Antivenom shortage is not circumstantial but structural

Amazingly, although the shortage of antivenoms dates back to the 1990s,1,2 it is only now that this public health issue is being addressed. We have to thank Médecins Sans Frontières (MSF) who raised the alarm, even if their reasons are not those that explain the current situation. MSF's objective was clearly to draw attention to a real problem—independent of the discontinuation of a particular antivenom—to generate financial resources that are sorely lacking. To understand the causes of antivenom shortage, one needs to consider several factors: 1. the perception of snakebites by the patients, 2. economic models developed for the management of envenoming, production and distribution of antivenoms, 3. historic reluctance of health workers in the use of antivenoms and 4. the agenda of policy makers and health authorities.3 For most snakebite patients in the rural tropics, the encounter is perceived not to result from natural and opportunist causes, but appears to be most often the consequence of a malicious and supernatural act due to enemies or evil power.4 The patient primarily consults a traditional healer (the only one able to conjure the spell), which delays or even prevents the patient presenting at a hospital with management capability. Given this cultural perception, antivenoms are not considered relevant or even effective. Patients do not feel encouraged to patronise hospitals and the hospitals often do not stock effective antivenoms. Only the traditional practitioner may, after his intercessions, recommend the use of modern medicine. Until the development of enzyme-digested and purified immunoglobulins, antivenoms were considered dangerous even if their effectiveness was not questioned. However, the manufacturing processes have significantly reduced the risk of side effects, especially severe reactions that are common with the new generation of antivenoms.5 This technological gain was accompanied by a significant increase in the price of antivenoms, sustaining the vicious cycle of their inaccessibility.3 It resulted in expensive treatments, of the order of 100–300 US$, which exceeds several months of income of many low-earning farming families. To overcome this serious problem, Asian and South American countries promoted local manufacture of antivenoms, subsidised by governments, sometimes at the expense of quality, particularly in terms of safety and tolerability. However, much of sub-Saharan Africa (South Africa excepted) has not been able to follow this example and is subject to the supply of antivenoms by outside manufacturers. These are often large multinational companies that find these products poorly profitable, which in many cases leads to cessation of production (e.g., Behringwerke 20 years ago and now Sanofi Pasteur). Of available antivenoms, FAV Afrique produced by Sanofi Pasteur probably had the broadest distribution and use throughout West and Central African sub-regions where saw-scaled or carpet viper is a major cause of mortality and morbidity. However, according to a Sanofi Pasteur spokesmen in response to the controversy raised by MSF, the production of FAV-Afrique was stopped due to a drastic drop in sales. Although nearly 200 000 doses of the precursor antivenom (IPSER-Afrique at that time) had been used annually in the 1980s, sales fell to 30 000 doses/year in the 2000s and to less than 5000 doses in 2010. Yet, regional needs are estimated at over 500 000 doses/year.6 This puts into perspective the number of deaths potentially attributable to the discontinuation of FAV-Afrique, assuming no other antivenom fills the gap: 5000/500 000 needed doses is only a 1% loss relative to the need, implying 3000 more untreated cases and 70 deaths. This antivenom shortage was not caused only by the disappearance of one of the available antivenoms nor by a technology deficit: world manufacturers have had the know-how to make good antivenoms for decades. Nor is it attributable to high costs of production, which constitutes only a small fraction of the price.7 This shortage is directly linked to poor product distribution, utilisation and to lack of funding, all of which are especially severe in Africa. The training of health personnel in the management of snakebites is no longer part of the curriculum in most countries of the world. What may be justified in temperate countries where most medical doctors will never treat any envenoming during their entire career is not acceptable in tropical countries where every day during the rainy season many patients attend hospitals. Envenoming constitutes over 10% of indoor patients in rural hospitals.8 Without training, health staff do not use antivenoms and deprive hundreds of thousands of patients of life-saving treatment each year. For all these reasons, snakebites are not listed on the agenda of health and policy makers. However, it was recently shown that the benefit/cost ratio of antivenoms was one of the highest of neglected tropical diseases.9 Faced with this public health crisis—300 000 envenomations treated annually in sub-Saharan health facilities, causing more than 7000 reported deaths and nearly 10 000 permanent disabilities6—the African Society of Venimology (ASV) proposed a control strategy that aims to improve management of snake bites. During the ASV meeting in Abidjan this year (3–5 June 2015), ASV described the plan to reverse the vicious cycle of the antivenom inaccessibility, based on three points:10 Thus, ASV hopes to reduce mortality in sub-Saharan Africa by 90% by 2020. Mandatory notification of envenomation in every country in sub-Saharan Africa, as is done in Asia and Latin America, will identify antivenom needs in both the number of doses required and where they are stored, to meet national priorities. Training health personnel will improve the management of snakebites and reduce clinical complications too often observed during envenoming; of course, the traditional healers will be included in the process to ensure a quick referral without offending patient's beliefs. Financing broader and expanded antivenom access by sharing and allocation of costs between all stakeholders will foster more rapid use and will limit the incidence of clinical complications. The state, local governments, private enterprises, especially agricultural or construction companies employing workers at risk of snakebites, as well as insurance and mutual health organisations, should be urged to support the purchase of antivenoms to significantly reduce the patient's financial contribution. Such initiatives already exist in Togo, Burkina Faso, Côte d'Ivoire and some states in Nigeria mainly through government subsidies. They should be extended to the entire sub-Saharan region. Authors' contributions: JC and AH drafted the manuscript and critically revised the paper for intellectual content. All authors read and approved the final manuscript. JC is guarantor of the paper. Funding: None. Competing interests: None. Ethical approval: Not required.