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Nundes RNC, Almeida AECC, Moura WC, Gonzalez MS, Araújo HP. A Cytotoxicity Assay as an Alternative to the Murine Model for the Potency Testing of Bothrops jararaca Venom and Antivenom: An Intralaboratory Pre-validation Study. Altern Lab Anim 2024; 52:82-93. [PMID: 38438161 DOI: 10.1177/02611929241237518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Antivenom therapy is the only specific treatment for snakebite envenomation, and antivenom potency determination is key in the efficacy assurance quality control process. Nowadays, this process relies on the in vivo murine model - thus, the development of alternative in vitro methods is imperative. In the current study, the principle of the proposed method is the ability of Bothrops venom to induce cytotoxic effects in Vero cells, and the capacity to evaluate the inhibition of this cytotoxicity by the respective antivenom. After exposure to the venom/antivenom, the relative proportions of adherent (viable) cells were evaluated by direct staining with Coomassie Blue. The optical density (OD) of the lysed cell eluate was directly proportional to the number of adherent cells. This cytotoxicity-based alternative method could represent a potential candidate for validation as a replacement for the current in vivo test. The in vitro-determined cytotoxicity of the Brazilian Bothrops reference venom (expressed as the 50% effective concentration; EC50) was 3.61 μg/ml; the in vitro-determined 50% inhibitory concentration (IC50) of the Brazilian Bothrops reference antivenom was 0.133 μl/ml. From these two values, it was possible to calculate the potency of the reference antivenom. The results from the assays exhibited a good linear response, indicating that the method could be a potential candidate replacement method for use in antivenom quality control prior to lot release, subject to further validation.
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Affiliation(s)
- Renata N C Nundes
- Oswaldo Cruz Foundation, National Institute for Quality Control in Health, Rio de Janeiro, Brazil
- Post-Graduate Programmes in Science and Biotechnology, Federal Fluminense University (UFF), Niterói, Brazil
| | - Antonio E C C Almeida
- Oswaldo Cruz Foundation, National Institute for Quality Control in Health, Rio de Janeiro, Brazil
| | - Wlamir C Moura
- Oswaldo Cruz Foundation, National Institute for Quality Control in Health, Rio de Janeiro, Brazil
- BraCVAM (Brazilian Center for Validation of Alternative Methods), Rio de Janeiro, Brazil
| | - Marcelo S Gonzalez
- Post-Graduate Programmes in Science and Biotechnology, Federal Fluminense University (UFF), Niterói, Brazil
- Science and Technology National Institute in Molecular Entomology (INCT-EM, CNPq), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Post-Graduate Programmes in Applied Physics, Physics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Humberto P Araújo
- Oswaldo Cruz Foundation, National Institute for Quality Control in Health, Rio de Janeiro, Brazil
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Araújo SCM, Câmara JT, Guedes TB. Snakebites in Northeastern Brazil: accessing clinical-epidemiological profile as a strategy to deal with Neglected Tropical Diseases. Rev Soc Bras Med Trop 2023; 56:e02242023. [PMID: 37820102 PMCID: PMC10561396 DOI: 10.1590/0037-8682-0224-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/23/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Brazil ranks first in the number of snakebites in South America. A detailed analysis of these cases is required to improve the public health planning. In this study, we retrospectively examined the clinical and epidemiological profiles of snakebites in Maranhão between January 2009 and December 2019. METHODS Data were obtained from the compulsory notification forms provided by the Health Department of Maranhão. RESULTS A total of 17,658 cases were recorded during the study period. Most of the bites were from snakes belonging to the genus Bothrops. Medical care was mostly within three hours after the bite. Most cases were classified as mild and most victims recovered; however, 139 deaths were recorded. Most bites occurred among people aged 20-39 years, mainly among rural workers. The most frequent local clinical manifestations were pain, edema, and ecchymosis. The most common systemic clinical manifestations include neuroparalysis, vagal syndrome, and myolysis. Most snakebites occurred between January and March. The municipalities with the highest number of notifications were Buriticupu (936 cases), Arame (705 cases), and Grajaú (627 cases). CONCLUSIONS The clinical profile of snakebites in Maranhão is similar to that observed in other states of Northeast Brazil. However, we found that some systemic manifestations are not compatible with the etiology of snakebites, which leads us to believe that the problem could be the lack of knowledge of the health professionals at the site of envenomation, who may not be ready for attendance, and an important lack of health centers with snake antivenom to treat snakebites.
