SNAKEBITE ENVENOMING

A strategy for prevention

For millions of men, women and children
around the world, the risk of snakebite and control
is a daily concern as they go about their
everyday activities where a misplaced step,
a momentary lapse of concentration or
being in the wrong place at the wrong time
can be fatal.

Department of Control of Neglected Tropical Diseases

World Health Organization ISBN: 978-92-4-151564-1

20, Avenue Appia

CH-1211 Geneva 27
www.who.int/neglected_diseases/en
www.who.int/snakebites/en

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SNAKEBITE ENVENOMING
A strategy for prevention and control
Snakebite envenoming: a strategy for prevention and control

ISBN 978-92-4-151564-1

© World Health Organization 2019

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CONTENTS

Foreword������������������������������������������������������������������������������������� v
Acknowledgements���������������������������������������������������������������������� vii
Executive summary������������������������������������������������������������������������ x
Action to reduce and control the effects of snakebite envenoming�������������1
Disease burden and social and socioeconomic effects............................................... 1
Treatment................................................................................................................ 5
Challenges to improving the quality, safety and cost–effectiveness of antivenoms....... 6

Rationale for the strategy����������������������������������������������������������������9

Snakebite envenoming is preventable........................................................................ 9
Snakebite envenoming is treatable............................................................................ 9
Investment in prevention and treatment of snakebite envenoming saves victims
from poverty and reduces health inequality............................................................... 11
The prevention and treatment of snakebite envenoming is a model of
collaboration for “One health”. ................................................................................. 11

Strategy for prevention and control of snakebite envenoming����������������� 13

Target, strategic objectives and activities..................................................................13
Implementation phases............................................................................................14
Empower and engage communities�������������������������������������������������� 17
Ensure safe, effective treatment����������������������������������������������������� 21
Strengthen health systems������������������������������������������������������������� 27
Increase partnerships, coordination and resources������������������������������ 35
Planning, monitoring and evaluation ������������������������������������������������ 41
Managing risk����������������������������������������������������������������������������� 43
Costs���������������������������������������������������������������������������������������� 45
References�������������������������������������������������������������������������������� 49
iv Snakebite envenoming A strategy for prevention and control
 v

FOREWORD

Dr Tedros Adhanom Ghebreyesus

Director-General
World Health Organization

Snakebites are a significant risk to health and well-being for 5.8 billion
people around the world, and for those affected carry a high financial
burden that often cannot be met.

In the homes of families exposed to this threat snakebites are a cause

of considerable fear and anxiety. The consequences of being bitten by
a snake extend beyond the impact on health and drive families further
into poverty, undermining their futures and trapping them in debt.

Last year, the 71st World Health Assembly adopted a comprehensive

resolution calling for a coordinated response to the address the global
burden of snakebite envenoming. WHO has developed a comprehen-
sive strategy to fulfil our mandate to direct and coordinate global ac-
tion on snakebite, as requested by Member States in the resolution.

The strategy places countries at the centre, sets priorities, focusses

on outcomes and impact, and is aligned with targets set in WHO’s
13th  General Programme of Work and the Sustainable Development
Goals. It is a clear plan of action across all aspects of snakebite enve-
noming, and many of the elements in this approach will not only help
to reduce snakebites, but to improve and strengthen health systems.

The people most affected by snakebite are often those with the least
access to services and medicines. The most powerful force for redu-
cing the impact of snakebite envenoming is therefore for countries to
commit to universal health coverage, based on strong health systems
and people-centred primary health care. Engaging communities and
national and international partners is also essential.

I urge all policy-makers and managers in countries, as well as our in-

ternational partners, to work with WHO to implement this strategy and
achieve sustained prevention and control of this disease that affects
many of the world’s most vulnerable people.
vi Snakebite envenoming A strategy for prevention and control
 vii

ACKNOWLEDGEMENTS

The WHO departments of Control of Neglected Tropical Diseases (NTD) and of Regulation of
Medicines and Other Health Technologies (RHT) thank all those who contributed to the prepa-
ration of this strategy to prevent and control snakebite envenoming.

We acknowledge the members of the WHO Snakebite Envenoming Working Group who contri-
buted their expertise: Edward Abwao (Kenya), Gabriel Alcoba (Switzerland), Zuhair Amr (Jor-
dan), Jean-Philippe Chippaux (France), Delese Mimi Darko (Ghana), Mhd Abul Faiz (Bangla-
desh), Hui Wen Fan (Brazil), Christeine Gnanathasan (Sri Lanka), Abdulrazaq G. Habib (Nigeria),
Robert Harrison (United Kingdom), Ahmad Khaldun Ismail (Malaysia), Denny John (India),
Thomas Junghanss (Germany), Priyanka Kadam (India), David Lalloo (United Kingdom), Fa-
tima Laraba-Djebari (Algeria), Andreas Laustsen (Denmark), Matthew Lewin (United States of
America), Thea Litschka-Koen (Swaziland), Tri Maharani (Indonesia), Leonardo Nuñez (Colom-
bia), Kavi Ratanabanangkoon (Thailand), Sanjib Sharma (Nepal), Nget Hong Tan (Malaysia),
Michael Turner (United Kingdom), Benjamin Waldmann (Netherlands), David A. Warrell (United
Kingdom) and David J. Williams (Australia). The Working Group was co-chaired by Dr Williams
and Professor Faiz.

We are grateful to Mike Turner, Kirstie Eaton and Rebecca Holland from the Wellcome Trust for
their support and assistance in hosting a planning meeting in London on 28–29 June 2018. Ms
Liz Baltesz acted as meeting facilitator, and Stuart Ainsworth, Tommaso Bulfone and Andrea
Nickerson served as rapporteurs.

The WHO Secretariat members Bernadette Abela-Ridder, Naoko Obara (NTD), Emma Cooke,
Claudius Micha Nübling, François-Xavier Lery and Carmen Rodriguez-Hernandez (RHT) over-
saw the preparation of the document, which was drafted by Dr Williams and Dr Abela-Ridder
with editorial support from Professor Warrell. Tim Reed and Mieke Bakz from Health Action
International provided additional support in drafting the final strategy. WHO regional and head-
quarters staff provided additional review. Anne-Marie Labouche provided layout and design.
A  number of interns assisted the Working Group during their time at WHO.
viii Snakebite envenoming A strategy for prevention and control

Children are especially

vulnerable to snakebite
envenoming and often
become disabled or die.
 ix

© D.J. Williams
x Snakebite envenoming A strategy for prevention and control

EXECUTIVE SUMMARY

“ The large majority of the victims of

snakebite are politically voiceless:
subsistence farmers and the rural poor,
displaced populations, and children. It
is up to the international community to
countries around the globe have appealed for
a coordinated response. Following a recom-
mendation by WHO’s Strategic and Technical
be their voice.” Advisory Group for Neglected Tropical Di-
Kofi Annan Foundation, February 2017 seases (4) and a resolution on snakebite en-
venoming adopted by the Seventy-first World
Health Assembly in 2018 (5), WHO has added
A disease whose time has come this disease to its list of category A NTDs.
Snakebite envenoming is a neglected tro- It has now developed a strategy to reduce
pical disease (NTD) that is responsible for mortality and disability from snakebite enve-
enormous suffering, disability and premature noming by 50% before 2030. This document
death on every continent. As over 5.8 billion describes the strategy for action in countries,
people are at risk of encountering a veno- supported by regional collaboration, that will
mous snake, it is not surprising but no less save lives and prevent needless suffering.
tragic that almost 7400 people every day are
bitten by snakes, and 220–380 men, women A comprehensive strategy
and children die as a result i
(1, 2), adding up For millions of men, women and children
to about 2.7 million cases of envenoming and around the world, the risk of snakebite is a
81 000–138 000 deaths a year. The economic daily concern as they go about their every-
cost of snakebite envenoming is unmana- day activities – walking to school, tending
geable in most countries, as it affects not only gardens, herding livestock, fetching water or
the victims but often their entire families, par- simply going to the toilet – where a misplaced
ticularly in poor communities (3) in low- and step, a momentary lapse of concentration or
middle-income countries that do not have being in the wrong place at the wrong time
social security. can be fatal. Reducing the problem starts
with improving community education about
As work towards achieving the objectives of the risk and encouraging them to seek health
UHC2030 (https://www.uhc2030.org/) acce- care and ensuring intensified case manage-
lerates, immediate action is needed to reduce ment for every patient. First aid, effective,
the burden of suffering of some of the wor- affordable treatment provided by well-trained
ld’s most disadvantaged communities, and medical staff and rehabilitation will allow many
 xi

victims to return more quickly to good health cy will be necessary to build a global coali-
and productive lives. tion to drive change, generate investment,
implement projects and accelerate research
The core of the strategy is the goal for all pa- into new therapies, diagnostics and medical
tients to have better overall care, so that the interventions. Country capacity-building and
numbers of deaths and cases of disability are knowledge exchange will be emphasized. The
reduced by 50% before 2030. strategy will require transformational public–
private investment, with long-term commit-
For this to be achieved, four strategic aims ment by partners and governments.
will be pursued.
A multifocal incremental response
Empower and engage communities by countries
Prevent snakebite envenoming and  increase The strategy is based on existing resources,
use of treatment through education, training skills and experience while looking ahead to
and facilitation. Research will be conducted next-generation solutions. A central objective
to determine the sociocultural, economic, is to strengthen national health systems to pro-
political and geophysical influences on per- vide solutions at community level. Access to
ceptions of snakebite and treatment-seeking treatment will be improved, renewing commu-
by populations at risk and the results used to nities’ confidence in early treatment with safe,
change behaviour, policy and practice. effective, affordable medicine. Innovative re-
search will address clinicians’ needs for better
Ensure safe, effective treatment Build a diagnosis and treatment. Better case manage-
stable, sustainable market for safe, effective ment – from first aid, through hospital care, to
antivenoms at reasonable cost and assured post-discharge rehabilitation – will help victims
access to treatment. The production and to resume healthy, productive lives.
quality of snakebite treatments must meet
internationally accepted standards, through The strategy will be tested in 2019–2020 in
cooperation among academia, industry and 10–12 countries with a high burden of snake-
public and private institutions for innovation bite envenoming and urgent need of a solu-
and modernization. The current crisis in the tion. Countries will be supported in designing
supply of antivenoms should be addressed by and implementing locally relevant plans and
WHO by creating a revolving stockpile of an- in participating in regional initiatives. During
tivenoms proven to be effective, so they can the scaling-up phase in 2021–2024, a further
be sent where they are needed. 35–40 countries will be involved, as resources
increase and experience demonstrates the ef-
Strengthen health systems fectiveness of the strategy. During full roll-out
The principles of the WHO Health Systems in 2025–2030, all countries will be able to inte-
Framework should be used to integrate grate the strategy into their public health agen-
more effective prevention, treatment and das.
management of snakebite envenoming into
national health systems, national health plans The strategy will be reviewed and adapted
and policy frameworks. regularly to ensure that it meets the needs of
countries. Through advocacy, WHO will build
Increase partnerships, coordination and a sustainable global coalition committed to
resources ensuring that the targets and milestones are
Strong collaboration will be required for this achieved to halve the numbers of snakebite
comprehensive plan of action, and advoca- deaths and cases of disability by 50% by 2030.
xii Snakebite envenoming A strategy for prevention and control

For millions of men, women and children

around the world, the risk of snakebite is a
daily concern as they go about their everyday
activities where a misplaced step, a momentary
lapse of concentration or being in the wrong
place at the wrong time can be fatal.

