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Chanda A, Salvi NC, Shelke PV, Kalita B, Patra A, Puzari U, Khadilkar MV, Mukherjee AK. Supplementation of polyclonal antibodies, developed against epitope-string toxin-specific peptide immunogens, to commercial polyvalent antivenom, shows improved neutralization of Indian Big Four and Naja kaouthia snake venoms. Toxicon X 2024; 24:100210. [PMID: 39398349 PMCID: PMC11471238 DOI: 10.1016/j.toxcx.2024.100210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 09/04/2024] [Accepted: 09/19/2024] [Indexed: 10/15/2024] Open
Abstract
Snakebites profoundly impact the rural population of tropical nations, leading to significant socio-economic repercussions. Polyvalent antivenom (PAV) therapy faces several limitations, including intra-specific variations and poor efficacy against some major toxins and low molecular mass, poorly immunogenic toxins, which contribute to increased mortality and morbidity rates. Innovative strategies for developing novel antivenoms are continuously explored to address these challenges. The present study focuses on designing of 17 epitope-string toxin-specific peptide immunogens from pharmacologically active major and/or poorly immunogenic toxins (snake venom metalloprotease, Kunitz-type serine protease inhibitor, phospholipase A2, three-finger toxin) from the venom of the 'Big Four' venomous snakes and Naja kaouthia (NK) in India. These custom peptide antibodies demonstrated robust immuno-reactivity against the venoms 'Big Four' and NK. When these antibodies were supplemented with commercial PAV at a defined ratio (formulated polyvalent antivenom or FPAV), it significantly enhanced the neutralization of snake venom enzymes and in vivo neutralization of lethality and pharmacological activities such as haemorrhage, necrosis, pro-coagulant, defibrinogenation, and myotoxicity of 'Big Four' and NK venoms compared to PAV in mice. The present study highlights a promising strategy for developing next-generation antivenoms using synthetic peptide-based immunogens, offering a targeted approach to address the limitations of current antivenom therapy.
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Affiliation(s)
- Abhishek Chanda
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, 97331, Oregon, USA
| | - Nitin C. Salvi
- Premium Serums and Vaccines Pvt. Ltd, Narayangaon, Pune, 410504, Maharashtra, India
| | - Pravin V. Shelke
- Premium Serums and Vaccines Pvt. Ltd, Narayangaon, Pune, 410504, Maharashtra, India
| | - Bhargab Kalita
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
- Amrita Research Centre, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, 121002, India
| | - Aparup Patra
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
- Amrita Research Centre, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, 121002, India
| | - Upasana Puzari
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
| | - Milind V. Khadilkar
- Premium Serums and Vaccines Pvt. Ltd, Narayangaon, Pune, 410504, Maharashtra, India
| | - Ashis K. Mukherjee
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
- Division of Life Sciences, Institute of Advanced Study in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, 781035, Assam, India
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Hamman NA, Ibrahim AD, Hamza M, Jahun MG, Micah M, Lawal HA, Abubakar SB, Iliyasu G, Chedi BAZ, Mohammed I, Harrison RA, Gutiérrez JM, Habib AG. A Randomized Controlled Trial to Optimize Antivenom Therapy for Carpet Viper (Echis romani)-Envenomed Children in Nigeria. Am J Trop Med Hyg 2024; 111:904-910. [PMID: 39106853 PMCID: PMC11448515 DOI: 10.4269/ajtmh.24-0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/18/2024] [Indexed: 08/09/2024] Open
Abstract
In an open randomized controlled trial, we compared one vial (10 mL) to two vials (20 mL) of EchiTAb-plus-ICP (EPI) antivenom among children with systemic carpet viper (Echis romani) envenoming of moderate severity in northeastern Nigeria. Systemic envenoming, presenting with incoagulable blood, was diagnosed using the 20-minute whole blood clotting test (20WBCT). Eligible patients with positive 20WBCT whose guardians assented were recruited and randomly allocated to receive either one vial or two vials of EPI administered either as a bolus or as a slow continuous infusion. The primary outcome was permanent restoration of blood coagulability 6 hours after the start of treatment, assessed by the 20WBCT and repeated at 6, 12, 24, and 48 hours after treatment. Secondary outcomes were the incidences of early adverse reactions to antivenom treatment. Initial doses permanently restored blood coagulability at 6 hours in 34/39 (87.2%) of those treated with one vial and 39/41 (95.1%) of those treated with two vials of EPI (P = 0.258). However, the proportion with permanent restoration of clotting at 6 hours among patients randomized to bolus administration was 41 of 42 (97.6%) patients compared with 32 of 38 (84.2%) patients randomized to slow infusion of EPI antivenom (P = 0.049); however, the difference was not sustained through the remaining time points. There was no difference in early adverse reactions between those treated with the two different doses or modes of delivery. We conclude that the one-vial dose compared favorably to two vials of EPI antivenom with regards to effectiveness and safety among children with carpet viper envenoming of moderate severity in Nigeria.
