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SouthViews 


No. 178, 19 March 2019
 
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South-South cooperation for confronting the neglected problem of snakebite envenoming: the role of Costa Rica



By Dr. Jose María Gutiérrez and Ambassador Elayne Whyte Gómez
As of 2018, the international community has a global framework to address the problem of snakebite envenomings, an acute problem that affects rural populations in tropical areas of the world, which mainly affects people from the most vulnerable sectors of the population and leaves significant negative consequences in millions of people around the world. This global framework was adopted by a resolution of the World Health Organization (WHO) at its 71st World Assembly on May 24, 2018, thus providing for a strong mandate to develop a comprehensive plan to address this health problem, work with affected countries, partners, stakeholders and industry, and develop a comprehensive approach that will allow countries to implement an effective response to this health issue.

Decades of neglect of the problem ended when the Resolution "Addressing the burden of snakebite envenoming" was adopted. The lack of global awareness of the magnitude of this disease left this problem without proper and articulated attention from national and international health authorities, pharmaceutical companies, and research agendas.

Costa Rica, a middle-income country with high standards of health and social development, played a strategic role in the development of this global cooperation platform and has decades of international cooperation experiences in this area.

Costa Rica has given attention to snakebite envenoming since the first half of the XXth century. The country has established an integrated model for confronting this disease, based on a combination of scientific and technological research, active extension programs to communities at risk and to health professionals in charge of treating snakebites, and production, quality control and distribution of antivenoms, among other lines. These actions have been closely linked to the development of the public health system in the country.

This thorough experience has allowed Costa Rica to establish a cooperation platform with other developing countries that suffer this neglected disease, resulting in international networks of various sorts involved in South-South and South-North cooperation. On the basis of this long-standing tradition in the study and confrontation of snakebite envenoming, Costa Rica has been at the forefront of an international initiative to raise the attention to snakebites and to promote actions within the World Health Organization.


 
The public health impact of snakebite envenoming
Envenomings resulting from the bites of venomous snakes constitute a serious public health problem, particularly in sub-Saharan Africa, Asia, Latin America and parts of Oceania. It has been estimated that, every year, more than 2 million people suffer these envenomings and, as a consequence, between 81,000 and 138,000 fatalities occur. Moreover, among the people who survive, more than 400,000 are left with permanent physical disabilities and psychological sequelae (Gutiérrez et al., 2017). Snakebites affect predominantly impoverished populations living in rural settings and, therefore, contribute to a vicious cycle of poverty, since affected people often need to cover the costs of treatment, and the physical disabilities resulting from envenomings directly affect their working capacity (Harrison et al., 2009). Snakebite envenoming has been included in the official list of neglected tropical diseases by the World Health Organization (WHO).  

Owing to the fact that snakebites mostly affect vulnerable communities having little political voice, this problem has traditionally received very little attention from health authorities, research agendas, pharmaceutical companies and groups of the civil society. Therefore, snakebite envenomings constitute a truly neglected tropical disease. In the midst of this critical scenario, there have been several countries where this issue has been confronted through public policies and efforts from the research communities. One of these countries is Costa Rica; in addition to developing a strong national program for attending the problem of snakebite envenoming, Costa Rica has been involved in international cooperation activities, particularly under the frame of South-South cooperation, which have greatly impacted in various regions of the world. The present communication describes these developments.



From national experience to international leadership: the dawn of the snakebite programs in Costa Rica


In the first decades of the XXth century, Clodomiro Picado Twight (1887-1944), a renowned Costa Rican scientist, devoted much of his scientific efforts to the study of snakes, snake venoms and snakebite envenomings in his country. Picado identified the most important venomous snakes in Costa Rica, studied the toxic profile of their venoms and searched for novel therapies for envenomings. His scientific contributions are summarized in the book Serpientes Venenosas de Costa Rica. Sus Venenos, Seroterapia Antiofídica (Picado, 1931). Besides his scientific legacy, Picado promoted a visionary law for reducing the impact of snakebite envenomings in the country. Moreover, he established a cooperation program with Instituto Butantan, in São Paulo, Brazil, an institution that, since 1901, had been producing ‘antivenoms’, the only scientifically validated therapy for snakebite envenomings. This was the first South-South international cooperation developed in Costa Rica on this problem. Through this program, Picado sent snake venoms to Brazil and Instituto Butantan prepared and sent back antivenoms to Costa Rica. This introduced the modern therapy of envenomings to this Central American country. As a consequence of this breakthrough, the mortality due to envenomings in Costa Rica was drastically reduced.

