IMPLEMENTATION OF A CULTURALLY TAILORED DECENTRALIZATION PROGRAMME FOR SNAKEBITE TREATMENT IN INDIGENOUS COMMUNITIES IN THE BRAZILIAN AMAZONIA

Snakebite envenomations (SBE) is an emergency health condition with freely available efficacious treatment. This disease burden on the indigenous population is entirely preventable. As described, the central obstacles to overcome in improving SBE patient outcomes are the patient's need to seek higher-level care and, thus, leave the indigenous village, alongside the lack of resources that strangle indigenous health care as a whole. Current community health centres (CHC) care in the Brazilian Amazon region lacks the training and capacity to offer specialized care for SBE. Though systemic challenges are complex and multifaceted, decentralizing antivenom from hospitals to the local CHC is feasible, likely cost-effective, and addresses these central obstacles. Indigenous peoples in the Brazilian Amazon are caught between an undervalued and disintegrating traditional culture and an inaccessible western system. In Brazil, antivenom is produced by public manufacturers and provided to patients free of charge but is only available at limited hospitals in the urban areas. Absence of antivenom in indigenous CHCs limits timely access to SBE care for patients in the villages. Our preliminary work with indigenous populations has shown a resistance to leaving the community to receive care contributing to the delays, exacerbated by cultural and geographical barriers in the region. A short-term, safe and efficacious solution is to decentralize SBE treatment with antivenoms to the level of indigenous CHCs. The AJURI intervention assists a historically oppressed and underserved population to develop, implement, and evaluate an integrative model of care that delivers quality, patient-centered treatment to their peoples. If successful, this intervention could drastically reduce the burden of SBE and prevent a significant population health and economic burden among the indigenous population. This implementation study will provide evidence-based knowledge to develop a novel strategy for antivenom delivery that could be implemented for other vulnerable populations. This proposal will provide conditions for the necessary work leading to a proposal to the UKRI Medical Research Council (MRC) to (a) evaluate the most cost-effective scenario to optimize distribution of antivenom, (b) analyze the feasibility, barriers and facilitators of implementing this strategy, and (c) evaluate the cost-effectiveness of this SBE care delivery strategy. This proposal specifically responds to UK Research and Innovation-Applied global health research, calling for studies on Implementation Science, aimed to ensure that evidence-based SBE treatment is implemented in an accessible and fair way for indigenous population in the Brazilian Amazonia, a vulnerable population with great difficulty in accessing the health system. We propose the development and pilot implementation of an innovative multi-modal intervention to improve SBE treatment in the Brazilian Amazonia. This intervention model will be potentially generalizable to other indigenous areas and to other diseases. This proposal responds also to the WHO strategic aims, which advocates that the numbers of deaths and cases of disability from SBEs be reduced by 50% before 2030 through initiatives that "empower and engage communities, ensure safe and effective treatment, strengthen health systems, and increase partnerships, coordination and resources".

Globally, more than 90% of all snakebite envenomation (SBE) occur in low resource settings. This NTD affects 2.7 million people, with 81,000-138,000 deaths and approximately 400,000 permanent disabilities annually. Antivenom is a safe, efficacious, time-dependent, and evidence-based treatment, but the availability and timely access to this standard of care is inadequate. In this proposal, we aim to develop a multimodal intervention, the AJURI Protocol, to optimise timely, safe and cost-effective SBE care delivery among the existing indigenous primary community health centres (CHC) in the Brazilian Amazon. This innovative intervention combines 1) a state-focused health system resource allocation model for antivenom distribution leveraging the CHC infrastructure; 2) a CHC-focused culturally-tailored clinical practice guideline, training and care coordination, and 3) a community-level engagement strategy with SBE health education and outreach. In this proposal we will evaluate the impact of the AJURI protocol in a pragmatic health system scale-up implementation. We will conduct a phased implementation evaluation of the AJURI protocol, with a micro-level CHC-based pragmatic cluster effectiveness/implementation hybrid (type 2) trial and a macro-level health systems impact evaluation. By the end, we will have evaluated the effectiveness and the implementation of a multimodal health system intervention to improve SBE care in the Brazilian Amazon and determined the mediators and moderators. We will have the evidence on the macro-level (Amazonas state) to facilitate the translation to other LRS and NTDs. Implementing and evaluating the AJURI protocol aligns with strategic priorities of the UK Research and Innovation-Applied global health research, aimed to ensure that evidence-based SBE care is implemented in an accessible and fair way for indigenous population in the Brazilian Amazon, a vulnerable population with great difficulty to access the the health system.