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Affiliation(s)
| | - Agom D. Ibrahim
- Department of Community Medicine, Federal Teaching Hospital, Gombe, Nigeria
| | - Muhammad Hamza
- Infectious & Tropical Diseases Unit, Bayero University, Kano, Nigeria
| | | | - Musa Micah
- Kaltungo Snakebite Research Hospital, Gombe State, Nigeria
| | - Hadiza A. Lawal
- Department of Medical Laboratory Sciences, Bayero University, Kano, Nigeria
| | | | - Garba Iliyasu
- Infectious & Tropical Diseases Unit, Bayero University, Kano, Nigeria
| | | | - Idris Mohammed
- Immunology & Infectious Diseases Unit, Federal Teaching Hospital, Gombe, Nigeria
| | - Robert A. Harrison
- Centre for Snakebite Research & Intervention, Liverpool School for Tropical Medicine, Liverpool, United Kingdom
| | - José-María Gutiérrez
- Instituto Clodomiro Picado, School of Microbiology, University of Costa Rica, San José, Costa Rica
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3
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Kakati H, Patra A, Mukherjee AK. Composition, pharmacology, and pathophysiology of the venom of monocled cobra (Naja kaouthia)- a medically crucial venomous snake of southeast Asia: An updated review. Toxicon 2024; 249:108056. [PMID: 39111718 DOI: 10.1016/j.toxicon.2024.108056] [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: 06/18/2024] [Revised: 07/31/2024] [Accepted: 07/31/2024] [Indexed: 08/15/2024]
Abstract
The Monocled Cobra (Naja kaouthia), a category one medically significant snake from the Elapidae family, inflicts severe envenomation in South and Southeast Asian countries. N. kaouthia is distributed throughout the eastern and northeastern parts of India, Nepal, Bangladesh, Myanmar, Thailand, Vietnam, Malaysia, and southwestern China. Envenomation by N. kaouthia is a medical emergency, and the primary clinical symptoms are neurotoxicity and localized tissue destruction. Unfortunately, data on the actual magnitude of N. kaouthia envenomation is scarce due to poor record keeping, lack of diagnostic kits, and region-wise well-coordinated epidemiological surveys. The present review highlights the diversity in the composition of N. Kaouthia venom (NKV) across various geographical regions, as revealed through biochemical and proteomic analyses. The qualitative and quantitative differences in the toxin isoforms result in differences in lethality and pathophysiological manifestation that may limit the effectiveness of antivenom therapy. Studies on commercial polyvalent antivenom (PAV) effectiveness against distinct NKV samples have revealed varying toxicity and enzymatic activity neutralization. Additionally, the identification of snake venom's poorly immunogenic toxins by mass spectrometry, quantification of venom-specific antibodies, and implications for antivenom therapy against snakebites are highlighted. Future directions involve clinical studies on NK envenomation where the snake is frequently encountered and the correlation of this data with NKV composition in that region. For more efficient and superior hospital management of NK envenomation, research should enhance the current immunization procedure to boost the development of antibodies against less immunogenic venom components of this snake.
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Affiliation(s)
- Hirakjyoti Kakati
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur- 784028, Assam, India
| | - Aparup Patra
- Institute of Advanced Studies in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati-781035, Assam, India; Amrita Research Centre, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, 121002, India
| | - Ashis K Mukherjee
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur- 784028, Assam, India; Institute of Advanced Studies in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati-781035, Assam, India.
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4
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Naz H, Chamola R, Sarafraz J, Razabizadeh M, Jain S. An efficient densenet-based deep learning model for Big-4 snake species classification. Toxicon 2024; 243:107744. [PMID: 38701904 DOI: 10.1016/j.toxicon.2024.107744] [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: 02/04/2024] [Revised: 04/19/2024] [Accepted: 04/30/2024] [Indexed: 05/05/2024]
Abstract
Snakebite poses a significant health threat in numerous tropical and subtropical nations, with around 5.4 million cases reported annually, which results in 1.8-2.7 million instances of envenomation, underscoring its critical impact on public health. The 'BIG FOUR' group comprises the primary committers responsible for most snake bites in India. Effective management of snakebite victims is essential for prognosis, emphasizing the need for preventive measures to limit snakebite-related deaths. The proposed initiative seeks to develop a transfer learning-based image classification algorithm using DenseNet to identify venomous and non-venomous snakes automatically. The study comprehensively evaluates the image classification results, employing accuracy, F1-score, Recall, and Precision metrics. DenseNet emerges as a potent tool for multiclass snake image classification, achieving a notable accuracy rate of 86%. The proposed algorithm intends to be incorporated into an AI-based snake-trapping device with artificial prey made with tungsten wire and vibration motors to mimic heat and vibration signatures, enhancing its appeal to snakes. The proposed algorithm in this research holds promise as a primary tool for preventing snake bites globally, offering a path toward automated snake capture without human intervention. These findings are significant in preventing snake bites and advancing snakebite mitigation strategies.
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Affiliation(s)
- Huma Naz
- School of Computer Science and Engineering, University of Petroleum and Energy Studies Dehradun, India
| | - Rahul Chamola
- Department of Mechanical Engineering, School of Advanced Engineering, University of Petroleum and Energy Studies, Dehradun, India.
| | - Jaleh Sarafraz
- UMR7179 CNRS/MNHN, Département Àdaptations du vivant, Museum National d'Histoire Naturelle, Paris, France
| | - Mahdi Razabizadeh
- Department of Biodiversity, Institute of Science and High Technology and Environmental Sciences, Graduate University of Advanced Technology, Kerman, Iran.
| | - Siddharth Jain
- Department of Mechanical Engineering, School of Advanced Engineering, University of Petroleum and Energy Studies, Dehradun, India
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Lim ASS, Tan KY, Tan CH. Immunoreactivity and neutralization efficacy of Pakistani Viper Antivenom (PVAV) against venoms of Saw-scaled Vipers (Echis carinatus subspp.) and Western Russell's Vipers (Daboia russelii) from the Indian subcontinent. Acta Trop 2024; 250:107099. [PMID: 38097152 DOI: 10.1016/j.actatropica.2023.107099] [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: 10/19/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 12/31/2023]
Abstract
Snakebite envenoming (SBE) is a priority Neglected Tropical Disease listed by the World Health Organization. South Asia is heavily affected, and virtually all countries in the region import polyvalent antivenom products from India for clinical use. The imported antivenoms, however, have suboptimal effectiveness due to geographical venom variation. Recently, a domestic bivalent product, named Pakistani Viper Antivenom (PVAV) has been developed specifically for Pakistani vipers, Echis carinatus sochureki and Daboia russelii. As a bivalent viperid antivenom, it is unknown yet if PVAV exhibits higher immunological binding and neutralization activities against viper venoms from distant locales compared with polyvalent antivenoms manufactured in India. This study thus examined the preclinical efficacy of PVAV against venoms of Western Russell's Vipers and Saw-scaled Viper subspecies from selected locales in the Indian subcontinent. PVAV generally outperformed the commonly used VINS polyvalent antivenom (VPAV, manufactured in India) in binding toward venoms, and showed superior or comparable neutralization efficacy against the venom procoagulant and hemorrhagic effects of Saw-scaled Vipers as well as Russell's Vipers from Pakistan and Sri Lanka. Based on normalized potency values, PVAV is far more potent than VPAV in neutralizing the lethality of all viper venoms, except that of the Indian Russell's Viper. The study shows conserved antigenicity of toxins responsible for major toxicity across these viperid venoms, and suggests the feasible production of a viper-specific antivenom with higher potency and broader geographical utility for the region.
