Snakebite anti-venom shortages: A preventable public health crisis

This post was written by two of Duncan's colleauges, Possible's C.O.O. Ryan Schwarz and Medical Director Bikash Gauchan.

Dr. Schwarz is the Chief Operating Officer of Possible, and a physician at Harvard Medical School. Dr. Gauchan is the Medical Director of Possible. Learn more about Possible's work at www.possiblehealth.org.

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"This is a 32 year old male who presented early this morning with snake bite. He has received anti- venom per the protocol sir. He is asymptomatic and we can discharge this afternoon if he remains stable." The health assistant presented the patient to his senior doctor - we were on morning inpatient rounds at Bayalpata Hospital in rural Achham, Nepal. "Excellent work bhai, this saved his life."

Snake venom can be rapidly fatal; globally snake bites kill over 100,000 people per year, and permanently disable four times that number. Anti-venom treatment can save hundreds of thousands of lives annually, but without rapid access for patients, it can't help anyone - not two weeks earlier our team lost a 39 year old mother of four after a snake bite on her ankle while she slept on the dirt floor of her home; she died within 24 hours as she did not have access to anti- venom. Tragically, this live-saving medication will soon be much less available.

Many of the world's most toxic snakes are located in Sub-Saharan Africa, Australia, and South Asia, including Nepal where our team works with the Ministry of Health. Snake bites are one of the many "diseases of poverty" - that is, medical conditions that effect primarily the impoverished of our world due to lack of medicines and access to necessary healthcare. In Nepal - currently one of the world's thirty poorest countries - regular stock-outs of anti-venom, as well as limited access to healthcare, leads to frequent and unnecessary deaths due to snake bites. Globally there are multiple types of anti-venoms, each made specific to the species of snakes they treat. While the anti-venom stock-outs we struggle with in Nepal is similar in dozens of other countries, in sub-Saharan Africa the anti-venom shortage is about to get much worse.

Fav-Afrique, a critical anti-venom that treats some of the most deadly snake bites in sub-Saharan Africa, was discontinued from production in 2014 by French pharmaceutical company Sanofi; the last produced batch will expire in June of 2016, putting in danger hundreds of thousands of lives. Why was production discontinued? Put simply, anti-venom production is a complex and expensive process, and markets most in need of anti-venom are predominantly in developing countries with limited ability to pay the high prices, anywhere from US$250-500 per dose. Sanofi has committed to working on a "tech transfer" of the production process for Fav-Afrique to another company, however the two-year lead time in production means that new Fav-Afrique would not be on the market until sometime in 2018 at the earliest. Throughout sub-Saharan Africa alone an estimated 30,000 people died from snake bites last year - without access to Fav-Afrique this number will be dramatically higher.

The 2014 Ebola outbreak was one of the most shameful public health crises in recent history. We learned the errors of a slow response to an inordinately complex medical and social challenge, and thousands died as a result of our inability to act more quickly. Vaccine trials are now demonstrating some promise, but it will be years before we truly have an answer to Ebola. Warnings about the oncoming Ebola epidemic surfaced months before its peak, yet we ignored them. Now we stand at a similar inflection point as we anticipate a rapidly dwindling supply of anti-venom. This is a sad consequence of the realities of a pharmaceutical industry that is beholden to quarterly profits, and not necessarily public health priorities. Yet we cannot simply blame pharmaceutical companies like Sanofi as we also sit idly by watching a coming crisis. We as a global public health community must work together, and quickly, with the pharmaceutical industry, politicians, Ministries of Health, NGO's, and most importantly the public to create policy and financing mechanisms that enable our pharmaceutical partners to continue to supply these critical cures.

Some immediate steps we can take:

1) Funding - virtually no funding is dedicated to this deadly and worsening public health problem. Global development agencies and foundations have an excellent opportunity to provide the urgently needed financing to maintain the supply of anti-venom.

2) Policy - the WHO requires additional funding to develop a formal program for snake-bite prevention, monitoring, and treatment. The WHO can then spearhead the initiative with national Ministries of Health who similarly do not have snake bite programs and are poorly capacitated to train healthcare workers, or to purchase necessary anti-venom.

3) Partnership - similar to other innovative partnerships for public health priorities - including the GAVI Vaccine Alliance - donor agencies should partner with Sanofi to ensure that, until their tech transfer process is complete, they are able to continue to produce the necessary anti-venom. In parallel, donor agencies can help to stimulate other production facilities by subsidizing costs and capital expenditures necessary to enter the market.
Whether in Nepal or sub-Saharan Africa or New York, there is no excuse for anything less than immediate action.

Photo credit: Subeksha Poudel