The cost of implementing the four strategic objectives

between 2019 and 2030 will be spread over three phases

Timeframe 2019−2020 2021−2024 2025−2030

Empower and engage communities US$ 0.65 m US$ 8.97 m US$ 17.19 m

Ensure safe, effective treatments US$ 4.29 m US$ 15.58 m US$ 29.86 m

Strengthen health systems US$ 1.89 m US$ 13.26 m US$ 21.80 m

Increase partnerships, coordination US$ 2.13 m US$ 7.63 m US$ 13.51 m

and resources

-------------- -------------- --------------

Total US$ 8.96 m US$ 45.44 m US$ 82.36 m

 xiii

© D.J. Williams
Costs of implementation Countries should mobilize domestic and in-
WHO’s budget will be used to deliver solu- ternational resources to achieve sustainable
tions in the field. Thus, 54.1% will be for ac- financing and implementation of their control
tivities in countries where snakebite is a pu- programmes, with strong technical support
blic health problem, with regional support from WHO. National costs and the cost of
and collaboration (17.1%). The cost of work commodities to be deployed from revolving
by WHO technical departments will account antivenom stockpiles are not included in the
for the remaining 28.8% of the budget. The budget; however, as antivenom production is
number of countries involved will increase strengthened, the current costings will pro-
over the next 11 years as resources are mo- bably become redundant. WHO will prepare
bilized and capacity built. The success of the an investment case for the commodities re-
programme during the first 2–4 years will de- quired to operate the stockpiles and will work
termine whether support can be found for the with governments and other partners to ob-
full 12-year strategy. tain effective, quality-assured products for
distribution.
During the pilot phase, we will prepare a de-
tailed work plan and, in parallel, a strong,
evidence-based investment case to demons-
trate the cost–effectiveness and the cost–
benefit of interventions, as compelling argu-
ments for investment, support, participation
and commitment. The projected budget will (i)
Longbottom J, Shearer FM, Devine M, Alcoba G, Chap-

be updated as the strategy advances and as puis F, Weiss DJ, Ray SE, Ray N, Warrell DA, Ruiz de Cas-

economic and geopolitical circumstances tañeda R, Williams DJ, Hay SI, Pigott DM. Vulnerability to

evolve. snakebite envenoming: a global mapping of hotspots.

Lancet. 2018: 392(10148):673-684.

xiv Snakebite envenoming A strategy for prevention and control

In humans and animals, snake venom can precipitate multi-

organ or multi-system disease

Damage to eyes leading Indirect toxin effects on

to blindness after contact brain and pituitary
with spat venom from gland tissue
spitting cobras

Damage to nerves and

blockage of neuro-muscular Myocardial ischaemia ,
transmission leading to direct damage, and
paralysis of muscles cardiovascular effects
including those vital to airway
protection and breathing

Direct and indirect effects Acute kidney injury that

on liver function can kill or lead to chronic
renal health problems in
survivors

Pregnant mother and

Direct muscle cell fetus may suffer due to
destruction by myotoxins bleeding and placental
dysfunction, and from
direct effects of toxins

Haemorrhage due to damaged Local tissue damage including

blood vessel walls, swelling, oedema and necrosis due
consumption of clotting factors to destructive effects of some
and degraded platelets snake venoms and secondary
effects on blood supply

Leaking capillaries throughout Toxin effect on mineral balance

the body caused by direct and causing low serum sodium
indirect effects of toxins concentration
 Action to reduce and control the effects of snakebite envenoming 1

ACTION TO REDUCE
AND CONTROL
THE EFFECTS
OF SNAKEBITE
ENVENOMING
Snakebite envenoming is a medical emer- altogether. The situation in sub-Saharan Afri-
gency that results from contact with snake ca is of particular concern. With limited pro-
venoms, which are complex mixtures of duction of antivenom products in only one
toxins that are injected when a snake bites country, the region depends almost entirely
or when venom is sprayed into the eyes and on importation of antivenoms manufactured
onto mucosal surfaces as a defence strategy. in other parts of the world, most of which are
Snake venoms are evolutionarily adapted to marketed with no evidence of their safety or
kill prey rapidly by targeting and negating the effectiveness. Antivenom production was
function of various cell receptors. In humans abandoned by some companies in the 1980s
and animals, this can precipitate multi-or- and 1990s, and a crisis point was reached in
gan or multi-system disease that can cause 2015 when a manufacturer of antivenoms for
(depending on the species of snake and the Africa and the Middle East also ceased pro-
classes of toxins in the venom) haemorrhage, duction, citing competition from less expen-
prolonged disruption of thrombosis and hae- sive, unproven products. Similar crises are
mostasis, neuromuscular paralysis, tissue emerging in Asia. Without urgent reshaping
necrosis, generalized muscle breakdown, of the market, greater regulatory control and
cardiotoxicity, acute kidney injury, hypovolae- other measures, a public health emergency is
mic shock and other effects (6). imminent.

WHO recognized snakebite envenoming as

an NTD in 2017 and acknowledged that, al- Disease burden and social and
though data are incomplete, the mortality socioeconomic effects
and morbidity associated with this disease,
particularly in tropical and sub-tropical re-
gions, have been underestimated and that a As for other NTDs, it is difficult to estimate
coordinated international response is neces- morbidity, disability and mortality globally, for
sary. WHO also recognized that, because of a number of reasons. First, snakebite is most
decades of inattention to this disease, the prevalent in impoverished agricultural and
fundamental systems, resources and tools herding communities in low- to middle-in-
required to reduce and control the burden come countries, who have poor access to
have either lagged behind or disappeared health care and where health ministries do
2 Snakebite envenoming A strategy for prevention and control

not collect specific data. An attempt to quan-

tify deaths due to snakebite envenoming by
WHO in 1954 based on inadequate data ar-
rived at 30 000–40 000 deaths per annum.
More recent attempts with better (although
still incomplete) data provide broad estimates
of 81 000–138 000 deaths resulting from
1.8–2.7 million cases of envenoming and up
to 5.4  million snakebites (6). The Institute for
Health Metrics and Evaluation estimated that
there were 79 000 deaths due to bites from ve-
nomous animals in 2016, with an uncertainty
range of 56 800–89 400 (7), which is lower
than in most other studies (1, 2). An estimated
400 000 people a year suffer permanent disa-
bility, including blindness, extensive scarring
and contractures, restricted mobility and am-
putation after snakebite envenoming  (8), and
the psychological effects of snakebite are un-
der-recognized. In Sri Lanka, snakebite enve-
noming had long-term psychological seque-
lae, the prevalence of post-traumatic stress
disorder being similar to that observed after
the 2004 tsunami in Asia or major road traffic
accidents (9).

Snakebite envenoming typically affects pre-

dominantly poor, rural communities in tro-
pical and sub-tropical countries throughout
the world. WHO recognizes 109 species of
venomous snakes as category 1, of highest
medical importance, in the countries in which
they occur. At least another 142 species are
regarded as category 2 (medically important
but to an uncertain degree) because exact
epidemiological or clinical data are lacking
and/or they are less frequently implicated
in envenoming cases because of their acti-
vity cycles, behaviour, habitat preferences
or occurrence in areas remote from large
human populations. Despite their abundance
(see Fig. 1), the majority of the most medi-
cally important species in each region belong
to a few genera. For example, the 25 catego-
ry-1 species recognized in the African region
belong to five genera, and the 30 category-1
species in the Americas belong to only four
genera.
 Action to reduce and control the effects of snakebite envenoming 3

Fig. 1. Worldwide distribution of medically important snake

species, with the relative abundance of species in each country.
 4 Snakebite envenoming A strategy for prevention and control
Medically important snake species in WHO regions
© D.J. Williams

© D.J. Williams
Region of the Americas African Region
Bothrops asper Bitis arietans
Common names: Fer-de-lance or Terciopelo Common name: Puff adder
© W. Wuster

© W. Wuster
Eastern Mediterranean Region South-East Asia Region
Naja haje Daboia russelii
Common name: Egyptian cobra Common name: Russell’s viper

© D.J. Williams
© D.J. Williams

European Region Western Pacific Region

Vipera berus Calloselasma rhodostoma
Common name: European viper Common name: Malayan pit viper
 Action to reduce and control the effects of snakebite envenoming 5

Snakebite envenoming
Snakebite envenoming has many conse-
quences for victims and their families. It

typically affects often makes poor people poorer, because

of the high treatment costs and loss of inco-

predominantly poor, rural me. In sub-Saharan Africa, a dose of effec-

tive antivenom alone can cost US$ 55–640,

communities in tropical with an average cost of US$ 124 per dose

(18). In India, the cost of initial treatment has
and sub-tropical countries been reported to be as high as US$ 5150 and

throughout the world. long-term cost of US$ 5890 (19). Some vic-
tims have suffered financial losses equivalent
to 3.6 years’ income, and others have sold
land worth up to 14 years of income. Some
families have to remove their children from
A large body of literature demonstrates a education because of lost income following
strong association between low socioeco- snakebite envenoming or so that the children
nomic status or poverty and a high burden can work to contribute to the family income or
of snakebite envenoming and death. Rural care for a disabled snakebite victim. In Zim-
hunter-gatherers, agricultural workers, wor- babwe, the average cost of hospitalization of
king children (10–14 years of age), fami- an envenomed patient was US$ 225 per day,
lies living in poorly constructed houses and before treatment was given (20). In Bangla-
people with limited access to education and desh, nearly 75% of snakebite victims spent
health care are all particularly vulnerable (3, their savings on treatment, and over 60% had
10–12). In West Africa, 16 low- to middle-inco- to borrow to meet the costs (21).
me countries have at least 3500–5350 deaths
annually, equivalent to 1.2 deaths/100 000
population per annum (95% CI: 0.9–1.4/100 Treatment
000) (13). In just one Nigerian hospital, 6687
people were treated for snakebite enveno- Immunotherapy with antivenom preparations
ming over 3 years (14), and in Burkina Faso 114 from animals, containing either immunoglo-
126 cases of snakebite were reported over 5 bulin G or its derivative fractionation products,
years (15). While the data are incomplete, 20 F(ab′)2 or Fab, has been the main treatment
000–32 000 people in sub-Saharan Africa die for snakebite envenoming for over 120 years.
each year from snakebites (2). A study in India Antivenoms that are manufactured according
provided a direct estimate of 1.4–2.8 million to the highest standards, that comply with
snakebites a year, which resulted in at least good manufacturing practice and undergo ri-
46 000 fatalities (16). In Bangladesh, the esti- gorous preclinical and clinical evaluation be-
mated annual incidence of snakebite was 589 fore registration are very effective, especially
919 and 6041 deaths (17). Snakebite results in if administered early in an adequate dose (22).
large numbers of disability-adjusted life years
(DALYs) in Africa, due to factors such as the In many regions, however, appropriately ma-
size and density of both human and snake nufactured, quality-assured products are not
populations. Overall, 320 000–330 000 DALYs available or accessible, due partly to poor
are lost to snakebite envenoming annually in control and regulation of preparations (23, 24).
West Africa (7, 13), which is more than those In many places, there are no minimum spe-
lost due to dengue, echinococcosis, intes- cifications for the potency, efficacy, dose or
tinal nematode infestations, leishmaniasis, safety of antivenom products. Weak health
trachoma and trypanosomiasis (13). systems and regulatory frameworks let un-
6 Snakebite envenoming A strategy for prevention and control

safe, ineffective products enter markets, with ment with antivenom and other drugs, sur-
no preclinical or clinical evaluation before re- gical and medical care of local tissue injury,
gistration (25, 26). One consequence of such better treatment of organ or system sequelae
fragile systems is that inferior products have such as acute kidney injury and recovery and
become ubiquitous, particularly in sub-Saha- rehabilitation. The aim should be to restore
ran Africa and in Asia, so that competitors that function so that snakebite victims can return
are rigidly regulated have had to abandon to healthy productive lives.
production (27). The weakness of the market
also discourages investment in research to im-
prove current treatments and in development Challenges to improving the quality,
of a next generation of antivenoms at lower safety and cost–effectiveness of
cost and with greater safety and efficacy. antivenoms

