The VAPAGuide - guidance for the biological and clinical management of accidents involving Venomous And Poisonous Animals - is a very ambitious attempt to provide a systematic approach to one of the most neglected fields of medicine.
Most clinicians are not familiar with the names of animals, let alone their taxonomic identification, and yet, this is knowledge they need to have. To be able to treat envenomed patients, to be prepared for the course of acute and delayed events (is there the likelihood of respiratory failure, of late onset of skin necrosis etc.?) and, most importantly, to select the specific remedy for an individual case, the antivenom which is capable of neutralizing the venom components of the offending animal, they may need to descend as far as the subspecies level in their effort to clarify the identity of the culprit.
The BIOLOGICAL SECTIONS of the VAPAGuide provide the clinician the tools necessary to succeed in this difficult task of identifying the culprit in clinical stress situations. The challenge is to narrow down the possible culprits to the level necessary to be able to start treatment. Central to this process are the animal groups, assignment to which limits the possible number of culprits substantially. In some groups further identification is only needed to single out a small number of offenders for which highly specific remedies are of proven value; for example, the box jellyfish is the only genus in the large group comprising the jellyfish for which an antivenom is available. It is a very different matter with regard to the terrestrial snakes. In Thailand, for example, identification of the culprit has to be made to the species level to be able to select the right antivenom from the gallery of species-specific antivenoms available. The VAPAGuide provides the tools for this purpose: a morphological key which should be manageable by the clinician to identify the snake if it is brought along by the patient, and drawings and descriptions in the Key to the animal groups (& picture guide) and in the Biomedical database. Geographical distribution tables and biological charts help the clinician to identify the culprit as closely as possible if it is not available for evaluation. The “Sherlock Holmes approach” is supplemented by staging of the patients with regard to the patterns of signs and symptoms with regional and culprit-specific unique “fingerprints”.
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The CLINICAL SECTIONS of the VAPAGuide set out to provide a systematic approach to the clinical management of the hundreds of species of venomous and poisonous animals dangerous to humans on the basis of the current best evidence. The central component of this unified approach at the level of each animal group is the animal group-specific Emergency Flowchart. These flowcharts lead the clinician through the relevant process. Starting with the acute signs and symptoms with which the patient presents, each flowchart then branches out to the various possible culprits and ends with the appropriate specific remedies (antivenoms) should they exist. The Emergency Flowchart guides the clinician to the important clinical sections of the VAPAGuide:
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There is a clear distinction between the presentation of available data (Biomedical Database) and the “Clinical Guidance” components of the VAPAGuide (Emergency Flowchart, Diagnosis & Treatment sections for each animal group, Clinical Flowchart):
The Biomedical Database records the available data on the basis of explicit and transparent quality standards; most importantly, clinical information is only incorporated into the database when the identification of the culprit is unambiguous and the quality of the clinical data collection is appropriate. It is stratified into case reports, case series and the various categories of clinical studies and trials.
The “Clinical Guidance” components of the VAPAGuide (Emergency Flowchart, Diagnosis & Treatment sections for each animal group, Clinical Flowchart) translate the data from the Biomedical Database into action.
In this way the VAPAGuide fulfils the requirements of a modern clinical approach: the clinician and the patient both know how well grounded treatment decisions are. They can assess the balance of positive effects and adverse events of the various treatments available and the uncertainty which is implied.
With regard to the need to generate better knowledge, the structure of the VAPAGuide allows very clear identification of information gaps. In some, if not all, animal groups it shows how poorly our clinical decisions are supported by data – a unique feature of all neglected diseases, which are, for the greatest part, poverty-related diseases.
We would like to invite the (small) community of VAPA biologists and VAPA clinicians to support our attempt at a globally unified approach to the management of VAPA accidents (-> bio@vapaguide.info for biological input and med@vapaguide.info for clinical input). It is not possible to release an internet platform that is perfect, and it will require a great deal of effort to keep it updated. We are certain that we have fallen short of having included everything which should have been included at this point in time. We would like to ask authors of valuable clinical and biological papers not yet included in the VAPAGuide to alert us to how and where it can be improved.
The continued quality of the VAPAGuide will depend on regular updates. For an open, free-access platform, this is not easy to guarantee in the long term. We are currently working on a funding model and would be grateful for any proposals. We would also like to appeal to funders of neglected diseases to invest in this most neglected field of medicine.
We hope that the VAPAGuide will make a major contribution to the improved care of patients who suffer from what is probably the “most neglected disease” of all and win greater attention for this world-wide problem.
Thomas Junghanss
Mauro Bodio