Part 2, Dr. Robert Harrison: Strategies to revert the neglect on tropical snakebite victims.

I will continue with the transcription of the 38 minutes talk given by Dr. Robert Harrison, from the Liverpool School of Tropical medicine on February 4th, 2016.

First part stops when Dr. Harrison pointed at the big crisis that happened with the sudden cessation of anti-venom supply in year 2000.

On the second part Dr. Harrison explain the reasons behind the crisis, the consequences and the measures that were taken to overcome it and the role of political and civil movements.

Cont. 11:15

AV CRISIS IN NIGERIA. WAYS TO SOLVE IT.

Why? what happened? what happened was this: an accumulation of facts. Antivenom (AV) is extremely expensive. It is not uncommon a course of AV treatment to cost between 400 and 700 dollars. That is a lot of money for people earning less than a dollar a day. It is a lot of money for hospitals that have very limited drug budgets. AV also causes adverse effects, that's because you are giving horse or sheep IgG directly into the blood stream of a human, you are going to have adverse effects. In fifty percent of the patients this is mild. AV is also ineffective against this tissue destructive effects of the venom. You are loosing now the confidence not only the physician who is treating the patient but the victim themselves. And that confidence, loss of confidence has ramifications but is also compounded by economic factors. Africa is the only continent worldwide that is completely dependent upon the manufacture, delivery of the AV from commercial supplies. South America, more o less without exception, have governments that sponsor AV production and sponsor AV delivery and provide it free. At that is why the case-fatality rate in south, latin america is so much lower. 

THE REASONS BEHIND THE CRISIS

AV is expensive to manufacture, the demands of government are poor for all the reasons described up here and so the production of this two really good AV out of Europe stopped. Two companies decided they were not going to continue the manufacture of the AV because there were such loss makings. And so the AV supply to Nigeria came to nil. One of the ramifications of this lack of supply was the influx of a number of AV that where manufactured with venom of snakes that were "non-african snakes" and so they were 1/10th of the price of FAV-Afrique which is a very good AV but this cheap AV where ineffective and all that they did was to increase the case-fatality from 1.8% to 12.1%. This report was from Ghana and we have seen that in Nigeria, we have seen that in Tanzania and just two weeks ago we saw it in Kenya. This highly dangerous AV, because the physician thinks is effective, is  very very dangerous and it is flooding sub-saharian Africa. So there is a great need, an urgent need quality control regulations of the AV before they a used in humans throughout sub-saharian Africa. 

INTERNATIONAL RESPONSE TO DEVELOP A NEW AND EFFECTIVE AV

In response to request from the Nigerian Federal Ministry of Health, in collaboration with groups, two doctors in Syria, Ministry of Health in Nigeria, we in Liverpool and Dr. David Warrel in Oxford we responded to this crisis of AV supply in Nigeria. What we did is we imported the three most important medical snakes from Nigeria into our facility in Liverpool, we extracted venom from those animals, we provided venom stocks to five different groups worldwide who very generously agreed to their spare manufacturing capacity to see if they can make AV for Nigeria, and it was worldwide: UK, Costa Rica, Egypt, Mexico and Colombia.  We pre-clinically tested all of this in a mouse model to determine efficacy, three of those AV then were forward into the largest Human Clinical Trial of AV ever conducted, supervised by Dr. Habib and Prof. David Warrel, one AV was withdrawn rapidly because of the adverse effects and that left us with two AV: one a poly-specific against three snakes and one mono-specific against saw scaled viper. 

THE NEED FOR EXPERT PHYSICIANS TO TREAT SB / SUCCESSFUL MEASURES

We created all those AV, we tested them, they were effective and we decided that it was really not enough, so this is Kaltungo Hospital in Gombe State, we constructed snakebite wards, this was important because that meant that the training of physicians is proof wall in the process of discussing a case with Dr. Abubaku that we trained and... so the training of physicians mean that those physicians trained in an expert management of SB will stay in the SB ward, they would not get lost elsewhere in the hospital, and it was also not only the clinical management of SB but also the surgical management of SB that is quite specific. We also purchased two ambulances to accelerate the SB victims to hospital. There is a very clear association between rapidity of treatment and the outcome of AV treatment. We provided those, while we had the founding, free to patients and the AV was very effective and had very few adverse effects relative to other AV and that word got out, it spread as I said before, people came in from Camerun, from Chad, from all over north-east and North-Nigeria together. So this figures are .... now, we were getting over 3.000 patients per year, in Kaltungo and .... hospitals and sometimes there were 35 to 40 patients admitted per day into this hospitals. We have delivered in the last between 2006 and 2011, 37.000 vials, equating to 18.500 life saving treatments, which has substantially reduced deaths without doubt and morbidity. 