Apart from antivenom treatment, victims The practical challenges to reducing the bur-
usually also require a range of health ser- den of snakebite envenoming and bringing it
vices, as antivenom neutralizes accessible under long-term control throughout the world
venom components but does not reverse the epitomize many of the obstacles to ensuring
damage to organ systems, as some toxins healthy lives and well-being for everyone at
that are sequestered inside cells are inac- all ages under United Nations Sustainable
cessible to antivenom immunoglobulins. Development Goal (SDG) 3 and the aspira-
Effective treatment therefore involves both tion of achieving universal health coverage by
antivenom and other interventions, such as 2030 (28). National and sub-national supplies
cardiorespiratory and/or fluid resuscitation, of good-quality antivenoms are not enough,
airway intubation, mechanical ventilation, as, in many countries, poor-quality products
haemodialysis, wound debridement, recons- and the absence of effective treatment have
tructive surgery, physiotherapy and other re- eroded confidence in conventional health
habilitation services. Improving the outcomes care. Strong engagement with communities
of patients will require strengthening health and health workers is necessary to encourage
systems, improving access to essential me- victims to seek care early, which will require a
dicines, eliminating substandard antivenoms coordinated health promotion strategy.
and other medicines, strengthening diagno-
sis and treatment, improving regulatory capa- Decades of neglect and inaction in the sys-
city and ensuring effective distribution of an- tems, tools and safeguards required to en-
tivenoms and monitoring their use and safety. sure access to safe, effective treatment have
resulted in the collapse of the largely un-
The need to involve wound care experts, re- der-regulated, under-supported market for
habilitation services, prosthetic limb manu- antivenoms, because of low demand and a
facturers, oculists and others who can contri- glut of poor-quality products, while millions of
bute to recovery and rehabilitation has long victims have suffered unnecessarily. At least
been ignored. Similarly, the psychological three million effective treatments are required
consequences of snakebite envenoming, in- each year, yet important challenges remain
cluding post-traumatic stress disorder and to ensuring that the antivenoms on the mar-
chronic depression, should be prioritized. ket are safe, effective and affordable. WHO
Operational research is necessary as a basis is taking steps to establish the quality of an-
for robust clinical guidelines, assessment al- tivenoms on the sub-Saharan African market
gorithms and other resources to ensure the and will work with manufacturers to collect
chain of care, from evidence-based first aid in evidence of their safety and effectiveness.
the community or by first responders to treat- The programme should be extended to other
 Action to reduce and control the effects of snakebite envenoming 7

Box 1.
Case study of the cost–effectiveness of antivenom
treatment in West Africa

The incremental cost–effectiveness ratio associated with making antivenom avai-

lable for each death averted in 16 West African countries (29) ranged from US$ 1997
in Guinea-Bissau to US$ 6205 in Liberia and Sierra Leone, while the cost per DALY
averted ranged from US$ 83 in Benin to US$ 281 in Sierra Leone. The probability
that treatment with antivenom would be cost–effective was 97.3–100.0%. These
estimates compare favourably with the cost–effectiveness of other commonly
funded health interventions and indicate that a relatively modest cost can substan-
tially reduce mortality and losses in DALYs. In Nigeria, the country with the highest
burden of snakebite envenoming in West Africa, the incremental cost–effectiveness
ratio was US$ 92.56 per DALY averted and US$ 2160.33 per death averted. These
sums were far lower than Nigeria’s gross domestic income per capita at the time
(US$ 2742), confirming that antivenom treatment is highly cost-effective.

BENIN
BURKINA FASO

CAMEROON

CHAD

CÔTE D’IVOIRE

GAMBIA

GHANA

GUINEA

GUINEA-BISSAU

LIBERIA

MALI

NIGER

NIGERIA

SENEGAL

SIERRA LEONE

TOGO

0 200 400 600 800

Incremental cost-effect ratio (ICER)/DALY (US $)

 8 Snakebite envenoming A strategy for prevention and control

regions where there are similar doubts about 83  000 treatments were supplied at an ave-
products and a thorough, independent inves- rage cost of US$ 124 per treatment, irrespec-
tigation and validation are required. tive of their effectiveness. The most effective
product at that time cost US$ 640 per treat-
The issue of treatment cost should be in- ment (but only 1250 treatments could be sup-
vestigated operationally, by simulations of plied by the manufacturer), a cost that is un-
production system cost–efficiency and eva- sustainable for large-scale supply. The cost
luations of cost–effectiveness, to develop of treatment for other NTDs is much lower.
pricing models that will convince countries, For example, post-exposure prophylaxis for
partners and donors to support investment in rabies costs as little as US$ 12 per treatment.
these essential medicines. Box 1 shows the It is difficult to convince countries and donors
results of a study of the cost–effectiveness of to accept the much higher costs of antive-
antivenoms for snakebite in 16 countries in noms, and providing the necessary quantity
West Africa in 2016 (29). will require substantial market growth and
increased industrial production. Facilitating
Small-scale production results in high costs, improved access to academic research out-
which are a disincentive to investment. In a comes, new technology and technical assis-
study of products in sub-Saharan Africa in tance can help manufacturers to eliminate
2012, the number of effective treatments was unnecessary costs, streamline and moder-
estimated to represent only 2.5% of those nize production and deliver products at more
needed (18). In 2010–2011, approximately affordable prices.

In Amazonas for every snakebite

death up to 10 survivors are
left with permanent disability,
including amputations.
© M. O’Shea
 Rationale for the strategy 9

RATIONALE FOR THE

STRATEGY

Our approach is based on the conviction that Snakebite envenoming is

empowered communities with well-functioning preventable.
health systems that have access to safe, ef-
fective medicines can effectively prevent and The risk for snakebite envenoming can be
control snakebite envenoming. Once a com- reduced through community education and
munity recognizes the value of prevention, often through measures for preventing other
avoidance of risks and early medical care for diseases. Use of bed nets to prevent trans-
snakebite envenoming, the outcomes will im- mission of mosquito-borne diseases can
prove. More people will seek help sooner, will also reduce the risk of bites from snakes
suffer less and will be more likely to survive and entering houses at night (30). Encouraging
recover. Community education to promote bet- people to protect their feet, ankles and lower
ter health-seeking behaviour and prevention of legs by wearing boots protects them not only
injury, training of health workers, stronger health from snakebites but also from infection by
systems and access to good-quality medicines soil-transmitted helminths, bacteria and fungi,
will benefit everyone and contribute to achieving podoconiosis and trauma associated with
the SDGs. walking or working barefoot.

When health professionals are taught funda-

mental clinical skills, they not only diagnose Snakebite envenoming is treatable.
and treat snakebite envenoming better but also
improve their entire practice of medical care. The means for treating snakebite envenoming
Likewise, improvements in health systems for are available, and, by ensuring that those who
the management of snakebite benefit the health are bitten have access to safe, effective, affor-
needs of everyone. Snakebite envenoming is a dable medicines, the toll of death and disabi-
multi-organ system disease that requires holis- lity caused by snakebites can be substantially
tic management and expertise in many areas of reduced. Technological support, investment
medicine. Better access to medicines, training and training can rapidly improve the produc-
and provision of basic equipment and laboratory tion and regulation of antivenoms. This will
and other services will increase the return on in- not only result in better snakebite treatment
vestment and bring some of the most vulnerable but will also improve the safety and quality of
people closer to universal health coverage. other biotherapeutics, such as for diphtheria,
10 Snakebite envenoming A strategy for prevention and control
West African
carpet vipers are
the major cause
of snakebites in
the Brong Ahafo
Region of Ghana

© D.J. Williams
Box 2
Case study in Ghana

At Yeji, on the shores of Lake Volta in the north of the Brong Ahafo Region of Ghana, snakebite was one of
the 10 main reasons for hospital admission, and the case fatality rate was 11.1% (31). A case review system,
a new treatment strategy and new antivenoms were introduced and the effects monitored for 33 months.
The case fatality rate fell to 1.3%, the number of admissions increased by 50%, the time between bite and
admission was reduced by 40%, and the proportion of patients who required wound debridement dropped
from 6.9% to 2.2%.

The interventions for achieving these changes were simple: apply a standard protocol to the treatment
of all patients, introduce staff training, monitor compliance, and use effective antivenoms.
 Rationale for the strategy 11

Our approach is based on the

conviction that empowered envenoming is part of achieving SDG 1, to “end
poverty in all its forms”, and the commitment

communities with well-functioning of Member States to “leave no one behind”. It

also contributes to the goals of SDG 3, to “en-

health systems that have access sure healthy lives and promote well-being for
all at all ages” and, specifically, SDG 3.3, that
to safe, effective medicines can “by 2030, end the epidemics of … neglected
tropical diseases”, and SDG  3.8, to “achieve
effectively prevent and control universal health coverage … and access to

snakebite envenoming. safe, effective, quality and affordable essential

medicines and vaccines for all” (28).

tetanus and rabies, and of other drugs and WHO based its 13th Global Programme of
equipment necessary to treat infections and Work on a commitment to leave no one behind
circulatory, respiratory and renal failure. Box 2 (32). The right to the highest attainable stan-
provides a case study of how outcomes can be dard of health as expressed in WHO’s Consti-
improved even with few resources. tution underpins all WHO’s work. WHO is com-
mitted, at all levels of engagement, to gender
equality, equity and rights-based approaches
Investment in prevention and to health to enhance participation, build resi-
treatment of snakebite envenoming lience and empower communities. Investment
saves victims from poverty and in antivenoms will meet these commitments
reduces health inequality. and WHO’s goals of ensuring that one billion
more people have health coverage, one billion
Most victims of snakebite envenoming live in more people’s lives are made safer, and one
impoverished, vulnerable communities with billion more lives are improved. It will accele-
poor health indicators. Most are inhabitants rate progress to achieving universal health co-
of rural areas in tropical and sub-tropical re- verage by 2030 so that all people have a safer,
gions of Africa, the Middle East, Asia, Ocea- healthier, fairer world in which to live produc-
nia and Latin America, where a bite by a ve- tive, fulfilling, active lives.
nomous snake can lead to death or to months
(or years) of depression, disability and eco-
nomic destitution. Without access to effective The prevention and treatment of
treatment, many victims lose their livelihoods, snakebite envenoming is a model of
savings and property. A debilitating snake- collaboration for “One health”.
bite may leave an agricultural worker fit only
to beg and be supported by his or her family. Snakebite envenoming also causes substan-
Their immediate and even extended families tial economic losses by disabling and killing
may have to share and endure the economic livestock and working animals. Engagement
consequences, marginalization and stigmati- with communities to prevent human snake-
zation. Investment in antivenoms can relieve bites may increase their awareness of the
the suffering of the victims and their families little-known problem of fatal and debilitating
and give them a chance to recover, rebuild snakebites among valuable domestic lives-
their lives and resume their roles as produc- tock. Coordination between human and ve-
tive members of their communities. terinary health systems to reduce the impact
of snakebite envenoming on communities is a
Investment in improving the prevention of model for other “One health” collaborations.
snakebites and controlling the incidence of
12 Snakebite envenoming A strategy for prevention and control

-50%
by 2030

FULL ROLL-OUT
2025 All affected countries
2030
3 million treatments

SCALE-UP PHASE
2021 +35-40 countries
2024
500 000 treatments

PILOT PHASE
2019 2020
10-12 high-risk countries
10 000-50 000 treatments

Empower and Ensure safe, Strengthen Increase

engage effective health systems partnerships,
communities treatment coordination and
resources

Fig. 2. Strategic objectives, target and implementation phases

 Strategy for prevention and control of snakebite envenoming 13

STRATEGY FOR
PREVENTION
AND CONTROL
OF SNAKEBITE
ENVENOMING
The strategy is a coordinated, evidence-based Strengthen health systems: Within establi-
approach to the control of snakebite enveno- shed frameworks and in line with SDG 3.8 and
ming, with technical support, the availability, 3B–D, build strong national health systems
accessibility and affordability of safe, effec- to ensure that the resources, information and
tive treatments, technical cooperation among health personnel required for the control of
Member States and strengthening of their ca- snakebite envenoming are available and ac-
pacity to deal with this disease in a multifocal cessible.
manner.
Increase partnerships, coordination and
resources: Use advocacy, data, collabora-
Target, strategic objectives and tion and partnerships to build a transforma-
activities tional, multi-stakeholder alliance to find solu-
tions and generate public–private investment
The goal of the strategy is to prevent and for sustained success.
control snakebite envenoming in order to
halve the numbers of deaths and cases of di- The next sections briefly describe the tasks
sability that it causes by 2030. The four strate- involved, examples of expected outcomes
gic objectives, illustrated in Fig. 2, are: and information on the rationale for each task.
Some of the practical results of the strategy
Empower and engage communities: are expected to be:
Through education, communication, training
and facilitation, give communities the tools • availability of safe, effective treat-
and capability to make informed decisions to ments: 50 000 for snakebite envenoming
prevent snakebites and improve the outco- by the end of 2020, increasing to 500 000
mes of those who are affected. by 2024 and full coverage with 3 million by
2030;
Ensure safe, effective treatment: In line
with SDG 3.8 and 3B, ensure that safe, ef- • restoration of a sustainable market
fective, affordable, accessible treatments for for snakebite treatment: a long-term
snakebite envenoming are available to all the supply of well-regulated, safe, effective
people who need them. treatments and conditions to ensure an
14 Snakebite envenoming A strategy for prevention and control

