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Grave warnings from snakebite experts as minister of health is asked to intervene in antivenom crisis

Grave warnings from snakebite experts as minister of health is asked to intervene in antivenom crisis
Estelle Ellis
By Estelle Ellis
5 Apr 2023
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Trauma specialists, snakebite experts and emergency responders have asked the minister of health, Dr Joe Phaahla, to intervene in the ongoing snakebite antivenom crisis in South Africa and outsource production of the life-saving medicine if the country cannot continue producing it.

The National Snakebite Advisory Group (NSAG), appealed to the minister of health, Dr Joe Phaahla, in an open letter on Wednesday to intervene and ensure funding and emergency upgrades of equipment and backup power supply at the South African Vaccine Producers’ (SAVP’s) production plant.

SAVP falls under the National Health Laboratory Service and manufactures snake antivenom for sub-Saharan Africa including a polyvalent antivenom that can treat bites from the black mamba, green mamba, Jameson’s mamba, Cape cobra, snouted cobra, (Egyptian cobra), forest cobra, gaboon viper, Mozambique spitting cobra, puff adder and rinkhals. It also makes a monovalent antivenom for boomslang bites and one for the bite of the saw-scaled viper found in countries north of South Africa.

Outsourcing


The letter urges the minister to consider outsourcing the production of snake antivenom for sub-Saharan Africa until the crisis is resolved.

“There is a serious risk of death from black and green mamba, Cape cobra and limb loss from other cytotoxic venomous snakes,” the letter states. Cytotoxic venom causes necrosis of body tissue.

“While boomslang bites are less common, they require a specific antivenom. Children, in particular, are at high risk of poor outcomes from a snakebite. Patient medical management, hospital length of stay, morbidity and mortality are all adversely affected without early and appropriate administration of antivenom, an essential component in the clinical management of snakebites over the last few decades,” the letter continues. 

“The inability and lack of expected delivery of antivenom, therefore poses a major health risk, despite the drug being an essential listed drug on the Essential Drug List. While we appeal for the minister to intervene … we also implore the minister to ensure that the procurement processes are effectively and compliantly performed so that the unreliable machines, backup generators, and uninterrupted power supplies are made available and to ensure that reagents and other essential production items are procured to assist to enhance production, and the release of batches are made available in sufficient volume to restock the country.  

“We also propose an investigation of the outsourcing of production to recently built pharmaceutical production operations established in other parts of the country as a longer-term solution, and the potential identification of alternative products that cover our southern African snakes and that are reliable to provide an option until this shortage is resolved. 

Precautionary measures


“We would appreciate a response to us and ideally a public statement warning the public to be careful when in the natural environment and take the necessary precautionary measures. We as the National Snakebite Advisory Group and the leaders of emergency medicine, trauma surgery, and critical care across South Africa implore you to act before lives and limbs are lost. 

“There is no suitable alternative product approved for use in this country (even under Section 21), nor is there truly a reliable alternative for the Echis (saw-scaled viper) bites common north of our borders. 

“While we acknowledge that batches of antivenom have recently been released, many public and private facilities have run out of stock, while others have limited stock unable to treat even one snakebite patient effectively.

“The concern and challenge is the unreliable production of the SAVP/NHLS antivenom products due to management, staffing constraints, animal welfare, unreliable generator capacity, machine breakdowns, and refrigeration issues. 

“There were limited numbers of vials of polyvalent product left in SAVP stores and large backlog orders that have still not been filled, with limited volumes in stock at a number of the public and private hospitals, while some facilities have already run out of stock in high snakebite areas which cannot be replenished. This is not to even mention the need for veterinary use, especially with dogs that are bitten,” the letter concludes. 

‘Antivenom doses are being manufactured’


On Wednesday night, the National Health Laboratory Service (NHLS) insisted that “there is snakebite antivenom available in South Africa and more snakebite antivenom doses are being manufactured”.

The spokesperson for the NHLS, Mzimasi Gcukumana, said the NHLS “recognises and appreciates the public’s concern about the current antivenom shortage and had distributed 1,077 vials of snake antivenom since Monday”. 

That is close to what they have managed to make and distribute in four months from December to the end of March (1,422 doses). 

Read more in Daily Maverick: Nationwide snake antivenom stockpile shortage an ‘absolute catastrophe’ – reptile expert  

“The NHLS management is addressing this matter with the utmost urgency and is actively working to resolve it. The problem is that we need a consistent and dependable power supply to produce antivenom. The continuous switchover to generators during power outages interrupts production which impacts productivity and maintaining a stockpile,” said Gcukumana.

