Maximizing Operational & Economic Value of Vaccine Drone Transport

1. The economic and operational value of using drones to transport vaccines Leila Haidari, MPH Patrick Wedlock, MSPH July 26, 2016

2. Simulation Modeling for Technology Assessment • Technology assessment involves forecasting how a technology will perform in the real world and affect or be affected by the system the new technology will inhabit. • Investing in, developing, or implementing a technology without understanding its potential in the real world could waste substantial time, effort, and resources. It could even lead to unanticipated negative effects. • Trials can provide data but can require time, effort, and resources to design and run. They alone also provide data on one set of specific locations and circumstances. • Basic mathematical models (e.g., spreadsheet and process optimization models) can provide a general sense of what may occur and help analyze specific aspects of the system but may not capture all of the complex interactions of the entire system. • Detailed simulation models are virtual representations of the entire system in which the new technology will reside and therefore serve as a “virtual real world” to test and assess new technologies. (Think “Sim City”) • Simulation modeling is used extensively in certain industries to test and evaluate new products, strategies, and people. • An example is flight and aerospace simulators to evaluate and train pilots, test new flight and aerospace technologies, equipment, vehicles, planes, spaceships, etc. These simulators are designed to duplicate the experience of flying through the air or space and every step, procedure, phenomena, and equipment involved.

3. HERMES: A “Flight Simulator” for Supply Chains • HERMES models can include virtual representations of: • Every storage location, storage device, transport route, transport vehicle, transportation device, personnel, and product in the supply chain • Each health center, outreach location, all healthcare workers at these locations, and people arriving to get vaccinated • Millions of vaccine vials being shipped, unpacked, stored, re-packed, shipped, and eventually administered or wasted at virtual locations Data on Supply Chain Structure, Storage Locations, Transport, Capacities, Personnel, etc. HERMES is a software platform that can rapidly generate a detailed discrete-event simulation model of any health product supply chain Standard input deck Economic Metrics Total Costs Discrete event simulation model of supply chain Supply chain performance metrics Unit Costs Cost Drivers

4. Example Topics HERMES Can Address & Sample Publications • Introducing new vaccines and technology • Lee BY, Assi T, Rajgopal J, Norman BA, Chen S, Brown ST, Bailey RR, Kone S, Kenea H, Welling J, Connor DL, Wateska AR, Jana A, Wiringa AE, Van Panhuis WG, Burke DS. (2012) Impact of introducing the pneumococcal and rotavirus vaccines into the routine immunization program in Niger. Am J Public Health, 102(2):269-76. • Norman BA, Nourollahi S, Chen S, Brown ST, Claypool EG, Connor DL, Schmitz MM, Rajgopal J, Wateska AR, Lee BY. (2013) A passive cold storage device economic model to evaluate selected immunization location scenarios. Vaccine, 31(45):5232-8. • 3 more • Altering characteristics of vaccines and other technologies • Lee BY, Cakouros BE, Assi TM, Connor DL, Welling J, Kone S, Djibo A, Wateska AR, Pierre L, Brown ST. (2012) The impact of making vaccines thermostable in Niger’s vaccine supply chain. Vaccine, 30(38):5637-43. • Lee BY, Assi T, Rookkapan K, Connor DL, Rajgopal J, Sornsrivichai V, Brown ST, Welling J, Norman BA, Chen S, Bailey RR, Wiringa AE, Wateska AR, Jana A, Van Panhuis WG, Burke DS. (2011) Replacing the measles ten-dose vaccine presentation with the single-dose presentation in Thailand. Vaccine, 29(21):3811-7. • 2 more • Changing configuration and operations of the supply chain • Assi TM, Brown, ST, Kone S, Norman BA, Djibo A, Connor DL, Wateska AR, Rajgopal J, Slayton RB, Lee BY. (2013)  Removing the regional level from the Niger vaccine supply chain. Vaccine, 31(26):2828-34. • 2 more • Investing or allocating resources • Haidari LA, Connor DL, Wateska AR, Brown ST, Mueller LE, Norman BA, Schmitz MM, Paul P, Rajgopal J, Welling JS, Leonard J, Chen S, Lee BY. (2013) Augmenting transport versus increasing cold storage to improve vaccine supply chains. Plos One, 8(5):e64303.  • 1 more • Optimizing vaccine delivery • Brown ST, Schreiber B, Cakouros BE, Wateska AR, Dicko HM, Connor DL, Jaillard P, Mvundura M, Norman BA, Levin C, Rajgopal J, Avella M, Lebrun C, Claypool E, Paul P, Lee, BY. (2014) The benefits of redesigning Benin's vaccine supply chain. Vaccine, 32(32):4097-103.