increase of at least 25% in the number of out phase (2025–2030), support to control
competent manufacturers by 2030; snakebite envenoming will be extended to all
countries that require it. Some of the outco-
• cost mitigation to reduce the debili- mes to be achieved during these phases are
tating financial impact of treatment: listed below.
better understanding of the barriers to
treatment, rehabilitation and reintegration PILOT PHASE (2019–2020)
and research and policy on mitigating the • A risk–benefit assessment of antivenom
costs of treating snakebite envenoming products in Africa and Asia will be com-
by 2030; pleted to ensure that at least three qua-
lity-assured, appropriate antivenoms are
• integration of treatment of snakebite accessible in each region.
envenoming into national health plans
in all affected countries: including sur- • A pilot project to design and test an ini-
veillance systems, policy frameworks, tial antivenom stockpile programme will
research priorities, health system com- be initiated, to deliver 10 000–50 000
ponents, community and civil society effective treatments in 10–12 countries
mechanisms for effective prevention and with a high burden of snakebite. Models
control; and based on WHO revolving stockpiles of
vaccine  (33) will be tested. A small-scale
• long-term sustainability and strong pilot project will be conducted to test the
collaborative partnerships for effec- model, and the findings will be used to im-
tive control: strong cases for medium- prove it for wider use.
and long-term investment to ensure
resources for the control of snakebite • Countries will be encouraged to integrate
envenoming and enduring multilateral training on snakebites into the professio-
partnerships to ensure the sustainability nal development and in-service training
and success of control. of health workers and to provide opportu-
nities for them to improve the prevention,
As the strategy is implemented, additio- diagnosis, treatment and management of
nal tasks and priorities will be identified, in the disease as part of overall investment in
consultation with partners and countries, and health systems.
flexibility will be necessary to ensure that the
strategy remains responsive and appropriate • WHO will identify and engage with a wide
locally, nationally, regionally and globally. range of potential partners and stakehol-
ders and prepare a framework to coordi-
nate investment and mobilize resources
Implementation phases for national and regional initiatives.

The roadmap will be rolled out in three phases, • Countries will be called upon to include
starting with a pilot phase (2019–2020) in snakebite envenoming and other NTDs in
10–12 high-burden countries to demonstrate national and regional health plans. WHO
the robustness and adaptability of the plan will encourage countries to adopt the un-
and of both individual and collective inter- dertakings in resolution WHA71.5 and to
ventions. As the programme evolves and re- add snakebite envenoming to their lists of
sources become available, it will be scaled up notifiable diseases in order to collect and
(2021–2024) by extending implementation report more complete, accurate data.
to another 35–40 countries. In the full roll-
 Strategy for prevention and control of snakebite envenoming 15

The goal of the strategy

• WHO will support low- to middle-income
countries in developing policy frameworks

is to prevent and control to encourage investment in viable new

manufacturing capacity in order to meet

snakebite envenoming in regional demand for quality-assured an-

tivenoms.

order to halve the numbers FULL ROLL-OUT PHASE (2025–2030)

of deaths and cases of • All countries will have access to the tools

disability that it causes by and interventions of the strategy.

2030. • Better market conditions will attract new

manufacturers, increasing the number of
companies producing high-quality antive-
• Research priorities will be promoted to noms by 25% and delivery of 3 million ef-
ensure that the clinical tools required to fective treatments a year globally by 2030.
tackle the disease become available.
• Integration of snakebite envenoming into
• Community-level snakebite education national health plans will ensure that all
programmes in countries will be sup- victims who suffer disability are afforded
ported with technical guidance and lear- equal, equitable access to rehabilitation
ning materials. and that the UHC2030 and SDG objectives
for access to medicines are achieved.
SCALE-UP PHASE (2021–2024)
• Risk–benefit assessments of antivenom • A new generation of products will become
products for the remaining regions of the available that are more effective, safe and
world will be completed, so that at least affordable for treatment of the local and
three quality-assured, appropriate antive- systemic effects of envenoming.
noms are accessible in every region of the
world.

• Another 35–40 countries will be included,

and the antivenom stockpile programme
will expand as demand increases, with the
aim of delivering a minimum of 500 000
effective treatments by 2024.

• Investment in clinical research, clinical

tools and translation of research results
into practice and policy will begin to deli-
ver results.

• WHO will work with countries, partners

and donors to apply strategies to reshape
regional antivenom markets.
 16 Snakebite envenoming A strategy for prevention and control

The risk of snakebite

envenoming can be reduced
through community education.
© D.J. Williams
 Strategy for prevention and control of snakebite envenoming 17

EMPOWER
AND ENGAGE
COMMUNITIES

Snakebite envenoming hurts communities. Effective control of snakebite envenoming is

Victims of snakebite are typically young, possible only if the affected communities are
healthy, productive members of their com- active participants. A bottom-up approach is
munities, until they are bitten. They may be more likely to succeed than an initiative from
heads of families who contribute to food pro- outside. Community participation, with the
duction, raise children, care for the sick and support from local leaders, civil society and
elderly and lead the life of their towns, villages health and social activists, will improve the
and hamlets. The strategy emphasizes the outcomes of snakebite envenoming.
importance of engaging with communities to
encourage better education about risks and Improve the prevention, reduce risk
avoidance to prevent snakebites and health and increase avoidance of snakebite
care-seeking behaviour. The aim is to em- envenoming.
power communities to be more proactive in
a holistic approach that integrates snakebite Qualitative research should be conducted on
awareness into programmes to prevent envi- community knowledge, perceptions, socio-
ronmental, zoonotic and other diseases. cultural and spiritual understanding and de-
piction of snakes and snakebite envenoming.
Ensure active community engagement Prevention, risk-reduction and avoidance
and participation. initiatives can then be designed and planned
with strong community participation. Com-
In many regions and communities, there are munity consultation and research are essen-
no quantitative or qualitative indicators of the tial for understanding their views on snake-
burden and impact of snakebite envenoming bite envenoming and using the information
for measuring the success of interventions. to design strategies that can be tested with
Systematic baseline data will be obtained affected communities. Strategies that work in
about the burden of snakebite envenoming, one setting may not work in others.
its impact on communities and the effects of
interventions over time. Applying new tools Operational research will be conducted to
for community-acquired data collection will evaluate snake avoidance and snakebite pre-
complement health systems data. vention strategies in communities. Research
results will be used to validate affordable,
18 Snakebite envenoming A strategy for prevention and control

context-appropriate prevention activities and Ensure effective first aid and ambulance
interventions, including targeted community transport to hospital.
education.
Guidelines, training and education will be
Research on human–animal interfaces and prepared for community first responders to
ecological and environmental risk factors to ensure that local communities have the basic
understand the ecology of venomous snakes skills and knowledge for pre-hospital care
will inform prevention and risk-reduction ap- and life support until medical assistance is
proaches. Studies will also be done to obtain available. Most victims of snakebite enveno-
a more accurate assessment of the economic ming have to travel considerable distances
burden of snakebite envenoming including to access primary health care; appropriate
the impact on domestic animals and lives- community response to snakebite enveno-
tock. Reducing the cost of snakebite enveno- ming can reduce mortality and change com-
ming to communities due to loss of livestock munity perceptions of snakebite envenoming
should be included in community approaches and its treatment.
to snakebite envenoming control.

Teaching communities how

to provide safe, effective
snakebite first aid is
fundamental to achieving
better outcomes.
© D.J. Williams
 Ensure safe, effective treatment 19

Improve health care-seeking behaviour.

The strategy emphasizes the importance
In many communities affected by snakebite
of engaging with communities to envenoming, 60–80% of victims rely on tra-

encourage better education about risks ditional medicine or spiritual healers for treat-
ment, often with poor outcomes. In order

and avoidance to prevent snakebites and to change or modify poor health-seeking

behaviour, the factors that influence these
health care-seeking behaviour. treatment decisions must be understood.
Treatment choices should be investigated to
understand why they persist within commu-
nities and how future choices in communities
can be positively influenced. Engaging with
Snakebite envenoming is a potentially traditional medicine practitioners and other
life-threatening emergency, and emergency influential community members to encourage
responders must be appropriately trained to them to support better health care-seeking
recognize the signs and symptoms of enve- behaviour and/or act as first responders will
noming and of associated medical issues result in greater use of allopathic medicine
that may be a threat to life during transport, and better outcomes.
such as severe shock, haemorrhage, airway
obstruction or respiratory paralysis. The trai- Research on socio-cultural and
ning of ambulance personnel who transport economic factors affecting outcomes
cases of snakebite envenoming will be impro-
ved in order to reduce pre-hospital mortality Understanding the social, cultural, economic
and complications. Pre-hospital mortality is and spiritual context of snakebite enveno-
reduced measurably if there is appropriate ming across communities is essential to im-
transport. Supervised, appropriately qualified proving outcomes. This operational research
ambulance transport services are an essen- is important because of the degree to which
tial part of a well-designed, functioning health these influences impact the outcome after
system and should be available to everyone snakebite envenoming varies considerably
in a community who has to be transported depending on the context and cultural dyna-
urgently to an appropriate health care facility. mics. Identifying the issues that contribute to
poor outcomes such as pre-hospital morta-
Accelerate development of pre-hospital lity, chronic morbidity and substantial eco-
treatment. nomic loss at national and subnational level
will enhance local programme specificity and
Time is critical after snakebite envenoming: success.
the longer the delay before treatment, the
poorer the outcome. Improving first-aid treat-
ment, developing and validating effective
strategies and introducing new drugs to inter-
rupt the natural progress of the disease until
the victim reaches hospital will save many
thousands of lives every year and reduce the
incidence and severity of sequelae. Invest-
ment in research on pre-hospital treatment,
including first aid, and pre-hospital therapeu-
tics will be improved.

20 Snakebite envenoming A strategy for prevention and control

Ensuring the
safety, quality and
effectiveness of
antivenoms requires
improving and
modernizing all
phases of production,
including the
collection of snake
venoms.

© D.J. Williams
 Ensure safe, effective treatment 21

ENSURE SAFE,
EFFECTIVE TREATMENT

In order for people to be successfully treated In addition to antivenom, victims require ad-
and recover from snakebite envenoming they ditional medical care and interventions that
require access to good-quality antivenoms, can vary according to the circumstances of
and all of the other aspects of medical treat- the individual case. Factors such as the type
ment that may be necessary. of snake involved, the length of time between
the bite and presentation to health care and
Antivenom is the first choice for treatment of the severity of envenoming can influence the
systemic snakebite envenoming. It must be need for other types of medical treatment.
well designed and formulated and adhere to It is also important that innovative research
international standards for the manufacture is supported to investigate, optimize and ra-
of sero-therapeutic medicines to ensure their tionalize treatment of snakebite envenoming
safety and effectiveness. Lack of safe, effec- to improve outcomes. Advances in the medi-
tive antivenoms in many parts of sub-Saha- cal treatment of snakebite envenoming, and
ran Africa and South and South-East Asia treatment of long-term sequelae (physical
is the primary cause of the continuing high and psychological) are possible, but require
rates of death and disability among tropical investment in clinical research and transla-
snakebite victims. Without urgent, strate- tion of that research into practice. Activities
gic investment to improve and strengthen that prospectively test new protocols, or un-
production, control and regulation of snake dertake clinical trials of antivenoms, medical
antivenom products, promote greater col- interventions and drug combinations will be
laboration between industry and academia prioritized. The data generated will provide
and restructure the current fragile market to the evidence needed to design and deliver
increase supply, large parts of the world may clinical guidelines and protocols for integra-
soon face increasing shortages. One aim of tion into national health worker training pro-
the strategy is to make sure that by 2030 eve- grammes, and will indicate how infrastructure
ryone who needs antivenom has access to an and health systems need to be strengthened
affordable, safe, effective product. New and and changed by countries and regions.
emerging technologies may revolutionize the
treatment of snakebite envenoming, and in-
vestment in research to deliver “next-genera-
tion” treatments is important.
22 Snakebite envenoming A strategy for prevention and control

New and emerging

Poor-quality products undermine market
confidence, thus contributing to market fra-

technologies may gility and potential collapse. Initiatives will be

taken to strengthen antivenom manufacture

revolutionize the treatment and encourage innovation and moderniza-

tion. Strong manufacturers with quality-as-

of snakebite envenoming, sured products will contribute to re-establi-

shment of a sustainable antivenom market.
and investment in research
to deliver “next-generation” When patients and their families undergo fi-
nancial hardship in order to obtain antivenom,

treatments is important. use decreases and markets become fragile.

