Nationwide snake antivenom stockpile shortage an ‘absolute catastrophe’ - reptile expert

2 Apr 2023

Amid a frantic scramble for snake antivenom in South Africa, snake bite victims are receiving half the prescribed dose - that’s if they’re lucky to be treated at all. Desperate veterinarians, meanwhile, are using expired doses to save pets bitten by snakes

South Africa used to have five years of antivenom in stock. Now, that stock has dwindled to almost nothing.

“This is not a shortage. It is an absolute catastrophe,” according to Arno Naude from Snake Bite Assist. Naude has been assisting doctors and veterinarians with snake bite treatment for the past 15 years.

He said some hospitals were rationing the few vials of snake antivenom they had left, giving minimal doses to snake bite victims, hoping it would be sufficient to pull them through. Vets all over South Africa had run out as well.

By Sunday night, Naude had received word that there was no more antivenom that could be distributed.

“So, what we have is all we have and when that is gone we are in serious trouble. It is not time to panic but it is time to avoid getting bitten at all costs,” Naude said.

He said if a patient was bitten multiple times they might need upwards of 20 vials of antivenom to save them.

“We had a guy bitten by a black mamba come in. He was already shaking and sweating. He was bitten three times. It took 23 vials of antivenom to save him.

“That was then; now we are now struggling like crazy and giving seriously sub-optimum dosages,” Naude said.

Ten to 12 people die of snake bites every year in South Africa, but industry experts now fear that unless the antivenom crisis is addressed with speed this number will increase dramatically.

Two types of snake antivenom are produced in South Africa. Polyvalent antivenom is used to treat snake bites from the black mamba, green mamba, Jameson’s mamba, Cape cobra, forest cobra, snouted cobra, Mozambique spitting cobra, rinkhals, puff adder and the gaboon adder. The second type is the monovalent vaccine made to treat the bite of a boomslang.

The polyvalent antivenom particularly is in short supply. Naude said rural hospitals, where snake bites are more often treated, were the worst affected.

“There isn’t any time to get doses from elsewhere. If you were bitten by a spitting cobra, for instance, and it takes six to eight hours for the antivenom to get to the hospital, the damage will be done.”

‘Rolling blackouts to blame’

The spokesperson for the National Health Laboratory System (NHLS), Mzimasi Gcukumana, confirmed there was a severe shortage of antivenom and cited rolling blackouts as a major cause. South African Vaccine Producers, the only manufacturer of snake antivenom in the country, falls under the NHLS.

“We are aware of the shortage and are working around the clock to resolve the issues that we have encountered … and while some successes have been achieved, the electricity disruptions continue to have a significant impact on our output.

“The antivenom production process requires a continuous power supply, and the switchover to generators during power outages has had an impact on our equipment. While the National Health Laboratory Service has generators and uninterrupted power supply [UPS] systems, we are purchasing more backup UPS systems, increasing the capacity of our backup generators, and investing in new equipment (including solar power and inverters) to address these energy challenges.

“It is envisaged that clearing the backlog and resuming stockpiling will take approximately two months. There is stock of antivenom currently in production, and stock is always available for emergency cases,” he said.

Gcukumana said antivenom had been dispatched to 45 sites in the past week, including public and private hospitals and veterinarians.

“There will be more antivenom vials distributed next week, and we have a large number of doses in the production phase.”

Naude said on Sunday, however, that he did not know of a single vet in South Africa who could treat an animal bitten by a snake. “A large percentage of hospitals also have no antivenom whatsoever. We are using expired anti-venom on people. Onderstepoort doesn’t have a single vial.”

He said people were importing antivenom from India in desperation.

“Today, about two hours ago someone was bitten by a snake. We usually start with six vials of antivenom. The hospital only had two. Yesterday in Rustenburg, a man was bitten by a snake. The hospital turned him away because they didn’t have their own antivenom and they wouldn’t use the antivenom he had in his possession.

