Snakebite envenoming in the NTDs priority list is an advance, says researchers José Maria Gutiérrez and Paulo Sérgio Bernarde

Publicação: 6 de June de 2018

The delay to add the theme in the Neglected Tropical Diseases list seems to evidence the little interest by governments of developed countries in combating the problem

There are many reasons why snakebite envenoming receives so little attention from the pharmaceutical industries and governments; the most relevant is perhaps it is a disease typically of the poor

Although snakebite envenoming kills over 100 thousand people every year and puts another 400 thousand with significant disabilities, as amputated limbs and blindness, and alerted by renowned researchers, among them Dr. José Maria Gutiérrez, who in 2013 published the paper The Need for Full Integration of Snakebite Envenoming within a Global Strategy to Combat the Neglected Tropical Diseases: The Way Forward” , in PLoS Neglected Tropical Diseases journal, only in 2017 the World Health Organization (WHO) was persuaded to add snake bite envenoming to the priority list of Neglected Tropical Diseases (NTDs).

Despite the delay, Dr. José Maria Gutiérrez sees the fact as a conquer, and that it means that specific programs to confront these envenomings will be designed and implemented at the WHO’s Neglected Tropical Disease Department. He explains there is already a relevant project going on under the coordination of this Department, which is the development of a global road map to reduce the impact of snakebite envenoming. “We hope that, in a close future, and with the financial support from diverse stakeholders, WHO will develop renewed efforts in the field, with the involvement of member states and other relevant stakeholders.”, he says. The researcher stresses that this achievement was the result of concerted efforts by many countries, representatives of the WHO itself, and organizations such as the Global Snakebite Initiative, Health Action International, The International Society on Toxicology, Médecins sans Frontieres, the African Society on Venimology and the Lillian Lincoln Foundation, among others. “I am very pleased that the government of my country, Costa Rica, has played a leading role in this initiative, with the involvement of many other countries, including of course, Brazil.”, he celebrates.

To researcher Paulo Sérgio Bernarde, who works in an ophidian accident project in Acre Federal University (UFAC) and the Acre Federal Institute (IFAC), in partnership with researchers from the Tropical Medicine Institute (Manaus) and Butantã Institute, this represents an advance and a great decision. The expert stresses those most exposed to this health problem are workers in rural areas and those who live in the forests, places many times very distant from hospital attention. “These regions where low-income populations live usually have no access to hospital resources to treat snakebite envenoming cases. These exposed populations must also have the conditions to be promptly assisted, since the delay in medical assistance is an aggravating factor for complications and associated to risk of death.”, he says.

Another problem is that despite snakebite envenoming has great global impact, it still receives little attention from the pharmaceutical industries and governments, besides, it has a low research priority. To Dr. José María Gutiérrez, there are several reasons for this. Perhaps the most relevant is that snakebite envenoming is a typical ‘disease of the poor’, affecting rural settings in Africa, Asia and Latin America. “The affected people have little political voice and hence this problem has lingered without attention.” he regrets. Another element that can explain this neglect is that the disease is not infectious and, therefore, is not amenable to eradication. Instead, it can only be controlled through a variety of interventions.

Still according to researcher José María Gutiérrez, since it is a disease of the poor, it does not represent an attractive market for the pharmaceutical industry, and has not been a priority for research agendas either. Amidst many other health issues, envenoming is usually not a priority for public health institutions, with few notable exceptions. In addition, snakebites have not been an attractive subject for the media, especially in developed countries. “However, the tide is shifting now, and more and more stakeholders are paying attention to snakebite envenoming.”, he says. Dr. Paulo Sérgio Bernarde agrees. “In some of the poorest countries in Africa, Asia and Latin America, where the incidence of cases and deaths is high, the lack of resources to deal with this problem is already one of the explanations.” The pharmaceutical industry is interested in diseases that strike people in the most developed countries, and this way, can provide a greater profit for their research investments”, he adds.

The delay to include the theme in the NTDs list seems to evidence the little interested given by the governments of developed countries in combatting this problem with appropriate financial and political resources. Researcher Paulo Sérgio Bernarde warns that great part of the population’s lower-income group has not been given proper attention in snakebite envenoming cases and ensures that other diseases like Cancer and AIDS, that also strike de most developed countries, have been given greater attention by pharmaceutical industries, since they can provide greater return in terms of profit”, he compares. The little attention is also reported by Dr. José María Gutiérrez. According to him, this happens because people affected by snakebite envenoming have had little political voice and influence. “Just recently the problem began to receive attention from diverse groups of stakeholders.” The involvement of governments of countries where this problem is highly prevalent is absolutely essential to raise the awareness and the attention of snakebites,” he alerts.