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Affiliation(s)
- Sâmia Caroline Melo Araújo
- Universidade Estadual do Maranhão, Programa de Pós-Graduação em Biodiversidade, Ambiente e Saúde, Caxias, MA, Brasil
| | - Joseneide Teixeira Câmara
- Universidade Estadual do Maranhão, Programa de Pós-Graduação em Biodiversidade, Ambiente e Saúde, Caxias, MA, Brasil
| | - Thaís B. Guedes
- Universidade Estadual de Campinas, Instituto de Biologia, Departamento de Biologia Animal, Campinas, SP, Brasil
- Gothenburg Global Biodiversity Center, University of Gothenburg, Department of Biological and Environmental Sciences, Göteborg, Sweden
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Parihar V, Mittal A, Vikarn V, Didel S, Singh K. Venom-induced consumptive coagulopathy leading to thrombotic microangiopathy following Echis carinatus sochureki bite: is snake antivenom effective? J Trop Pediatr 2022; 69:6984706. [PMID: 36629498 DOI: 10.1093/tropej/fmac113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The incidence of thrombotic microangiopathy (TMA) following snake bite is reported to be ranging from 3.6 to 15%. We report a 10-year-old boy who developed TMA and due to venom-induced consumptive coagulopathy (VICC) despite receiving adequate and timely doses of snake antivenom following a bite of saw-scaled viper (Echis carinatus sochureki). VICC was managed by plasmapheresis. Though snake bite envenomation-associated renal complications are not uncommon, possibility of TMA should be considered early during management. Our patient developed TMA with subsequent acute cortical necrosis after saw-scaled viper bite despite an adequate and timely dose of snake antivenom which emphasizes the ineffectiveness of antivenom against the venom of given snake species leading to long-term complications.
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Affiliation(s)
- Vivek Parihar
- Department of Paediatrics, AIIMS, Jodhpur 342005, India
| | - Aliza Mittal
- Department of Paediatrics, AIIMS, Jodhpur 342005, India
| | | | - Siyram Didel
- Department of Paediatrics, AIIMS, Jodhpur 342005, India
| | - Kuldeep Singh
- Department of Paediatrics, AIIMS, Jodhpur 342005, India
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Lin CC, Shih CP, Wang CC, Ouyang CH, Liu CC, Yu JS, Lo CH. The Clinical Usefulness of Taiwan Bivalent Freeze-Dried Hemorrhagic Antivenom in Protobothrops mucrosquamatus- and Viridovipera stejnegeri-Envenomed Patients. Toxins (Basel) 2022; 14:toxins14110794. [PMID: 36422968 PMCID: PMC9699225 DOI: 10.3390/toxins14110794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/18/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Snakebites from Protobothrops mucrosquamatus (Taiwan habus) and Viridovipera stejnegeri (green bamboo vipers) account for the most venomous snakebites in Taiwan. The bivalent freeze-dried hemorrhagic (FH) antivenom is employed to treat these two snakebite patients without a strict clinical trial. We evaluated the clinical usefulness of Taiwan bivalent freeze-dried hemorrhagic (FH) antivenom in Taiwan habu- and green bamboo viper-envenomed patients. We checked ELISA- based serum venom antigen levels before and after FH antivenom to evaluate FH's ability to neutralize patients' serum snake venom and its usefulness in reducing limb swelling after snakebites. Patients who had higher serum venom antigen levels had more severe limb swelling. Of the 33 enrolled patients, most of their snake venom antigen levels were undetected after the appliance of antivenom. Most enrolled patients (25/33) had their limb swelling subside within 12 h after antivenom treatment. The failure to reduce limb swelling was probably due to an inadequate antivenom dose applied in more severely envenomated patients. Our data indicate the feasibility of the FH antivenom in effectively eliminating venom and resolving the affected limb swelling caused by Taiwan habu and green bamboo viper bites.
