F-75010 Paris, France
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Romo E, Torres M, Martin-Solano S. Current situation of snakebites envenomation in the Neotropics: Biotechnology, a versatile tool in the production of antivenoms. BIONATURA 2022. [DOI: 10.21931/rb/2022.07.04.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Snakebite envenomation is a neglected tropical disease that affects millions of people around the world with a great impact on health and the economy. Unfortunately, public health programs do not include this kind of disease as a priority in their social programs. Cases of snakebite envenomations in the Neotropics are inaccurate due to inadequate disease management from medical records to the choice of treatments. Victims of snakebite envenomation are primarily found in impoverished agricultural areas where remote conditions limit the availability of antivenom. Antivenom serum is the only Food and Drug Administration-approved treatment used up to date. However, it has several disadvantages in terms of safety and effectiveness. This review provides a comprehensive insight dealing with the current epidemiological status of snakebites in the Neotropics and technologies employed in antivenom production. Also, modern biotechnological tools such as transcriptomic, proteomic, immunogenic, high-density peptide microarray and epitope mapping are highlighted for producing new-generation antivenom sera. These results allow us to propose strategic solutions in the Public Health Sector for managing this disease.
Keywords: antivenom, biotechnology, neglected tropical disease, omics, recombinant antibody.
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Affiliation(s)
- Elizabeth Romo
- Carrera de Ingeniería en Biotecnología, Departamento de Ciencias de la Vida y la Agricultura, Universidad de las Fuerzas Armadas-ESPE, Sangolquí, Ecuador
| | - Marbel Torres
- Carrera de Ingeniería en Biotecnología, Departamento de Ciencias de la Vida y la Agricultura, Universidad de las Fuerzas Armadas-ESPE, Sangolquí, Ecuador, Grupo de Investigación en Sanidad Animal y Humana (GISAH), Carrera de Ingeniería en Biotecnología, Departamento de Ciencias de la Vida y la Agricultura, Universidad de las Fuerzas Armadas-ESPE, Immunology and Virology Laboratory, Nanoscience and Nanotechnology Center, Universidad de las Fuerzas Armadas, ESPE, Sangolquí, Ecuador
| | - Sarah Martin-Solano
- Carrera de Ingeniería en Biotecnología, Departamento de Ciencias de la Vida y la Agricultura, Universidad de las Fuerzas Armadas-ESPE, Sangolquí, Ecuador, Grupo de Investigación en Sanidad Animal y Humana (GISAH), Carrera de Ingeniería en Biotecnología, Departamento de Ciencias de la Vida y la Agricultura, Universidad de las Fuerzas Armadas-ESPE, Grupo de Investigación en Biodiversidad, Zoonosis y Salud Pública, Universidad Central del Ecuador
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Dias da Silva W, De Andrade SA, Megale ÂAA, De Souza DA, Sant’Anna OA, Magnoli FC, Guidolin FR, Godoi KS, Saladini LY, Spencer PJ, Portaro FCV. Antibodies as Snakebite Antivenoms: Past and Future. Toxins (Basel) 2022; 14:toxins14090606. [PMID: 36136544 PMCID: PMC9503307 DOI: 10.3390/toxins14090606] [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: 08/04/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/30/2022] Open
Abstract
Snakebite envenomation is considered a neglected tropical disease, affecting tens of thousands of people each year. The recommended treatment is the use of antivenom, which is composed of immunoglobulins or immunoglobulin fragments obtained from the plasma of animals hyperimmunized with one (monospecific) or several (polyspecific) venoms. In this review, the efforts made in the improvement of the already available antivenoms and the development of new antivenoms, focusing on snakes of medical importance from sub-Saharan Africa and Latin America, are described. Some antivenoms currently used are composed of whole IgGs, whereas others use F(ab’)2 fragments. The classic methods of attaining snake antivenoms are presented, in addition to new strategies to improve their effectiveness. Punctual changes in immunization protocols, in addition to the use of cross-reactivity between venoms from different snakes for the manufacture of more potent and widely used antivenoms, are presented. It is known that venoms are a complex mixture of components; however, advances in the field of antivenoms have shown that there are key toxins that, if effectively blocked, are capable of reversing the condition of in vivo envenomation. These studies provide an opportunity for the use of monoclonal antibodies in the development of new-generation antivenoms. Thus, monoclonal antibodies and their fragments are described as a possible alternative for the production of antivenoms, regardless of the venom. This review also highlights the challenges associated with their development.
