An International Matching Grant Joint Research Project of Pakistan, Malaysia and Nigerian Universities

Peoples University of Medical & Health Sciences For Women Nawabshah Pakistan	Federal University Birnin Kebbi Nigeria
University of Sindh Jamshoro Sindh. Pakistan	Federal University Sokoto Nigeria
Sindh Agriculture University Tando Jam	University of Science & Technology Aloria Nigeria
Venom and Toxin Research Laboratory, University of Malaya, Kuala Lumpur, Malaysia

 

Dr. Naeemul Haque Quraishi
Project Director
Sindh ASV/ARV Serology Laboratory
Peoples Medical University Nawabshah Pakistan

 

Production of Camel Snake Anti Venom against Three Medically Important Vipers of Nigeria

 

Background

Snake bite and affiliated morbidity and mortality is one of the noticeable public health problems in many developing countries of Asia and Africa. The only known scientific remedy is Anti Snake Venom immunoglobulin. The appropriate technology of producing quality anti venom is clumped among the developed countries none of whom having snake bite as a significant health problem. The costly equipment and procedures of immunoglobulin separation and quality assurance, far expensive and high risk techniques of venom milking and processing, strict animal rights, relatively less profit than other biological products, specificity of application, no local demand in the country of origin, together inflict this life saving product nowhere in the production spectrum of any leading pharmaceutical corporation of technologically advanced countries. The quality compromised ASV production units in developing countries are very few and are working in a capsulated setting limited to share anything about production technology with other needy countries. Most of them are still using outdated old technologies with vulnerable safety of the product except Thailand and Costa Rica using somehow modern techniques and producing much efficient products. Unfortunately neither developed countries nor sister developing countries favor transfer of technology in the concern, hence many countries in Asia and Africa are facing scarcity of Anti Venom with resulting deaths and disabilities. Parallel to it, dearth of subject knowledge locally, social vulnerability of snake bite victims, poor political will, lack of resources and commitment, superfluous prioritization of problems, adverse governance issues prevents any strong initiative by developing countries to acquire such technology in need. The initial huge establishment together with equally expensive operational costs prevents most of the governments to establish such ASV production laboratories and they prefer to import it even of suspicious efficiency and safety. Perceiving such lethargy both of governments and international community although WHO declared snake bite as one of the 17 Neglected Tropical Diseases but removed it again from the list during 2015.

ASV Shortage in Africa.

To best perception of the researchers the entire continent of the Africa is experiencing acute shortage of appropriate Anti Snake Venom. Out of 58 African countries many do not have any Anti Snake Venom production laboratory or authentic supply of appropriate ASV except South Africa having South African Vaccine Producer (SAVP) producing two types of anti snake venoms against some local snakes and Egypt having Egyptian Organization for Biological Products & Vaccines. It is again dubious to ascertain the efficacy of South African and Egyptian anti snake venoms in other countries of the continent many of whom are having different snake taxonomy than South Africa or even Egypt. The Situation is worsened further when past year (2014) Sanofi Novartis stopped producing a Pan African Poly Snake Anti Venom effective against venom of ten common snakes of Africa.

Although the subject matter specialists talk and discuss high about the shortage of Snake Anti Venom in Africa and consider such shortage nearly at crisis level but probably failed so far to come with any workable solution of such crisis. It is commendable to notice lot of articles in the international journals and news papers but are they factually helping in reducing the misery of the affected? There are still many people in Africa who cut their body parts in case of snakebite just to avoid sure death because they know well there is no or very expensive ASV in their hospitals. Even if an ASV manufacturer focuses African region for expansion of his production scale he may be hampered by a lack of information of what to provide, which and where to source the venom, and what quantity to produce for any country under such focus. The net information and WHO list of regional snakes of medical importance can help some academic researchers but such knowledge is not sufficient for ASV manufacturers to tweak any workable strategy.