Patient outcomes worsen due to lack of pro-
per treatment and socioeconomic and pro-
ductivity loss costs to communities increase.
Cost-mitigation schemes will be established
Make safe, effective treatments available, to remove financial barriers, increase appro-
accessible and affordable to all. priate treatment-seeking behaviour and re-
sult in better clinical and socioeconomic out-
Global risk–benefit assessments of antivenom comes by reducing the numbers of deaths,
products will be conducted so that at least disability, socioeconomic hardship and loss
three quality-assured, appropriate antivenom of productivity.
treatments are recommended in each WHO
region. The assessments will indicate which Local political will and financial investment are
products are suitable for use on the basis of critical to the success of health interventions,
risk vs benefit and the issues in antivenom such as improving the availability, affordabi-
production that must be addressed. lity and accessibility of quality-assured an-
tivenoms. Long-term sustainability requires
Direct WHO action is needed to restore confi- local participation in solutions to ensure the
dence in the use of antivenoms and reshape supply of safe, effective antivenoms. The
regional antivenom markets. To counteract strategy will encourage political buy-in and
the current failure of the antivenom market commitment by national governments to es-
in sub-Saharan Africa, WHO-recommended tablish local policies and programmes for the
products will be provided through a revolving regulation, supply and distribution of antive-
supply facility, with an antivenom stockpile noms cost-mitigation and surveillance. New
programme established, initially for coun- public–private partnerships will emerge for
tries in sub-Saharan Africa, to deliver 10 000– antivenom production in low- and middle-in-
50  000 treatments from the pilot stockpile come countries, contributing to reaching the
in 2019–2020, up to 500 000 treatments a target of a 25% increase in the number of ma-
year by 2024 and contribute to the delivery nufacturers by 2030.
of up to 3 million treatments a year by 2030.
The outcome should be greater confidence, Improve control and regulation of
which will generate demand and extend the antivenoms.
availability, accessibility and affordability of
WHO-recommended antivenoms. Many regulatory agencies, drug control la-
boratories and health authorities lack the
Weak manufacturing leads to poor-qua- technical capacity to adequately regulate and
lity products that are ineffective and unsafe. control the safety, effectiveness and quality of
 Ensure safe, effective treatment 23

the antivenoms marketed in their countries. these materials as a further precursor to WHO
In many countries, products that are not sui- prequalification, in collaboration with techni-
table for use are marketed, with poor clinical cal partners and national drug control labo-
outcomes. Poor-quality products undermine ratories and health authorities. The process
market confidence, thus contributing to mar- for production and validation of reference
ket fragility and potential collapse. materials will be established by the WHO Ex-
pert Committee on Biological Standardization
The strategy will provide guidance, norms, (ECBS) in 2019; adoption of technical speci-
standards and technical support on antive- fications for individual venom and antivenom
noms to regulatory agencies, drug control reference standards endorsed by the ECBS
laboratories and health authorities to build in 2020–2022; and production of reference
their capacity to evaluate, license and mo- standards for WHO antivenom prequalifica-
nitor antivenoms in all regions. WHO training tion will start in 2023–2024. A WHO antive-
and laboratory services will support countries nom prequalification programme will then be
in comprehensive assessment of application established.
dossiers for product registration and marke-
ting approval and also in evaluation of com- Prequalification helps national regulatory
pliance with good manufacturing practice agencies and other organizations to make
and validation of product quality and appli- good-quality medicines available to those
cability. Inappropriate, unsafe or ineffective who need them. It also allows purchasers,
products will be removed from markets and donors and users to be confident that me-
replaced with products that meet appropriate dicines are safe, effective and made to high
standards of safety, effectiveness and quality. standards. Some organizations support the
procurement only of prequalified medicines.
Introduce prequalification for Introduction of prequalified antivenoms will
antivenoms. contribute substantially to rehabilitating the
antivenom market and ensuring its sustaina-
Target product profiles are not available for bility. Manufacturers will have access to an-
most of the antivenom products marketed tivenom prequalification in 2023–2024, and
in WHO regions, which has resulted in many products that meet the standards will be avai-
antivenoms that are inadequate for their in- lable for procurement. The demand for pre-
tended use. This contributes to poor outco- qualified antivenoms will stimulate the mar-
mes and loss of confidence by users. WHO ket, increasing the supply, affordability and
will work with technical partners to establish sustainability of well-designed, safe, effec-
minimum specifications for antivenom pro- tive, affordable antivenoms. Prequalification
ducts manufactured for specific purposes facilitates inclusion of antivenom products in
(e.g. broad-spectrum coverage against a programmes for financing medicines.
range of snake species) by 2020. Target pro-
duct profiles and minimum specifications will Encourage investment in innovative
be introduced in 2021 as essential prerequi- research on new therapeutics.
sites for introduction of a formal WHO antive-
nom prequalification scheme. Lack of investment restricts the ability of ma-
nufacturers to improve production, undertake
Reference standards for venoms and antive- research and development and finance es-
noms are essential for reliable, reproducible sential improvements to their infrastructure.
evaluation of antivenom products submitted Relatively modest investment into strengthe-
for prequalification. WHO will establish a new ning manufacturing and the development
process for the preparation and validation of and validation of new products is essential to
24 Snakebite envenoming A strategy for prevention and control
WHO will evaluate
antivenom
production to
ensure that safe
and effective
products are
available in all
regions of the
world.

© D.J. Williams
overcome the current supply crisis. Invest- needs of industry. Support for partnerships
ment in delivering new treatments that can and collaboration between academia and in-
be brought to the market now will immedia- dustry to strengthen, innovate, improve and
tely reduce mortality, morbidity and disabi- expand the production, quality control and
lity. The strategy will stimulate investment for preclinical and clinical testing and pharmaco-
rapid delivery of new treatments for snakebite vigilance of antivenoms and other treatments
envenoming in regions that currently lack ef- could lead to rapid improvements in access to
fective products. If manufacturers are able safe, effective antivenoms. The strategy will in-
to access capital to modernize production clude support for innovative and collaborative
infrastructure, introduce new technologies research between industry and academia. Re-
and invest in research, new products will be search and development into new products,
introduced in adequate quantities to overco- processes and other areas will accelerate, with
me the immediate chronic shortages, with support from research funding agencies.
measurable reductions in indicators.
Several exciting avenues of research have
Most manufacturers lack the resources for strong potential to deliver innovative therapeu-
innovative research, and academic research tics with better safety, efficacy and cost-effec-
on antivenoms is often poorly aligned with the tiveness in the medium to the long term, but
 Ensure safe, effective treatment 25

most currently lack investment to be com- kers to increase their knowledge and practi-
mercially viable. Support will be provided to cal clinical competence. Improved manage-
research and development into new techno- ment of snakebite envenoming and overall
logies and innovative treatments to revolutio- improvements in clinical practice will benefit
nize the management of snakebite enveno- all patients.
ming. Research funding agencies and other
stakeholders will be encouraged to increase Working health professionals require regular
investment in strategic research on new tech- in-service training in clinical skills for the ma-
nologies and therapeutics. New therapeutic nagement of snakebite envenoming. Many
candidates will be identified so that drug deve- rural health workers lack regular in-service
lopment pipelines can deliver these next gene- training. The skills relevant to snakebite enve-
ration treatments by 2030. noming are often multiple, and training there-
fore improves overall clinical practice. A num-
Integrate health worker training and ber of workforce training measures adopted
education. by Member States would directly improve and
standardize treatment and recovery.
Health workers receive little if any training in
diagnosing and treating snakebite enveno- Snakebite envenoming is poorly covered in
ming, and many have limited opportunities most of the tertiary and vocational training
for in-service professional development of curricula for health professionals. Graduates
clinical practice. Training packages should be are often poorly equipped to manage snake-
integrated into health worker curricula at all bite envenoming, and most have limited ex-
levels to improve the management of snake- perience. Integration of clinical toxinology
bite envenoming. Locally relevant training into training programmes will improve patient
packages will be prepared for all health wor- care and treatment at all levels. Integration of

Teaching health
workers to
properly treat
snake bites
provides them with
fundamental cross-
cutting clinical
skills.
© D.J. Williams
26 Snakebite envenoming A strategy for prevention and control

education on the prevention and treatment accurate and reliable, which will reduce treat-
of snakebite into medical, nursing and other ment delays and improve patient outcomes. A
schools, colleges and university curricula will framework will be developed for delivering in-
make health professionals better qualified novative new point-of-care diagnostic tools.
and more confident of their ability to manage
snakebite envenoming. Such efforts would Post-acute care and services for disability
benefit from clinical toxinology becoming a support and rehabilitation have long been
recognized medical speciality coordinated by neglected. Critical pathways should be refra-
a professional college or association as a for- med to include these elements of treatment
mal qualification. and recovery. Adoption of such measures by
Member States will directly improve and stan-
Few resources are available to help health dardize treatment and recovery, and more
professionals improve the care and treatment patients will have access to care and support
of snakebite envenoming. The availability of during recovery.
appropriate guidelines, resources and other
tools will improve clinical practice. Guidelines, Awareness will be raised about the rehabili-
resources and learning tools will be deve- tation needs of snakebite victims, and strate-
loped to improve and standardize the preven- gies will be found to increase access to re-
tion, clinical diagnosis, treatment, recovery habilitation services to accelerate recovery.
and rehabilitation of snakebite patients. Rehabilitation care providers will provide the
necessary services that will hasten recovery
Improve clinical decision-making, and a return to a productive life for snakebite
treatment, recovery and rehabilitation. envenoming patients who have experienced
disability.
The success of treatment can be evaluated
only if the clinical criteria for different enveno- Current medical management focuses mainly
ming syndromes are specified, yet these are on treatment in the acute phase and manage-
not available in many countries. Furthermore, ment in other phases such as post-discharge
lack of clear clinical end-points that define are often not included in the training of health
the effectiveness of treatment for these syn- professionals. The importance of after-care
dromes confounds objective assessment of should be included in management protocols
treatment success or failure and compari- to ensure that all snakebite patients are fol-
sons of effectiveness across different health lowed up. Follow-up will increase participa-
care settings and locations. Standardized, tion in care and rehabilitation during recovery,
objective clinical criteria will be defined for reducing morbidity and disability. More com-
envenoming syndromes in consensus do- prehensive snakebite envenoming manage-
cuments with clear clinical end-points for ment protocols, medical and health worker
treatment effectiveness. Health workers will training curricula, guidelines and tools will be
be better able to diagnose snakebite enveno- prepared.
ming objectively and identify specific clinical
syndromes, which will improve case manage-
ment. Standardized tools will be available to
support decision-making and improve treat-
ment outcomes, allowing more reliable analy-
sis and comparison of data.

Current point-of-care diagnostic tests for

snakebite envenoming could be made more
 Strengthen health systems 27

STRENGTHEN HEALTH
SYSTEMS

Snakebite envenoming is a serious medi- Strengthen community health services.

cal emergency, but most health systems are
unable to provide the services, personnel, me- Primary health care services for snakebite
dicines and technologies required to manage envenoming must be improved to ensure that
it effectively. Improving snakebite treatment facilities have the capacity and resources to
means strengthening the entire health care manage life-threatening medical emergen-
system, so that it will benefit everyone. Better cies associated with snakebite envenoming
disease surveillance and reporting systems, and are appropriated staffed. Strengthening
strong regulatory and policy frameworks, well- primary health care capacity, performance
trained staff working in well-equipped health and resources will increase the number of
facilities are necessary to improve the outlook services that can provide initial treatment of
for victims of all diseases, including snakebite. snakebite envenoming, including administra-
tion of antivenom and other life-saving inter-
For many, the costs of antivenom, other treat- ventions.
ments and hospitalization are beyond their
financial means. In countries such as India Snake antivenoms are only one of the es-
and Bangladesh, these costs have been sential medicines that may be needed in the
shown to drive people further into poverty and treatment of snakebite envenoming. Health
debt  (19,  21). The strategy encourages the es- facilities require many other drugs, items of
tablishment of initiatives to defray such costs. medical equipment and consumables to treat
Including snakebite treatment in professional snakebite envenoming and the full range of
insurance schemes (e.g. farm insurance) or, other medical conditions with which people
preferably, making treatment free of charge, present. Ensuring that all facilities have ac-
as in India, should be a priority (34). In coun- cess to these products will advance progress
tries where governments pay compensation towards universal health coverage by 2030.
for deaths and injuries caused by wild animals, The strategy will improve access to medi-
more efficient, cost-effective use of this fun- cines, medical products and consumables,
ding might be the provision of access to effec- with measurable improvement in access to
tive treatment, such as antivenom or ambu- essential medicines, including antivenoms,
lance services, and reimbursement of health and all other medical drugs, equipment and
care expenses. consumable items.
 28 Snakebite envenoming A strategy for prevention and control

The strategy
encourages the
establishment of
© D.J. Williams

initiatives to defray
treatment costs.