“I paid R30,000 in August for an order of antivenom. I still haven’t received it,” he said.

Public health crisis

“This is a huge, urgent and pressing public health crisis,” Naude said. “The people who are suffering the most are not glamorous or well-known. People in rural areas are badly affected … If one of the Ministers’ kids got bitten tomorrow this problem will be solved in a second.”

He said without antivenom, patients often lost limbs.There was a high suicide rate among snake bite victims, even with mental health assistance, because of the debilitating after-effects such as phantom pains and kidney problems. “Breadwinners are most often affected because they are the ones working out where the snakes are,” he said.

“We used to supply the sub-Saharan countries with antivenom. Now we are struggling to get a single vial of it.”

He said pet owners were also suffering. “This week alone we had 12 dogs bitten. Three survived. The owners phone me … crying on the phone. I have nothing to give them.”

He said that while there had been sporadic stock-outs in the past few years, the real problem started in 2020. “We really struggled to get antivenom, but it was lockdown so people were not moving around so much … It really started becoming a problem two years ago.

“They keep on promising us that stock will arrive in six to eight weeks. But it has been months.

“We are really struggling to get answers. We hear the story of the loadshedding and then we hear they can’t access the chemicals. A few years ago the World Health Organisation (WHO) flagged the quality of the antivenom produced by the South African Vaccine Producers after a string of bad reactions. There were bad batches of antivenom going out,” Naude said.

‘Nobody knows what the problem is’

Snake expert and CEO of the African Snakebite Institute Johan Marais said that while they had experienced sporadic stock-outs over the past seven years, these were always short-lived. “The real trouble started eight or nine months ago.”

He said the initial story from the South African Vaccine Producers was that it was undertaking quality checks on the insistence of the WHO.

“Then they said they had sourcing problems. I don’t know what they couldn’t find to make the antivenom but they didn’t talk to us, even though we can help. We are the industry experts. Then we heard … load shedding.

“The truth is that nobody really knows what the problem is … Vets have been out for months.

“I fully agree that this is a public health crisis. I used up the last of my antivenom the other day. I work with poisonous snakes every day. But there was an emergency so I gave it to a doctor. To order more, they wanted that doctor to tell them what they did with it.

“The rural communities are the worst affected by this. We do not hear what is happening in northern KwaZulu-Natal. Nobody will say anything.

“We are getting to the end of the snake bite season at the moment, but there will be a peak of activity just before winter as the snakes get ready. I don’t think there is an easy fix for this problem mostly because they won’t tell us what the problem is.”

He said some doctors and vets had in desperation been importing antivenom from India.

“But these haven’t been tested clinically. Where you would need 12 to 15 vials of South African antivenom you might need 70 to 80 vials of Indian antivenom.

“One of the products has just been banned in Kenya after terrible results. You can bring it in, but it is not registered – you have to keep that in mind.

“It makes me angry that in treating a snakebite victim the antivenom is the cheapest part … It will cost R21,000 for 10 vials as opposed to the R50,000 a day the person will have to spend in ICU without it.”

“We have been promised several times that they will address the backlog in two months. How are they going to do that? There are dozens of vet practices that need antivenom. How do you supply thousands of vials?

“What we need right now is honesty,” Marais said.

Steve Meighan, the owner of Deep South Reptile Rescue, said desperate vets were using expired stock to save animals. He said another plan was to supply mosquito nets to rural residents as they could keep them safer as snakes hunted at night.

Mike Perry, who provides snake venom to the South African Vaccine Producers to create antivenom, said the shortage was not due to a lack of venom.

“I have supplied snake venom to them since 1999. They work on a five-year buffer stock, meaning if I stop venom production they can carry on producing anti-venom for another five years. The problem is that the facilities are 50 years old. Load shedding breaks their old machines … It takes many weeks for them to find spares to fix these machines.” DM/MC

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South Africa

‘Rolling blackouts to blame’

Public health crisis

‘Nobody knows what the problem is’