Improving antivenom availability and accessibility: Science, technology, and beyond José María Gutiérrez * Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica article info Article history: Received 7 February 2012 Accepted 23 February 2012 Available online 3 March 2012 Keywords: Snakebite Envenoming Antivenom Availability Accessibility Acceptability Cooperation abstract Snakebite envenomings constitute a serious and neglected public health problem. Despite the fact that effective treatment exists, i.e. administration of animal-derived antivenoms, the availability and accessibility of these life-saving immunobiologicals is deficitary in various parts of the world, particularly in sub-Saharan Africa and some regions of Asia. This article discusses some of the problems that need to be circumvented in order to improve the availability and accessibility of antivenoms. The conglomerate of antivenom manu- facturers is highly heterogeneous in terms of technological base, qualification of staff, implementation of Good Manufacturing Practices (GMPs), and volume of production. Therefore, improvements in antivenom quality and availability should be based on strat- egies tailored to the situation of each region or country; in this context, three different scenarios are discussed. Accessibility of antivenoms demands concerted efforts at multiple levels, including raising the awareness of public health authorities on the relevance of the problem, implementing innovative antivenom purchasing schemes, strengthening national distribution channels on the basis of robust epidemiological information, improving the cold chain and the provision of health services in remote rural settings, supporting the correct use of antivenoms, and promoting the involvement of local community organizations in various aspects of prevention and management. These tasks should be envisaged in terms of synergistic, interprogrammatic and intersectorial inter- ventions, with the participation of many players. Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction Envenomings by snakebites represent a serious public health problem worldwide, particularly in Asia, Africa, Latin America, and some regions of Oceania (Gutiérrez et al., 2006; WHO, 2007a; Williams et al., 2010; Warrell, 2010). Despite its high impact, this disease has received very little attention from national public health authorities, interna- tional foundations supporting the combat of tropical diseases, research agendas and pharmaceutical companies. Therefore, snakebite envenoming has been categorized as a neglected tropical disease by the World Health Organization (www.who.int/neglected_diseases/diseases/ en). Moreover, it belongs to the category of Type III diseases, i.e. those that occur overwhelmingly in low income countries, and which largely lack commercially based research and development in rich countries (WHO, 2006). Most affected people are poor rural inhabitants who lack the political voice to raise this issue in the public health agendas (Harrison et al., 2009; Williams et al., 2010). In the complex landscape of neglected tropical diseases, efforts to confront snakebite envenomings do not receive the needed priority and, consequently, the impact of this pathology in terms of mortality and morbidity remains unacceptably high. Several initiatives have emerged in the last decade, promoted by the World Health Organization (WHO, 2007a), the Global Snake Bite Initiative (GSI; Williams * Tel.: þ506 2229 3135; fax: þ506 2292 0485. E-mail address: jose.gutierrez@ucr.ac.cr. Contents lists available at SciVerse ScienceDirect Toxicon journal homepage: www.elsevier.com/locate/toxicon 0041-0101/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.toxicon.2012.02.008 Toxicon 60 (2012) 676–687