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Affiliation(s)
- Andy Shing Seng Lim
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Kae Yi Tan
- Protein and Interactomics Laboratory, Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Choo Hock Tan
- Venom Research and Toxicology Laboratory, Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
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6
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Sørensen CV, Fernández J, Adams AC, Wildenauer HHK, Schoffelen S, Ledsgaard L, Pucca MB, Fiebig M, Cerni FA, Tulika T, Voldborg BG, Karatt-Vellatt A, Morth JP, Ljungars A, Grav LM, Lomonte B, Laustsen AH. Antibody-dependent enhancement of toxicity of myotoxin II from Bothrops asper. Nat Commun 2024; 15:173. [PMID: 38228619 PMCID: PMC10791742 DOI: 10.1038/s41467-023-42624-5] [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: 06/13/2023] [Accepted: 10/17/2023] [Indexed: 01/18/2024] Open
Abstract
Improved therapies are needed against snakebite envenoming, which kills and permanently disables thousands of people each year. Recently developed neutralizing monoclonal antibodies against several snake toxins have shown promise in preclinical rodent models. Here, we use phage display technology to discover a human monoclonal antibody and show that this antibody causes antibody-dependent enhancement of toxicity (ADET) of myotoxin II from the venomous pit viper, Bothrops asper, in a mouse model of envenoming that mimics a snakebite. While clinical ADET related to snake venom has not yet been reported in humans, this report of ADET of a toxin from the animal kingdom highlights the necessity of assessing even well-known antibody formats in representative preclinical models to evaluate their therapeutic utility against toxins or venoms. This is essential to avoid potential deleterious effects as exemplified in the present study.
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Affiliation(s)
- Christoffer V Sørensen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Julián Fernández
- Instituto Clodomiro Picado, Facultad de Microbiologia, Universidad de Costa Rica, San Jose, Costa Rica
| | - Anna Christina Adams
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Helen H K Wildenauer
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Sanne Schoffelen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Line Ledsgaard
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Manuela B Pucca
- Medical School, Federal University of Roraima, Boa Vista, BR-69310-000, Brazil
| | - Michael Fiebig
- Absolute Antibody Ltd, Wilton Centre, Redcar, Cleveland, TS10 4RF, UK
| | - Felipe A Cerni
- Postgraduate Program in Tropical Medicine, University of the State of Amazonas, Manaus, BR-69040-000, Brazil
| | - Tulika Tulika
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Bjørn G Voldborg
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | | | - J Preben Morth
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Anne Ljungars
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Lise M Grav
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark
| | - Bruno Lomonte
- Instituto Clodomiro Picado, Facultad de Microbiologia, Universidad de Costa Rica, San Jose, Costa Rica.
| | - Andreas H Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, DK-2800, Kongens Lyngby, Denmark.
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Lai R, Yan S, Wang S, Yang S, Yan Z, Lan P, Wang Y, Li Q, Wang J, Wang W, Ma Y, Liang Z, Zhang J, Zhou N, Han X, Zhang X, Zhang M, Zhao X, Zhang G, Zhu H, Yu X, Lyu C. The Chinese guideline for management of snakebites. World J Emerg Med 2024; 15:333-355. [PMID: 39290598 PMCID: PMC11402871 DOI: 10.5847/wjem.j.1920-8642.2024.076] [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: 06/06/2024] [Accepted: 08/08/2024] [Indexed: 09/19/2024] Open
Abstract
In 2009, the World Health Organization included snakebite on the list of neglected tropical diseases, acknowledging it as a common occupational hazard for farmers, plantation workers, and others, causing tens of thousands of deaths and chronic physical disabilities every year. This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims. These recommendations are based on clinical experience and clinical research evidence. This guideline focuses on the following topics: snake venom, clinical manifestations, auxiliary examination, diagnosis, treatments, and prevention.
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Affiliation(s)
- Rongde Lai
- Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Shijiao Yan
- School of Public Health, Hainan Medical University, Haikou 571199, China
| | - Shijun Wang
- Surgery Department of Traditional Chinese Medicine, the Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China
| | - Shuqing Yang
- Emergency Department, Chongqing University Central Hospital/Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Zhangren Yan
- Department of Surgery of Traditional Chinese Medicine, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang 330006, China
| | - Pin Lan
- Department of Emergency Medicine, the Fifth Affiliated Hospital of Wenzhou Medical University/Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Yonggao Wang
- General Surgery Department, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, China
| | - Qi Li
- Emergency Department, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350001, China
| | - Jinlong Wang
- Emergency Department, Chongqing University Fuling Hospital, Chongqing University, Chongqing 408000, China
| | - Wei Wang
- Emergency Department, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Yuefeng Ma
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zijing Liang
- Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jianfeng Zhang
- Emergency Department , Wuming Hospital of Guangxi Medical University, Nanning 530021, China
| | - Ning Zhou
- Emergency Department, Central People's Hospital of Zhanjiang, Zhanjiang 524037, China
| | - Xiaotong Han
- Emergency Department, Hunan Provincial People's Hospital, Changsha 410005, China
| | - Xinchao Zhang
- Emergency Department, National Geriatrics Center of Beijing Hospital, Beijing 100020, China
| | - Mao Zhang
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiaodong Zhao
- Emergency Department, the Fourth Medical Center of the PLA General Hospital, Beijing 100048, China
| | - Guoqiang Zhang
- Emergency Department, China-Japan Friendship Hospital, Beijing 100029, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, BeiJing 100730, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, BeiJing 100730, China
| | - Chuanzhu Lyu
- Emergency Department, Sichuan Academy of Medical Sciences/Sichuan Provincial People's Hospital, Chengdu 610072, China
- Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences (No. 2019RU013), Hainan Medical University, Haikou 571199, China
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Gyawu VB, Firempong CK, Hamidu JA, Tetteh AY, Ti-Baliana Martha NJ, Yingshu F, Yi Z. Production and evaluation of monovalent anti-snake immunoglobulins from chicken egg yolk using Ghanaian puff adder (Bitis arietans) Venom: Isolation, purification, and neutralization efficacy. Toxicon 2023; 231:107180. [PMID: 37290727 DOI: 10.1016/j.toxicon.2023.107180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023]
Abstract
Snakebites are rampant in Ghana, especially among the farmers, herdsmen, military recruits, hunters, and rural dwellers, and the antisnake venoms (ASV) use to treat these bites are not locally produced but rather imported, which come with a high cost, lack of constant supply and low specificity. The study was therefore aimed at isolating, purifying, and evaluating the efficacy of monovalent ASV from chicken egg yolk using puff adder (Bitis arietans) venom from Ghana. The major pathophysiological properties of the venom and the efficacy of the locally produced ASV were evaluated. The results showed that the snake venom (LD50 of 0.85 mg/kg body weight) had anticoagulant, haemorrhagic, and edematic activities in mice which were effectively neutralized using the purified egg yolk immunoglobulin Y (IgY), with two distinct molecular weight bands (∼70 and 25 kDa). The cross-neutralization studies also showed that the venom/IgY mixture (2.55 mg/kg body weight: 90 mg/kg body weight) offered 100% protection to the animals with ED50 of IgY being 22.66 mg/kg body weight. However, the applied dose (11.36 mg/kg body weight) of the available polyvalent ASV offered 25% protection compared with the 62% protection of the IgY at the same dose. The findings showed successful isolation and purification of a Ghanaian monovalent ASV with a better neutralization efficacy compared with the clinically available polyvalent drug.