WHEN GOVERNMENT AND CIVIL MOVEMENTS ARE THE OBSTACLES.

The problem is that there was major political changes in Nigeria, in 2012, in the ministry, the new minister was reluctant to continue with this program despite its successes and also the terrorist activities of "Boka Haram" (https://en.wikipedia.org/wiki/Boko_Haram) had a massive effect on the continue the operation. So, civil changes, political changes can make an enormous difference as have done to this project. There is therefore a need, and urgent need for effective advocacy to improve the recognition of the SB public health burden by International Heath Agencies and governments, to effect policy change and also for research, to develop better tools. By that I think, I mean there is a enormous opportunity to improve the ways antivenoms are manufactured. 

Minute 17:59, I would stop here for today as the rest of the talk is on the role of research in snakebite treatment, and in particular about the challenges on improving AV.

I've been goggling about the nowadays situation at Kaltungo hospital.... 

You may read this news from may, 2016

http://naijagists.com/over-200-snake-bite-victims-die-of-poison-in-gombe-state-nigeria-as-hospital-runs-out-of-anti-snake-venom/

News on Gombe State snakes infestation one year ago on the news. 

http://graphittinews.blogspot.in/2015/09/tackling-snakebites-in-north-east.html

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

Where is the snake?

Where is the snake?
Found this when I was looking for pictures of Saw Scaled Viper.

Very important to create AWARENESS. Look!

Try to find the snake. I'm posting only the ones where I could find it. I must admit that there are some other pictures where I was completely unable to do it!

This is the first one, quite easy

 Second, quite easy too,

One of my favorites! Amazing!

Look for the copperhead, is there!

What about this one? it is here! promised!

Hope you enjoy it. This time it was for fun. Keep this in mind if you go to the forest or places where snakes are common. Be Alert and Aware!

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

Part 1, Dr. R. Harrison: Strategies to reverse the neglect of tropical snakebite victims

This is a talk given by Dr. Robert Harrison from the Liverpool School of Tropical Medicine, on the occasion of the "One-day meeting: Topics on infection", organized by the Royal Society of Tropical Medicine and Hygiene, in London, on February 4th, this year.

As Dr. Harrison is one of the impulsors of the "Global Snake Bite Initiative", I would like to continue with his talk before moving forward. I'm adding the transcription of the speech. As it is quite long and really deserves to be listen and read with attention, I will split it into several post. The first part is mostly dedicated to present which could be the main reasons for such a high numbers of SB in Africa and Asia. 

I would like to start with the last slide of his presentation, that highlights these key points: 
* Snakebite is an important, neglected disease of the rural poor in Africa and Asia.
- more accurate data is needed on mortality, morbidity and socieconomic impact - raise     awareness.
- need Gov'ts and IHAs to recognize the neglected snakebite disease burden
* Current antivenom therapy can be effective but requires urgent improvement
- better regulatory control needed
- production and delivery of effective and affordable antivenoms
- need to establish regional training on clinical management of snakebite
- need Gov'ts and IHAs to support development and delivery of effective, affordable antivenom
*Need for funding agencies to support science devising more effective, affordable snakebite therapy

"I'm going to be talking about the strategies to reverse the neglect of tropical SB victims and to introduce that topic by describing to you that there are two main groups of snakes: The elapids that include the cobras, the mambas, the krait snakes that primarily cause a neuromuscular paralysis, and then you got the vipers, the pit vipers and the adders and so on that primarily cause cardiovascular effects: bleeding, sometimes coagulopathy, sometimes hypovolemic shock and the antivenom can be a very effective treatment for either of this pathologies as consequences of snakebite. 

Antivenom is a drug that has been around in its essence for over a hundred years and hasn't changed that much. Essentially what you do is you take the venom from a snake, you lyophilized that and then you resuspend it in the required amounts, in sub-toxic amounts and inject that into horses or sheep, and you do that on numerous occasions until you get a state of hyper-immunization. Once the animals are seroconverted to that venom, you then harvest the blood and then the process, the expensive process is purifying the IgG from the blood. That is the drug: IgG from hyperimmunized animals.

