title: Needs and availability of snake antivenoms: relevance and application of international guidelines.
abstract: BACKGROUND
  Snakebite has recently been declared a global public health emergency. Empirical data showing the true burden of snakebite is lacking. Treatment with specific antivenoms is considered the only cure. However, several factors have led to an ongoing antivenom crisis. This study offers recommendations concerning the improvement of antivenom access and control, by providing an overview of the factors limiting the successful implementation of international guidelines within the international industry and state institutions. It further investigates the reasons for the epidemiological knowledge gap regarding snakebites.
  
  
  METHODS
  Data for this study was collected using surveys with closed- and open-ended questions, which allowed for descriptive and thematic analysis, respectively. Participants for this study were selected as follows: 46 manufacturers were contacted from the open-access World Health Organization (WHO) Database for antivenom producers; 23 National Health Authorities (NHAs) of high-burden countries were contacted; and 11 poison centers or experts were randomly contacted.
  
  
  RESULTS
  In total, responses from 6/46 (13%) manufacturers, 10/23 (43%) NHAs, and 3/11 (27%) poison centers were received. The low response rates had a limiting effect on the coverage of this study, allowing only exploratory conclusions to be drawn. Based on the gathered information, a probable reason for the epidemiological knowledge gap is the low priority given to snakebites on public health agendas, driving interest and funding away from research in this field. As a consequence, the ensuing lack in funding is preventing state institutions and manufacturers from implementing international guidelines to the highest standards. Furthermore, manufacturers indicated that international guidelines were often not applicable in the field, lacking technical information and protocols.
  
  
  CONCLUSIONS
  Snakebite ranks low on international public health agendas, and partially due to this low priority, NHAs have shown limited efforts in conducting epidemiological studies, training health workers on snakebite management and creating national snakebite management strategies. The lack of NHA involvement is reflected in poor access to appropriate antivenoms as well as a lack of antivenom regulation. Manufacturers are taking positive steps toward full implementation of international guidelines and are improving quality control procedures. However, in order for international guidelines to become truly useful in the field, more technical guidance is required. This study reflects that there is a general lack of knowledge transfer amongst various actors: most producers, health authorities, and experts expect increased and improved communication and guidance from leading international bodies. Due to the low response rates observed in this study, conclusions drawn herein are not representative of the global situation; yet provide an exploratory insight on the difficulties facing antivenom management.
authors.affiliation: Athena Institute, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands.
authors.forename: Laura
authors.initials: L
authors.lastname: Scheske
authors.affiliation: Athena Institute, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands.
authors.forename: Joost
authors.initials: J
authors.lastname: Ruitenberg
authors.affiliation: Athena Institute, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands.
authors.forename: Balram
authors.initials: B
authors.lastname: Bissumbhar
mesh_terms: D000931:Antidotes / Q000191:economics* / Q000627:therapeutic use*; D000997:Antivenins / Q000627:therapeutic use*; D017408:Guidelines as Topic; D006297:Health Services Accessibility / Q000592:standards; D006801:Humans; D020380:Needs Assessment / Q000592:standards; D011634:Public Health / Q000592:standards*; D012909:Snake Bites / Q000188:drug therapy*; D012910:Snake Venoms / Q000009:adverse effects*
chemical_list: D000931:Antidotes; D000997:Antivenins; D012910:Snake Venoms
keywords: Antivenom; Envenomation; Guidelines; International Public Health; Neglected Tropical Disease (NTD); Snakebite