Snake bite: a global failure to act costs thousands of lives each yearBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5378 (Published 27 October 2015) Cite this as: BMJ 2015;351:h5378
- 1Australian Venom Research Unit, Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Australia
- 2Charles Campbell Toxinology Centre, University of Papua New Guinea, Boroko, Papua New Guinea
For many years snake bite experts have sought to raise the profile of this forgotten problem with public health authorities and donors. Lamentably, however, it has taken news of the departure of antivenom manufacturer Sanofi-Pasteur from the sub-Saharan African market to focus the spotlight on the calamity of snake bite among the world’s poorest people.
Nevertheless, beyond this successful media storm,1 2 the reality is that for the majority of people bitten by snakes in Africa the loss of Sanofi’s FAV-Afrique polyvalent antivenom will mean little, if anything at all. This is because the product simply never reached them in the first place. In a region where median gross domestic product per capita is $550 (£360; €490), Sanofi’s product was simply too expensive (a four vial treatment cost about $540) and produced in insufficient quantities to meet the needs of more than a small part of the African continent.3 4
The harsh fact is that the continent is largely devoid of safe, effective, and affordable treatments for something that is eminently treatable. For decades there have been chronic gaps in antivenom supply globally that have cumulatively cost millions of lives, maimed millions more, and contributed to the burden of poverty and disenfranchisement that lingers heavily over many nations.5 And for just as long experts have been urging the relevant authorities to redress this denial of access to an essential medicine, without any meaningful response.6 7
Successive efforts to drive change by people from outside Africa have largely failed. Despite several high profile meetings of international experts with World Health Organization (WHO) support and participation, many problems remain. Snake bite prevention initiatives and community education programmes exist on a small localised scale or not at all. WHO guidelines for the medical management of patients, authored by some of the world’s leading clinical toxinologists, have not filtered through to local health workers. Throughout most of sub-Saharan Africa snake bite is still mainly treated by traditional healers, and even when medical treatment is sought the resources to provide effective treatment are often unavailable.8 9 National training programmes for health workers and doctors that focus on teaching situationally relevant practices and protocols for the assessment, diagnosis, management, and rehabilitation of people with snake bites are urgently required.
African nations also fall prey to a new breed of snake oil sales representatives. These purveyors of profit take advantage of poorly resourced regulatory environments, lack of transparency, and few testing laboratories to introduce unproved imitations and poorly tested alternatives.10 In Ghana the replacement of an effective antivenom with a completely untested alternative resulted in case fatality increasing from 1.8% to 12.1% within a year.11 Similarly in Chad, use of unsafe, ineffective antivenom resulted in case fatality reaching 15.3% compared with 2.3% with the previous product.12 The key to preventing the use of poor quality or ineffective antivenoms is to strengthen the capacity of national regulatory agencies to assess these products. There are several barriers to this, including a lack of national or regional reference venom collections, poor laboratory infrastructure, weak governance structures, and lack of funding support. Despite WHO developing international consensus guidelines on the production, regulation, and control of snake antivenom five years ago,13 regulatory agencies have not yet adopted them. A new initiative by WHO to ensure communication and technical support is urgently needed.14
Another major barrier to effective care is cost. Snake bite mortality is strongly associated with poverty and poor investment in health by national governments.5 High cost medical treatments perpetuate poverty, leading to debt and loss of land holdings and personal property.15 With antivenom costs alone ranging from $56 to $640 there is huge potential for snake bite to drive patients and their families into deeper poverty and debt.4 Strategies to reduce the cost of antivenoms to end users are required, and although disease specific global health initiatives have been criticised for having counterproductive effects on strengthening overall health systems, an international financing initiative similar to those for vaccine preventable diseases may be essential to improving access to antivenoms among the world’s rural poor.16
Several things need to happen before we can truly be satisfied that the voices of people with snake bite are being heard and listened to. The WHO must re-elevate snake bite to its list of neglected tropical diseases, rather than obliquely referring to it as a “neglected condition,” and it must incorporate snake bite in current and future work plans for neglected tropical diseases. For this to happen, however, the health ministries in nations where the burden of snake bite is felt most acutely, including countries throughout Asia and places such as Papua New Guinea as well as Africa, can no longer ignore their responsibility to their citizens. A motion to initiate a multifocal international effort to ensure effective reduction of the risks, burden, cost, and access to treatment for snake bite must be brought before the World Health Assembly and passed to mobilise resources. The time for talk has passed; action must be taken now.
Cite this as: BMJ 2015;351:h5378
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I have conducted a trial of antivenom, supplies of which were donated by the manufacturers CSL and Instituto Clodomiro Picado (ICP); CSL has engaged me through my employer, the University of Melbourne, to undertake research into the coldchain infrastructure available in Papua New Guinea for the distribution and storage of its antivenom products.
Provenance and peer review: Commissioned; not externally peer reviewed.