To put the numbers in perspective, the Western Cape alone, where certain hospitals were identified as facilities that must have a minimum of 15 vials of polyvalent antivenom, would need 345 vials of antivenom as a minimum.

Naude said on Sunday that veterinarians countrywide had run out of stock and snake catchers had back orders for thousands of vials that have not been delivered.

“This life-saving medication is especially important in remote areas where medical services are limited. We are working tirelessly to provide this life-saving treatment for snake bites to all, including animals, regardless of location,” Gcukumana said.

Ministerial statement pending…


National Department of Health spokesperson Foster Mohale has not answered questions on the issue since Monday, but promised a statement from the minister would arrive on Wednesday night. It has not yet been distributed.

“Antivenom is a critical life-saving treatment in patients bitten by venomous snakes and has excellent outcomes when used timeously and correctly,” said Professor Timothy Hardcastle, co-chair of NSAG.

Hardcastle said the main source of reliable cost-effective antivenom against the common major venomous snakes in South Africa and other parts of the continent is the SAVP group of products, namely the 10-snake polyvalent, the Echis monovalent and the Boomslang monovalent antivenoms. 

“Unfortunately, there is no suitable alternative product approved for use in South Africa — even under Section 21. At present, our greatest concern and challenge is the unreliable production of the South African Vaccine Producers’ products due to management, staffing constraints, animal welfare, unreliable generator capacity, machine breakdowns, and refrigeration issues.

“There has been a promise of the product since December 2022… at present, extremely limited numbers of polyvalent vials are left in the South African Vaccine Producers stores…. Certain public and private hospitals — many situated in high snakebite areas — have already run out of stock while others have precious little antivenom on hand. 

“There is also a shortage of antivenom among veterinarians who are currently unable to acquire any antivenom. There is no sign that these will be replenished any time soon,” he said.  

“We as the National Snakebite Advisory group and the leaders of emergency medicine, trauma surgery, and critical care across South Africa implore the minister to act before lives and limbs are lost.”  

The letter by the National Snakebite Advisory Group to the health minister was signed by the country’s foremost snake experts and trauma specialists: 

  • Prof Timothy Craig Hardcastle, co-chair of NSAG; 

  • Prof Andreas Engelbrecht, co-chair of NSAG from the Steve Biko Academic Hospital and Head of Emergency Medicine, University of Pretoria;

  • Prof Fathima Paruk, president, Critical Care Society of Southern Africa and intensivist at Steve Biko Hospital and University of Pretoria; 

  • Prof Feroza Motara, president, Emergency Medicine Society of SA;

  • Prof Maeyane Steven Moeng, president, Trauma Society of SA;

  • Mande Toubkin, National Trauma and Transplant Manager of the Netcare Group; 

  • Prof Vidya Lalloo, specialist in emergency medicine at Steve Biko Academic Hospital; 

  • Dr Sharadh Garach, chief specialist in emergency medicine at the KwaZulu-Natal Department of Health; 

  • Prof George Oosthuizen, head of surgery at Ngwelezana Hospital, Empangeni; 

  • Dr Morné Strydom, Snake Venom Research Interest Group, Department of Pharmacology, University of Pretoria;

  • Dr Cindy Stephen, Red Cross Hospital Poisons Information Centre/UCT; National 24/7 Poison Information Helpline; 

  • Dr Jenna Taylor, head of clinical unit division of Paediatric Anaesthesia at the University of KwaZulu-Natal;

  • Nic van der Walt, ECP, Access Professional Development, snakebite retrieval team member; 

  • Maqshuda Kajee, emergency nurse specialising in snakebites and a member of the snakebite retrieval team;

  • Bernard Segal, emergency care practitioner and member of the Hatzolah volunteer team for Emergency Medical Services;

  •  Dr Christoff Bell, rural hospital GP snakebite expert, Mosvold Hospital KZN; 

  • Dr Sian Geraty, emergency medicine specialist at Livingstone Hospital in the Eastern Cape;

  • Dr John Bruce, surgeon at Grey’s Hospital in KwaZulu-Natal;

  • Hiral Naik, herpetologist, Save the Snakes, University of the Witwatersrand; 

  • Dr Jessica Briner, veterinarian, Briner Veterinary Services; 

  • Chris Cooke, herpetologist, Hoedspruit Reptile Centre; 

  • Arno Naude, Snake Bite Assist; 

  • Mike Perry, African Reptiles and Venom; 

  • Chris Hobkirk, Lowveld Venom Supplies; 

  • Johan Marais, African Snakebite Institute; 

  • Jason Seale, Hartbeespoort Animal and Reptile Park; and 

  • Kaleb Lachenicht, Rocket Helicopter Emergency Services. DM/MC

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