Nigeria is the most populous country of the Sub Sahara, hence logically is having the highest number of snakebite cases in Africa. The collapse of the snake anti venom market in Africa is one of the great medical tragedies of the twentieth century. Nowhere in the world is this more confronting than in Africa and thus affecting Nigeria proportionally higher. Despite high numbers of snakebite in Africa, recent decades have been characterized by declining production, loss of product confidence, and under-utilization of trusted life-saving anti-venom products.

This has been due to a combination of local and international influences, including:

• Weak political will.
• Ill framed priorities by governments.
• Poor governance and corruption.
• Inadequate investment by governments and non-government organizations;
• High manufacturing costs.
• Dubious quality control and inefficient production processes;
• Absence of any qualified management protocol.

Lack of profitability has led some manufacturers to cease production of this much-needed product in Africa that has become commercially unviable for them. There are clear signs that manufacturer’s remaining active in the industry are compensating for reduced sales by raising prices; a move that will almost certainly depress demand even further. As the crisis has deepened, it has been exacerbated by the opportunistic infiltration of poor quality counterfeits and inappropriate anti-venoms that neutralize venom from snake species on other continents, often with disastrous results.

The self-perpetuating cycle responsible for the decline in anti venom production in sub-Saharan Africa, inadequate financial support for anti-venom production and variable quality have catalyzed the collapse of the anti-venom market, which is now characterized by deficient supply, deficient quality control, rising prices and poor profitability.

Although an important humanitarian and social issue, death from snakebite lacks the status and assistance afforded to other international health crises in Africa. Part of the reason for this is that in an era where public health issues are often robustly taken up as socio-political causes, and specific interest groups lobby governments and donors to support their interests, snakebite has until recently been largely non-political, and without an effective voice at the table of global health organizations. Under-recognition of snakebite as a major medical and social problem has seen it neglected by governments, policy makers, international aid agencies and private grant organizations.

Research Rational.

The Pakistan project of establishing Anti Snake Venom/ Anti Rabies serology laboratory was started under a situation very mimicking with the present situation in Africa. It was purely a need driven project in a province having the highest number of snake bite cases and with drastically short supply of quality ASV over past many decades. The multiple influences retarding cost effective production of National Institute of Health developed a cul-de-sac for every effort by national and provincial governments except to opt only for imported ASV and benefit the private importing firms. Interestingly such cruel way of limiting governments to a peculiar ASV supply, found a major source of securing more influence and power among the governance circles of this country. It could be dream of any supplier when the Surgeon General of Armed Forces, Director General Rangers, Federal and Provincial Health Ministers, Executives of international collaborating agencies request personally and pay in advance to book their share in the upcoming lot of such imported ASV. When combined with the multi-layered drug distribution pathways in Africa, which see prices incrementally increased at every step along the way, it seems remarkable that there is any anti-venom available in Africa at all. Good quality anti-venoms made by proven, long-established manufacturers have sadly become unaffordable to all except a few. Analysis of the anti-venom market makes it very clear that high volumes of production are what are needed to produce lower prices. At the same time, the higher the price, the lower the demand, which ultimately drives prices higher even beyond the purchase power of the families and states. Again it is now well understood that even if a regular source of quality ASV supply is ascertained that may not resolve their problem fully, they surely need transfer of ASV production technology as a permanent and sustainable solution to this chronic problem.

The international collaborating agencies especially WHO is striving hard to sensitize member countries to tune their health development programs more factual and need oriented and solve their major public health problems with local initiative and within their available resources. It usually extends technical and advisory assistance and invests generously for human resource development and institutional capacity building of their public and private sectors. Unfortunately for availability of reliable and safe anti snake venom in various needy countries the role of WHO remained dormant without any tangible program except to declare snake bite as one of the seventeen “Neglected Tropical Diseases NTDs” (withdrawn again from the list) and to publish guidelines on production and storage of Immunoglobulin against snake venom which are merely a general knowledge of the subject with no procedural description to assist the countries in need if they want to have such technology locally. There are certain examples where W
HO assisted countries in establishing their Anti Snake Venom production laboratories like NIH Islamabad in Pakistan and Red crescent laboratory Bangkok in Thailand but these limited examples cannot justify the laxity for many other similar countries in need especially in Africa by such precisely concerned organization. However the recent move of Global Snakebite Initiative (GSI) supported by a Netherland based NGO the Action Health International is highly commendable with hope of a favorable change very soon.