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Affiliation(s)
- Wilmar Dias da Silva
- Immuchemistry Laboratory, Butantan Institute, São Paulo 05503-900, Brazil
- Correspondence: (W.D.S.); (F.C.V.P.)
| | - Sonia A. De Andrade
- Biopharmaceuticals Laboratory, Butantan Institute, São Paulo 05503-900, Brazil
| | | | | | | | | | | | | | - Lucas Yuri Saladini
- Laboratory of Structure and Function of Biomolecules, Butantan Institute, São Paulo 05503-900, Brazil
| | | | - Fernanda Calheta Vieira Portaro
- Laboratory of Structure and Function of Biomolecules, Butantan Institute, São Paulo 05503-900, Brazil
- Correspondence: (W.D.S.); (F.C.V.P.)
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5
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Silva DPD, Ferreira SDS, Torres-Rêgo M, Furtado AA, Yamashita FDO, Diniz EADS, Vieira DS, Ururahy MAG, Silva-Júnior AAD, Luna KPDO, Fernandes-Pedrosa MDF. Antiophidic potential of chlorogenic acid and rosmarinic acid against Bothrops leucurus snake venom. Biomed Pharmacother 2022; 148:112766. [PMID: 35247716 DOI: 10.1016/j.biopha.2022.112766] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 12/22/2022] Open
Abstract
Bothrops leucurus is responsible for most cases of snakebite in Northeast Brazil; however, this species is not included in the pool of venoms used in antivenom production in Brazil. The serotherapy has logistical and effectiveness limitations, which stimulates the search for therapeutic alternatives. Chlorogenic acid and rosmarinic acid present several biological activities, but their antiophidic potential has been poorly explored. Thus, the aim of this approach was to evaluate the potential inhibitory effects of these compounds on B. leucurus venom. Initially, the enzymatic inhibition of toxins was evaluated in vitro. Then, anti-hemorrhagic, anti-myotoxic, and anti-edematogenic assays were performed in vivo, as well analysis of several biochemical markers and hemostatic parameters. In addition, the interaction of inhibitors with SVMP and PLA2 was investigated by docking analysis. Results revealed that compounds inhibited in vitro the enzymatic activities and venom-induced edema, with a decrease in both myeloperoxidase and interleukin quantification. The inhibitors also attenuated the hemorrhagic and myotoxic actions and mitigated changes in serum biochemical and hemostatic markers, as well as decreased lipid peroxidation in liver and kidney tissues. Docking analysis revealed attractive interactions of both inhibitors with the zinc-binding site of SVMP and, in the case of PLA2, chlorogenic acid showed a similar inhibition mechanism to that described for rosmarinic acid. The results evidenced the antiophidic potential of both compounds, which showed higher efficiency than antivenom serum. Thus, both inhibitors are promising candidates for future adjuvants to be used to complement antivenom serotherapy.
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Affiliation(s)
- Diana Pontes da Silva
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Sarah de Sousa Ferreira
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Manoela Torres-Rêgo
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil; Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Allanny Alves Furtado
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Fabiana de Oliveira Yamashita
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Eduardo Augusto da Silva Diniz
- Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Davi Serradella Vieira
- Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Marcela Abbott Galvão Ururahy
- Biochemistry Laboratory, Department of Clinical Analysis and Toxicological, College of Pharmacy, Federal University of Rio Grande do Norte, Rua General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Arnóbio Antônio da Silva-Júnior
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Karla Patrícia de Oliveira Luna
- Center of Biological and Health Sciences, State University of Paraíba, Avenue Baraúnas, S/N, Bodocongó, Campina Grande 58429-500, Brazil.