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Affiliation(s)
- Vincent Baffour Gyawu
- Department of Biochemistry and Biotechnology, Faculty of Biosciences, College of Science, KNUST, Kumasi, Ghana
| | - Caleb Kesse Firempong
- Department of Biochemistry and Biotechnology, Faculty of Biosciences, College of Science, KNUST, Kumasi, Ghana.
| | - Jacob Alhassan Hamidu
- Department of Animal Science, Faculty of Agriculture, College of Agriculture and Natural Resources, KNUST, Kumasi, Ghana
| | - Antonia Yarney Tetteh
- Department of Biochemistry and Biotechnology, Faculty of Biosciences, College of Science, KNUST, Kumasi, Ghana
| | | | | | - Zou Yi
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China
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9
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Kakati H, Giri S, Patra A, Taye SJ, Agarwalla D, Boruah H, Choudhary G, Kalita B, K Mukherjee A. A retrospective analysis of epidemiology, clinical features of envenomation, and in-patient management of snakebites in a model secondary hospital of Assam, North-east India. Toxicon 2023; 230:107175. [PMID: 37257518 DOI: 10.1016/j.toxicon.2023.107175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/02/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
Assam, a Northeastern State of India, is inhabited by several venomous snake species causing substantial morbidity and mortality. The data on the epidemiology of snakebites and their management is underreported in this region. Hence, a secondary health-based retrospective study was carried out at Demow Model Hospital, Sivasagar, Assam, to evaluate the clinical and epidemiological profile of snakebite cases reported in this rural hospital and their management. Snakebites occurring between April 2018 to August 2022 were reviewed based on socio-demographic details of the patient, clinical symptoms, and treatment using a standard questionnaire. Out of the 1011 registered snakebite cases, 139 patients (13.7%) counted for venomous bites, among which 92 patients (66.19%) accounted for viper bites (green pit viper and Salazar's pit viper), and 30 patients (21.5%) were bitten by elapid snakes (Indian monocled Cobra, banded krait, and greater/lesser black krait). A maximum number of snakebite cases (80.5%) were reported from the interior rural villages and documented from July to September (51.3%). Elapid snake envenomed patients, except one, were successfully treated with commercial antivenom, neostigmine, and glycopyrrolate. Because commercial polyvalent antivenom against "Big Four" venomous snakes of India showed poor neutralization of pit-vipers envenomation; therefore, pit-viper bite patients were treated with repurposed drugs magnesium sulfate and glycerin compression dressing. Adverse serum reactions were reported only in 3 (11.1%) cases. The preventive measures and facilities adopted at the Demow Model Hospital significantly reduce snakebite death and morbidity; therefore, they can be s practised across various states in India as a prototype.
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Affiliation(s)
- Hirakjyoti Kakati
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India
| | - Surajit Giri
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar, Assam, India.
| | - Aparup Patra
- Institute of Advanced Studies in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, 781035, Assam, India
| | - Simanta J Taye
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar, Assam, India
| | - Deepak Agarwalla
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar, Assam, India
| | - Hridoy Boruah
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar, Assam, India
| | - Gaurav Choudhary
- Demow Government Community Health Centre, Raichai, Konwar Dihingia Gaon, Sivasagar, Assam, India
| | - Bhargab Kalita
- Amrita School of Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Ponekkara, Kochi, 682041, Kerala, India
| | - Ashis K Mukherjee
- Department of Molecular Biology and Biotechnology, School of Sciences, Tezpur University, Tezpur, 784028, Assam, India; Institute of Advanced Studies in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, 781035, Assam, India.
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10
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Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet 2023; 401:1382-1398. [PMID: 36931290 DOI: 10.1016/s0140-6736(23)00002-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 03/16/2023]
Abstract
There is increasing recognition of the public health importance of snakebite envenoming. Worldwide annual incidence is likely to be 5 million bites, with mortality exceeding 150 000 deaths, and the resulting physical and psychological morbidity leads to substantial social and economic repercussions. Prevention through community education by trained health workers is the most effective and economically viable strategy for reducing risk of bites and envenoming. Clinical challenges to effective treatment are most substantial in rural areas of low-resource settings, where snakebites are most common. Classic skills of history taking, physical examination, and use of affordable point-of-care tests should be followed by monitoring of evolving local and systemic envenoming. Despite the profusion of new ideas for interventions, hyperimmune equine or ovine plasma-derived antivenoms remain the only specific treatment for snakebite envenoming. The enormous interspecies and intraspecies complexity and diversity of snake venoms, revealed by modern venomics, demands a radical redesign of many current antivenoms.