A renewed impetus on this topic occurred in the decade of the 1960s, when the government of Costa Rica promoted an international cooperation program involving the Ministry of Health, the University of Costa Rica, and the Embassy of the United States of America in Costa Rica. This tripartite partnership had the aim of producing, for the first time, antivenoms for the treatment of snakebite envenomings in this country. This international and inter-institutional antivenom program, known as Programa de Sueros Antiofídicos, succeeded in the manufacture of the first batches of antivenoms in 1967. The program received the political support of the Costa Rican government and, as a consequence, an institute for the production of antivenom was created in 1970, the Instituto Clodomiro Picado. Originally a dependence of the Ministry of Health, this institute was then ascribed to the University of Costa Rica, in 1972, owing to the leading role played by researchers of this university, among them Róger Bolaños Herrera, in the consolidation of this project. During almost five decades, the program has kept a close coordination with the public health institutions of Costa Rica, namely the Ministry of Health and the social security system of Costa Rica (Caja Costarricense del Seguro Social, CCSS).

An integrated perspective for confronting snakebite envenoming

An essential feature of the way Costa Rica has dealt with the issue of snakebite envenoming has been the integrated and holistic character of the program. From the very beginning, the strategy involved concerted actions in four main branches: (1) manufacture and distribution of antivenoms; (2) scientific and technological research on the topics of snakes, snake venoms, envenomings and development of antivenoms; (3) extension programs to convey the basic aspects of prevention and management of snakebites; and (4) university teaching programs at undergraduate and graduate levels. Such holistic philosophy of development avoided the ‘reduccionist’ approaches of focusing only on antivenom production, and allowed the building up of a solid scientific and technological basis for the development of this initiative. Moreover, a solid partnership was established with the public health institutions and with the academic community of the country.

Despite the fact that, initially, this program was focused on finding solutions to the snakebite problem in Costa Rica, the Instituto Clodomiro Picado had, from the beginning, an international perspective of cooperation, reflected in early efforts to translate the developments made in Costa Rica to other countries in the region.


A history of cooperation

From its onset, the Instituto Clodomiro Picado started an ambitious international cooperative program in its main lines of action, i.e., scientific and technological research, antivenom production, extension, and teaching. In research, a solid frame of academic partnerships has been established with groups in 35 countries of the Americas, Europe, Africa, Asia and Oceania. Of particular relevance is the platform developed on South-South cooperation, not only in research and training of students, scientists and technicians, but also in the development and distribution of antivenoms to be used in the treatment of snakebite envenoming, especially in Latin America and sub-Saharan Africa, and also in Sri Lanka and Papua New Guinea. This extensive network of antivenom distribution has developed in parallel with the transfer of knowledge and technology for the production and quality control of antivenoms in several countries, particularly in Latin America. Hence the South-South cooperation of Costa Rica has involved the provision of these life-saving products and the collaboration for antivenom manufacture in other countries, under a frame of solidarity. This South-South cooperation has also impacted in the training of physicians and nurses of many countries in Latin America in the clinical management of envenomings. Table 1 summarizes the regions and countries with which Costa Rica has established cooperation links in this field. This ambitious platform of cooperation is described in more detail in the following sections.


Table 1. Summary of the international cooperation activities developed by Costa Rica for improving the study and control of snakebite envenoming


Source: Archives of projects of Instituto Clodomiro Picado.