| | - Matheus de Freitas Fernandes-Pedrosa
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
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Choraria A, Somasundaram R, Janani S, Rajendran S, Oukkache N, Michael A. Chicken egg yolk antibodies (IgY)-based antivenom for neutralization of snake venoms: a review. TOXIN REV 2021. [DOI: 10.1080/15569543.2021.1942063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ankit Choraria
- Department of Microbiology, PSG College of Arts and Science, Coimbatore, India
| | | | - S. Janani
- Nanobiotechnology Laboratory, PSG Institute of Advanced Studies, Coimbatore, India
| | - Selvakumar Rajendran
- Nanobiotechnology Laboratory, PSG Institute of Advanced Studies, Coimbatore, India
| | - Naoual Oukkache
- Venoms and Toxins Laboratory, Institute Pasteur of Morocco, Casablanca, Morocco
| | - A. Michael
- Department of Microbiology, PSG College of Arts and Science, Coimbatore, India
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Muniz EG, Noronha MDDN, Saraiva MDGG, Monteiro WM, Oliveira SS. Neutralization of hemostatic disorders induced by Lachesis muta venom using Brazilian antivenoms. Toxicon 2020; 191:44-47. [PMID: 33359389 DOI: 10.1016/j.toxicon.2020.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/20/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
We characterized the hemorrhagic, coagulant and defibrinogenant activities of Lachesis muta venom and evaluated the capacity of the Brazilian antivenoms in neutralizing these activities. The hemorrhagic activity of L. muta venom was similarly neutralized by Bothrops, Bothrops-Lachesis and Bothrops-Crotalus antivenoms. The coagulant and defibrinogenant activities were better neutralized by the Bothrops-Lachesis antivenom. Bothrops-Crotalus antivenom also neutralized these activities, indicating that it can be an alternative to treat Lachesis envenomations when Bothrops-Lachesis antivenom is unavailable.
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Affiliation(s)
- Emiro G Muniz
- Departamento de Epidemiologia e Saúde Pública, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil.
| | - Maria das Dores N Noronha
- Departamento de Epidemiologia e Saúde Pública, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Maria das Graças G Saraiva
- Departamento de Epidemiologia e Saúde Pública, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil; Departamento de Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Wuelton Marcelo Monteiro
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Sâmella S Oliveira
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus 69040-000, Brazil.
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Clinical Features and Management of Snakebite Envenoming in French Guiana. Toxins (Basel) 2020; 12:toxins12100662. [PMID: 33086750 PMCID: PMC7589911 DOI: 10.3390/toxins12100662] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/11/2020] [Accepted: 10/14/2020] [Indexed: 12/19/2022] Open
Abstract
The management of snakebite (SB) envenoming in French Guiana (FG) is based on symptomatic measures and antivenom (AV) administration (Antivipmyn Tri®; Instituto Bioclon—Mexico). Our study aimed to assess clinical manifestations, the efficacy, and safety of Antivipmyn Tri® in the management of SB. Our study is a prospective observational work. It was conducted in the Intensive Care Unit (ICU) of Cayenne General Hospital between 1 January 2016 and 31 December 2019. We included all patients hospitalized for SB envenoming. Our study contained three groups (without AV, three vials, and six vials Antivipmyn Tri®). During the study period, 133 patients were included. The main clinical symptoms were edema (98.5%), pain (97.7%), systemic hemorrhage (18%), blister (14.3%), and local hemorrhage (14.3%). AV was prescribed for 83 patients (62.3%), and 17 of them (20%) developed early adverse reactions. Biological parameters at admission showed defibrinogenation in 124 cases (93.2%), International Normalized Ratio (INR) > 2 in 104 cases (78.2%), and partial thromboplastin time (PTT) > 1.5 in 74 cases (55.6%). The time from SB to AV was 9:00 (5:22–20:40). The median time from SB to achieve a normal dosage of fibrinogen was 47:00 vs. 25:30, that of Factor II was 24:55 vs. 15:10, that of Factor V was 31:42 vs. 19:42, and that of Factor VIII was 21:30 vs. 10:20 in patients without and with AV, respectively, (p < 0.001 for all factors). Patients receiving Antivipmyn Tri® showed a reduction in the time to return to normal clotting tests, as compared to those who did not. We suggest assessing other antivenoms available in the region to compare their efficacy and safety with Antivipmyn Tri® in FG.