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Affiliation(s)
- David A Warrell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Experimental Medicine Division, John Radcliffe Hospital, Headington, UK.
| | - David J Williams
- Regulation and Prequalification Department, World Health Organization, Geneva, Switzerland
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11
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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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12
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Virus-like particles displaying conserved toxin epitopes stimulate polyspecific, murine antibody responses capable of snake venom recognition. Sci Rep 2022; 12:11328. [PMID: 35790745 PMCID: PMC9256628 DOI: 10.1038/s41598-022-13376-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/24/2022] [Indexed: 11/14/2022] Open
Abstract
Antivenom is currently the first-choice treatment for snakebite envenoming. However, only a low proportion of antivenom immunoglobulins are specific to venom toxins, resulting in poor dose efficacy and potency. We sought to investigate whether linear venom epitopes displayed on virus like particles can stimulate an antibody response capable of recognising venom toxins from diverse medically important species. Bioinformatically-designed epitopes, corresponding to predicted conserved regions of group I phospholipase A2 and three finger toxins, were engineered for display on the surface of hepatitis B core antigen virus like particles and used to immunise female CD1 mice over a 14 weeks. Antibody responses to all venom epitope virus like particles were detectable by ELISA by the end of the immunisation period, although total antibody and epitope specific antibody titres were variable against the different epitope immunogens. Immunoblots using pooled sera demonstrated recognition of various venom components in a diverse panel of six elapid venoms, representing three continents and four genera. Insufficient antibody yields precluded a thorough assessment of the neutralising ability of the generated antibodies, however we were able to test polyclonal anti-PLA2 IgG from three animals against the PLA2 activity of Naja nigricollis venom, all of which showed no neutralising ability. This study demonstrates proof-of-principle that virus like particles engineered to display conserved toxin linear epitopes can elicit specific antibody responses in mice which are able to recognise a geographically broad range of elapid venoms.
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13
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Bhaumik S, Beri D, Tyagi J, Clarke M, Sharma SK, Williamson PR, Jagnoor J. Outcomes in intervention research on snakebite envenomation: a systematic review. F1000Res 2022; 11:628. [PMID: 36300033 PMCID: PMC9579743 DOI: 10.12688/f1000research.122116.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION A core outcome set (COS) is a minimal list of consensus outcomes that should be used in all intervention research in a specific domain. COS enhance the ability to undertake meaningful comparisons and to understand the benefits or harms of different treatments. A first step in developing a COS is to identify outcomes that have been used previously. We did this global systematic review to provide the foundation for development of a region-specific COS for snakebite envenomation. Methods: We searched 15 electronic databases, eight trial registries, and reference lists of included studies to identify reports of relevant trials, protocols, registry records and systematic reviews. We extracted verbatim data on outcomes, their definitions, measures, and time-points. Outcomes were classified as per an existing outcome taxonomy, and we identified unique outcomes based on similarities in the definition and measurement of the verbatim outcomes. RESULTS We included 107 records for 97 studies which met our inclusion criteria. These reported 538 outcomes, with a wide variety of outcome measures, definitions, and time points for measurement. We consolidated these into 88 unique outcomes, which we classified into core areas of mortality (1, 1.14 %), life impact (6, 6.82%), resource use (15, 17.05%), adverse events (7, 7.95%), physiological/clinical (51, 57.95%), and composite (8, 9.09%) outcomes. The types of outcomes varied by the type of intervention, and by geographic region. Only 15 of the 97 trials (17.04%) listed Patient Related Outcome Measures (PROMS). CONCLUSION Trials evaluating interventions for snakebite demonstrate heterogeneity on outcomes and often omit important information related to outcome measurement (definitions, instruments, and time points). Developing high quality, region-specific COS for snakebite could inform the design of future trials and improve outcome reporting. Measurement of PROMS, resource use and life impact outcomes in trials on snakebite remains a gap.
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Affiliation(s)
- Soumyadeep Bhaumik
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
- Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Deepti Beri
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Jyoti Tyagi
- Meta-research and Evidence Synthesis Unit, George Institute for Global Health, New Delhi, Delhi, 110025, India
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Paula R Williamson
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales,, Sydney, New South Wales, 2042, Australia
- Injury Division, The George Institute for Global Health, New Delhi, Delhi, 110025, India
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14
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Babo Martins S, Bolon I, Alcoba G, Ochoa C, Torgerson P, Sharma SK, Ray N, Chappuis F, Ruiz de Castañeda R. Assessment of the effect of snakebite on health and socioeconomic factors using a One Health perspective in the Terai region of Nepal: a cross-sectional study. THE LANCET GLOBAL HEALTH 2022; 10:e409-e415. [DOI: 10.1016/s2214-109x(21)00549-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022] Open
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15
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A randomised trial of adaptive support ventilation in patients with neuroparalytic snake envenomation. Br J Anaesth 2022; 128:e232-e234. [PMID: 35027167 DOI: 10.1016/j.bja.2021.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/02/2022] Open
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16
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Ceesay B, Taal A, Kalisa M, Odikro MA, Agbope D, Kenu E. Analysis of snakebite data in Volta and Oti Regions, Ghana, 2019. Pan Afr Med J 2021; 40:131. [PMID: 34909099 PMCID: PMC8641636 DOI: 10.11604/pamj.2021.40.131.28217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction globally about 5.4 million people are affected by snakebite annually leading to 2.7 million cases of snakebite envenoming and 81,000-138,000 deaths. In sub-Saharan Africa, the burden of disease caused by snakebite is often underestimated despite its status as a category A neglected tropical disease. We reviewed snakebite data to determine the magnitude of snakebite by person, place, and time in the Volta and Oti Regions of Ghana. Methods we conducted a descriptive secondary data analysis using snakebite data from 2014-2018 extracted from the District Health Information and Management Systems (DHIMS 2) database. Data were analyzed descriptively by person, place, and time using summary statistics and results were presented in proportions and graphs. Missed outbreaks were determined through calculation of cumulative sum (CUSUM 2). Results a total of 2,973 cases of snakebites were reported over the 5 years of which 1675 (56.3%) were males. Majority 867 (29.2%) of snakebite victims were between 20-34 years of age with recorded 5-year average incidence of 24 snakebite cases per 100,000. Nkwanta North District recorded the highest cases 499 (16.8%) with most of the snakebite cases 2,411 (81%) recorded in the rainy season. Overall, there was a decreasing trend of snakebites and four missed snakebite outbreaks occurred during the period. No snakebite death was recorded. Conclusion a 5-year average snakebite incidence of 24 cases per 100,000 persons was recorded and Nkwanta North District recorded the highest cases with peaks occurring in rainy and harvesting seasons. Four outbreaks were missed. There is a need to conduct periodic data analysis for effective intervention programs.