Cooperation in scientific and technological research

A solid scientific and technological research program was created at Instituto Clodomiro Picado along various lines, such as the study of the biology of venomous snakes, the biochemistry and mechanism of action of snake venoms, the epidemiology and clinical aspects of snakebite envenoming, the development of antivenoms, the analysis of the efficacy and safety of antivenoms from Costa Rica and other countries, and the search for novel therapies to treat envenomings. Along the development and consolidation of this ambitious research program, fruitful international cooperation programs were established with universities and other institutions from many countries in all continents, including many countries from the South. This extensive network of cooperation is clearly reflected in the authorship of scientific publications generated by Instituto Clodomiro Picado. As the following figure shows, the number of publications with combined authorships by Costa Rican and foreign researchers has steadily increased along the five decades of this institute as a reflection of this international partnership trend.


Figure 1. Numbers of scientific publications by researchers of Instituto Clodomiro Picado per decade, highlighting the publications authored by Costa Rican scientists alone (N) and those in which authorship was shared by researchers from Instituto Clodomiro Picado and from foreign institutions (I). A clear trend towards international cooperation is observed. From: Gutiérrez, J.M. (2018). Reflexiones desde la academia. Universidad, ciencia y sociedad. San José, Costa Rica: Editorial Arlekín.


The extension of this network of international cooperation in research is evident by analyzing the number of countries with which Instituto Clodomiro Picado has established academic partnerships, illustrated in the following figure. As indicated, a significant component of this international cooperation universe is based on partnerships with institutions from the South, particularly in Latin America.

 
Figure 2. Countries that have one or more institutions with which Instituto Clodomiro Picado has established academic networks of cooperation. Each dot represents a country. In several countries, such as Brazil, academic partnerships have involved many institutions. From: Gutiérrez, J.M. (2018). Reflexiones desde la academia. Universidad, ciencia y sociedad. San José, Costa Rica: Editorial Arlekín.


As an example, the results of a regional-based investigation published in 2010 in the journal Toxicon described the capacity of antivenoms manufactured in various Latin American countries to neutralize the venoms of medically-relevant snakes of South and Central America (Segura et al., 2010). In this publication, ten Latin American public institutions participated in this study, which received support from the organization CYTED (Ciencia y Tecnología para el Desarrollo), an Iberoamerican network for promoting cooperation. This type of cooperative academic effort has had a high impact in building up knowledge-based policies in the public health realm in the region.

Beyond the fruitful output of this international scheme, in terms of scientific publications in specialized journals and books, such academic cooperation has involved an extensive exchange of researchers and students from many countries, which has contributed to the strengthening of the human capital in science and technology of Costa Rica and other countries. In particular, a strong component of this exchange has involved a number of countries in Latin America and the Caribbean, such as México, Guatemala, El Salvador, Honduras, Nicaragua, Panamá, Colombia, Venezuela, Ecuador, Peru, Brazil, Bolivia, Argentina, and Martinique. Likewise, this academic cooperation has expanded to groups in the USA, Europe, Asia, Africa and Oceania (see Gutiérrez, 2016). This international cooperative platform greatly benefited groups with limited laboratory resources to be able to participate in studies using advance technological tools which, as a consequence, resulted in the strengthening of their own endogenous capacity to develop scientific research.


International cooperation for improving the prevention and management of snakebite envenomings

The knowledge generated through research has been transferred to the general population and the health professional sector by an extension program initially designed for Costa Rica. Through this program, rural communities in high risk of snakebites have been identified and a diverse set of extension activities have been designed to convey to these communities the basic aspects of how to prevent snakebites and what actions to do in the event of a bite by a venomous snake. This includes the avoidance of harmful interventions and the rapid transportation of the affected person to the nearest health facility in order to receive appropriate treatment. These activities have involved indigenous communities that suffer a high number of snakebites, as well as farmers, students in rural areas, workers of private and public institutions, and other groups in risk. In parallel, a permanent education program has been developed for conveying the basic aspects of the diagnosis and treatment of snakebite envenomings to professionals of the public health system, particularly physicians and nurses, as well as to students of Medicine, Nursing and other careers of the health area. This program has significantly improved the prevention of snakebites and the clinical management of these accidents. 