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Rey-Suárez P, Lomonte B. Immunological cross-recognition and neutralization studies of Micrurus mipartitus and Micrurus dumerilii venoms by two therapeutic equine antivenoms. Biologicals 2020; 68:40-45. [PMID: 32928631 DOI: 10.1016/j.biologicals.2020.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/13/2020] [Accepted: 08/29/2020] [Indexed: 11/16/2022] Open
Abstract
New world Coral snakes comprise 82 species of medical importance distributed from southeastern United States to Argentina. In Colombia, Micrurus mipartitus and M. dumerilii are responsible for most coral snakebite accidents. Although infrequent, the severity of these envenomings, as well as the limited information available on the neutralizing coverage of commercially available antivenoms, underscores the need to perform studies to assess the cross-neutralizing ability of these life-saving immunobiologicals. In the present work, we evaluated the cross-recognition and neutralization ability of two equine therapeutic antivenoms: PROBIOL and SAC-ICP. PROBIOL antivenom showed cross-recognition towards both M. mipartitus and M. dumerilii venoms, with a significantly higher binding to the latter in both whole-venom ELISA and fractionated-venom immunoprofiling. In contrast, SAC-ICP antivenom cross-recognized M. dumerilii venom, but not that of M. mipartitus. Lethality of M. dumerilii venom was neutralized by both antivenoms, with a slightly higher potency for the SAC-ICP antivenom. However, the lethality of M. mipartitus venom was not neutralized by any of the two antivenoms. Results uncover the need to include M. mipartitus venom, or its most relevant toxins, in the production of coral snake antivenoms to be used in Colombia, to assure the neutralizing coverage for this species.
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Affiliation(s)
- Paola Rey-Suárez
- Programa de Ofidismo y Escorpionismo, Universidad de Antioquia, Medellín, Colombia.
| | - Bruno Lomonte
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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Ponce-López R, Neri-Castro E, Borja M, Strickland JL, Alagón A. Neutralizing potency and immunochemical evaluation of an anti-Crotalus mictlantecuhtli experimental serum. Toxicon 2020; 187:171-180. [PMID: 32891663 DOI: 10.1016/j.toxicon.2020.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/10/2020] [Accepted: 08/30/2020] [Indexed: 12/26/2022]
Abstract
Snakebite in Mexico is commonly treated with an antivenom which uses Bothrops asper and Crotalus simus venoms as immunogens. Current taxonomic recommendations for the C. simus species complex suggest a novel endemic species from Mexico: Crotalus mictlantecuhtli. The aim of this report was to evaluate the immunogenic properties of C. mictlantecuhtli venom and its potential to generate polyclonal antibodies capable of neutralizing other pitviper venoms. We generated an experimental anti-Crotalus mictlantecuhtli serum, using the rabbit model, to test recognition and neutralizing capacity against the homologous venom as well as venoms from C. atrox, C.basiliscus, C. durissus terrificus, C. scutulatus salvini, C. tzabcan and Ophryacus sphenophrys. Pre-incubation neutralization experiments using our experimental serum showed positive results against venoms containing crotoxin, while venoms from two non-neurotoxic pit-vipers were not neutralized. Rescue experiments in mice showed that, when intravenously injected (i.v.), C. mictlantecuhtli venom is not neutralized by a maximum dose of Antivipmyn® and the experimental serum after 5 min of envenomation, albeit mice envenomated intraperitoneally (i.p.) and rescued i.v. with Antivipmyn® survived even at 50 min after envenomation. Our results highlight the importance of using the highly neurotoxic C. mictlantecuhtli venom to increase antivenom effectiveness against Mexican neurotoxic pitvipers.