It is therefore the researchers are of firm belief that the experience sharing and capacity building ordained under this joint research project will surely be helping other developing countries especially those of African Sub Sahara where many hundred people are still dying due to acute shortage of Anti Snake Venom. It will be a more focused attempt to transfer a much cost effective and locally appropriate technology to these needy countries and to solve permanently their ASV supply problem. It is also much synchronizing with the main theme of Global Snakebite Initiative, hence likely to benefit more than 50 African countries constituting 1/4th of United Nations.

Research Objectives.

It is firmly anticipated that at successful completion of this joint research project it will be possible:

1. To convince Nigerian Government sufficiently to establish a serology laboratory locally for production of Anti Snake Venom, Anti Rabies Immunoglobulin and other life saving biological products preferably at Federal University Birnin Kebbi.
2. To enable swift transfer of cost effective and locally appropriate technology to Nigeria and other needy countries in Sub Saharan Africa.
3. To make easy resolving decades old problem of ASV shortage in Africa and subsequently help in reducing the morbidity and mortality due to snakebite among huge population of more than 50 UN member countries.
4. To introduce a model of action research by national Universities for solving national problems and helping governments in community centered sustainable development.
5. To elaborate cost and quality edge of Camel ASV over other routine ASVs in the world, and to introduce a cost effective, workable and easy to operate technology of ASV production for developing countries having limited resources.

Methodology.

The core methodology of this joint research program includes a general plan encompassing mostly the management aspects and the scientific plan comprising of methods and techniques used for ASV production and Human Resource Development.

The general plan includes fund raising, office establishment, staff recruitment/ placement, purchasing essential articles, instituting viable linkages, development of strategic and operational plans, monitoring mechanism, and field extension programs.

Once the research proposal is approved by all stakeholders including all seven Universities in Pakistan, Malaysia and Nigeria and funds are realized in project account the principal investigator together with relevant scientific staff will visit Nigeria and milk the “three big” medically important vipers responsible for almost 95% of snakebite cases in Nigeria. He together with scientific staff will conduct hands on training of local Universities staff in snake catching, milking, farming, feeding and safe handling parallel with field sessions in wild for venom collection, preservation, and transport storage and lyophilizing. In principal the research project will not encourage any caging or discomfort for snakes and will leave the snakes in wild after milking. The project will provide free of cost snake sticks to these Nigerian Universities staff and the communities at risk in project area for safe handling and removing of venomous or non venomous snakes. The team will conduct mass awareness and community education program on “How to Live With Snakes” among the Nigerian rural communities and share with them the importance of snakes in natural ecosystem. The staff of Nigerian Universities will be trained through a training of trainers “TOT” to continue to conduct such awareness and other IEC programs focusing how to prevent snakebite, evidence based first aid of snakebite at community level, and better to move the snakes rather to kill them. After getting enough dried venom of three big vipers of Nigeria the team will come back and immunize three to five camels with such venom and will produce the ASV against these vipers. The newly developed ASV will be tested in vitro for it’s efficacy and safety and than in vivo for further confirmation of the same. Once satisfied the newly produced ASV will be brought to Nigeria for a WHO registered clinical trial at Nigerian Hospitals by local Physicians for which necessary documentation and process will be completed. The production and use record of the ASV will be documented and will be submitted to Nigerian Health authorities for allowing a project of Establishing a serology laboratory for production of Snake Anti Venom against the venom of all medically important snakes of Nigeria. The Pakistan Universities while working together on this joint research project will facilitate swift transfer of technology to the Nigerian Universities staff and if the Nigerian government invest for establishment of a cost effective and workable ASV production unit, a small team of Pakistani counterpart will go to Nigeria and assist in construction and operation of such unit till the local staff learn and take over all the operational responsibilities.