This extension program has been expanded to include other countries in Central and South America. Regular training activities are coordinated with public health institutions of these countries, and seminars have been offered by Costa Rican professionals in these countries, hence contributing to the strengthening of the management of snakebite envenomings in the region as a whole. As an example, the audience that attended a seminar on snakebite envenoming in the Ecuadoran community of Loja in 2017 is shown in the photo below. This activity was offered by staff of Instituto Clodomiro Picado to health professionals of the Seguro Social Campesino of Ecuador.


Photo: Attendees of a seminar on snakebite envenoming presented by Instituto Clodomiro Picado to health professionals, organized by Seguro Social Campesino of Ecuador in the city of Loja, Ecuador, in 2017.

 

Ensuring the provision of life-saving antivenoms in Latin America and the Caribbean


As indicated above, one of the main goals of Instituto Clodomiro Picado is to produce and distribute antivenoms for the treatment of snakebite envenomings. The administration of antivenoms in health centers is the only scientifically-validated therapy for these envenomings. Unfortunately, owing to the neglected character of this tropical disease, there has been a chronic deficit in the availability and accessibility of antivenoms, particularly in countries of sub-Saharan Africa and Asia and, in some cases, also in Latin America. Hence, one of the main goals of the efforts developed by Costa Rica in this field has been the manufacture and distribution of antivenoms.

Initially, during the decade of the 1970s, the volume of antivenom produced in Costa Rica only covered the needs of this country. Nevertheless, since the very beginning, Instituto Clodomiro Picado established cooperation agreements with other public laboratories in charge of antivenom production in Latin America. The technical expertise developed in Costa Rica was transferred to laboratories in Colombia and Ecuador, and then to other countries. Many of these cooperation activities have been developed in coordination with the Pan American Health Organization (PAHO). This philosophy of integration and cooperation has evolved along the decades and, in the past fifteen years, a network of public laboratories involved in antivenom production and quality control in Latin America was established, with a leadership role of Instituto Clodomiro Picado and Instituto Butantan. This network has promoted workshops, training activities, and collaborative research projects and has allowed an extensive exchange of colleagues between these institutions (Gutiérrez, 2016). This network has been financially supported by the program CYTED, the Organization of American States (OAS), through the program FEMCIDI, and PAHO.

As a corollary of the improvements and innovations carried out in Costa Rica in the technology for antivenom manufacture, the production capacity of Instituto Clodomiro Picado has increased steadily over the last decades. Hence, in the decade of 1990s it was feasible to distribute antivenoms beyond Costa Rica, particularly to the rest of Central American countries. As a consequence, this region has become self-sufficient in terms of the supply of antivenoms. It is relevant to remark that Costa Rica provides antivenoms at a low cost for the public health systems of countries in Latin America, the Caribbean and sub-Saharan Africa, hence ensuring the availability and accessibility of this previous medicine to the populations in need. The distribution of antivenoms has been done in parallel with continuous education programs and preparation of teaching materials to train the physicians and nurses in charge of the treatment of envenomings in the countries of this region. More recently, antivenoms manufactured in Costa Rica have been deployed to other countries in South America and the Caribbean, such as Ecuador, Saint Lucia, Guyana and French Guyana. Thus, the endogenous scientific and technological development in this field in Costa Rica over the last decades has greatly contributed to the amelioration of the impact of snakebite envenomings in the region as a whole. Plans are underway to foster this international cooperation scheme to other countries, and cooperation agreements are being negotiated with other public antivenom manufacturers in Latin America.