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Affiliation(s)
- Roberto Ponce-López
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Av. Universidad 2001, Colonia Chamilpa, Cuernavaca, Morelos, C.P. 62210, Mexico
| | - Edgar Neri-Castro
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Av. Universidad 2001, Colonia Chamilpa, Cuernavaca, Morelos, C.P. 62210, Mexico
| | - Miguel Borja
- Facultad de Ciencias Biológicas, Universidad Juárez del Estado de Durango, Av. Universidad s/n. Fracc. Filadelfia, C.P. 35010 Gómez Palacio, Durango, Mexico
| | - Jason L Strickland
- Department of Biological Sciences, Clemson University, 190 Collings St, Clemson, SC, 29631, USA
| | - Alejandro Alagón
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Av. Universidad 2001, Colonia Chamilpa, Cuernavaca, Morelos, C.P. 62210, Mexico.
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11
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Mamede CCN, de Sousa Simamoto BB, da Cunha Pereira DF, de Oliveira Costa J, Ribeiro MSM, de Oliveira F. Edema, hyperalgesia and myonecrosis induced by Brazilian bothropic venoms: overview of the last decade. Toxicon 2020; 187:10-18. [PMID: 32846146 DOI: 10.1016/j.toxicon.2020.08.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/15/2020] [Accepted: 08/19/2020] [Indexed: 01/19/2023]
Abstract
Snakebite accidents are considered serious public health problems. They are often neglected, and individuals who have received insufficient treatment are subjected to various disabling alterations. Snake venoms are secretions composed of biologically active molecules capable of triggering local and systemic effects in envenomation victims. Bothropic snakes are responsible for most of the ophidian accidents in Brazil; their venoms are mainly related to local manifestations, due to a composition that is especially rich in proteases and phospholipases A2. The most common local damages are inflammation, with consequent cellular activation and release of inflammatory mediators, hemorrhage, edema, pain and (myo)necrosis, which may lead to amputation of the affected areas. Antivenom therapy is the main treatment for snakebites. However, the efficiency is mainly due to the neutralization of the toxins responsible for the systemic alterations. Thus, the local damages can evolve to markedly compromise the tissue. The complexity of these local effects associated with the toxicity of the snake venom components of the genus Bothrops, arouse interest in the study of the biochemical and pathophysiological mechanisms involved with the actions caused by toxins of the venom. Therefore, this review aims to analyze the edematogenic, hyperalgesic and myotoxic effects caused by Brazilian bothropic venoms in order to contribute to the study and elucidation of the mechanisms of action of its components and, consequently, enable discoveries of more effective combined therapies in the treatment of local damages resulting from envenoming.
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Affiliation(s)
| | | | | | - Júnia de Oliveira Costa
- Instituto Federal de Educação, Ciência e Tecnologia do Triângulo Mineiro (IFTM), Ituiutaba, MG, Brazil
| | | | - Fabio de Oliveira
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil
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12
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Pla D, Quesada-Bernat S, Rodríguez Y, Sánchez A, Vargas M, Villalta M, Mesén S, Segura Á, Mustafin DO, Fomina YA, Al-Shekhadat RI, Calvete JJ. Dagestan blunt-nosed viper, Macrovipera lebetina obtusa (Dwigubsky, 1832), venom. Venomics, antivenomics, and neutralization assays of the lethal and toxic venom activities by anti- Macrovipera lebetina turanica and anti- Vipera berus berus antivenoms. Toxicon X 2020; 6:100035. [PMID: 32550590 PMCID: PMC7285993 DOI: 10.1016/j.toxcx.2020.100035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023] Open
Abstract
We have applied a combination of venomics, in vivo neutralization assays, and in vitro third-generation antivenomics analysis to assess the preclinical efficacy of the monospecific anti-Macrovipera lebetina turanica (anti-Mlt) antivenom manufactured by Uzbiopharm® (Uzbekistan) and the monospecific anti-Vipera berus berus antivenom from Microgen® (Russia) against the venom of Dagestan blunt-nosed viper, Macrovipera lebetina obtusa (Mlo). Despite their low content of homologous (anti-Mlt, 5–10%) or para-specific (anti-Vbb, 4–9%) F(ab')2 antibody fragments against M. l. obtusa venom toxins, both antivenoms efficiently recognized most components of the complex venom proteome's arsenal, which is made up of toxins derived from 11 different gene families and neutralized, albeit at different doses, key toxic effects of M. l. obtusa venom, i.e., in vivo lethal and hemorrhagic effects in a murine model, and in vitro phospholipase A2, proteolytic and coagulant