Every year, an estimated 5.4 million people are bitten by snakes, up to 2.7 million of whom are envenomed, resulting in death for more than 100,000 people and life-long disfigurement and disability for 400,000 more. Snakebite envenoming predominantly afflicts the rural poor, including migrant workers, farmers, and displaced people fleeing conflict or violence, and kills more people than any other disease on World Health Organisation’s (WHO) Neglected Tropical Diseases list.
The article below shows the devastating impacts of snakebite in Agok, South Sudan, and also how a new, long-awaited WHO strategy on the prevention of snakebite offers greater hope for patients.
AWIEN, 10, SOUTH SUDAN
For the nineteenth time, ten-year old Awien is being taken into the operating theatre. Her right arm, damaged beyond repair, hangs limply in a sling around her neck. But at least she still has it. And most importantly, she is still alive.
Two months ago, Awien was bitten by a snake as she slept at night. Like many other snakebite victims across sub-Saharan Africa, reaching medical treatment in time was not a given for Awien. She lives in a small village in South Sudan, far from the nearest road and even further from the nearest hospital. In rural areas like this, people’s first reaction to a snakebite is usually to treat it with traditional remedies. Awien’s family tried a number of things: a frog was cut in two and put on the bite to remove the venom; she was given raw egg to drink and then a mixture of seeds and leaves to make her vomit so as to get the venom out of her body. None of these remedies helped, so her uncle decided to carry her on his back to the nearest hospital. It took him a whole night to walk to Agok, where Médecins Sans Frontières (MSF) runs the only hospital in the region.
Big problem, little remedy
In Agok, MSF treats around 300 snakebite victims each year, most of them during the rainy season, which is when snakebites are most frequent. To escape the water, snakes often enter people’s houses, which is where about half of victims are bitten. Children playing outside and people working in the fields are also at risk. But wherever they are bitten, everyone has the same problem: how to get treatment. Most snakebite victims live in remote areas and have to travel long distances to seek care. During the rainy season, when roads can become impassable, people may have to travel for several days to reach a hospital.
In the village of Rumdong, a few hours by foot from Agok, the local leader, James Kuol War, tells how a man died this year after being bitten by a snake because he did not reach hospital in time. Two other people in the same village, including a 13-year old girl, have been treated for snakebite at MSF’s hospital in the past year. It is a longstanding problem. Another villager – a man in his seventies – says that he was lucky to survive two different snakebites in the same leg over the years. His foot is now badly misshapen, but he is otherwise healthy and can still fish and farm.
Globally, about 5 million people are bitten, and about 100,000 people die from snakebite every year, 30,000 of them in Africa. MSF clinical officer Jacob Chol Atem explains: “Some people come too late and some don’t come at all, so we don’t actually know the full extent of the snakebite burden in the area. But we do know it is a big problem and that people lose their lives because they can’t get treatment.”
Antidote out of reach and out of price
Snakebite envenoming – the medical condition resulting from a snakebite – needs to be treated with antivenom in most cases. But antivenom is expensive and not available in many health facilities. It can cost several hundred US$ per patient, more than a year’s salary for many people, especially those in rural areas, where most snakebite victims live. Snakebite is a poor person’s disease, but pharmaceutical companies don’t create medicines for the poor; they create products that will be lucrative.
Previously, MSF used an antivenom called FAV-Afrique, an all-in-one antivenom that was used to treat envenoming from ten different snake species in sub-Saharan Africa. But the manufacturer decided to stop producing it and the last batch expired in June 2016. As there was no equivalent available, MSF had to find suitable alternative treatments. Two years down the line, MSF medical teams are now successfully using two new antivenoms in South Sudan: EchitabPlus and SAIMR-Polyvalent. Atem says: “Before it was more straightforward: we could give the same antivenom even if we didn’t know which snake the patient had been bitten by. Now, the treatment has become more complex and we administer antivenom depending on the patient’s symptoms. But overall, it works and we are glad to have found an alternative.”
Whilst this is good news for MSF patients in Agok, this is not the solution for all snakebite victims, as choosing among two antivenoms based on symptoms is difficult for non-specialists. Antivenoms that are effective against venomous snakes in any given area need to be made available in all health facilities, but the high price of these antivenoms is a problem. It is vicious circle, where countries don’t buy antivenoms for their hospitals because they are too expensive, and pharmaceutical companies don’t make them because so few buyers are purchasing them. The result is that they remain largely out of reach of the people who need them.
Antivenom is not always enough
Even with antivenom, treatment for snakebite is much more difficult when victims arrive late at hospital. Delays can cause further damage, including ‘compartment syndrome’, when swelling caused by the venom increases pressure within a muscle compartment, to the point that blood cannot supply the muscles and nerves with oxygen and nutrients. If left untreated, muscles and nerves fail and may eventually die. Once acute compartment syndrome has occurred, surgery is the only option. In the most severe cases, the damage may be so extensive that patients lose the use of their limbs or need amputations. An estimated 400,000 people globally are maimed or disabled every year as a result of snakebite.
Long road to a cure
Awien has been at the hospital for two months now. She was in a critical condition when she arrived, and was treated with three doses of antivenom. She was unconscious for the first five days, but eventually she woke up and her condition started to improve. She has had multiple surgeries to remove dead tissue, as the muscles in her arm were damaged beyond repair as a result of compartment syndrome. Nineteen surgical procedures sounds like an awful lot, but her family did not want her arm amputated and asked the medical team to do all they could to save it. Awien was lucky to get treatment; this is not the case for countless others.