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Affiliation(s)
- Baba Ceesay
- Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), School of Public Health, University of Ghana, Accra, Ghana.,Ministry of Health, Banjul, The Gambia
| | - Abdoulie Taal
- Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), School of Public Health, University of Ghana, Accra, Ghana.,Ministry of Health, Banjul, The Gambia
| | - Momodou Kalisa
- Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), School of Public Health, University of Ghana, Accra, Ghana.,Ministry of Health, Banjul, The Gambia
| | - Magdalene Akos Odikro
- Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), School of Public Health, University of Ghana, Accra, Ghana
| | | | - Ernest Kenu
- Ghana Field Epidemiology and Laboratory Training Programme (GFELTP), School of Public Health, University of Ghana, Accra, Ghana
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17
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Bhatia S, Blotra A, Vasudevan K. Immunorecognition capacity of Indian polyvalent antivenom against venom toxins from two populations of Echis carinatus. Toxicon 2021; 201:148-154. [PMID: 34474069 DOI: 10.1016/j.toxicon.2021.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
Clinicians report low efficacy of Indian polyvalent antivenom (PAV), with >20 vials required for treatment of a snakebite envenoming. We hypothesize that the antivenom efficacy could be reduced due to insufficient antibodies against some venom toxins. To test this, we used third-generation antivenomics to reveal bound and unbound venom toxins of Echis carinatus venom from Goa (ECVGO) and Tamil Nadu (ECVTN). We used 60, 120, 180, 240, 300, and 360 μg of venom and passed through mini-columns containing ~5 mg Antivenom bound to CNBr beads. The non-retained (unbound) and retained (bound) toxins were identified using reverse-phase HPLC and tandem mass spectrometry. Low molecular weight toxins - Short disintegrins (5.3 kDa) and DIS domain of P-II SVMP from ECVGO and ECVTN showed poor binding with antivenom. The immunorecognition sites of antivenom saturated at the lower antivenom-venom ratio for ECVGO than for ECVTN. The immunoretained capacity of antivenom against ECVTN was 140.6 μg and ECVGO was 125.1 μg. The amount of immunoretained toxins quantified can further be used to estimate the efficacy of antivenom by correlating it with in-vivo studies. The unbound toxins identified from this study could be targeted to improve the effectiveness of antivenom.
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Affiliation(s)
- Siddharth Bhatia
- CSIR-Centre for Cellular and Molecular Biology, Laboratory for the Conservation of Endangered Species, Hyderabad, 500048, India
| | - Avni Blotra
- CSIR-Centre for Cellular and Molecular Biology, Laboratory for the Conservation of Endangered Species, Hyderabad, 500048, India
| | - Karthikeyan Vasudevan
- CSIR-Centre for Cellular and Molecular Biology, Laboratory for the Conservation of Endangered Species, Hyderabad, 500048, India.
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18
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Hamza M, Knudsen C, Gnanathasan CA, Monteiro W, Lewin MR, Laustsen AH, Habib AG. Clinical management of snakebite envenoming: Future perspectives. Toxicon X 2021; 11:100079. [PMID: 34430847 PMCID: PMC8374517 DOI: 10.1016/j.toxcx.2021.100079] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Snakebite envenoming is a major cause of morbidity and mortality in rural communities throughout the tropics. Generally, the main clinical features of snakebites are local swelling, tissue necrosis, shock, spontaneous systemic hemorrhage, incoagulable blood, paralysis, rhabdomyolysis, and acute kidney injury. These clinical manifestations result from complex biochemical venom constituents comprising of cytotoxins, hemotoxins, neurotoxins, myotoxins, and other substances. Timely diagnosis of envenoming and identification of the responsible snake species is clinically challenging in many parts of the world and necessitates prompt and thorough clinical assessment, which could be supported by the development of reliable, affordable, widely-accessible, point-of-care tests. Conventional antivenoms based on polyclonal antibodies derived from animals remain the mainstay of therapy along with supportive medical and surgical care. However, while antivenoms save countless lives, they are associated with adverse reactions, limited potency, and are relatively inefficacious against presynaptic neurotoxicity and in preventing necrosis. Nevertheless, major scientific and technological advances are facilitating the development of new molecular and immunologic diagnostic tests, as well as a new generation of antivenoms comprising human monoclonal antibodies with broader and more potent neutralization capacity and less immunogenicity. Repurposed pharmaceuticals based on small molecule inhibitors (e.g., marimastat and varespladib) used alone and in combination against enzymatic toxins, such as metalloproteases and phospholipase A2s, have shown promise in animal studies. These orally bioavailable molecules could serve as early interventions in the out-of-hospital setting if confirmed to be safe and efficacious in clinical studies. Antivenom access can be improved by the usage of drones and ensuring constant antivenom supply in remote endemic rural areas. Overall, the improvement of clinical management of snakebite envenoming requires sustained, coordinated, and multifaceted efforts involving basic and applied sciences, new technology, product development, effective clinical training, implementation of existing guidelines and therapeutic approaches, supported by improved supply of existing antivenoms.
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Affiliation(s)
- Muhammad Hamza
- Infectious and Tropical Diseases Unit, Bayero University Kano, Nigeria
| | - Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | | | - Wuelton Monteiro
- Department of Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- School of Health Sciences, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Matthew R. Lewin
- Center for Exploration and Travel Health, California Academy of Sciences, San Francisco, USA
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
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19
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Abouyannis M, Aggarwal D, Lalloo DG, Casewell NR, Hamaluba M, Esmail H. Clinical outcomes and outcome measurement tools reported in randomised controlled trials of treatment for snakebite envenoming: A systematic review. PLoS Negl Trop Dis 2021; 15:e0009589. [PMID: 34339410 PMCID: PMC8360524 DOI: 10.1371/journal.pntd.0009589] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 08/12/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Snakebite is a priority neglected tropical disease and causes a range of complications that vary depending on the snake species. Randomised clinical trials have used varied outcome measures that do not allow results to be compared or combined. In accordance with the Core Outcomes Measurements in Effectiveness Trials (COMET) initiative, this systematic review aims to support the development of a globally relevant core outcome set for snakebite. METHODS All randomised controlled trials, secondary analyses of randomised controlled trials and study protocols investigating the efficacy of therapeutics for human snakebite envenoming were eligible for inclusion. Study screening and data extraction were conducted in duplicate by two independent reviewers. All primary and secondary outcome measures were extracted and compiled, as were adverse event outcome measures. Similar outcome measures were grouped into domains. The study was prospectively registered with PROSPERO: CRD42020196160. RESULTS This systematic review included 43 randomised controlled trials, two secondary analyses and 13 study protocols. A total of 382 outcome measures were extracted and, after duplicates were merged, there were 153 unique outcomes. The most frequently used outcome domain ('venom antigenaemia') was included in less than one third of the studies. The unique outcomes were classified into 60 outcome domains. Patient-centred outcomes were used in only three of the studies. DISCUSSION Significant heterogeneity in outcome measures exists in snakebite clinical trials. Consensus is needed to select outcome measures that are valid, reliable, patient-centred and feasible. The results of this systematic review strongly support the development of a core outcome set for use in snakebite clinical trials.