activities. The calculated lethality neutralization potencies for Uzbiopharm® anti-Mlt and anti-Vbb Microgen® antivenoms were 1.46 and 1.77 mg/mL, indicating that 1 mL of Uzbiopharm® and Microgen® antivenoms may protect mice from 41 to 50 LD50s of Mlo venom, respectively. The remarkable degree of conservation of immunogenic determinants between species of the clades of European and Oriental viper, which evolved geographically segregated since the early Miocene, suggests an eventual window of opportunity for the treatment of envenomings by Eurasian snakes. Clearly, the rational use of heterologous antivenoms requires establishing their para-specificity landscapes. This paper illustrates the analytical power of combining in vitro and in vivo preclinical quantitative assays toward this goal. Efficacy against M. l. obtusa venom by two antivenoms was investigated. Quantification of lethality neutralizing antibodies was assessed. Anti-Vipera berus antivenom showed paraspecificity against M. l. obtusa venom. This study provides hints as how to improve the potency of the antivenoms sampled.
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Affiliation(s)
- Davinia Pla
- Laboratorio de Venómica Evolutiva y Traslacional, CSIC, Jaime Roig 11, 46010, Valencia, Spain
| | - Sarai Quesada-Bernat
- Laboratorio de Venómica Evolutiva y Traslacional, CSIC, Jaime Roig 11, 46010, Valencia, Spain
| | - Yania Rodríguez
- Laboratorio de Venómica Evolutiva y Traslacional, CSIC, Jaime Roig 11, 46010, Valencia, Spain
| | - Andrés Sánchez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-206, Costa Rica
| | - Mariángela Vargas
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-206, Costa Rica
| | - Mauren Villalta
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-206, Costa Rica
| | - Susana Mesén
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-206, Costa Rica
| | - Álvaro Segura
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, 11501-206, Costa Rica
| | | | | | | | - Juan J Calvete
- Laboratorio de Venómica Evolutiva y Traslacional, CSIC, Jaime Roig 11, 46010, Valencia, Spain
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Resiere D, Monteiro W, Houcke S, Pujo JM, Mathien C, Mayence C, Neviere R, Hommel D, de Almeida Gonçalves Sachett J, Mehdaoui H, Gutiérrez JM, Kallel H. Bothrops Snakebite Envenomings in the Amazon Region. CURRENT TROPICAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40475-020-00203-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Sánchez M, Solano G, Vargas M, Reta-Mares F, Neri-Castro É, Alagón A, Sánchez A, Villalta M, León G, Segura Á. Toxicological profile of medically relevant Crotalus species from Mexico and their neutralization by a Crotalus basiliscus/Bothrops asper antivenom. Toxicon 2020; 179:92-100. [PMID: 32345455 DOI: 10.1016/j.toxicon.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Abstract
Specimens of the Crotalus genus represent a potential snakebite problem in Mexico, and despite the great number of species of Crotalus present in this country, only a few of them are relevant from a medical point of view. Crotalus envenomed patients can present a range of signs and symptoms, depending on the species involved, and their treatment is indistinctly with either of the anti-viperid antivenoms available in the Mexican Public Health System. One of these antivenoms is produced by immunization of horses with a mixture of only two venoms: Crotalus basiliscus and Bothrops asper venoms. In light of the high variability found in Crotalus species venom composition, it is important to demonstrate the cross-neutralization of this antivenom against other Crotalus species. Therefore, in this work the toxic variability of eight medically important Crotalus venoms from Mexico and its neutralization by the Crotalus basiliscus/Bothrops asper antivenom were assessed. The present study evidenced the variability of toxic and enzymatic activities among the following Crotalus venoms: (1) Crotalus atrox, (2) Crotalus basiliscus, (3) Crotalus culminatus, (4) Crotalus simus, (5) Crotalus tzabcan, (6) Crotalus scutulatus salvini, (7) Crotalus scutulatus scutulatus-A, and (8) Crotalus scutulatus scutulatus-B. All venoms studied possess lethal and hemorrhagic activity on a murine model, although there are important variations among the species; in contrast, the PLA2 activity was similar for all venoms. Interestingly, only C. simus venom exhibited coagulant activity on human plasma under 100 μg. The antivenom neutralized the lethality and all the other assessed activities for all venoms tested. However, the dose required varied depending on the venom and the evaluated activity. Our preclinical data support the recommendation of using this antivenom to clinically manage Crotalus snakebites produced by the species assessed in this study. Nonetheless, only clinical trials could categorically validate these results.