Facilitate research and policy conducted on the direct and indirect costs of
development to reduce treatment costs. treatment and recovery for victims of snake-
bite envenoming and into models for finan-
Most victims of snakebite envenoming are at cing and cost-mitigation schemes by public
or below the poverty index, and the cost of and private agencies.
treatment can be financially crippling, with
long-term effects on whole families. Bet- Inclusion of snakebite envenoming in sche-
ter understanding of the economic costs of mes for equitable access to health care,
snakebite envenoming and approaches to in- which remove the burden of poor families,
cluding it as a disease eligible for coverage by will encourage more victims to seek medical
public and private health finance schemes will treatment, resulting in better outcomes and
reduce the economic harm. Research will be reducing the long-term financial impacts.
 Strengthen health systems 29

Snakebite envenoming should be included crease access to effective health care, inclu-
in private and public health care funding ding transport, communications and support
mechanisms in countries and as an approved services, to improve access to health care for
condition in rural or agricultural health insu- all citizens.
rance programmes.
Many regulatory agencies, drug control la-
Governments in some countries have sche- boratories and health authorities lack the
mes to reduce or eliminate high treatment technical capacity to adequately regulate and
costs for snakebite envenoming. Extending control the safety, effectiveness and quality
the number of countries that prioritize a re- of antivenoms marketed in their countries.
duction or elimination of user-pays barriers to The solution will be to improve their capacity
access to antivenoms will contribute to achie- to undertake normative, regulatory and labo-
ving universal health coverage and influence ratory activities to improve access to safe, ef-
health care-seeking behaviour, thus reducing fective quality-assured antivenoms and other
the burden of snakebite envenoming on com- medicines.
munities. Economic models will be developed
to make a strong case for government sup- Innovative, validated systems for the procu-
port of programmes to reduce financial and rement, distribution and surveillance of an-
social vulnerability at the time of treatment tivenoms are important to overcome current
and throughout recovery. logistical, infrastructure and communications
difficulties in remote rural communities. Prag-
Improve infrastructure, services and matic investment in research for emerging
health facilities. technologies should be encouraged, such as
low-cost portable cold-chains, delivery sys-
Strong health systems are fundamental to tems and mobile surveillance and reporting
improving treatment of snakebite enveno- tools. Research will be conducted for better
ming. Rural primary health services, district implementation, monitoring and evaluation
secondary, sub-national and national tertiary of innovative interventions to improve distri-
health services can all improve treatment and bution systems and post-marketing surveil-
recovery after snakebite envenoming and lance of safety and effectiveness for antive-
should be strengthened in line with SDG3 and noms in health facilities and communities.
UHC2030. Targeted investment will be sought New approaches will be introduced for the
to build-up peripheral infrastructure and in- procurement, distribution and surveillance of
antivenoms.

Stronger, more effective supply chains and

Improving snakebite
surveillance systems will ensure that antive-
noms are accessible to all who need them.

treatment means Better procurement and distribution will re-

duce stock outages in rural areas, and better

strengthening the entire surveillance will identify problems in quality

and product safety more rapidly. National

health care system, so that drug procurement, distribution and surveil-

lance systems will be improved.
it will benefit everyone. Snakebite envenoming is rarely reported
either sub-nationally or nationally in most
countries. Better data collection and analy-
30 Snakebite envenoming A strategy for prevention and control

sis are essential for resource allocation and rate modelling of the economic, health and
investment. Common tools and applications social impacts of the disease. This will en-
and clearly defined minimum data set requi- sure that appropriate resources are allocated
rements, should be defined for assessing the and distributed to the countries and regions
burden of the disease in the health system in which the problem is most severe and will
and communities. Support will be provided accelerate implementation of the strategy for
to improve the capacity of health systems to control of snakebite envenoming. More accu-
collect, compile and analyse data on snake- rate sub-national, national, regional and glo-
bite envenoming. The success of the mea- bal estimates of the burden of snakebite en-
sure will be determined by the number of venoming the resources required and priority
countries that use new or repurposed data areas will be identified.
collection tools and applications to monitor
and assess the burden of snakebite enve- Snakebite envenoming, like many other
noming and the number that contribute data NTDs, is significantly under-reported, partly
on snakebite envenoming to the WHO Global because a large proportion of cases are not
Health Observatory. registered in health systems. The most accu-
rate data are those acquired from both health
Include snakebite envenoming in systems and communities, with various tools
national and sub-national health plans. and applications. Ensuring that data are stan-
dardized, comparable and reliable requires
Snakebite envenoming must be addressed to investment in data collection methods, tools
meet the SDGs and UHC2030. Integration of and applications. Robust, standardized ap-
snakebite envenoming into health plans en- plications, software packages, tools and di-
sures inclusivity and recognition that, as for sease surveillance systems will be developed
other NTDs, control of snakebite envenoming to improve the collection, storage, analysis
is essential to improve the lives of the world’s and reporting of snakebite envenoming.
poor.
Measurement of the burden of snakebite
Overall improvements in health systems be- envenoming requires application of a stan-
nefit everyone. In some regions, the effects of dardized minimum set of definitions, agreed
some types of snakebite envenoming require by consensus, harmonized epidemiologi-
additional resources, and some countries cal parameters, surveillance methods and
will require support. For example, long-term agreement to contribute data to a common
renal injury is a disproportionately prevalent global repository. This is essential to ensure
consequence of envenoming by certain that data are comparable at sub-national, na-
snake species in some countries, which re- tional, regional and global levels. Internatio-
quires substantial investment in specialist nally agreed standards will be established for
care and medical consumables. National and surveillance, guidance and harmonization of
sub-national level programmes to meet spe- strategies for snakebite envenoming. A mini-
cific needs and requirements should be sup- mum data set and definitions and standardiza-
ported by programmes, tools and resources. tion of common epidemiological parameters
will be agreed, with a snakebite envenoming
Enhance monitoring and surveillance of data repository within the WHO Global Health
the disease burden. Observatory and inclusion of queries on
snakebite envenoming in the questionnaire
Inclusion of snakebite envenoming as a no- for the Global Burden of Disease and other
tifiable disease will hasten accumulation of health surveillance projects. Agreed repor-
accurate data on disease burden for accu- ting parameters will then be incorporated into
 Strengthen health systems 31

Most of the antivenoms used

The current “gold standard” for testing the ef-
ficacy of antivenoms is in laboratory animals

today have not been tested in in vivo. New testing procedures to reduce or
eliminate the use of live animals in such re-

formal clinical trials, and the search will meet international commitments
to the principles of “replacement, reduction

evidence for the safety and and refinement” and may be more relevant
and cost-effective. The strategy will encou-
effectiveness of some is weak. rage research into preclinical models of an-
tivenom safety and efficacy. New preclinical
tests for the safety and efficacy of antivenoms
that adhere to new principles of animal tes-
sub-national and national health plans and ting will improve the quality and reliability of
disease surveillance programmes. preclinical test data and reduce the costs of
quality control testing.
Foster research on the ecology,
epidemiology, clinical outcomes and Most of the antivenoms used today have not
therapeutics of snakebite envenoming. been tested in formal clinical trials, and the
evidence for the safety and effectiveness
In most countries affected by snakebite en- of some is weak. Investment in pragmatic,
venoming, the quality and reliability of data cost–effective clinical studies of snakebite
are poor. In order to implement programmes envenoming will improve understanding of
and measure their effectiveness, a series of the disease in different countries and regions
benchmarks should be established based on and associated with different species of ve-
research in communities and health systems. nomous snake, in addition to providing good
Sub-national and national baseline data will evidence about specific antivenom products.
be published to establish benchmarks against Incorporation of cost data in clinical studies
which programmes can be evaluated. Inte- will allow better resource allocation by health
gration of consolidated baseline data into the ministries. The strategy emphasizes support
Global Health Observatory will allow establi- for preclinical and clinical research, including
shment of regional benchmarks. Improving clinical trials, to improve understanding of
the quality of data from countries or regions snakebite envenoming and the effectiveness,
where surveillance is particularly weak will en- safety and affordability of treatment. One out-
sure that gaps in knowledge about the burden come might be establishment of field centres
of snakebite envenoming are filled and that re- for snakebite envenoming clinical research
gional assessments are accurate and reliable. and sentinel clinical trial sites, with publication
of well-designed clinical studies of the safety,
There is substantial disparity between data effectiveness and costs of treatments or me-
acquired in communities and those acquired dical interventions. The data could be used to
from health systems, mainly because many inform policy, procurement, clinical care and
victims of snakebite envenoming do not pre- resource allocation decisions at sub-national
sent to health services. Research integrating and national level.
data from these two sources will provide a
more accurate assessment of the overall bur- The risk of snakebite envenoming is higher
den. Combined evaluation of data acquired in in populations in frequent contact with ve-
communities and in health systems will raise nomous snakes, such as those in certain
the priority of this disease and increase re- agricultural occupations, or who engage in
source allocation. high-exposure activities. Understanding of
 32 Snakebite envenoming A strategy for prevention and control
© D.J. Williams
 Strengthen health systems 33

The risk of snakebite

envenoming is higher in
populations in frequent
contact with venomous snakes,
such as those in certain
agricultural occupations, or
who engage in high-exposure
activities.
© D.J. Williams
34 Snakebite envenoming A strategy for prevention and control

the ecology and epidemiology of these inte- Operational research on the challenges to be
ractions can be used to frame interventions overcome to reinvigorate and rebuild a sus-
to reduce or eliminate these risks. Additional tainable market for antivenoms in regions
resources will be directed to areas in which such as sub-Saharan Africa will make it pos-
the incidence of snakebite envenoming is sible to plan interventions and strategies for
high because of occupational, environmen- implementation, development of a business
tal or behavioural factors. Epidemiological case and resource planning. Additional re-
research will be undertaken on the distribu- search will be conducted on the supply and
tion and factors associated with snakebite demand of health, socioeconomic factors,
envenoming in high-risk populations to iden- the economics of antivenom production and
tify occupations, behaviour and other factors barriers to efficiency, the antivenom mar-
responsible for risk and exposure. The data ket, needs, affordability and cost–effective-
will be used for risk mitigation, prevention or ness. Analysis will be conducted to better
elimination strategies and interventions. understand the market for antivenoms and
the forces that affect access and affordabi-
The incidence of snakebite envenoming is ra- lity. Tools will be found to acquire data on the
rely uniform throughout a country or a region. cost–effectiveness of antivenoms, and eco-
The distribution of venomous snake varies nomic analyses will be made of antivenom
according to ecological, geographic and en- production processes and recommendations
vironmental parameters. Climate, human po- to improve and rationalize production, reduce
pulation density, transport networks, land use costs and increase product quality and effi-
and habitat should all be better understood. cacy. “Forward-needs” assessment tools will
Research with geospatial and other tools can be developed to improve forecasting and re-
build a more accurate picture of the distri- source planning by procurement agencies.
bution of the incidence of snakebite enve-
noming and the reasons for it, and this can
be used directly to guide resource alloca-
tion and the design and use of interventions.
The outcomes might include production of
sub-national, national and regional maps of
snakebite envenoming incidence and other
metrics. Better geospatial understanding of
the determinants of snakebite envenoming will
improve resource allocation and the prioritiza-
tion of interventions, leading to new strategies
for prevention and control at all levels.
 Increase partnerships, coordination and resources 35