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Affiliation(s)
- Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
| | - Dinesh Aggarwal
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas R. Casewell
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Mainga Hamaluba
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Hanif Esmail
- MRC clinical trials unit at UCL, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
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20
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Abdeldayem A, Alanazi AA, Aljabri JN, Abid I. Challenges in the Management of an Echis coloratus Adult Snakebite Victim at a Tertiary Care Hospital: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931532. [PMID: 34103465 PMCID: PMC8197442 DOI: 10.12659/ajcr.931532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 18-year-old Final Diagnosis: Snakebite envenomation Symptoms: Coagulopathy Medication:— Clinical Procedure: Anti snake venom Specialty: General and Internal Medicine • Toxicology • Tropical Medicine
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Affiliation(s)
- Ahmed Abdeldayem
- In-Charge Drug and Poison Information Center, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alhanouf Ayed Alanazi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,Internal Medicine Department, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia
| | - Jawaher N Aljabri
- Internal Medicine Department, National guard health Affairs, Al Madinah Al Monawara, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ijaz Abid
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.,Internal Medicine Department, Prince Mohamed Bin Abdulaziz Hospital, Al Madina Al Monawara, Ministry of the National Guard Health Affairs, Al Madinah Al Monawara, Saudi Arabia
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21
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Patra A, Mukherjee AK. Assessment of snakebite burdens, clinical features of envenomation, and strategies to improve snakebite management in Vietnam. Acta Trop 2021; 216:105833. [PMID: 33485869 DOI: 10.1016/j.actatropica.2021.105833] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 12/16/2022]
Abstract
The sheer paucity of scientific documentation of herpetofauna in Vietnam and the rudimentary healthcare response to snakebite have stimulated this review. Over six decades of data culled from public data bases and search engines, have been used to assess snakebite burdens, clinical features of envenomation, and strategies for snakebite management in Vietnam. In addition, biochemical and proteomic analyses to decipher venom composition, rapid analytical techniques to be used for clinical diagnosis of snakebite in Vietnam have been discussed in detail. The assessment of efficacy, safety, and quality of commercial antivenom produced in Vietnam and improvement of antivenom production to meet the national requirement has been critically examined. It is apparent that snake bite incidence in Vietnam is exacerbated by mismatch in demand and supply of antivenom therapy, insufficient medical facilities, preference for traditional healers and poor management of clinical records. The impediments arising from geographical and species-specific variation in venom composition can be overcome by the 'Omics approach', and scientific documentation of pathophysiological manifestations post envenomation. The development of next generation of therapeutics, encouraging clinical research, novel approaches and social awareness against snakebite and its treatments have been suggested to significantly reduce the snakebite mortality and morbidity in this region.
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Affiliation(s)
- Aparup Patra
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India.
| | - Ashis K Mukherjee
- Microbial Biotechnology and Protein Research Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; Institute of Advanced Study in Science and Technology, Vigyan Path Garchuk, Paschim Boragaon, Guwahati, Assam 781035, India.
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22
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Mukherjee AK. Species-specific and geographical variation in venom composition of two major cobras in Indian subcontinent: Impact on polyvalent antivenom therapy. Toxicon 2020; 188:150-158. [DOI: 10.1016/j.toxicon.2020.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 10/13/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022]
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23
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Watson JA, Lamb T, Holmes J, Warrell DA, Thwin KT, Aung ZL, Oo MZ, Nwe MT, Smithuis F, Ashley EA. A Bayesian phase 2 model based adaptive design to optimise antivenom dosing: Application to a dose-finding trial for a novel Russell's viper antivenom in Myanmar. PLoS Negl Trop Dis 2020; 14:e0008109. [PMID: 33196672 PMCID: PMC7704047 DOI: 10.1371/journal.pntd.0008109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 11/30/2020] [Accepted: 10/10/2020] [Indexed: 01/15/2023] Open
Abstract
For most antivenoms there is little information from clinical studies to infer the relationship between dose and efficacy or dose and toxicity. Antivenom dose-finding studies usually recruit too few patients (e.g. fewer than 20) relative to clinically significant event rates (e.g. 5%). Model based adaptive dose-finding studies make efficient use of accrued patient data by using information across dosing levels, and converge rapidly to the contextually defined 'optimal dose'. Adequate sample sizes for adaptive dose-finding trials can be determined by simulation. We propose a model based, Bayesian phase 2 type, adaptive clinical trial design for the characterisation of optimal initial antivenom doses in contexts where both efficacy and toxicity are measured as binary endpoints. This design is illustrated in the context of dose-finding for Daboia siamensis (Eastern Russell's viper) envenoming in Myanmar. The design formalises the optimal initial dose of antivenom as the dose closest to that giving a pre-specified desired efficacy, but resulting in less than a pre-specified maximum toxicity. For Daboia siamensis envenoming, efficacy is defined as the restoration of blood coagulability within six hours, and toxicity is defined as anaphylaxis. Comprehensive simulation studies compared the expected behaviour of the model based design to a simpler rule based design (a modified '3+3' design). The model based design can identify an optimal dose after fewer patients relative to the rule based design. Open source code for the simulations is made available in order to determine adequate sample sizes for future adaptive snakebite trials. Antivenom dose-finding trials would benefit from using standard model based adaptive designs. Dose-finding trials where rare events (e.g. 5% occurrence) are of clinical importance necessitate larger sample sizes than current practice. We will apply the model based design to determine a safe and efficacious dose for a novel lyophilised antivenom to treat Daboia siamensis envenoming in Myanmar.