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Affiliation(s)
- Melvin Sánchez
- 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
| | - Mariángela Vargas
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Francisco Reta-Mares
- Laboratorios de Biológicos y Reactivos de México S.A. de C.V. (BIRMEX), México DF, Mexico
| | - Édgar Neri-Castro
- Departamento de Medicina Molecular y Bioprocesos Del Instituto de Biotecnología de La Universidad Nacional Autónoma de México (UNAM), Cuernavaca, Morelos, Mexico
| | - Alejandro Alagón
- Departamento de Medicina Molecular y Bioprocesos Del Instituto de Biotecnología de La Universidad Nacional Autónoma de México (UNAM), Cuernavaca, Morelos, Mexico
| | - Andrés Sánchez
- 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
| | - Guillermo León
- 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.
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Fan HW, Natal Vigilato MA, Augusto Pompei JC, Gutiérrez JM. [Situation of public laboratories manufacturing antivenoms in Latin AmericaA situação dos laboratórios públicos produtores de soros antivenenos na América Latina]. Rev Panam Salud Publica 2019; 43:e92. [PMID: 31772565 PMCID: PMC6863067 DOI: 10.26633/rpsp.2019.92] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/10/2019] [Indexed: 11/25/2022] Open
Abstract
Se analiza la situación de los laboratorios públicos productores de antivenenos en América Latina, con base a los resultados de en un taller coordinado por el Centro Panamericano de Fiebre Aftosa (PANAFTOSA) de la Organización Panamericana de la Salud (OPS). Nueve países en la región poseen doce laboratorios públicos que producen y distribuyen antivenenos contra venenos de diferentes animales ponzoñosos. Se discutió la situación de cada laboratorio, se analizó el escenario actual caracterizado por las crecientes demandas regulatorias y la heterogeneidad de estos en términos de infraestructura y capacidad productiva y se planteó la necesidad de concertar procesos de cooperación regional dirigidos a mejorar la disponibilidad de antivenenos, incluyendo proyectos de investigación y desarrollo para el mejoramiento de los procesos y las tecnologías; estudios del perfil de la capacidad neutralizante de los antivenenos contra diferentes venenos, y programas de capacitación técnica de profesionales y personal técnico. En el contexto actual, en el que la Organización Mundial de la Salud elaboró una estrategia global para la prevención y el control de los envenenamientos ofídicos, el Centro PANAFTOSA de la OPS ha asumido la coordinación de estas acciones en las Américas, mejorar la disponibilidad de antivenenos es prioritaria. Como resultado de ese taller, se creó la Red de Laboratorios Públicos Productores de Antivenenos de América Latina (RELAPA), con el objetivo de fortalecer estos laboratorios y de aumentar la disponibilidad y accesibilidad de antivenenos eficaces y seguros a toda América Latina.