INCREASE
PARTNERSHIPS,
COORDINATION AND
RESOURCES

Transformation of the strategic objectives noming, the strategy will encourage national
into effective outcomes will require strong health authorities to identify and engage with
partnerships among WHO, Member States, relevant stakeholders, such as ministries of
development partners, donors and other agriculture, fisheries and natural resources,
stakeholders. The strategy will build such and perhaps assign them roles in implemen-
partnerships through advocacy, supported by tation of the strategy, especially in reducing
robust data, consensus and effective coordi- the incidence of snakebite and promoting
nation, monitoring and reporting. We will build early health-seeking in the communities they
a sound investment case for the strategy ove- serve.
rall and for its key activities. This will involve
collecting and analysing data from countries Support governance and leadership.
about the burden of snakebite envenoming
and how it changes over time with the inter- Snakebite envenoming is one of the many
ventions proposed in this strategy. Robust health problems facing the world’s poorest
health economics analyses of the cost–bene- citizens in some of the least developed coun-
fits and cost–effectiveness of certain actions tries. It is a disease strongly associated with
should persuade countries and development poverty and affects millions of people each
partners to support the strategy and its im- year. Ensuring that snakebite envenoming
plementation. is integrated into aspirations for universal
health coverage and the SDGs will ensure
Greater visibility and recognition of the di- that efforts to control snakebite envenoming
sease burden, coupled with strong invest- are accelerated and prioritized, so that all
ment to sustain the strategy and achieve its affected individuals and communities have
objectives will be essential. The focus will be access to good-quality essential health ser-
on integrating snakebite envenoming into pu- vices without suffering financial hardship. The
blic health programmes and into the health task will be to encourage country coordina-
plans of affected countries. tion to integrate snakebite envenoming with
other health activities for ensuring universal
The incidence of snakebite is affected by va- health coverage through better manage-
rious socioeconomic factors. While seeking to ment of resources. Snakebite envenoming
reduce the overall impact of snakebite enve- should therefore be integrated into national
36 Snakebite envenoming A strategy for prevention and control

health plans, regulatory systems and activity Promote advocacy, effective

frameworks, and policies should be adopted communication and productive
to improve affordable, equitable access to engagement.
essential health services for people affected
by snakebite envenoming. Strong advocacy is necessary to build a coa-
lition of partners and stakeholders to opera-
Supporting countries with tools for snakebite tionalize the strategy and raise the necessary
envenoming will help them to accelerate pro- resources and the profile of the disease suf-
gress towards meeting the overall objectives ficiently for sustainable change. Broad ad-
of UHC2030 and the SDGs for better health vocacy about snakebite envenoming should
outcomes for everyone. Health policy to im- be conducted to raise the awareness of all
prove the guidance, standards, norms and stakeholders. Advocacy and communica-
monitoring and evaluation frameworks is es- tion can result in tangible, measurable out-
sential for achieving UHC2030 and the SDGs. comes, including resource allocation and
Countries should incorporate snakebite initiation of projects in countries. A strong
envenoming into their SDG and UHC2030 coalition of countries, development partners
agendas and identify the actions necessary and stakeholders will be established and
to meet those objectives, with published re- extended over time.
ports of updated assessments and progress
to achieving the targets. Engagement with communities can be im-
proved by use of validated tools and informa-
Most countries in which snakebite enveno- tion resources tailored to contexts (e.g. lan-
ming is prevalent face similar development guage, cultural, social) and delivered by local
challenges. Many have weak regulatory “champions”, advocacy groups and activists.
frameworks and, particularly for antivenoms, A toolkit will be adopted to provide partners
limited capacity to regulate these essential with effective communications, training and
medicines effectively. Greater regional coo- learning solutions to ensure that the core
peration in the regulation of antivenoms, with messages are standardized and consistent
technical support from WHO, will strengthen across communities and countries. Tools and
their systems multilaterally. Strong regio- information resources will be prepared, with
nal regulatory frameworks should be esta- standard core messages that can be adap-
blished for accountable, evidence-based ted to different contexts. Networks of local
health systems and cooperative intersectoral partners will be established and empowered
partnerships between countries and other to engage with communities. The outcome
stakeholders. Regional regulatory pathways will be measured as improvements in use of
for the registration, evaluation and control prevention and risk-mitigation strategies.
of antivenoms will measurably improve ac-
cess to quality-assured, appropriate antive- Effective snakebite envenoming communi-
noms. Common registration pathways result cation and engagement is based on maxi-
in reduced costs and streamlined application mization of opportunities afforded by various
processes for manufacturers of antivenoms, forms of media, communication outlets and
thus facilitating wider market penetration of stakeholders in industry, business and go-
products. vernment agencies linked to or serving po-
pulations at risk. Provision of health promo-
tion information on snakebite envenoming to
communities can increase the effectiveness
of campaigns and other activities. Health
promotion strategies can be disseminated
 Increase partnerships, coordination and resources 37

Victims of snakebite
are typically young,
healthy, productive
members of their
communities, until
they are bitten.
© D.J. Williams
38 Snakebite envenoming A strategy for prevention and control

Enhance integration, coordination and

Supporting countries cooperation.

with tools for snakebite WHO will integrate its snakebite envenoming

envenoming will help them prevention and control programme into its
General Programme of Work to ensure that

to accelerate progress the activities are aligned with its objectives

and aims. It will also be aligned with relevant
towards meeting the overall regional and country health systems and

objectives of UHC2030 and partners. One of the outcomes will be an in-

crease in the number of WHO programmes

the SDGs for better health that incorporate snakebite envenoming ac-
tivities in their activities in the General Pro-

outcomes for everyone. gramme of Work.

WHO will identify synergies with other pu-

blic health programmes and leverage
partnerships to maximize the impact and
use of resources by addressing the overall
health needs of affected communities and
through mass and social media, educators, integrating snakebite envenoming into other
agribusiness, industry, labour unions, em- programmes, rather than working in isola-
ployers and governments. A comprehensive tion and potentially duplicating efforts. Mul-
communications strategy for snakebite en- tifocal partnerships will be formed to deliver
venoming will be prepared, with core media coordinated solutions, identify synergies in
materials and resources. Regional health human and animal health programmes and
promotion will be conducted in collaboration provide technical support for the integra-
with countries, with targeted activities for tion of snakebite envenoming into existing
high-risk communities. health programmes. The outcomes should
be measurable increases in international col-
The strategy is central to WHO’s response to laboration and cooperation among countries
World Health Assembly resolution WHA71.5, and development partners, and productive
and active engagement with Member States cooperation between WHO with other pu-
and other stakeholders is essential to imple- blic health or disease-specific initiatives that
menting the resolution. Information about the address common challenges.
strategy and progress being made will encou-
rage its uptake in other countries and provide Build strong regional partnerships and
an incentive for other stakeholders to engage alliances.
and participate. More dialogue between WHO
regional and country offices, Member States Countries in some regions have the same
and focal points will raise the profile of snake- requirements for antivenom and face simi-
bite envenoming and advance the activities in lar technical and health systems challenges.
the strategy. Member States should allocate WHO will work with countries to find coopera-
resources to support implementation of the tive activities for addressing common issues
strategy by WHO. Engagement with other and deliver solutions to shortages of antive-
stakeholders can lead to productive collabo- nom and problems with supply, production or
ration on projects and allocation of resources quality. WHO will also work with neighbouring
to support WHO activities. countries with the same venomous snakes
 Increase partnerships, coordination and resources 39

and the same challenges to clinical care and Establish a strong, sustainable
treatment to find regional solutions. It will col- investment case.
laborate to establish regional cooperation
projects for improved antivenom production There are currently few high-quality data on
and create antivenom stockpiles, training and which to base a strong health economics ar-
technical support. These activities should re- gument to prioritize funding for snakebite en-
sult in partnerships and regional collaboration venoming. Addressing this deficiency is es-
to improve and sustain adequate supplies of sential to finding the resources to implement
effective antivenoms. Regional technical as- the strategy and to fund commodities such as
sistance and training programmes will improve antivenoms. A strong investment case should
prevention and control of snakebite enveno- be prepared to ensure adequate resources
ming and sustain reductions in morbidity, di- for the programme, based on robust data and
sability and mortality. Other bilateral and mul- analysis of cost–benefit and cost–effective-
tinational projects and partnerships will also ness. Data can be analysed and modelled to
promote the objectives of the strategy. prepare an investment case for countries and
funding partners to fund specific strategic
Coordinate data management and projects, activities and human resources.
analysis.
The business case for the prevention and
WHO will use the Global Health Observato- control snakebite envenoming will be sup-
ry and other resources to establish a central ported by data demonstrating the economic
repository for data on snakebite enveno- and health benefits of integration of snake-
ming that is open and accessible to all inte- bite envenoming into health systems, by
rested parties. This will ensure that data are combining control of this disease with that of
collated and available for analysis and that other NTDs, which are often prevalent in the
the results can be extracted and used for same communities affected by snakebite en-
evidence-based decision-making. Essential venoming. Implementation research should
data will be captured, analysed and stored be conducted to demonstrate the benefits of
in accessible repositories. Standardized na- integration with the control of other NTDs and
tional, regional and global data on snakebite medical conditions. This will stimulate new
envenoming will be deposited in the Global partnerships and collaboration with other
Health Observatory, and data analyses will be health groups and progress to the elimination
published regularly to inform decision-ma- or control of several NTDs and other health
king. and development issues in affected commu-
nities.
The 11th edition of the International Classifi-
cation of Diseases (ICD-11) contains global In addition to the resources required by WHO
health information, in which clinical and epide- to implement the strategy, funding will also be
miological parameters and causes are coded. required to purchase and distribute commo-
It can provide data that can be used to unders- dities, finance national prevention and control
tand the etiology of snakebite envenoming activities, regional cooperation, research in-
and its outcomes. By ensuring that snakebite vestments and capital to fund manufacture
envenoming is correctly classified in this re- of therapeutics and other activities. Coordi-
source and encouraging increased use of nation of investment and resource mobiliza-
ICD-11 for coding presentations of snakebite tion and a framework to track, monitor and
envenoming to health services better-quality coordinate activities among all stakeholders
hospital-acquired data will be obtained. will allow WHO to monitor and evaluate imple-
mentation of the strategy nationally, regionally
40 Snakebite envenoming A strategy for prevention and control

and globally and create a dynamic network One reason for considering snakebite enve-
of stakeholders as the strategy moves towar- noming as an NTD is the substantial disparity
ds its 2030 goals. A framework will there- between the extent of the problem and in-
fore be established to coordinate invest- vestment in research. WHO recognizes that
ment, resource mobilization, collaboration, research is fundamental to effective control of
knowledge exchange, engagement and im- NTDs such as snakebite envenoming. Invest-
plementation at country and regional levels. ment by research funding bodies and other
WHO will maintain a clear view of progress agencies in a range of topics to inform deci-
towards the 2030 goals and make use of in- sion-making, improve surveillance, change
formation to update and modify the strate- behaviour, deliver new treatments or improve
gy according to the progress made and the understanding of the clinical effectiveness
opportunities, obstacles and challenges en- and safety of antivenoms will contribute si-
countered. Strong coordination mechanisms gnificantly to achieving the objectives of the
will be established to ensure that resources strategy. Funding for research on snakebite
are used strategically, with minimum dupli- envenoming will be sought in accordance
cation, and that stakeholders have access to with the priorities highlighted in this strategy
information that stimulates partnership and and particularly to improve existing antive-
collaboration. Resource wastage will be mi- nom production technologies and products.
nimized and opportunities for collaboration, Funding agencies should commit themselves
knowledge exchange, investment and impro- to increase support for research on snakebite
ved resource maximized. envenoming and to deliver solutions to spe-
cific problems, including modernization and
improvement of current antivenom produc-
tion technology and antivenom products.
 Planning, monitoring and evaluation 41