Antivenom in many ways provides the tool to control SB but despite that, despite the fact that has been around for over a hundred years, we have over hundred thousand people dying of SB every year. This is the Global SB mortality map, remarkable coincidence with the map of the previous talk here on yaws (yaws is tropical infection of the skin, bones and joints caused by the spirochete bacterium Treponema pallidum pertenue), or any of the Neglected Tropical Diseases (NTD). Is the same map, the same people that suffers SB that suffers the other NTDs.

We do know from diverse studies that this are widely inaccurate, probably greatly underestimated, because they are mostly hospital based data. A lot of SB victims never get the hospital, so the deaths are not recorded on the hospital based data, we do not capture that, so it could be as many as three times that, we do not know. So, one of the recommendations is to improve the SB disease burden accuracy by getting data from community based studies and also to capture the socioeconomic burden of SB. We will go through that with more detail later. 

It is absolutely clear that most of the SB deaths occur in Africa and Asia and the question is why is that? given that antivenom (AV) is so effective or can be so effective, why is it?. In particular, the Africa SB victims suffer the highest case mortality rate, twice the number of people die in Africa that they do in Asia, and nearly four fold that in Latin America. What is the reason for that? And is partly this. This is a study that we did sometime ago. Just looking into the global data and dividing that by countries various indices related to poverty and here you can see that those countries with a higher SB mortality spend the least on health per person. Those countries with a higher SB mortality have the lowest quality of life indices. This is very significant statistical data and so, for that reason we describe SB as a tropical disease of rural poverty and it causes very hight mortality and disability. 

In a context of other tropical diseases, SB annually kills one fifth of the number of people dying from malaria every year, half the number of people that are dying from HIV in India are dying from SB. What's very significant about that is those tropical diseases, have extraordinary support, and thanks goodness they do, from International Health Agencies (IHAs). SB receives no support from any of those IHAs including the W.H.O., ?,?, Bill and Gates Foundation. We have tried several times to get them involved, its not happening, we do not know why. Is it because SB is not eradicable? Don't know, but is also neglected by many of the tropical governments whose people are suffering from that, who are dying from this, and that is something that we are trying to reverse and one of the reasons I'm here giving this talk. 


So, the question then is: it is something to do with the people that makes some difference than suffering from this other NTDs? no, that's really no. An example of one of the communities when we are working in North-East Nigeria, in Gomba State, the landscape is dominated by the savannah, it is either used for subsistence farming or for cattle grazing, and is the poverty-induced system's that creates SB. This communities cannot afford mechanized agricultural equipment: tractors, ?... They cannot afford boots that will protect from most of the SB in this area, "flip-flops" is the normal, probably more comfortable in the heat as well. The way they store the grain... It takes them away from the chickens and the goats and so on but it doesn't stop the rats getting up in there and then snakes follow the rats so then when the farmer comes to the harvest he is at risk of SB. 

Saw scaled viper

Their homes offer very little if any protection to ingress of snakes in fact, that fact that is perfect environment for rodents and rodents attract snakes. And in Africa particularly snakes can be very hard to see, there is a snake in here, very dangerous snake of Africa, you cannot see it because it is very well camouflaged and is so small but kills more people than any other snake in Africa. So, it's not surprise that subsistence farmers are at greatest risk of SB and they get bitten, here all this pictures from Nigeria, primarily on the feets and also the hands, and this is an example why never to use tourniquet as a first aid treatment for SB as in can result in amputation, because it restricts the venom necrosis into one area. 

Permanent disfigurement is a result of SB tissue necrosis, is not at all uncommon. 

Children are the next highest next risk group so this two young lals where putting the hands down rat holes trying to play have some fun, they both got bitten by snakes because the snakes were following the rat. This girls was showing the signs of coagulopathy as a results of saw scaled viper bite. All survived well. This is a four month old girl in Caltunga in north east Nigeria bitten in the kitchen of the house by a huge pufadder. Pufadders deliver vast amounts of venom that are very necrotic and you can see the airways here of this young girl of extreme risks irrespectible of what the toxins are doing. But the physician, Dr. Abubaku was able to pull this... /... by taking a lot of scalp away by debriding it. By the point is, in this particular hospital where we are providing AV, I will talk to you about that, it can be dramatically effective, a really positive drug. This is the little girl two days later treated expertly by Dr. Abubaka and obviously  very well in the way to recovery. 