This joint research project of production of Nigeria specific polyvalent Snake Anti Venom will help not only in convincing the Nigerian government but also in transfer of immensely required technology of a biological product required for reducing massive morbidity and mortality due to snakebite. Any such establishment of a serology unit by Nigerian government ordained out of this joint research project will enable local universities to use this ASV production unit as an academic and research laboratory thus availing dual benefit with one investment. Pertinent to it the studying scholars of post graduate studies of the subject will be a ready source for replenishing any leaving staff of the laboratory.

Parallel with a program of ASV production and transfer of technology the principal and co investigators are committed to design and implement a comprehensive training program of Nigerian Doctors, paramedics and high risk communities in Scientific and evidence based management, first aid and prevention of snakebite, how to live with snakes and role of snakes in maintaining the equilibrium of natural ecosystem as an integral part of this joint research program without any further investment. Such instructional program will include developing material and guidelines, training of trainers and impact evaluation mechanism of such capacity building effort. It would be comprehensive assistance encompassing almost all affiliated aspects parallel with production of quality ASV.

The scientific plan of research methodology includes some very cost effective, workable and already practiced techniques of ASV production well according to the approved SOPs expressed in WHO global guidelines of Snake Anti Venom Immunoglobulins Production and Storage 2010, which will be explained elaborately in the micro plan of this join research project.

Resources Required:

Physical Infrastructure and Transport

All the seven participating universities are having adequate infrastructure to be spared for office, laboratory or any other project related work till completion of the project. Each university providing any space will disburse all the expenses for providing all facilities including energy, water, and communication within that space till the occupancy of project. All required furniture and fixture will also be provided by that University however any minor wear and tear will be replenished by the project from the project funds. No new vehicle will be purchased for project field activities, the Sindh ASV project and relevant Universities will provide vehicles for all sorts of field activities however the project will provide, fuel, lubricant, repair and maintenance and periodical service of the vehicles ordained under project activities. The expenses of air travel from Pakistan to Nigeria and vice versa will be meet from project funds. The participating Universities at their own will arrange boarding and lodging facilities for the visiting researchers of the project.

Manpower

The Pakistan Universities are already having well qualified and adequately skilled manpower to conduct the proposed joint research and produce quality Camel ASV by using WHO recommended techniques and quality control.  The principal and co investigators are already having experience for producing similar invention against the venom of medically important snakes of Pakistan. It is therefore no practical hindrance can be foreseen in acquiring required trained manpower. However some secretarial and auxiliary staff may be recruited to perform project specific secretarial and managerial responsibilities. The already working staff of the Universities and the project will be provided honorarium equal to their basic salary, and the temporary hired secretarial and auxiliary staff will be provided market computable salaries for their service period under a service contract.

Equipment and Glassware

Similar to space and trained power the Pakistan Universities will contribute their available equipment and laboratory spaces for any project related procedure. Most of the equipment required under this joint research proposal are already available with Pakistan Universities however some quality assessment equipment can be imported up to the budgetary ceiling of not more than 20000 US$s. The required glassware is readily available in the local market and will be purchased from project funds when and where required.

Chemicals, Reagents and other Consumables

Unfortunately most of the chemicals, reagents, filters and consumables are not available in Pakistan and need to be imported from abroad. The fortnightly camel immunization with venom takes almost four to five months hence will provide sufficient time space to import and arrange the required chemicals and reagents before final production process. However the Pakistan Universities, University of Malaya Malaysia and Sindh Project will arrange well in advance the antibodies titer assessment equipment, chemicals and reagents for assessing antibodies titer progress after each immunization dose and for an uninterrupted and fluent operation of the project.

