Snakebite envenoming is one of the world’s most neglected disease. It kills between 81,000 and 138,000 people a year and leaves many more with life-changing disabilities. Snakebite is one of the 20 WHO Neglected Tropical Diseases (NTDs) included on the Roadmap agreed by Member States in 2019, with the aim of substantially reducing the damage and suffering caused by these diseases by 2030.
While part of the solution to achieving the WHO targets remains at the international level, including ensuring the development of effective antivenoms and international donor funding, governments of countries impacted by snakebite, and local communities also have an important role to play. Their experience of snakebite, adapted to their own specific contexts is key to an effective response. The closer to care and treatment the snakebite happens, the faster and more effective the response can be. But in order to respond efficiently, there needs to be a well-thought-out plan, inclusive of all relevant actors, and which is, critically, adequately resourced.
Dr Alan Pereira has been a Medical Coordinator for MSF in Ethiopia for the past year. During that time, he’s been involved in many medical activities including supporting the project teams with treating patients with snakebite in our programmes. He has also been working with the national authorities to develop a nationwide plan to tackle snakebite. In this interview, Dr Pereira shared his experiences with us.
Hello! Dr Pereira, could you start off by describing MSF’s involvement tackling snakebite in Ethiopia?
MSF has been present in the northwest of Ethiopia for more than 20 years, working mainly with patients living with other neglected tropical diseases like kala azar. There is a large population of migrant workers in the region who come to work on the farmlands every year seasonally to harvest cotton or sesame, alongside workers from the local community. While they're working in the open fields, or sleeping close by them at night, they are prone to get bitten by snakes, mostly on their legs or arms as they often have limited protection.
Around 2014, we realised there was a gap in addressing the problem of snakebite where MSF could support the Ministry of Health. So, we started treating snakebite and our work has been increasing ever since. Over the years the word got out that MSF was providing access to free and quality snakebite care (includes antivenoms) in the small rural community of Abdurafi. We are the only facility in the area offering this service. Today, Abdurafi is MSF’s largest facility where we treat snakebite out of all our projects around the world. We treated 1,753 patients in the project for snakebite in 2023 alone.
What are the barriers when it comes to people getting access to snakebite treatment?
After someone has been bitten by a snake, the time taken to reach a healthcare centre is critical. Yet, most of the cases of snakebite envenoming happen in rural or remote areas, very far away from any kind of healthcare provision. And most people affected are often unable to afford transport to get to the nearest healthcare centre in a timely way, so that in itself is a barrier to treatment. Additionally, the current conflict in northwest Ethiopia is worsening access to health care in terms of restricting mobility.
A second barrier is the limited availability of antivenoms in healthcare facilities. Current antivenoms require cold chain for good management and that facility of being able to keep medicines at the right low temperature is not often available in remote settings. The antivenoms are also quite expensive for the Ministry of Health or the patients themselves to purchase. Patients in MSF clinics receive free treatment.
The next problem is related to diagnosis. There is no polyvalent antivenom at the moment – meaning there is no antivenom that is effective against all the different types of snakes found in Ethiopia. Clinicians therefore have to examine the patient’s symptoms, to see if they can link these particular symptoms to the type of snake that is likely responsible for biting the patient, and on that basis select an available antivenom that will hopefully be effective.
While there are often challenges around limited supply of antivenoms available to people, the treatment itself can also have challenging side effects, so patients need to be monitored by trained staff. It becomes very clear that the time and resources required to care for people with snakebite mounts up.
How can the snakebite issue be addressed to ensure more people get access to lifesaving treatment?
Many countries where we know snakebite is a problem - including Ethiopia - still have not yet recognised snakebite as a health priority and included it as a neglected tropical disease in their national health plan. There's no national guideline against snakebite available for the Ethiopian context that healthcare workers in peripheral health centres can easily use. The Ministry of Health has not yet developed an action plan or roadmap, and also needs the funding to implement such a plan, once developed. These are key steps that are needed to move things forward.
Why do you think it has not been listed by the authorities as a national health priority before?
Ethiopia has been facing multiple challenges recently, including several other healthcare challenges, which all need attention and resources. Snakebite has therefore fallen under the radar. I think we are definitely underestimating how big the problem is in Ethiopia, and in fact across the world. For example, the ministry’s information systems only capture the data about ‘animal’ bites as a single class, and don’t break that information down to feature snakebite in its own category. So, at the national level there is no clear idea of how many victims of snakebite there are countrywide or across all the health facilities. In order to add it to a list of health priorities, the first step is to have a realistic view of the scale of the problem – by collecting the data. This will support the Ministry of Health in making choices and allocating appropriate resources to the priority areas, where they are needed.
Quantifying and describing the problem is also really important to be able to highlight the impact it has on people's lives. We should not forget that each of these ‘cases’ is a human being, with a family and a community. It is often young men and women working on farms, and children, who are most impacted.
You mentioned an action plan or roadmap for snakebite, what would be the key elements?
The main and first point of the plan would be to decentralise access to medical care. Ethiopia needs many more centres where people can get access to free, quality antivenoms closer to where they live. The second part of the plan would be to create a national snakebite guideline or a protocol that clinicians can easily follow when needing to treat people with snakebite.
The third point would be ensuring funding for antivenoms, so that they are actually made available where they are needed. And a fourth point would be generating more evidence on new antivenoms that are polyvalent, with fewer side effects and don’t need to be kept in the cold chain. MSF is currently engaged in carrying out research in this area. MSF is working with WHO to support the Ministry of Health in the development of this wide-ranging plan to tackle snakebite
You are moving on to another MSF project and leaving Ethiopia, what are your hopes for the work to tackle snakebite in Ethiopia?
I would have three hopes for snakebite in Ethiopia. I am definitely hopeful for my first hope - that snakebite will soon be recognised as a neglected tropical disease priority in Ethiopia. Once it is recognised, my second hope is for an action plan to be developed for all the healthcare workers, led by the Ministry of Health, to combat it. My third hope is that the funding needed to implement this plan, and in particular provide access to better antivenoms, comes in.
We are now where we were 20 years ago in tackling another neglected disease in Ethiopia, visceral leishmaniasis, or kala azar as it is more commonly called. Back then, the treatments available were toxic and not fully effective, and not enough people were working on this issue. Today, there is a vibrant community of people working to combat kala azar, and it has received the funding and attention it needs in Ethiopia. So, we hope to replicate this success story with snakebite for people affected in Ethiopia.
Which lessons can be taken from Ethiopia?
Having worked for MSF in India, Bangladesh and other places, I've seen similar challenges for people bitten by snakes in accessing effective antivenom treatment. A national action plan is key, but funding to implement the plan is also critical. In a lot of settings, the government alone cannot take on the financial burden, and patients simply do not have the money to buy the antivenom themselves out of pocket. Additionally, there is an urgent need for more research for newer tests and treatments. International donors must step up and release funding to help tackle the silent crisis of snakebite around the world.
አለም አቀፍ የእባብ ንክሻ ግንዛቤ ቀን፡ በኢትዮጵያ የእባብ ንክሻንየተሻሻለ የህክምና መተግበሪያ እቅድ ስለማውጣት
ኢትዮጵያ፦ ሆስፒታል ዓብይ ዓዲ ቀስብቀስ ካብቲ ናይ ዂናት ፅልዋ ስለዝደሓነ ኤምኤስኤፍ ዝነበሮ ምንቅስቓስ ኣረኪቡ ኣሎ