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[CAPE TOWN] There is, perhaps, no better illustration for the difficulty of accessing appropriate antivenom in Africa than the death of Ryan Soobrayan, manager of the African Reptiles and Venom snake farm, in September this year.
 
The South African snake farm, ironically, supplies snake venom to laboratories for the development of antivenom, and also provides training in the handling of venomous snakes. Soobrayan died on 29 September after being bitten by a black mamba, whose venom he was trying to extract. But it was not the snakebite itself that killed him — it was anaphylactic shock, an allergic reaction following treatment with inappropriate antivenom.
 
African Reptiles and Venom, which maintains 500 snakes at its premises for venom extraction, is one of the few companies involved in the production of antivenom in Sub-Saharan Africa, where approximately one million snakebites occur each year. Around half of these result in envenomation, with 25,000 ending in death and another 25,000 in permanent disabilities.
 

A problem of poverty

 
The rural areas of the West and East African savannah are at high risk for snakebite, because they are home to many dangerous snake species such as the carpet viper, says Julien Potet, policy advisor on neglected tropical diseases and vaccines at the Médecins Sans Frontières’ Access Campaign, which supports the roll-out of cheap medicine in developing nations.
 

“African governments should recognise snakebite treatment as an essential part of universal health coverage.”

Julien Potet, Médecins Sans Frontières

In Africa, many snakebite victims go to traditional healers rather than to health centres because the cost of formal medical care is beyond the reach of the average income of a family of farmers. Antivenom is particularly expensive and few can afford it, meaning the provision of treatment for these areas is not profitable for companies.
 
This is the main reason for the current antivenom shortage, says Jean-Philippe Chippaux, a physician at the French Institute of Research for Development. “Antivenom accessibility could significantly reduce mortality and disability, probably by more than 75 percent,” he says.
 
But the picture of antivenom production in Africa is a grim one. There are manufacturers in Algeria, Egypt, South Africa and Tunisia, but they are not looking to sell outside their own countries. Morocco has stopped production entirely. Germany, which used to make antivenom for Africa, stopped in the 1990s and France stopped in 2010. Britain still produces some antivenom, and India has three active manufacturers. Brazil intends to produce one antivenom for Africa.

Chippaux, notes that African countries are importing Asian and American antivenoms at a huge cost. Making antivenoms, he says, is complex, as the antibodies that compose it are produced by an animal after it has been injected with the appropriate venom.
 
Chippaux established a snake farm at the Institut Pasteur of Cote d'Ivoire to study snake venom, as well as the biology and taxonomy of snakes. Another challenge is training physicians, nurses, and public health professionals on envenomation and possible treatments, he says.
 

Outside interventions

 
On a continent where health budgets are inadequate, MSF has been offering antivenom treatment in some of its hospitals for several decades through a dedicated budget. “We have seen an influx of patients in several MSF hospitals following introduction of free-of-charge antivenoms,” Potet says. “This simply means that a lot of victims, before that, couldn’t access antivenom therapy, because it was too expensive for them.”
 
“Antivenom therapy is very effective in treating snakebite if given early and if the product meets certain quality standards,” he tells SciDev.Net, adding that quite a few poor quality antivenoms had entered the markets over the last two decades.
 
MSF screens all available antivenom products and selects those that are appropriate for use in its own hospitals. “Mortality from snakebite envenoming is very low in our hospitals, less than one per cent, and treatment with antivenom is provided free of cost,” Potet says.
 
The lack of skilled and experienced health workers in many rural areas, as well as the lack of functional supply chains, are other major concerns. “Schools of medicine, pharmacy and nurses teach nothing about envenomation and antivenoms,” said Chippaux
 
The lack of interest by authorities to deal with snakebites, Chippaux adds, is because of a lack of understanding of the disease or the means of control. He is however hopeful that, “this will change now that the WHO has placed snakebites in the list of neglected tropical diseases”.
 
Affordability is another big challenge, Potet says, as antivenoms cost several dozen dollars per treatment, and in most public or private hospitals patients must pay out of their own pockets. “It is really important that antivenom prices be covered by national insurance or international aid,” he said.
 

Government intervention

 
A few governments are tackling the issue in Africa. In Burkina Faso, a national fund is available to cover to a large extent the cost of antivenoms. In Northern Nigeria, similar support was provided for some time.
 
“But much more needs to happen. African governments should recognise snakebite treatment as an essential part of universal health coverage,” says Potet.
 
Globally, not much is being done to deal with snakebite in Africa either, Chippaux agrees. “In any case all actions are paralysed until the means to implement them are available, but I think that the initiatives should come from Africa itself,” he says. However, there are some examples of successful partnerships that could bring relief to Africa. Snapp is the first medical decision‐making support tool for snake identification based on artificial intelligence and remote collaborative expertise. Being developed at the Institute of Global Health, at the University of Geneva, it has special value for Africa with its vast variety of snakes.
 
Snapp aims to build a global photo repository of venomous and non-venomous snakes. But thousands of snake photos would be needed to develop and train the machine learning algorithm to make it capable of identifying snakes taxonomically, its developers say.
 
A partnership between the Nigerian health ministry, the Liverpool School of Tropical Medicine, Oxford University, Costa Rica’s Instituto Clodomiro Picado and Micropharm, a UK-based antivenom manufacturer, has resulted in an antivenom currently in clinical use. Such international partnerships hold out hope in an otherwise bleak scenario.

This article was produced by SciDev.Net Global edition.

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