Information, Education and Communication (IEC) Material

As a complementary gesture for this pivotally important affiliated subject the Sindh Project will invest and organize all the required expertise for designing and publication of IEC material together with guidelines for trainers. Any additional demand by the Nigerian Universities or government will be meeting from project funds after seeking concurrence of all the stakeholders.

Consultancy

The principal and co investigators of this joint research project are subject matter specialists of almost all themes of the proposed study hence no specific funds will be required under this heading except to pay consultancy charges to a professional firm for seeking registration on WHO International Clinical Trials Registry Platform for accredited clinical trials of the project product. The international charges for such consultancy services to facilitate WHO registered clinical trials is enormously high, however a Pakistan based firm will be convinced to invoice some concessional charges preferably 1/10th of their usual charges.

Quality Control

The Department of Molecular Medicine University of Malaya, Malaysia will ensure the in vitro quality control of the in process and finished product.

Proposed Plan of Action

#	Activity	Time in Months
		1	2	3	4	5	6	7	8	9	10	11	12
01	Establishment of project office and recruitment
02	Collection of Venom from Nigeria and finding LD50
03	Training of Nigerian Staff in venom and snake handling
04	Purchase of Animals and vaccination
05	Immunization of camels and titer assessment
06	Bleeding of Camels
07	Antibodies isolation, washing and concentration
08	In-vitro and In-vivo assessment of product
09	Clinical Trials Registration
10	Actual Clinical Trials
11	Reporting and Documentation
12	Final Report Writing and publication

Note: The first month of the PPA will be the project start month.

Funding and Audit

It will be a matching grant research project wherein the participating Universities of Nigeria and Pakistan will contribute more than 50% of the total project expenses. The initial cost estimates confirms expenditure not less than 120,000 US$s inclusive of all operational costs to accomplish the tasks expressed in proposed plan of action. The Universities and Sindh Project will contribute around 70,000 US$s (10,000 US$s each) for which written consent of each is in hand, however for remaining 50,000 US$s any International or national collaborating organization within or outside will be welcomed. The finance documents and bank account of the project will be open to all stakeholders for any periodical, planed or random verification or audit. However the project will be responsible to communicate a monthly performance and expenditure report to each of the Vice Chancellor’s office and to the office of collaborating organization regularly. With approval of stakeholders the principal investigator will be the principal operating and drawing and disbursing officer of project funds.

Financial Plan.

#	Activity	Cost in US$s	Pakistan Rupees	Nigerian Naira
01	Purchase of Camels and small experimental animals	10,000	1,000,000	2,000,000
02	Animal fodder, medicine, and farming	12,000	1,200,000	2,400,000
03	Purchase of QC equipment	15,000	1,500,000	3,000,000
04	Chemicals, reagents, filters and other consumables	15,000	1,500,000	3,000,000
05	Salaries and Honorarium	42,000	4,200,000	8,400,000
06	Clinical Trial Registration	10,000	1,000,000	2,000,000
07	Report Writing and Publication	1,000	100,000	200,000
08	Air Travel	15,000	1,500,000	3,000,000
09	Total	120,000	12,000,000	24,000,000

Note: The Sindh Project and Peoples Medical University Nawabshah will take over the responsibility of project animal farming beyond project stipulated period and will continue to provide ASV to Nigeria (if desired) after successful clinical trial as part of complete technology transfer.

Participant Universities:

1. Peoples University of Medical & Health Sciences For Women, Nawabshah, Sindh Pakistan
2. University of Sindh, Jamshoro, Sindh, Pakistan
3. Sindh Agriculture University, Tandojam, Sindh, Pakistan
4. Federal University, Birnin Kebbi, Nigeria
5. Federal University, Sokoto, Nigeria
6. University of Science & Technology, Aloria, Nigeria
7. Venom and Toxin Research Laboratory, University of Malaya, Kuala Lumpur, Malaysia

Research Coordinator:

Sindh ASV/ ARV Serology Laboratory Project Peoples Medical University for Women Nawabshah.