Beyond the Americas: cooperation in antivenom provision on a global basis


In the first decade of this century, Costa Rica became engaged in an ambitious international cooperation program to confront the serious deficit of antivenoms in sub-Saharan Africa, which has become critical (WHO, 2007). A partnership was established with the Federal Ministry of Health of Nigeria, the Liverpool School of Tropical Medicine, and the University of Oxford, in the United Kingdom, to generate a new antivenom for western sub-Saharan Africa. This antivenom, developed in Costa Rica, was evaluated in a clinical trial in Nigeria, and proved to be highly effective and safe. This antivenom is regularly produced at Instituto Clodomiro Picado and is currently being distributed to Nigeria, Mali, Burkina Faso, Benin, and is being also used in the Central African Republic and South Sudan by the organization Médecins sans Frontieres (MSF). The volume of production of this antivenom is being increased in order to cope with the demand of this product by other sub-Saharan African countries. This represents an example of a South-South partnership resulting from endogenous scientific and technological developments in Costa Rica for the benefit of faraway countries in sub-Saharan Africa.

Such South-South trans-continental cooperation has further expanded with a cooperative project with the University of Papua New Guinea and the University of Melbourne.  An antivenom has been developed in Costa Rica for the treatment of a highly venomous snake in Papua New Guinea. This antivenom is currently under clinical evaluation in this country and it is expected that, in the near future, it will be produced in Costa Rica and sent to Papua New Guinea for treating snakebite envenomings. A similar effort is being carried out in collaboration with Sri Lanka, in order to develop a new antivenom for this Asian country, where more than 30,000 cases of snakebite envenoming occur every year. At the same time, Instituto Clodomiro Picado has extensive communication links with manufacturers of antivenoms from countries in Latin America and Asia, with whom various sorts of technical cooperation are promoted. Hence, the global projection of Costa Rica in this field involves not only the production and distribution of antivenoms, but also permanent technical cooperation activities of various sorts aimed at improving antivenom manufacture by producers in other countries, particularly in the South.  

The knowledge and expertise developed in Costa Rica in antivenom production and, in general, in the field of snakebite envenoming, have also impacted in international health organizations such as the WHO and PAHO. This has been reflected in the involvement of professional and technical staff from Costa Rica in the preparation of official guidelines for the production and control of antivenoms, and in the treatment of envenomings (see for example WHO, 2017).

Leading at the global stage

Costa Rica's historical experience in the successful management of this issue has allowed the country to assume a global leadership role, by means of a partnership between the Ministry of Health, the University of Costa Rica / Instituto Clodomiro Picado and the Ministry of Foreign Affairs.

A solid basis of support was built, especially among tropical low- and middle-income countries where the overwhelming majority of snakebite victims live, which were determined to generate global awareness and action. The magnitude of the snakebite problem calls for international cooperation as the only way to significantly control and reduce its impact. It is through the synergies of the strengths and resources of various stakeholders that this ambitious goal can be achieved.

In May 2016, Costa Rica, along with 18 co-sponsors
[1], chaired a Member State side-event, to set out a vision for a comprehensive holistic approach to the burden of snakebite envenoming. The motivation for global action was born, with the involvement of member states, public and private sectors and civil society, including several non-governmental organizations, such as the Global Snakebite Initiative (GSI), Médecins sans Frontiéres (MSF), Health Action International (HAI) and others. This was the start of a long and fruitful journey that gathered the support of more than 30 countries, and the regional organizations of the Americas, Asia, Africa and the Pacific.

As a follow-up, in 2017 a group of 18 states
[2] filed a technical request to the WHO subcommittee of the WHO Strategic Technical Advisory Group for Neglected Tropical Diseases at its 10th meeting. After technical consideration of the file, this group recommended that snakebite envenoming should be included in the  WHO  neglected  tropical  diseases  portfolio  as  a  Category  A  neglected  tropical  disease. Such recommendation was later endorsed by the WHO Director-General and snakebite envenoming was officially included in the list of neglected tropical diseases in June 2017.

With this achievement, snakebite envenoming was incorporated as part of WHO comprehensive efforts to overcome the global impact of neglected tropical diseases, a terminology that embraces a diverse group of communicable and zoonotic diseases that prevail mainly under tropical and subtropical conditions, largely affecting socially and economically vulnerable people. 