 

The path to follow towards a globally integrated strategy

To change this scenario, according to Dr. Paulo Sérgio Bernarde, first we must have political will so programs oriented towards envenoming are idealized and executed. “It is necessary that all countries have notification systems for these cases so we can have a precise approach of the problem’s real dimension in each region. With this kind of information, we will be able to define strategies. By knowing which regions have the greatest mortality and lethality coefficient, we will be able to assess the treatment quality and whether the anti-venom is indeed effective”, he adds. The researcher also defends that institutions that produce antivenom and that research the theme should be strengthened and given the proper resources. To him, it is fundamental to create integration by knowledge and experience exchange in all phases of the antivenom production phases, since obtaining the snakes and maintaining them in captivity, handling and venom extraction, antivenom production and distribution with proper quality.

“Investments in research are fundamental. We must understand the snake’s basic biology, the epidemiology and circumstances these accidents happen, the envenoming clinics, treatment and study the best process to develop antivenom, able to produce lower allergic reactions. Creating new diagnostic methods able to be performed in patients to quickly and precisely knowing which snake was responsible for the envenoming and that can be performed in any hospital unit is very important in regions where the venomous animals fauna is very diverse”, he observes. The researcher explains that few people bring the snake to the hospital after the accident, restricting diagnostic to symptom and signs observation in the patient, and usually in tropical regions, especially in Africa and Asia, the snake fauna is very diverse. “Health workers training in venomous accidents is also crucial. Training to identify venomous snakes, to diagnose by symptoms and signs the patient shows and for treatment, he adds.

One of the ongoing strategies is a road map to attend the problem of snakebite envenoming. Coordinated by the WHO, the map will include actions and interventions at many different levels, such as: prevention, community organization, strengthening of public health systems, improvement in the technology for antivenom manufacture, innovative research on new diagnostic and therapeutic tools, improvements in antivenom availability and accessibility, training of health staff on the diagnosis and clinical management of envenomings, following up of people suffering of sequelae as a consequence of envenomings, and international cooperation programs, among other tasks. To Dr. José María Gutiérrez, the key issue behind this strategy is that it needs to be holistic and comprehensive, encompassing a wide array of actions and involving diverse stakeholders. “The global strategy should be complemented by regional strategies adapted to the particular issues of countries and regions.” “In Latin America and the Caribbean, the Pan American Health Organization is developing a diverse set of actions on this issue.” he says.

 

Brazil as a role model in dealing with ophidism

To researcher Paulo Sérgio Bernarde, Brazil is a role model dealing with ophidism, although some adjustments are needed: antivenom availability according to each region’s demands; health professionals training to deal with snakebites; inclusion of subjects about venomous animals in curriculum frameworks. “Strategies should be elaborated in a way that the most isolated populations, and in greater risk, as in the Amazon, can be quickly cared for. Possible solutions to think about is the production of freeze-dried antivenom, which does not require refrigeration.

Dr. José María Gutiérrez ensures that both Butantã Institute and other Brazilian institutions can somehow contribute with this global integrated strategy. According to him, Brazil has a strong tradition in snakebite envenoming, and Butantã Institute has been in this battle since it began producing antivenom in 1901. “Brazil has built an extraordinary ability to study snakes, venoms and antivenoms, with several research groups in several states. Besides this, it has consolidated a program for antivenom production. “The country has a central regulatory laboratory, the Instituto Nacional de Controle de Qualidade em Saúde (INCQS), and a national program that ensures availability and accessibility of antivenoms in all states of the country.”, he remembers. The researcher acknowledges this highly consolidated platform has to play a leading role in confronting this problem at a global basis. “Butantã Institute, and other institutions in Brazil, can provide advice to other countries in aspects as varied as antivenom manufacture and quality control, national policies of antivenom distribution, training of health staff, and public health interventions in the subject of snakebites.”, he says. He also mentions Brazil’s capacity of antivenom production could be applied in the production of antivenoms for other regions of the world in need of these immunobiologicals, such as sub-Saharan Africa, for example.

Finally, Dr. José María Gutiérrez argues the renewed global interest in the topic of snakebite envenoming should be strengthened with the involvement of many stakeholders around the world. The commitment of the WHO and its regional offices should be promoted and enhanced, together with the participation of ministries of health in countries of high incidence of snakebites. Community organization in this area should evolve in parallel with the strengthening of the public health systems, especially in rural health posts where most snakebite cases are attended. “The confrontation of snakebite envenoming should not be viewed as an isolated intervention, but instead should be conceived within the general frame of the improving access to health for all. In the long term, the goal should be the reduction in human suffering provoked by this and other diseases that disproportionately affect the poorest of the poor in our world”, he ends.