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Affiliation(s)
- Chih-Chuan Lin
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence:
| | - Chia-Pang Shih
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chien-Chun Liu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jau-Song Yu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Cell and Molecular Biology, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Chih-Hong Lo
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Negrin A, Battocletti MA, Juanena C, Morais V. Reports of Doses Administered and Adverse Reactions to Snake Antivenom Used in Uruguay in 2018. Front Toxicol 2022; 3:690964. [PMID: 35295149 PMCID: PMC8915907 DOI: 10.3389/ftox.2021.690964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
In Uruguay, around 60 cases of snakebite accidents occur every year that need to be treated with specific antivenom. They are caused by two snakes of Bothrops genus: Bothrops alternatus and Bothrops pubescens. Snakebite accidents are mandatory notification events, allowing the acquisition of an accurate registry and a fluent communication with the health care services. The aim of this study is to analyze and report the doses administered to achieve the neutralization of the venom and the adverse reactions caused by snake antivenoms used in Uruguay in 2018, when a change was made in the type of antivenom available. In this year, Uruguay started to use the BIOL® antivenom (lyophilized) and this use coexists with traditional antivenom liquid forms (Vital Brazil and Malbran). The number of patients treated with heterologous BIOL® antivenom were 28 and the ones treated with heterologous solutions Malbran and Vital Brazil antivenoms were 21. The initial dose of BIOL antivenom was 8 vials instead of 4 vials regularly used with the others antivenoms and it achieved the neutralization of most cases (27/28 cases). Early adverse reactions were detected in 4 patients (3 in children) treated with BIOL antivenom and there were no adverse reactions in those treated with Malbran or Vital Brazil antivenoms. Lyophilized antivenom BIOL is being used widely in Uruguay without major complications.
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Affiliation(s)
- Alba Negrin
- Toxicology Department, School of Medicine, University of the Republic, Montevideo, Uruguay
| | | | - Carolina Juanena
- Toxicology Department, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - Victor Morais
- Department of Biotechnology, Faculty of Medicine, Institute of Hygiene, University of the Republic, Montevideo, Uruguay
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Finney ER, Padula AM, Leister EM. Red-bellied black snake (Pseudechis porphyriacus) envenomation in 17 dogs: clinical signs, coagulation changes, haematological abnormalities, venom antigen levels and outcomes following treatment with a tiger-brown snake antivenom. Aust Vet J 2020; 98:319-325. [PMID: 32390184 DOI: 10.1111/avj.12953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/07/2020] [Accepted: 04/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND This report describes 17 cases of red-bellied black snake envenomation (RBBS; Pseudechis porphyriacus) in dogs in south-eastern Queensland. Patients were prospectively enrolled for the treatment with a new tiger-brown snake antivenom 8000 units, (TBAV; Padula Serums Pty Ltd, VIC, Australia). CASE REPORT Clinical diagnosis of RBBS envenomation was made by either snake venom detection kit, snake identification using scale counting, or owner observed dog-snake interaction in patients with clinical signs of envenomation. An RBBS venom antigen sandwich ELISA was used to retrospectively quantify venom levels in frozen serum and urine. Mechanical ventilation was required in 11% (2/17) patients, whole blood transfusion in 12% (2/17), tissue swelling at the bite site occurred in 53% (9/17) and facial palsy in 12% (2/17). One dog was euthanised, and overall, 94% (16/17) survived to hospital discharge. Clinicopathological changes pre-TBAV included variable haemolysis, increased CK, pigmenturia and mildly prolonged active clotting time with a median of 134 s (n = 13, range 91-206 s). Haematological profiles post envenomation revealed anaemia (6/6) and spherocytosis (5/5), which resolved without the use of corticosteroids. Pre-TBAV, median RBBS venom antigen concentration was 22.6 ng/mL (n = 15, range 2-128) in serum and 58 ng/mL (range 1-452) in urine; RBBS venom antigen was undetectable in serum post-TBAV in all patients. CONCLUSION Some RBBS envenomed dogs required, critical care including mechanical ventilation, blood transfusion, additional antivenom and prolonged hospitalisation. TBAV was effective with excellent prognosis despite stated specificity for tiger and brown snake.