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Affiliation(s)
- James A. Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas Lamb
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David A. Warrell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Min Zaw Oo
- University of Medicine 2, Yangon, Myanmar
| | - Myat Thet Nwe
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
- Lao-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Vientiane, Laos
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24
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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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Jenkins TP, Laustsen AH. Cost of Manufacturing for Recombinant Snakebite Antivenoms. Front Bioeng Biotechnol 2020; 8:703. [PMID: 32766215 PMCID: PMC7381290 DOI: 10.3389/fbioe.2020.00703] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/04/2020] [Indexed: 01/14/2023] Open
Abstract
Snakebite envenoming is a neglected tropical disease that affects millions of people across the globe. It has been suggested that recombinant antivenoms based on mixtures of human monoclonal antibodies, which target key toxins of medically important snake venom, could present a promising avenue toward the reduction of morbidity and mortality of envenomated patients. However, since snakebite envenoming is a disease of poverty, it is pivotal that next-generation therapies are affordable to those most in need; this warrants analysis of the cost dynamics of recombinant antivenom manufacture. Therefore, we present, for the first time, a bottom-up analysis of the cost dynamics surrounding the production of future recombinant antivenoms based on available industry data. We unravel the potential impact that venom volume, abundance of medically relevant toxins in a venom, and the molecular weight of these toxins may have on the final product cost. Furthermore, we assess the roles that antibody molar mass, manufacturing and purification strategies, formulation, antibody efficacy, and potential cross-reactivity play in the complex cost dynamics of recombinant antivenom manufacture. Notably, according to our calculations, it appears that such next-generation antivenoms based on cocktails of monoclonal immunoglobulin Gs (IgGs) could be manufacturable at a comparable or lower cost to current plasma-derived antivenoms, which are priced at USD 13-1120 per treatment. We found that monovalent recombinant antivenoms based on IgGs could be manufactured for USD 20-225 per treatment, while more complex polyvalent recombinant antivenoms based on IgGs could be manufactured for USD 48-1354 per treatment. Finally, we investigated the prospective cost of manufacturing for recombinant antivenoms based on alternative protein scaffolds, such as DARPins and nanobodies, and highlight the potential utility of such scaffolds in the context of low-cost manufacturing. In conclusion, the development of recombinant antivenoms not only holds a promise for improving therapeutic parameters, such as safety and efficacy, but could possibly also lead to a more competetive cost of manufacture of antivenom products for patients worldwide.
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Affiliation(s)
- Timothy Patrick Jenkins
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Lyngby, Denmark
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Knudsen C, Ledsgaard L, Dehli RI, Ahmadi S, Sørensen CV, Laustsen AH. Engineering and design considerations for next-generation snakebite antivenoms. Toxicon 2019; 167:67-75. [DOI: 10.1016/j.toxicon.2019.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 11/27/2022]
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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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Ralph R, Sharma SK, Faiz MA, Ribeiro I, Rijal S, Chappuis F, Kuch U. The timing is right to end snakebite deaths in South Asia. BMJ 2019; 364:k5317. [PMID: 30670457 PMCID: PMC6340368 DOI: 10.1136/bmj.k5317] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ravikar Ralph
- Department of Internal Medicine, Christian Medical College, Vellore, India
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, BP Koirala Institute of Health Sciences, Dharan, Kathmandu, Nepal
| | | | - Isabela Ribeiro
- Dynamic Portfolio, Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Ulrich Kuch
- Department of Tropical Medicine and Public Health, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Germany
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Williams DJ, Habib AG, Warrell DA. Clinical studies of the effectiveness and safety of antivenoms. Toxicon 2018; 150:1-10. [PMID: 29746978 DOI: 10.1016/j.toxicon.2018.05.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 10/17/2022]
Abstract
In the 1890s, hyperimmune sera proved effective in animals against challenge by the snake venom against which they had been raised. They were first used, apparently successfully, in a human patient in about 1895. Since then, antivenoms have become accepted as the only reliable specific treatment for snake-bite envenoming. Despite decades of accumulated clinical experience and a number of published randomized comparative and observational studies, the clinical effectiveness and safety of some antivenoms remain open to question, due to a lack of robust randomized controlled trial data. Antivenoms in some poorly regulated markets may have high rates of potentially fatal adverse effects and their use must be balanced by demonstrable effectiveness. Even those manufactured to strict regulatory requirements may pose a rare risk of severe adverse reactions. Most antivenoms currently marketed around the world were registered without first being studied clinically. There is increasing pressure to subject antivenoms, even those that are long-established, to the same protocols of rigorous pre-clinical and clinical assessment that are standard regulatory requirements for other drugs. Conventional clinical testing progresses through Phases I, II, III to IV. Most authorities consider antivenoms too dangerous to be used in Phase I studies in healthy volunteers. An alternative method for preliminary estimation of safety, dose-finding and effectiveness, is proposed - the "3 + 3" dose escalation or de-escalation design, in volunteer patients, as used in oncology to test cytotoxic drugs. Antivenoms are so widely used and well trusted, that there are few ethical justifications for placebo controls. However, placebo might be ethically justified if there were no proven effective treatment and or if withholding or delaying treatment posed acceptably negligible risks to the participants. Antivenom trials are most urgently needed in low-to middle-income countries where there are many practical, logistical and funding challenges. Basic requirements for clinical trials include identification of the biting species of snake in every case; the use of objective, clinically-relevant endpoints, such as restoration of blood coagulability; definition of inclusion, exclusion and withdrawal criteria; assurance of antivenom safety; ethical considerations; inclusion of one or more control (comparator) groups; and analysis based on intention to treat. The highest quality evidence comes from Phase II and larger Phase III studies that have been designed as statistically powerful, randomized, controlled trials (RCTs), ideally with blinding of patients and investigators to avoid bias. Because of the challenges to carrying out clinical trials of antivenoms, Phase IV trials (post-marketing surveillance) are potentially more important and useful than for most other drugs.
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Affiliation(s)
- David J Williams
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, VIC, 3010, Australia; Charles Campbell Toxinology Centre, School of Medicine and Health Sciences, University of Papua New Guinea, Boroko, NCD, 121, Papua New Guinea.
| | - Abdulrazaq G Habib
- Department of Medicine, Bayero University Kano, Aminu Kano Teaching Hospital, PMB 3452, Kano, Nigeria.
| | - David A Warrell
- Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, VIC, 3010, Australia; Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 9DU, UK.
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