5. HERMES Global Work Formation of HERMES Logistics Team Vaccine Supply Chain Redesign Kenya Vietnam Niger Decade of Vaccines Senegal Benin Mozambique Thailand Passive Vaccine Storage Devices India Unmanned Aerial Vehicles 2010 2011 2012 2013 2014 2015 2009 2016

6. HERMES Graphical User Interface (GUI)

7. HERMES Modeling Assessment of UAVs for Vaccine Transport Vaccine article: http://dx.doi.org/10.1016/j.vaccine.2016.06.022 Forbespost: http://www.forbes.com/sites/brucelee/2016/06/30/the-next-new-frontier-for-drones-saving-lives/

8. HERMES Simulation Modeling Used to Compare Two Transport Systems: Traditional Multi-Tiered Land Transport Versus UAV Transport Unmanned Aerial Vehicle (UAV) Transport • Trucks are used to bring the vaccines to a depot for storage, but UAVs transport all vaccines from the depot to health facilities • UAVs distribute up to 1.5L of packaged vaccines to health centers up to a 75 km radius from a hub which is co-located next to a supply depot • Personnel costs for EPI logistics include 10% of a health worker’s time at each health center reached by UAVs Traditional Multi-Tiered Land Transport System (TMLTS) in Gaza Province, Mozambique • Trucks deliver vaccines from provincial depot to district stores on a fixed monthly schedule • A mix of truck/motorbike deliveries and pick ups via public transportation to move vaccines from district stores to health centers monthly • Personnel costs for EPI logistics include 18% of a health worker’s time at each health center

9. Full Province Scenario (Baseline Comparison) UAVs Supplying Selected Locations (and TMLTS for Remaining Locations) TMLTS for All Locations Results: • 94% vaccine availability • $0.41 logistics costper dose administered Results: • 96% vaccine availability • $0.33 logistics cost per dose administered Hub 1 Hub 3 Hub 2 Provincial store Provincial store District stores (12) District stores with hubs (3) District stores without hubs (3) Health Centers (123) Health Centers (123)

10. ≤75 km Subset Scenario: Focusing Just on Service Delivery Locations that are <75 km from a Single Provincial Store Hub • TMLTS for All Locations • UAVs for All Locations Results: • 97% vaccine availability • $0.31 logistics cost per dose administered Results: • 100% vaccine availability • $0.22 logistics cost per dose administered Provincial store Provincial store Hub at Provincial store (1) District stores (7 total) Health Centers (69) Health Centers (69)

11. ≤75km Subset: UAV Cost Savings Remain Robust in a Set of Sensitivity Analyses Logistics Cost Savings Per Dose Administered (USD) 100 km/hr (no effect) 5 km/hr Baseline mean: 59 km/hr mean: 180 newborns mean: 720 newborns Baseline mean: 360 newborns annually mean: 154 km mean: 39 km Baseline mean: 77 km 70% of population placed at 3 urban centers Evenly distributed (no effect) Baseline: Current Gaza population distribution 80% HCs unreachable, 4 months annually Across all sensitivity analysesUAVs are cost saving versus the TMLTS Percentage of health centers (HCs) unreachable for part of the year 75% increase (no effect) 75% reduction Baseline mean: 10 years for land transport, 375,000 km for UAVs Rota, IPV, MSD, & HPV introductions Baseline: mid-2015 Mozambique EPI schedule

12. ≤75km Subset: Potential for UAVs to Produce Cost Savings Also Depends on Flight Conditions and Equipment Costs No cost savings achieved with 4-week delays *Costs include energy, amortization, and maintenance

13. ≤75km Subset: UAV Carrying Capacity Thresholds Exist for UAVs to Achieve Cost Savings Over TMLTS *At-scale estimates are based on unverified costs provided by a UAV manufacturer Current UAV capacity of 1.5L achieves cost savings

14. Limitations • Sensitivity analyses were performed on a subset of the service delivery locations (≤75 km radius) and examined a set of key factors but did not explore all possible factors that may affect the relative value of the UAVs versus the traditional multi-tiered land-based transport system (TMLTS) • There are alternative land-based transport scenarios other than the TMLTS which may perform better • Currently did not explore changing shipping/ordering policies, integrating other commodities, and behavioral factors such as non-compliance with procedures, which future simulation experiments can explore • The experiments made assumptions (e.g., acceptance and compliance with stated policies and procedures); field testing could help test the strength of these assumptions and iteratively guide refinements in subsequent simulation experiments • Field testing will likely identify additional regulatory hurdles or human factors not explored in these models that may be subsequently incorporated into the model

15. Summary • Simulation modeling can help with technology development and assessment by providing a "virtual laboratory" to evaluate and test technology • The UAVs provide cost savings while maintaining equivalent or slightly better vaccine demand fulfillment compared to the TMLTS in a variety of scenarios • Major drivers of costs savings: road speed of traditional land vehicles, number of people needing to be vaccinated, and road distance • UAVs can still provide cost savings if weather conditions have a 50% probability of delaying flights by up to a 1 week

16. Acknowledgments • We wish to acknowledge our collaborators and co-authors at VillageReach • This study was supported by the Bill & Melinda Gates Foundation.

17. HERMES Logistics Modeling Team Daniel Hertenstein, BS Marie Ferguson, MSPH Diana L. Connor, MPH Leila A. Haidari, MPH Shawn T. Brown, PhD stbrown@psc.edu Jay DePasse, B.S. Patrick Wedlock, MSPH Eli Zenkov, BS Joel Welling, PhD Marie Spiker, MSPH, RD James Leonard Bruce Y. Lee, MD, MBA brucelee@jhu.edu