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Affiliation(s)
- E R Finney
- Pet Intensive Care Unit, Underwood, Queensland, Australia
| | - A M Padula
- Australian Venom Research Unit, Department of Pharmacology & Therapeutics, University of Melbourne, Melbourne, Victoria, Australia.,Padula Serums Pty Ltd, Bairnsdale, Victoria, Australia
| | - E M Leister
- Pet Intensive Care Unit, Underwood, Queensland, Australia
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Pla D, Sanz L, Quesada-Bernat S, Villalta M, Baal J, Chowdhury MAW, León G, Gutiérrez JM, Kuch U, Calvete JJ. Phylovenomics of Daboia russelii across the Indian subcontinent. Bioactivities and comparative in vivo neutralization and in vitro third-generation antivenomics of antivenoms against venoms from India, Bangladesh and Sri Lanka. J Proteomics 2019; 207:103443. [PMID: 31325606 DOI: 10.1016/j.jprot.2019.103443] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/14/2019] [Indexed: 02/07/2023]
Abstract
Russell's viper (Daboia russelii) is, together with Naja naja, Bungarus caeruleus and Echis carinatus, a member of the medically important 'Big Four' species responsible for causing a large number of morbidity and mortality cases across the Indian subcontinent. Despite the wide distribution of Russell's viper and the well-documented ubiquity of the phenomenon of geographic variability of intraspecific snake venom composition, Indian polyvalent antivenoms against the "Big Four" venoms are raised against venoms sourced mainly from Chennai in the southeastern Indian state of Tamil Nadu. Biochemical and venomics investigations have consistently revealed notable compositional, functional, and immunological differences among geographic variants of Russell's viper venoms across the Indian subcontinent. However, these studies, carried out by different laboratories using different protocols and involving venoms from a single geographical region, make the comparison of the different venoms difficult. To bridge this gap, we have conducted bioactivities and proteomic analyses of D. russelii venoms from the three corners of the Indian subcontinent, Pakistan, Bangladesh, and Tamil Nandu (India) and Sri Lanka, along with comparative in vivo neutralization and in vitro third-generation antivenomics of antivenoms used in India, Bangladesh and Sri Lanka. These analyses let us to propose two alternative routes of radiation for Russell's viper in the Indian subcontinent. Both radiations, towards the northeast of India and Bangladesh and towards south India and Sri Lanka, have a common origin in Pakistan, and provide a phylovenomics ground for rationalizing the geographic variability in venom composition and their distinct immunoreactivity against available antivenoms. BIOLOGICAL SIGNIFICANCE: Russell's viper (Daboia russelii), the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), and the saw-scaled viper (Echis carinatus) constitute the 'Big Four' snake species responsible for most snakebite envenomings and deaths in the Indian subcontinent. Despite the medical relevance of Daboia russelii, and the well documented variations in the clinical manifestations of envenomings by this wide distributed species, which are doubtless functionally related to differences in venom composition of its geographic variants, antivenoms for the clinical treatment of envenomings by D. russelii across the Indian subcontinent are invariably raised using venom sourced mainly from the southeastern Indian state of Tamil Nadu. We have applied a phylovenomics approach to compare the venom proteomes of Russell's vipers from the three corners of the Indian subcontinent, Pakistan, Bangladesh, and South India/Sri Lanka, and have assessed the in vitro (third-generation antivenomics) and in vivo preclinical efficacy of a panel of homologous antivenoms. The identification of two dispersal routes of ancestral D. russelii into the Indian subcontinent provides the ground for rationalizing the variability in composition and immunoreactivity of the venoms of extant geographic variants of Russell's viper. Such knowledge is relevant for envisioning strategies to improve the clinical coverage of anti- D. russelii antivenoms.
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Affiliation(s)
- Davinia Pla
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Libia Sanz
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Sarai Quesada-Bernat
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain
| | - Mauren Villalta
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica
| | - Joshua Baal
- Technische Universität Kaiserslautern, Erwin-Schrödinger-Straße 52, 67663 Kaiserslautern, Germany
| | | | - Guillermo León
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica.
| | - José M Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501-2060, Costa Rica.
| | - Ulrich Kuch
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Germany.
| | - Juan J Calvete
- Evolutionary and Translational Venomics Laboratory, Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain.