Nyandeng Goch, 60 years
From Wungdeng, 4 hours from Agok
Last night I was sleeping and woke up as I heard the goats crying. It was around midnight, I went to see why they were crying and when I opened the gate, I was bitten by a snake. It was a puff adder. I didn’t want to kill it, because the tradition says it is our ancestors inside. If we kill it, I will die. So we just moved the snake outside the goat pen by using a stick. My foot was bleeding from the fang marks and I was in pain. We dug a hole in the ground and I put my foot inside and stayed there for two hours. We are told this will help. After two hours, I decided to go to the hospital. I walked with a stick, we started at 4 am and arrived as the sun rose (6.30 am). I didn’t have a choice, but to walk. We have no means of transportation. During the rainy season, many snakes come into the house. A cobra used to come around the house and I killed it the day before I was bitten.
Arnal Lual, 13 years
From Majbong, caretaker Paulino Deng
My young sister-in-law was playing outside the neighbor’s house in the evening and she stepped on a snake in the dark. It was a puff adder and it bit her and then ran away. Two people helped carry her home and then we went to the military barracks where they took us on a vehicle to go to the hospital. But the vehicle got stuck in the mud on the road for an hour and a half. She was bleeding and crying a lot and her leg was very swollen. After that, it took another two hours to get to the hospital. Where we live there are many snakes. Some come inside the houses because there is a lot of water.
Arop Magut, man, 49 years
I was out harvesting sorghum. The fields were flooded with water from the recent rains and when I was busy cutting, I felt pain in my leg, it was a snake in the water but I didn’t see it. It was starting to hurt a lot, so I went home. I slept, I had fever and took paracetamol. The fever went down but the pain continued. I was worried because the leg continued swelling and I was afraid I would die. It was very painful and I couldn’t move. My house is far away from the others and I cannot go and ask for help. After four days, mother went to ask the neighbours for help and they came and carried me on my bed to the road. Then I went on a vehicle to get to the hospital in Agok. It took about two and a half hours. I have had five operations already and they say I will have more. There are many snakes where I live and there are many cases of snakebite.
New strategy 'a major step forward'
Despite an estimated 5.4 million people being bitten by snakes each year, resulting in death for more than 100,000 people and life-long disfigurement and disability for 400,000 more, the global response to this tragic situation has been, until recently, disappointing. Attempts to tackle this crisis over the last three decades have failed, and the domestic and international funds currently allocated by governments and donors to end snakebite remain extremely insufficient. As a result, financing of snakebite care and treatment predominantly relies on the out-of-pocket expenditure of victims who have limited financial resources and little political voice.
There was a major step forward on 23 May 2019 when the WHO released the long-anticipated strategy on the prevention and control of snakebite envenoming, with the ambitious targets to cut in half the number of snakebite deaths and cases of disability by 2030.
"It is time for everyone to harness this momentum and stop unnecessary deaths and disabilities from snakebites once and for all."
"We are cautiously optimistic that the WHO’s snakebite strategy could be a turning point in tackling this disease, and governments, donors and other stakeholders must not squander this opportunity, but instead provide concrete political and financial support to ensure its success," said Julien Potet, Policy Advisor on Neglected Tropical Diseases for MSF’s Access Campaign. "It is time for everyone to harness this momentum and stop unnecessary deaths and disabilities from snakebites once and for all."
Bonaventure Ndjekpe, 14, is being kept under surveillance at the MSF supported Paoua Hospital, CAR, after being bitten by a snake.
Bonaventure Ndjekpe, 14, is being kept under surveillance at the MSF supported Paoua Hospital, CAR, after being bitten by a snake.
MSF is encouraged that the multifaceted strategy includes a clear recommendation for current and future products to be safe and affordable, and ambitious plans to increase treatment rates and access to antivenoms in affected regions. The strategy also importantly emphasises the need to raise awareness around prevention, first aid and where to seek proper treatment through community-level education and training of medical personnel, especially those engaged in emergency medical services and primary health care. Clinical guidance will further ensure the appropriate use of expensive antivenoms and reduce their wastage by medical personnel.
Snakebite is curable, yet the vast majority of snakebite victims are unable to access effective treatment. Paying for all of the doses of antivenom needed for treatment can cost hundreds of dollars, and, especially in rural settings, it is often unavailable, with referral or ambulance services and trained health workers lacking. Due to the relatively high prices of antivenoms, people are often lured into purchasing unproven traditional therapies or cheaper antivenom products of questionable quality, further contributing to the high rate of death and disability from snakebite. Several pharmaceutical corporations recently stopped the production of antivenoms intended for use in Africa, because the products were not sufficiently lucrative, thus increasing the risk of a major supply crisis.
As the WHO’s strategy is rolled out by governments, concrete steps need to be taken to scale up access to safe antivenoms that already exist in the market, and to further prioritise the development of new and better tools against snakebite envenoming.
“Many more lives could be saved if all snakebite victims had access to timely and appropriate care, including antivenoms,” said Potet. “To ensure access to affordable, quality-assured antivenoms, the effectiveness of existing products must be urgently assessed, and additional funds must be pledged to develop an international mechanism to subsidise and guarantee a stable supply of antivenoms. Antivenoms must be available and free-of-charge to people affected by snakebite, for whom access is a matter of life or death.”