ByViJay K. U. Nathan; B.Pharm, M.Tech (BioEngg), PhD
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Subash Chapagain Mar 02, 2021
Localized Antigen Banks for venoms and similar biological toxins
Image credit: Alёsha Lamkinson from Pexels
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Can we imagine a world where no one has to die because of snakebite?
In what seems like one of the most neglected public health domain across the world, snakebites seem like an issue that we are not paying enough attention to. If you look at the numbers, the situation looks grim: each year, around 5 million snake bites are reported globally, causing 1.8 to 2.7 million cases of envenomings (poisoning due to venoms) - resulting in a large number of deaths (somewhere between 81410-137880). Other serious health issues leading to amputations and permanent disabilities are even more frequent, in fact thrice the number of deaths, as reported in the WHO website.
Most cases of venom related health issues occur in Africa, Latin America and Asia. In India only, an average of 58,000 people die annually from snakebites says a meta-analytical research report published a year ago . Envenoming chiefly affects children, women and underprivileged people usually from poor rural communities in low and middle-income countries. This in itself is a sad situation- the countries where health systems are the weakest and medical resources lacking are the ones with the most occurrences of snakebites and venom poisoning. WHO has already said that snakebite is a rising global health priority . Note that the problem of toxin-related fatality is not limited to snakebites only. There are other species, scorpions and spiders for example, that can be equally lethal and venomous. When you account for the total overall health burden, it is not so hard to imagine that the numbers can really spike up.
Venoming causes acute medical emergencies leading to paralysis, bleeding disorders and subsequent haemorrhage, and can cause the kidney to fail irreversibly, on top of local tissue derangement and disability. The medical effects are even more severe in children as they have a lower body mass and their immune system is more naive. Despite such solemn implications to public health, the problem of snakebites has been identified by WHO as very hard to deal with. Antivenoms are the best choice for treating snake (and other poisonous) bites. However, to design and manufacture antivenoms is not that easy. A correct antivenom requires the knowledge about the exact immunogen (venom) that we want to antagonize with the antivenom. Given a wide variety of snakes across the globe and the inherent diversity in their venoms, this is highly problematic from the design perspective. Add to this the poor availability of data, lack of resources and distribution and lack of incentives for the production and you have a recipe for a hugely neglected health niche that no one wants to look into.
Hence, to tackle the problem of ‘limited data/samples’ on the venoms and similar toxins and to pave a road for proactive production and distribution of antivenoms, I propose establishing localized venom banks across the major affected regions of the world. There are some things that we would need to consider for establishing these kind of venom banks:
-first, identify the pocket areas/ regions/ districts that are most-prone to venomous species and map them out
-then form a cohort of trained individuals (ecologists, zoologists and medical professionals, biological researchers) to deal with identifying the species and capturing them so as to extract the venom
-develop facilities for safe storage of the venoms
Once the venom is safely extracted and stored, depending upon the availability and capacity of research/development, the venom can then be used to produce antivenom by standard protocols. If the antivenom cannot be produced locally (which might be a prominent case in most of the low-income countries), the venoms can be shipped to high-end research facilities and pharmaceuticals in other countries/cities and then the antivenom subsequently produced.
If the antivenoms such produced could be effectively distributed in the affected regions, we can drastically reduce the associated mortality and health-hazards. Hence, the local venom banks can serve as the bridge between the problem and solution of the (snake)bite related fatality.
How else could we approach the problem of venom-related deaths and derailments? How could these venom banks be made more efficient and productive?
[1]Suraweera, W., Warrell, D., Whitaker, R., Menon, G., Rodrigues, R., Fu, S. H., Begum, R., Sati, P., Piyasena, K., Bhatia, M., Brown, P., & Jha, P. (2020). Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study. ELife, 9, 1–10. https://doi.org/10.7554/elife.54076
[2] https://www.bbc.com/news/world-asia-india-44253586
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Creative contributions
Education on poisonous snakes could save many lives
In this contribution I will share some information that I believe often gets overlooked when talking about poisonous snakes, and which I believe would be very important to teach people in areas where poisonous snakes are common. Most of this information comes from the knowledge and on-field experience of Frank Cuesta, also known as Wild Frank, a reputed expert in in-field herpetology and tv show conductor whose show has been broadcasted by Discovery all over the world.
First of all, one of the misconceptions Frank tries to educate against is the fact that snakes will bite you if they can. As he proves in this amazing video, where he literally sits down next to a King Cobra in the middle of the jungle (PSA: never do that if you're not an expert like he is), snakes will only bite a bigger animal (which they don't deem as prey) like us in self-defense, and will only attack when their safety space is invaded. Thus, normally leaving them alone is the best option since they won't go out of their way to attack anyone. This is particularly relevant when poisonous snakes are found in homes or urban areas. Most bites come from people who don't know enough about them and try to kill them or make them flee, putting themselved at risk. The recommended course of action in those cases is to lock the snake in a room, leave the house and call the authorities so they can send experts to retrieve the animal. Frank actually performs this service rutinely.
The second and crucial concept is what to do in the unlucky event of being bitten by a venomous snake. While some snake bites are deadly within minutes, most are not. Also, anti-venom treatments take an important toll in the patient's immune system, and thus may not be preferable when they can be avoided. Additionally, in situations where getting to a hospital in minutes is not a possibility, experts like Frank, who base their experience on science but also on the popular knowledge of indigenous populations in those areas, reccommend to keep your cool and avoid your heartbeat to get too fast. This includes not running away or doing any kind of physical activity. This helps the venom concentrate in the bitten body part instead of spreading quickly through the organism. This way, the kidneys and liver can have more time to eliminate the poison. Actually, Frank has demonstrated in his own flesh how to deal with the bite of a viper in the middle of the jungle.
If all of this knowledge could be taught in schools, especially in those areas that have a great incidence of venomous snake bites, it would be possible to reduce that incidence and their fatal effects. That, together with approaches like the ones described in the session description, should help target this important problem.
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Proper Identification of the snake can be a differential factor
In this contribution I'd like to put an emphasis on the importante of proper identification of the species that a snake pertains to. As reported by Bolon et al., snakes that had bitten patients were only identified in 53% of cases. This includes patients who captured or killed the snake and brought it with them to the health centre, patients who managed to take a picture of it, and patients who had enough prior knowledge of what the species was. The ready presence of experts who can quickly identify the snake species, either from the body or a photograph, was crucial to giving the proper treatment for the bite, and when necessary, the right antivenom. In the rest of cases, the snake could not be identified. It is important to point out that in about 30% of cases, the patient never properly saw the snake that bit them.
That can be because of darkness and because of the fact that most bites happen when stepping over a snake hidden in the jungle, which will bite and then retreat. Cases where there is no snake identification immediately become more complex. While, in some cases, experienced clinicians can identify the symptoms of particular snake bites, this is not ideal and can lead to misidentifications and thus to improper clinical mangement.
Thus, efforts to teach at risk communities the basics of snake identification and what to do when bitten (take a photograph, for example), as well as increasing the presence of experts on snake identification in the health centers, would probably be a big step in helping better treat snake bites in the future.
[1]Bolon I, Durso AM, Botero Mesa S, et al. Identifying the snake: First scoping review on practices of communities and healthcare providers confronted with snakebite across the world. PLoS One. 2020;15(3):e0229989. Published 2020 Mar 5. doi:10.1371/journal.pone.0229989
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