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Al-Shekhadat RI, Lopushanskaya KS, Segura Á, Gutiérrez JM, Calvete JJ, Pla D. Vipera berus berus Venom from Russia: Venomics, Bioactivities and Preclinical Assessment of Microgen Antivenom. Toxins (Basel) 2019; 11:E90. [PMID: 30717298 DOI: 10.3390/toxins11020090] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/27/2019] [Accepted: 01/29/2019] [Indexed: 12/20/2022] Open
Abstract
The common European adder, Vipera berus berus, is a medically relevant species, which is widely distributed in Russia and thus, is responsible for most snakebite accidents in Russia. We have investigated the toxic and enzymatic activities and have determined the proteomic composition of its venom. Phospholipases A2 (PLA2, 25.3% of the venom proteome), serine proteinases (SVSP, 16.2%), metalloproteinases (SVMP, 17.2%), vasoactive peptides (bradykinin-potentiating peptides (BPPs), 9.5% and C-type natriuretic peptides (C-NAP, 7.8%), cysteine-rich secretory protein (CRISP, 8%) and L-amino acid oxidase (LAO, 7.3%) represent the major toxin classes found in V. b. berus (Russia) venom. This study was also designed to assess the in vivo and in vitro preclinical efficacy of the Russian Microgen antivenom in neutralizing the main effects of V. b. berus venom. The results show that this antivenom is capable of neutralizing the lethal, hemorrhagic and PLA2 activities. Third-generation antivenomics was applied to quantify the toxin-recognition landscape and the maximal binding capacity of the antivenom for each component of the venom. The antivenomics analysis revealed that 6.24% of the anti-V. b. berus F(ab’)2 molecules fraction are toxin-binding antibodies, 60% of which represent clinically relevant antivenom molecules.
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Abstract
Introduction Snake bites are a silent public health problem in Kenya. Previous studies on snake bites in the country have mainly focused on identifying offending snake species, assessing the severity of envenomation and testing the efficacy of antivenom. Factors associated with snake
bites in the country are yet to be fully understood. The aim of this work was to determine pharmaco-epidemiological factors associated with snake bites in areas of Kenya where incidence, severity and species responsible for snake bites have been reported. Methods Kakamega provincial hospital, Kabarnet, Kapenguria and, Makueni district hospitals were selected as study sites based on previous findings on incidence, severity and species responsible for snake bites in catchment areas of these hospitals. Persistent newspaper reports of snake bites in these areas and distribution of snakes in Kenya were also considered. Cases of snake bites reported between 2007-2009 were retrospectively reviewed and data on incidence, age, site of the bites, time of bite and antivenom use was collected. Results 176 bites were captured, 91 of which occurred in 2009. Individual incidence was between 2.7/100,000/year and 6.7/100,000/year. Bites peaked in the 1-15 year age group while 132/176 bites were in the lower limb area and 49/176 victims received antivenom. Most bites occurred during the dry season, in the bush and in the evening. Overall mortality was 2.27%. Conclusion There is a need to sensitize the Kenyan public and healthcare personnel on preventive measures, first aid and treatment of snake bites.
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Affiliation(s)
- Francis Okumu Ochola
- Department of Pharmacology and Toxicology, School of Medicine, Moi University, Eldoret, Kenya
| | - Mitchel Otieno Okumu
- Department of Pharmacy, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya.,Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - Gerald Mwangi Muchemi
- Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - James Mucunu Mbaria
- Department of Public Health, Pharmacology & Toxicology, Faculty of Veterinary Medicine, University of Nairobi, Nairobi, Kenya
| | - Joseph Kangangi Gikunju
- Department of Medical Laboratory Science, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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Heiner JD, Bebarta VS, Varney SM, Bothwell JD, Cronin AJ. Clinical effects and antivenom use for snake bite victims treated at three US hospitals in Afghanistan. Wilderness Environ Med 2013; 24:412-6. [PMID: 23870762 DOI: 10.1016/j.wem.2013.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 03/31/2013] [Accepted: 05/23/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan. METHODS All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course. RESULTS Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12-30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2-5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge. CONCLUSIONS We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.
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Affiliation(s)
- Jason D Heiner
- University of Washington, Seattle, WA; San Antonio Military Medical Center, Fort Sam Houston, TX.
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