In October 2017, a group of nations
[3] tabled the proposal of the resolution “Addressing the burden of snakebite envenoming” to be discussed by the Executive Board of the WHO, which adopted it by consensus in January 2018, and submitted the proposal to the 71st World Health Assembly (WHA) held in May 2018. The WHA adopted the resolution by consensus on 24 May and gave way to a new era for cooperation, articulation and global action in this field. Including snakebite envenoming as a recognized Neglected Tropical Disease, the resolution grants a clear mandate for an integrated global action plan that can eradicate the disease burden wrought by snakebite. Thereafter, under the leadership of the WHO, a multi-stakeholder global action plan will bring together WHO, member states, the public sector, scientific community, civil society and the private sector in a global alliance to develop actions aimed at reducing the impact of this disease. A roadmap for confronting snakebite envenoming, developed by the WHO with the participation of many people, will be launched in May 2019.

The WHA resolution (see below) includes interventions at various levels, such as prevention of bites, involvement of communities in the solution of the problem, improvements in the availability and accessibility of antivenoms, training of health personnel in the subject, monitoring and rehabilitation of affected people, and encouragement of research and development to improve the diagnosis and treatment of envenomings.

From a South-South Cooperation perspective
 
From the perspective of international cooperation and the trends that increasingly mark the work in this area, it is clear that the commitment and associativity that have been generated around the efforts in research, production of antivenoms and accessibility to these antidotes reflect the versatility that characterizes collaborative forms in the scientific field. Moreover, they highlight the contribution of South-South Cooperation schemes where solidarity constitutes the ethical and pragmatic motive that guides exchange initiatives among developing countries themselves to address common challenges.

Costa Rica for several decades, due, among others, to its good indicators in areas such as health and education, has been progressively excluded from all Official Development Assistance and, consequently, has not only had to resort to new partners for development and to new forms of support to leverage its own challenges but has increased its capabilities as a provider of cooperation in those fields where it has been successful. In other words, it has placed its strengths at the service of other countries with the purpose of overcoming obstacles and threats together for the benefit of the greatest number of people. We must not forget that, after the international community adopted the 2030 Agenda of Sustainable Development in 2015, development has expressly ceased to be understood as a mere function of per capita income. That limited notion that prevailed for a long time, does not translate the highest standards that sustainable development entails today and that force to reinvigorate alliances with different public and private partners, with civil society and academia; alliances in which science plays a central role since knowledge has become a first order value to identify the real needs, priorities and solutions to which public policies, programs and actions should focus. It is not by chance that sustainable development goal (SDG) 17 intends to stimulate these multi-stakeholder alliances.

Although the efforts deployed by Costa Rica for more than six decades in the field that concerns us, and to which other countries and research centers have joined, have not always shown revolutionary ways of doing cooperation, they do have an unquestionable double merit: on the one hand, they have managed to bring to the forefront of the world attention to the unwavering fight against snake bites as a cause of mortality and disability in many regions and, on the other hand, the different cooperation mechanisms that have been put in place for these purposes have strengthened increasingly ambitious work networks among the developing countries that exceed the regional space. Whether it is scientific and technological research, the distribution of antidotes, the transfer of knowledge and technology in the production of antiophidics, the development of new products, the promotion of their accessibility where it is most needed ... it is undeniable that these synergies constitute an invaluable contribution to global public goods.

If the transfer of knowledge and technology is now a key factor in international cooperation, Costa Rica has historically understood this commitment and the returns it implies for the world's most vulnerable populations. This work, in crescendo and collective, has not only positively impacted millions of people but also has much potential to save more human lives.