PLANNING,
MONITORING AND
EVALUATION

WHO, in collaboration with partners, will pre- haviour will succeed. Likewise, greater use of
pare a framework for planning, monitoring allopathic health services and of antivenom
and evaluation for critical assessment of resulting from community engagement will
the strategy over time. As the plan is to de- increase the demand for antivenom and the
liver local solutions in the countries in which reversal of the current vicious circle that has
snakebite envenoming is a problem, monito- precipitated the current crisis in antivenom
ring and evaluation should be part of national supply in sub-Saharan Africa and other re-
plans. These activities will require collection of gions.
baseline data in order to measure progress in
programme activities and work plans tailored The planning, monitoring and evaluation
to the objectives of each country. Progress framework will be prepared during the initial
towards the objectives will be measured re- phase of the strategy and updated throughout
gularly, and annual reports will be issued and the programme. As baseline data and data
made publicly available. on progress improve, the framework will be-
come a composite of general elements and
For each of the four strategic objectives, we context-specific components.
will prioritize a pathway of change for short-,
medium- and long-term outcomes. The tasks Planning
to be undertaken in pursuit of these objectives WHO will prepare outcome-based work
will deliver both independent and interconnec- plans for implementation of the phases of
ted results, synergistically strengthening each the strategy. Interventions will be planned in
other and progress towards the 12-year tar- context-specific frameworks, and a “SMART”
get. While the pathways to the objectives are (specific, measurable, achievable, relevant,
non-linear and outcomes will probably be time-bound) approach will be used to achieve
reached at different times, they complement short-, mid- and long-term outcomes. Each
and support the overall goals, such as impro- component will be integrated into a risk miti-
ved antivenom products, better trained health gation matrix, and actions taken to ensure that
workers and health facilities with resources to risks are appropriately managed. Timelines,
manage snakebite envenoming, which are budgets and deliverables will be mapped and
essential for ensuring that community enga- resources identified and secured. Planning will
gement to change health care-seeking be- be updated annually or as necessary.
42 Snakebite envenoming A strategy for prevention and control

Monitoring WHO will work with countries and partners in a

A monitoring framework will be prepared, with structured approach to defining baseline data
indicators for each outcome to track progress requirements and the processes for acquiring
through a range of data sources and appro- and analysing the information. Various types
priate verification methods. Reports and data of data will be required to measure progress,
will be collected and aggregated regularly to which will be acquired with standard research
track overall and context-specific progress. methods, tools and applications based on
consensus. They include:
Evaluation • accurate data on burden of disease (i.e.
WHO will evaluate progress towards objec- incidence, morbidity, disability and mor-
tives and outcome targets, with particular tality) for geographically defined subna-
attention to the relevant indicators of SDG 3 tional, national and regional areas;
and WHO’s Thirteenth General Programme • access to data on antivenoms and other
of Work 2019–2023 (and subsequent Pro- commodities used in the treatment of
grammes of Work). Evaluations will be made snakebite envenoming;
at the end of each phase of the strategy to • data on community prevention, health
clearly understand progress and achieve- care-seeking behaviour and sociocultural
ments nationally, regionally and globally to perceptions of snakebite events and their
achieving the goal. consequences;
• analysis of the capacity and needs of na-
WHO will prepare an adaptable template of tional and local health systems;
the theory of change to enhance implemen- • analysis of gaps in antivenoms produced
tation of the strategy by matching context and by good manufacturing practice;
assumptions with a logic model for mapping • assessments of the clinical skills and
the sequence of steps, actions or milestones knowledge of health workers; and
for short-, medium- and long-term outco- • evaluation of the shortfalls in regulatory
mes. Application of the theory of change will agency capacity, training and resources.
strengthen planning, monitoring and evalua-
tion and ensure that the best approaches are
used to achieve the outcomes and objectives.
 Managing risk 43

MANAGING RISK

WHO will use a robust model of risk mitigation sessed regularly. WHO will also use validated
in the programme, to identify risks, assess risk assessment tools to manage external
their likelihood and possible consequences factors that may represent risks to the overall
and then find strategies to minimize or eli- strategy or to individual components by iden-
minate them (Fig. 3). Internal factors within tifying them early and reducing or removing
WHO that might affect implementation of the their likelihood. Partners and stakeholders
strategy will be evaluated and measures put in will be consulted regularly.
place to address them. The risks will be reas-

CONSULTATION AND COMMUNICATION

RISK ASSESSMENT
Context Risk Risk Risk
identification analysis evaluation RISK
TREATMENT

MONITORING AND REVIEW

Fig. 3. Model of risk mitigation for snakebite envenoming strategy

44 Snakebite envenoming A strategy for prevention and control

In assessing risks, WHO will use a matrix Table 1. Matrix of likelihood of a risk and the
to identify the likelihood (probability) that severity of its consequences

a risk will arise and evaluate the severity

of the consequences and the effect on the Likelihood Consequences
programme overall or on a specific project
(Table  1). The urgency with which speci- 1 Rare 1 Negligible
fic risks are addressed will be based on risk
ratings, the highest priority being given to 2 Unilkely 2 Minor
events that combine the highest likelihood
with the greatest impact. Consultation, moni- 3 Possible 3 Moderate
toring and regular review will ensure that risks
are managed pragmatically and strategically. 4 Likely 4 Major

With partners and other stakeholders, WHO 5 Expected 5 Severe

will ensure that the strategy is technically
sound at all times and addresses the objec-
tives to effect lasting, sustainable change.
Regular progress reviews and consultation
with experts in relevant fields will ensure that
risks are managed effectively.
 Costs 45

COSTS

WHO activities between 2019 and 2030 will US$ 2.85 million will be used to assess the
requires US$ 136.76 million in direct support. safety and effectiveness of currently available
The budget is incremental and annual costs antivenoms, to set up a trial antivenom stock-
will increase as the strategy is extended and pile for sub-Saharan African countries where
more countries are included (Fig. 4). A key access to antivenom is very limited and to
consideration in estimating the budget was improve antivenom manufacture, innovation
that actions are conducted with strong pa- and modernization. Another US$ 1.21 mil-
rallel regional coordination and collaboration. lion will be used to improve the treatment of
Consequently, 54% of the total budget over snakebite envenoming from first-aid before
12 years is for work in countries and 17% for admission to hospital through discharge and
regional activities (Fig. 5). subsequent return to normal life. Encoura-
Prevention and control of snakebite enveno- ging the development of new therapeutics,
ming will be integrated into broader national improving disease burden surveillance and
and sub-national health plans and into pro- ensuring coordinated data management and
grammes for improving health objectives and analysis will require US$ 1.84 million, and pre-
meeting needs. This approach will reduce paring and validating a strong, sustainable in-
duplication and maximize the impact in all af- vestment case for the programme to give do-
fected countries. A detailed case for the value nors confidence to support the interventions
of investment will be prepared in the first year will cost US$ 0.57 million.
of the programme. Regular planning, moni-
toring and evaluation and biannual budget An economic model for supplying up to 500
reviews will ensure that the strategy remains 000 effective antivenom treatments a year to
responsive and adapted to economic and sub-Saharan Africa will be designed during
other circumstances. the pilot phase. Additional funding for a sup-
ply of antivenom commodities will probably
PILOT PHASE (2019–2020): WHO will re- be sought from donors and governments in
quire US$ 8.96 million in 2019–2020 for the the affected regions. The cost of supplies for
pilot phase, in which communities and health the trial antivenom stockpile of 50 000 treat-
systems will be strengthened in 10–12 coun- ments for the 10–12 trial countries is expec-
tries where snakebite envenoming is a public ted to be US$ 6.0–7.2 million.
health problem. Highlights: Approximately
46 Snakebite envenoming A strategy for prevention and control

Fig. 4. Funding requirements during the three phases of the

strategy, for regions, countries and WHO technical divisions

PILOT PHASE SCALE-UP PHASE FULL ROLL-OUT

(20192020) (20212024) (20252030)
US$ 8.96 million US$ 45.44 million US$ 82.36 million

0 10 20 30 40 50
Million US$

Empower and
engage
communities

Ensure safe,
effective
treatment

Strengthen
health systems

Increase
partnerships,
coordination
and resources

National funding Regional funding WHO technical unit funding

 Costs 47

0 5 10 15 20 25
Million US $

Ensure active community engage-

ment and participation
Improve prevention, risk reduction and avoidance of EMPOWER
snakebite envenoming AND ENGAGE
Ensure effective pre-hospital care and COMMUNITIES
ambulance transport

Accelerate development of pre-hospital treatments US$ 26.21 m

Improve health care-seeking behaviour

Understand socio-cultural and economic factors that

affect outcomes

Make safe, effective treatments available, accessible

and affordable to all

Better control and regulate antivenoms

ENSURE SAFE,
Prequalify antivenoms EFFECTIVE
TREATMENT
Invest in innovative research on new therapies
US$ 49.73 m
Integrate health worker training and education

Improve clinical decision-making, treatment,

recovery and rehabilitation

Strengthen community health

services
Facilitate research and policy to
mitigate the costs of health care STRENGTHEN
Improve infrastructure, services HEALTH
and health facilities SYSTEMS
Ensure implementation within national
and subnational health plans US$ 36.64 m
Enhance disease burden monitoring and
surveillance
Facilitate research on the ecology, epidemiology, clinical
outcomes and therapeutics of snakebite envenoming

Support governance and

leadership
Promote advocacy, effective communication
INCREASE
and productive engagement
PARTNERSHIPS,
Enhance integration, coordination and COORDINATION
cooperation
AND RESOURCES
Build strong regional partnerships and
alliances
US$ 23.27 m
Coordinate data management and analysis

Establish a strong, sustainable investment case

Fig. 5. Total programme cost to 2030: US$ 136.76 million

48 Snakebite envenoming A strategy for prevention and control

SCALE-UP PHASE (2021–2024): As ano- FULL ROLL-OUT PHASE (2025–2030):

ther 35–40 countries are added to the pro- Community activities and health system im-
gramme, an additional US$ 45.44 million provement will be extended to up to 80 more
will be required. Highlights: US$ 6.71 mil- countries during this period, requiring the
lion will be for community engagement, US$ commitment of another US$ 82.36 million.
8.49 million for health systems and US$5.29 WHO recognizes that significant changes may
million for monitoring, surveillance and ana- occur in global, regional and even national
lysis of the burden of snakebite envenoming economic and geo-political circumstances
to ensure that data continue to improve, for during the 6-year period; consequently, this
accurate forecasting of priorities, resources costing is only an estimate based on current
and activities. WHO will continue to ensure predictions of global inflation and expected
that antivenoms and other treatments are programme progress. Planning, monitoring
safe, affordable and accessible, including a and evaluation of the phases of the strategy
prequalification programme for products and and a commitment to regular updating of the
additional commitment to access to antive- investment case and the programme strate-
nom stockpiles. These activities will require gy will help to ensure that they are dynami-
US$ 11.47 million over 4 years. Improvements cally responsive to any change. The mid- to
to first-aid and hospital treatment for snake- long-term budget will be adjusted accor-
bite, development of new treatments and dingly over time. Highlights: WHO’s work
health worker training and support will require with communities and health systems in all
US$ 6.37 million. US$ 0.80 million will be the affected countries will ensure advance-
spent to ensure a sound investment case that ment towards the SDGs and achievement of
reflects current circumstances. Monitoring universal health coverage. Community activi-
and evaluation of activities to meet all four ties will cost an estimated US$ 11.35 million
objectives will provide the data necessary for and health systems strengthening another
effective planning and review. US$ 6.35 mil- US$ 14.62 million. A full-scale WHO prequa-
lion will be required for increasing programme lification scheme for antivenoms and other
governance and leadership for the extended activities to ensure the safety, quality and
investment and greater communication, en- effectiveness of these essential medicines
gagement, integration and partnership deve- will cost US$ 23.61 million. As the impact of
lopment over the 4-year period. the investment is seen, a sustainable supply
of effective products will become available in
all regions of the world. Disease monitoring,
surveillance and analysis will require funding
of US$ 8.08 million, maintaining the momen-
tum of the global partnership will require US$
11.15 million and sustaining better first-aid,
and medical care, training and introduction
of new therapeutic solutions will account for
US$ 12.09 million).
 References 49

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The core of the strategy is the goal for
all patients to have better overall
care, so that the numbers of deaths and
cases of disability are reduced by 50%
© D.J. Williams

before 2030.
 SNAKEBITE ENVENOMING
A strategy for prevention
For millions of men, women and children
around the world, the risk of snakebite and control
is a daily concern as they go about their
everyday activities where a misplaced step,
a momentary lapse of concentration or
being in the wrong place at the wrong time
can be fatal.

Department of Control of Neglected Tropical Diseases

World Health Organization ISBN: 978-92-4-151564-1

20, Avenue Appia

CH-1211 Geneva 27
www.who.int/neglected_diseases/en
www.who.int/snakebites/en

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