SB are one of the 10 main causes of hospital admissions in Ghana. In some hospitals 70% of beds are occupied by SB victims. Many of my colleges would say "Rob that's rubbish", I toked pictures of the register. Pages and pages and pages, it is only the red entries the non-SB victims occupying this hospital beds and the reason is because those hospitals that have AV become informal referral centers and people flood in from miles. The two hospitals that we have got, we are working on north-east Nigeria, they are coming in from Chad, they are coming in from Camerun, spending 24, 48 hours to get this medicines. That is way you get this large numbers in the beds. I'm sorry we will get back there. We just completed a study in Burkina Fasso, working with lymphatic filariasis in ?program and ten hospitals provided their respective data on the last year and the most outstanding result was: 10 hospital, over one year, twenty seven thousand bed days were consumed by SB victims so there is a difference between other entities often treated as out patients and SB. SB occupies a lot, consumes a lot of energy and funds from this rural hospitals. 

SB is an unavoidable hazard in places like Nigeria, because people are bitten or at risk at whatever they do and whenever they are doing it, night, all day. And because the saw scaled viper is such a dangerous snake, one of five people bitten by this snake will die if they don't get treatment. So, this communities can't change their circumstances, can't reduce their risks of SB because they do not have political voice, they have very, very inadequate access to health care and they don't have income to change their circumstances and that very poor situation was made a great deal worse by the cessation of any AV supply to that region in 2000. Why? What happened? 
00:11:14. I will stop here. 

On the next posts Dr. Harrison is talking about what the actions they perform to mitigate the lack of AV in Nigeria, how they developed an antivenom in collaboration with several organizations and further which are the steps ahead.

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.

The Global Snake Bite Initiative

Snake bites are an important issue worldwide, and particularly in India. It is an important issue specially for the rural population, which is around 70% of the total. Numbers are not fixed but it is accepted that between 45.000 and 50.000 people die in India every year and much more will suffer from permanent physical and psychological disabilities.

Snake bites (SB) are considered an occupational disease. As they affect frequently a bread earning member of the family, they will have economic consequences like indebtedness, infant malnutrition and even suicide. All this should be considered too when we think on snake bites.

This is a resources blog. What to me has been helpful to start navigating throug the world of snake bite related diseases and their mitigation. Epidemiolgy, basic research, biology, law, communitary and emergency medicine, pharmacology, many disciplines are interconnected here. I would like to go through them step by step.


I would like to start with the "Global Snake Bite Initiative" website:

GLOBAL SNAKE BITE INITIATIVE

http://www.snakebiteinitiative.org

"Working to save lives in the world’s poorest communities …" this is the first statement we can read. This initiative comes from some of the most relevant scientist on snake-bite envenomation of the world, like Dr. Robert Harrisson (Liverpool School of Tropical Medicine, Dr. David Warrell (Oxford University) Dr. David Williams (University of Melbourne) or Dr. Jose Maria Gutierrez (University of Costa Rica). You will find them in the Board of Directors and the Advisory Commitee. It also links you to research resources, professional societies related to snake bite envenomation or country specific resources (See the Indian Snakebite Project).

In the "home" page, there is a 7,30 minutes video (posted here). Please watch it. Many scenes are not easy to see and yet, is a worderful description, very accurate on the snake bites situation all over the world. I've decided to transcribe it as the main points around snake bites are all depicted here. It coul be used as an informative and motivating tool to create awareness on the general population about the burden of snake bites.

https://vimeo.com/167436988

SNAKE BITES CONSEQUENCES, MUCH MORE THAN PHYSICAL
Prof. Abdulrazaq Habib
Bayero University, Kano, Nigeria
"We have seen death, we have see disability, we have seen desfigurement, we have seen depravation, we have seen destitution... from snake bite".

Dr. Andrew Kwonyike
County Minister of Health, Baringo County, Kenya
"At the moment, as a Minister for this County, I'm extremely worried. I'm scared, I do not know what will happend"

Voice: 
"It is a daily reality, a race to traverse the isolated, rocky and unforgiving terrain while knowing that treatment may be hours or days away".

Dr. Robert Harrison
Liverpool School of Tropical Medicine
"Can you imagine the distress from running from your home, perhaps in the night, with your child in your back, suffering from snake bite, screaming in pain?"