 
            Addressing the burden of snakebite
Resolution adopted by the 71st World Health Assembly, 2018,
will trigger the following main actions:
  1. to assess the burden of snakebite and, where necessary, establish prevention, treatment and rehabilitation programmes;
  2. to accelerate efforts for early treatment of snakebite cases;
  3. to improve the availability. accessibility and affordability of antivenoms to populations at risk, and to develop mechanisms to ensure that additional costs of treatment and rehabilitation after snakebite envenoming are affordable;
  4. to ensure that total costs of snakebite treatment envenoming do not discourage health-seeking behaviour or ongoing health care, and do not deepen poverty;
  5. to integrate, where possible, efforts to control snakebite envenoming with other relevant disease-control activities;
  6. within the context of health-system development, to establish and sustain partnerships for treatment of snakebite envenoming at country and regional levels;
  7. to improve access to specific treatment and rehabilitation services for all victims of snakebite envenoming, by mobilizing national resources;
  8. to provide training to relevant health workers on the management of snakebite envenoming;
  9. to intensify and support institutions working on research on snakebite envenoming, particularly in order to develop new tools to measure the burden of the disease, and to diagnose, treat and prevent snakebite envenoming;
  10. to promote  community  awareness  of  snakebite envenoming  in  support  of  early treatment and prevention, and to intensify community participation in awareness and prevention efforts.
 

References

Gutiérrez, J.M. (2016). Understanding and confronting snakebite envenoming: The harvest of cooperation. Toxicon 109: 51-62.

Gutiérrez, J.M., Calvete, J.J., Habib, A.G., Harrison, R.A., Williams, D.J., Warrell, D.A. (2017). Snakebite envenoming. Nature Review Disease Primers 3: 17063.

Harrison, R.A., Hargreaves, A., Wagstaff, S.C., Faragher, B., Lalloo, D.G. (2009). Snake envenoming: a disease of poverty. PLoS Neglected Tropical Diseases 3(12): e569.

Picado, C. (1931). Serpientes venenosas de Costa Rica. Sus venenos, Seroterapia Antiofídica. San José, Costa Rica: Imprenta Alsina.

Segura, Á., Castillo, M.C., Núñez, V., Yarlequé, A., Gonçalves, L.R.C., Villalta, M., Bonilla, C., Herrera, M., Vargas, M., Fernández, M., Yano, M.Y., Araújo, H.P., Boller, M.A., León, P., Tintaya, B., Sano-Martins, I.S., Gómez, A., Fernández, G.P., Geoghegan, P., Higashi, H.G., León, G., Gutiérrez, J.M. (2010). Preclinical assessment of the neutralizing capacity of antivenoms produced in six Latin American countries against medically-relevant Bothrops snake venoms. Toxicon 56(6): 980-989.

World Health Organization (2007). Rabies and envenomings. A neglected public health issue. Geneva: World Health Organization.

World Health Organization (2017). Guidelines for the Production, Control and Regulation of snake antivenom immunoglobulins. Geneva: World Health Organization.


 
[1] Afghanistan, Angola, Bangladesh, Benin, Burkina Faso, Cameroon, Chad, Costa Rica, Gabon, Guinea, Kenya, Namibia, Nepal, Nigeria, Pakistan, Philippines, Senegal, Uganda.
[2] Angola, Benin, Brazil, Cameroon, Chad, Colombia, Costa Rica, Ecuador, Honduras, Guatemala, Mexico, Namibia, Netherlands, Pakistan, Panama, Philippines, Peru, Uganda.
[3] Algeria, Angola, Argentina, Australia, Benin, Brazil, Burkina Faso, Congo, Costa Rica, Dominican Republic, Ecuador, France, Gabon, Guatemala, Honduras, India, Jamaica, Kenya, Mexico, Namibia, Netherlands, Nicaragua, Nigeria, Pakistan, Panama, Peru, Philippines, Senegal, Thailand, Togo, Venezuela, Vietnam and Zambia with the support of the African Group, the Group of the Americas.
 

Authors: Dr. Jose María Gutiérrez is from the Instituto Clodomiro Picado and Ambassador Elayne Whyte Gómez is the Permanent Representative of Costa Rica to the United Nations in Geneva.


* The views contained in this article are attributable to the author and do not represent the institutional views of the South Centre or its Member States.


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