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Affiliation(s)
- Hui Wen Fan
- Instituto Butantan Instituto Butantan São Paulo Brazil Instituto Butantan, São Paulo. Brazil
| | - Marco Antonio Natal Vigilato
- Centro Panamericano de Fiebre Aftosa Organización Panamericana de la Salud Rio de Janeiro Brasil Centro Panamericano de Fiebre Aftosa, Organización Panamericana de la Salud, Rio de Janeiro. Brasil
| | - Julio Cesar Augusto Pompei
- Centro Panamericano de Fiebre Aftosa Organización Panamericana de la Salud Rio de Janeiro Brasil Centro Panamericano de Fiebre Aftosa, Organización Panamericana de la Salud, Rio de Janeiro. Brasil
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología Universidad de Costa Rica San José Costa Rica Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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Castillo-Beltrán MC, Hurtado-Gómez JP, Corredor-Espinel V, Ruiz-Gómez FJ. A polyvalent coral snake antivenom with broad neutralization capacity. PLoS Negl Trop Dis 2019; 13:e0007250. [PMID: 30856180 PMCID: PMC6428337 DOI: 10.1371/journal.pntd.0007250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/21/2019] [Accepted: 02/19/2019] [Indexed: 01/08/2023] Open
Abstract
Coral snakes of the genus Micrurus have a high diversity and wide distribution in the Americas. Despite envenomings by these animals being uncommon, accidents are often severe and may result in death. Producing an antivenom to treat these envenomings has been challenging since coral snakes are difficult to catch, produce small amounts of venom, and the antivenoms produced have shown limited cross neutralization. Here we present data of cross neutralization among monovalent antivenoms raised against M. dumerilii, M. isozonus, M. mipartitus and M. surinamensis and the development of a new polyvalent coral snake antivenom, resulting from the mix of monovalent antivenoms. Our results, show that this coral snake antivenom has high neutralizing potency and wide taxonomic coverage, constituting a possible alternative for a long sought Pan-American coral snake antivenom.
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Affiliation(s)
- María Carlina Castillo-Beltrán
- Grupo de Investigación en Animales Ponzoñosos y sus Venenos, Grupo de Producción y Desarrollo Tecnológico, Dirección de Producción, Instituto Nacional de Salud, Bogotá, Colombia
| | - Juan Pablo Hurtado-Gómez
- Grupo de Investigación en Animales Ponzoñosos y sus Venenos, Grupo de Producción y Desarrollo Tecnológico, Dirección de Producción, Instituto Nacional de Salud, Bogotá, Colombia
| | - Vladimir Corredor-Espinel
- Parasitology Laboratory, Department of Public Health, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Francisco Javier Ruiz-Gómez
- Grupo de Investigación en Animales Ponzoñosos y sus Venenos, Grupo de Producción y Desarrollo Tecnológico, Dirección de Producción, Instituto Nacional de Salud, Bogotá, Colombia
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17
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Gutiérrez JM. Global Availability of Antivenoms: The Relevance of Public Manufacturing Laboratories. Toxins (Basel) 2018; 11:toxins11010005. [PMID: 30586868 PMCID: PMC6356591 DOI: 10.3390/toxins11010005] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/14/2018] [Accepted: 12/20/2018] [Indexed: 11/25/2022] Open
Abstract
Snakebite envenoming is a serious global public health problem, and international initiatives, under the coordination of the World Health Organization and its regional offices, are being developed to reduce the impact of this neglected tropical disease. The global availability of safe and effective antivenoms is one of the key aspects in this global strategy. This review discusses the role of public antivenom manufacturing laboratories for ensuring the supply of antivenoms. The difficulties faced by public laboratories are discussed, together with some tasks that need to be implemented for strengthening them. In addition, the concept of ‘redundancy’ in the supply of antivenoms is emphasized, as a way to cope with the risks associated with the provision of antivenoms by few manufacturers. In general, the public sector should play a leading role, in antivenom availability and other aspects as well, within the global struggle to reduce the mortality and morbidity caused by snakebite envenoming.
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Affiliation(s)
- José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica.
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18
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Gutiérrez JM, Fan HW. Improving the control of snakebite envenomation in Latin America and the Caribbean: a discussion on pending issues. Trans R Soc Trop Med Hyg 2018; 112:523-526. [PMID: 30219842 DOI: 10.1093/trstmh/try104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Hui Wen Fan
- Instituto Butantan, Avenida Vital Brazil, São Paulo, Brazil
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Snakebite envenomation in the Caribbean: The role of medical and scientific cooperation. PLoS Negl Trop Dis 2018; 12:e0006441. [PMID: 30001319 PMCID: PMC6042683 DOI: 10.1371/journal.pntd.0006441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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