Preliminary assessment of antivenom availability and management in the public health system of Costa Rica: An analysis based on a survey to pharmacists in public health facilities

Effectiveness of late and very late antivenom administration on recovery from snakebite-induced coagulopathy in French Guiana: a population-based study

Background

Snakebite (SB) envenoming is an acute emergency requiring early care delivery. However, sometimes, patients can take several hours before receiving antivenom (AV). We conducted this study to assess the effectiveness of antivenom in the recovery of clotting parameters in patients consulting tardily after SB envenoming in French Guiana. The primary endpoint of our study was to investigate the time needed from SB to recovery from SB-induced coagulopathy. The secondary endpoint was to investigate the time needed from AV administration to recovery from SB-induced coagulopathy in patients receiving AV (late or very late administration).

Methods

This prospective observational study was conducted in the Intensive Care Unit (ICU) of Cayenne General Hospital between January 2016 and September 2023. We included all patients hospitalized for SB envenoming who either did not receive AV or received it more than 6 h after SB. We excluded patients who received antivenom in less than 6 h from the SB and those who received incomplete AV doses.

Findings

We included 58 patients in the No AV group, 51 in the late AV group (6 h ≤ AV < 12 h), and 50 in the very late AV group (AV≥12 h). The median age of patients was 42 years (IQR: 29-53), 65.4% were male and 34.6% were female (104 and 55 out of 159 patients) without difference regarding the demographic parameters between groups. Data regarding ethnicity was not available. The median time from SB to AV was 8.5 h (IQR: 6.9-10) in the late AV group and 21.1 h (IQR: 16.7-27.4) in the very late AV group (p < 0.001). The time from SB to normal clotting parameters was shorter in patients receiving late AV than in those receiving very late AV and those not receiving AV. No differences were observed in the time from SB and recovery of fibrinogen and activated partial thromboplastin time (aPTT) between very late AV and no AV. However, the International Normalized Ratio (INR) recovery was shorter in the very late AV group than in the no AV group. On the other hand, the time from AV to normal fibrinogen was shorter in patients receiving very late AV than in patients receiving late AV (Log-Rank = 0.020). Meanwhile, the time from AV to normal INR or normal aPTT was similar in patients receiving very late AV compared to patients receiving late AV (Log-Rank = 0.722 and 0.740, respectively).

Interpretation

Late AV administration effectively reverses coagulopathic manifestations after SB envenoming. However, very late AV administration did not improve the correction of some clotting parameters when compared to patients not receiving AV. Our findings could be explained by the combination of venom toxicokinetics and the kinetics of the synthesis of clotting factors.

Funding

No funding.

Inequalities in access to antivenom: An ethical issue in the management of snakebite envenoming

Snakebite envenoming is a high-priority neglected tropical disease and antivenom is the cornerstone of treatment. Antivenom is listed among essential medicines and its access must be considered as a human right. Despite resolutions from various international organizations including the WHO, antivenom remains unavailable, unaffordable, and sometimes not targeted against the specific snake involved. Also, despite an expanding global antivenom market, some manufacturers have stopped production due to a lack of profits. However, justice and equitable access to care according to medical needs are among the four pillars of medical ethics. Overall, snakebite envenoming is a typical example of social and ethnic inequity in medicine. It is imperative that this issue be addressed from an ethical standpoint and that government laboratories take the lead in antivenom production.

First aid and pre-hospital practices in snakebite victims: The persistent use of harmful interventions

First aid intervention and pre-hospital (FAPH) practices are common in patients suffering from snakebite envenomation (SBE). In this study, we have reviewed the literature concerning the use of these practices in various regions of the world in the period 1947-2023 based on published prospective studies. A total of 71 publications fulfilled the inclusion criteria. In terms of the total number of patients in all studies that used each FAPH intervention, the most common practice was the application of tourniquets (45.8%). Other FAPH practices described include cuts/incisions (6.7%), the application of a variety of natural or synthetic substances at the bite site (5.6%), and ingestion of natural, usually herbal, remedies (2.9%). Washing the site of the bite was described in 9.1% of patients. There were other less frequent FAPH practices, including suction, splinting-immobilization, pressure-bandage, ice packs, application of a snake/black stone, and administration of alcoholic beverages. There were differences in the extent of application of FAPH interventions in different continents. Tourniquets were highest (55.7%) in Asia. Topical application of various products was common in South America, while pressure-bandage was only reported in Australia. We did not find any statistically significant variations in the frequency of the most frequent FAPH interventions at three-time intervals (before 2006, between 2006 and 2015, and after 2015). Our findings highlight the use of FAPH interventions in patients suffering SBE, some of which are known to be harmful. It is necessary to study these practices to a higher level of geographic granularity, using community-based surveys. Programs tailored to local contexts should be promoted, aimed at avoiding the use of harmful FAPH practices. It is also necessary to assess the efficacy and safety of some interventions through robust preclinical and clinical studies.

Effect of the time to antivenom administration on recovery from snakebite envenoming-related coagulopathy in French Guiana

BACKGROUND

Snakebite (SB) envenoming is an acute emergency requiring an early care delivery. We aimed to search for the time to reach healthcare facilities in various regions of French Guiana (FG) and to assess the impact of time to antivenom (AV) on the correction of coagulation parameters in these patients.

METHODOLOGY

This is a prospective observational study conducted in Cayenne General Hospital between January 1st, 2016, and July 31st, 2022. We included all patients hospitalized for SB envenoming less than 48h after the bite, and receiving antivenom (AV). We assessed the time lapse between SB and medical attention and the time needed to return of the coagulation parameters to normal.

PRINCIPAL FINDINGS

Overall, 119 patients were investigated, and 48.7% were from remote areas. The median time from SB to AV therapy was 09:15 h (05:32-17:47). The time was longer in patients from remote rural locations. AV was dispensed within the first six hours after the SB in 45 cases (37.8%). Time from SB to reaching normal plasma fibrinogen concentration was 23:27 h (20:00-27:10) in patients receiving AV≤6h vs. 31:23 h (24:00-45:05) in those receiving AV>6h (p<0.001). Whereas, the time from AV administration to reach normal fibrinogen dosage was similar in the two groups.

CONCLUSIONS

Patients from rural settings in FG suffer from a delay in AV administration after SB envenoming leading to an extended time in which patients are coagulopathic. Once AV is administered, clotting parameters recover at a similar rate. Supplying remote healthcare facilities with AV and with medical teams trained in its use should be planned.