The race to tackle snakebite

GENEVA — The World Health Organization launches its snakebite strategy Thursday, aiming to halve the number of deaths and cases of permanent disability caused by snakebites each year by 2030 — but its in-house expert believes it could be even more ambitious.

The United Nations health body estimates that between 81,000 and 138,000 people die each year after being bitten by a snake, while 400,000 are left disabled.

David Williams, WHO’s snakebite expert, told Devex at the World Health Assembly in Geneva, Switzerland, this week that the strategy is a holistic attempt to create and spread affordable, high-quality antivenoms, and change community habits.

But Williams acknowledged that “to some extent, I still think that even our strategy is too cautious,” adding that “we are only limited by our imagination.”

“We can solve this,” said the Australian, who has himself been bitten six times during fieldwork. “The only real barrier to [solving the problem of] snakebite is money, to be perfectly honest.”

Asked about the possibility of using drones to deliver antivenom to remote communities, for instance, Williams said that models with a range of up to 150 kilometers would in his experience be little better than cars. Instead, he said if donors are serious, they should consider Predator-type military drones.

“Seriously. If we want to deliver antivenom on a serious scale, stop pissing about with one little vial at a time. You set up a bloody Predator drone, with a refrigerated bay to hold product that can be positioned over a country and kept in the air for a week or two weeks at a time, that anyone can use their smartphone to send a request for supply, and that drone can be tasked to drop a package and then return to station,” Williams said. “Instead of firing bloody missiles, fire bloody drugs. I think we have got to change the scale we think about things.”

Don’t expect to find that in the WHO strategy though, which is instead focused on generating tangible improvements in the short-term, designed to inspire other donors to step up their contributions in future.

Similarly, Williams estimates that $200-300 million of investments could fast-track clinical trials for new antivenoms in Africa and Asia. But manufacturers remain reluctant, arguing that cheap, low-quality products have priced them out of the market. In Africa, for instance, Williams said only 1-2% of the required antivenom is available and even this may be unsafe or ineffective.

That’s where the WHO strategy — currently estimated to cost the organization $136.76 million up to 2030 — comes in. It envisages WHO creating a revolving stockpile of antivenoms that it has assessed, inspired by the oral cholera vaccine stockpile it created in 2013.

Williams said he expects the results generated to trigger growing demand from countries who will then contribute more money, providing manufacturers with a steady market across different regions through one simple process. As companies’ profits increase, Wiliams said, “they’ll have the incentive to invest in either expanding or improving elements of production, or even engaging in R&D [research and development].”

The WHO strategy also targets community behavior. Williams said there are an estimated 500,000 snakebite victims in Africa each year, but that the real figure is probably higher. If everyone bitten by a snake went to a health center for effective treatment, he said, “we can take a market that people disparage and think has failed and turn it into a sustainable market that can support research and development, can support the sort of acceleration that’s needed to get us to those next-generation products.”

Gaining locals’ trust takes time, Williams said, citing the case of Kenya where only about 30% of people bitten by a snake identify going to hospital as their first choice for treatment. “Most of them are going to go to a traditional healer ... because they don’t associate snakebite with a health problem,” Williams said. “In places like Cambodia, PNG [Papua New Guinea] and India, often people think someone has put a curse on them and sent the snake to kill them … So if someone puts a curse on you, you don’t go to a doctor, you go and find somebody who can lift a curse.”

Meanwhile, on the global health stage, the issue of snakebite is gaining momentum. It was recognized as a neglected tropical disease by WHO in 2017 and was the subject of resolution at last year’s World Health Assembly, which kicked off the consultations on the new strategy.

Wellcome Trust also recently announced it will spend £80 million ($100.9 million) over seven years working with producers to improve antivenoms, reduce regulatory barriers to investment, and improve data.

“Snakebite really suffers from a chicken and egg situation,” Philip Price, an expert at Wellcome, told Devex. “A lot of the other funders require pretty robust data in terms of the disease burden and the cost-effectiveness of treatments for them to really be interested in getting involved.”

The WHO strategy will begin with a pilot phase in about 10 countries, likely split between east and west Africa. “India is the biggest problem there is,” Williams said, with around half of all snakebite deaths occurring there. But he said its size, different state administrations, and numerous manufacturers made it a difficult place to seek the early results that Williams hopes will inspire others with deep pockets to jump in.

“What snakebite needs is to find a donor who wants to make this their particular issue and get behind it,” Williams said. “It doesn’t matter who it is. It’s just the right thing.”

Williams said the human toll of snakebite hit him when he was in PNG and saw a grieving man standing in a hallway of a health center. “His wife, she’d only had their fifth baby a week or two before. She had just gone down to the garden at the back of the house to get a pineapple for breakfast, [and] got bitten on the foot by a taipan. That was 9:30 a.m. ... They spent all day sitting on the side of the road waiting for the only vehicle that comes all day to turn up at 6 p.m. By the time she got to the health center I was at, which is another 50 miles down the road, she’d stopped breathing, she was hypoxic, she needed resuscitation, it was just too late.”

“And I remember seeing him standing outside the room in the hall while they were getting her body ready to transport home, holding this kid, and he just had tears running down his face non-stop, he didn’t say anything. But that shouldn’t happen to people.”