ANTI-VENOM, THE LIFE SAVING TREATMENT NOT ALWAYS AVAILABLE. 
Voice: 
"and when you finally flight down a passing vehicle in the hope it will take you to the hospital, will the hospital even have the anti-venom needed to save your daugther's life?".

Dr. A.K. At the hospital's pharmacy
"This only one left" "Mean there is only one left in the whole hospital?"
"Anti-venom is very scarce. It comes and it gets finished and then we stay without it for some time".

Voice: 
"Every day it is a sadness that never goes away, your daughter buried next to your house, yet another young life taken during the night, and the sister left behing, she met her fate from the very same cobra that slid into their bed. Her hand now is severely deformed, she is blind, cannot walk, she will never marry, an innocent victim without a chance to a productive life"

A RURAL PLIGHT, INDEBTEDNESS.
Voice: 
"Every day is devastation without end. A Coconut farmer, in Southern India, who can only watch someone else climbing the trees he once climbed. Already left with nothing but years of debt. Selvarasu and his wife part with what little they have just so they can pay to keep their children in school".

Selvarasu: 
"This is something that should never happend to anyone. No one should ever suffer like this".

Prof. David Warrel
Oxford University
"Those victims of snake bite are amongst the most impoverished levels of the community. They are nearly all agricultors, farmers, herdsmen, who live in a snakes infested environment and, city dwellers may be genuinely ignorant of the plight of people that lives a few miles away and are the food producers for the country".

Dr. A.K.: 
It is a huge cost, that you cannot imagine.
... "they have to sell and dispose all the assets that are in the family to ensure that this person is taken care of". 

Africa, a community gathering: 
"OK, so the people raising their hands that have been bitten by a snake..." "I want to say that the people need to come from overseas to come and help us because the problem is really real".

A VERY SLOW AND PAINFUL HEALING PROCESS
Voice: 
"But, actually, this are the real cries. This three year old kenyan girl wont be up playing today, instead one of the multiple visits each and every ongoing week to treat her wound. In a few months she will undergo a major skin graft."

AN OVERVIEW, SOME FIGURES.
Dr. David Williams
Global Snake Bite Initiative
"Man has faced major health challeges on the past. The world has the capacity to deal with this problems, we got Neglected Tropical Diseases that are no loger being neglected and this is important. 
But today, 342 snake bite victims accross the tropics again are taken from their families. We know 125.000 die each year from snake bites and two to three times that number are leaved without limbs, disabled or permanently disfigured, and those are the people that actually might go to a hospital to be counted. Wharever the number might be, the true figures go beyond any data, beyond any study.
The only way you can truly understand snake bites is to walk into any hospital, any village. Everybody knows somebody whose life has been turned upside-down.
Comparison figures of SB with malaria, tuberculosis, HIV-AIDS (cannot fully understand)."

Voice: 
"From Vietnam to Pakistan, from the Central African Republic to Latin America, if you colour in a world map with reported death tolds and stimates of over 1.000 people per year, it is a map that rapidely becomes more colourful, and if you add the countries with 50 or more deaths per year suddently, the magnitude becomes clear"

WAKE-UP!
Prof. A.H.
"If we are to save lifes, limbs, this is the time for the whole world to wake up to this important problem that has, for many years, linged with no interest.

THE ROLE OF PREVENTION
Voice:
"Realistically, the best long term strategy is to prevent snake bites, not to treat them, in the first place. We have scientist, doctors, advocates all around the world that fight for this people on a daily basis. 
Educating people on the ground to encourage the simple use of footware, training rural health workers, even teaching people that visiting a traditional healer is not necessarily of any use and of course, we have effective an afordable anti-venoms that have been developed and are making huge differences in places like South Africa, Latin America and even here in Papua New Guinea. 
We have the tools to make a change now. 

IT IS TIME FOR A GLOBAL CHANGE
Prof. Jose Maria Guitierrez
Instituto Clodomiro Picado
University of Costa Rica
"It is about time that snake bite is stopped being ignored by the world. It is a matter of human rights, a matter of social responsability, a matter of using science for what should be used, for the well-being of people. 

THE WISH, THE GOAL
Doctor:
"Nobody should die of snake bites"

ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥

Om Lokah Samasthah Sukhino Bhavantu

May all beings everywhere be happy and peaceful.