Cost Analysis and Feasibility of Using Unmanned Aerial Vehicles to Transport Laboratory Samples for Early Infant Diagnosis of HIV in Malawi

Transcription

1 Cost Analysis and Feasibility of Using Unmanned Aerial Vehicles to Transport Laboratory Samples for Early Infant Diagnosis of HIV in Malawi Daniel Singer 1, Judith Sherman 2. Emmanuel Saka 2, Emily Bancroft 3 1 Singer Global Health 2 UNICEF Malawi 3 VillageReach Presenting author s address: drdansinger@gmail.com Biography of Presenting Author: Daniel Singer is a physician and medical epidemiologist with expertise in global health policy. He has worked in multiple countries on four continents in both clinical and public health capacities. He serves as a consultant to UNICEF/Malawi on their UAV study, although most of his career has been with health agencies of the United States Government. This presentation reflects the views of the authors and does not necessarily represent the official positions of the United States Government or UNICEF. Abstract: An estimated 8000 new pediatric HIV infections occurred in Malawi in Successful management of these patients depends on Early Infant Diagnosis (EID), which requires a blood sample to be sent to a central laboratory for molecular diagnostic testing. Without treatment, 30% of HIV-infected children will die before their first birthday; 50% will die before the age of two. Access to life-saving treatment is hindered by an expensive and slow system for sample transportation. The average time from sample collection to receipt in the laboratory is days. Unmanned Aerial Vehicles (UAVs) may be a cost-effective way to reduce the turnaround time between testing and results. A study currently underway in Malawi is examining the use of UAVs for sample transportation. Phase 1 will achieve the following objectives: i) optimize the design of a UAV to serve as a robust sample transport vehicle; ii) demonstrate the capability of the UAV to safely transport simulated laboratory samples from the site of collection to the site of testing; iii) estimate the cost of this form of sample transportation and to compare it to current standard forms of sample transport. If UAVs are shown to be superior to motor vehicle transport either in cost or health system performance, it may warrant their introduction to augment the existing sample transportation system. The results of this study will provide the first rigorous scientific data that international organizations and major donors will need before committing resources to UAVs in the global health sector. Further studies will be necessary to validate these results, generalize them to additional countries, and assess the impact of future advances in UAV technology. Keywords: Unmanned Aerial Vehicles, Laboratory, Transport, Global Health Full Paper Malawi, a densely populated country in southern Africa, is the third poorest in the world by nominal gross domestic product per capita. 1 Its HIV prevalence is estimated at 10.6%, with 1.1 million people living with HIV. Nearly 40,000 children were born in Malawi to HIV positive mothers in A small proportion of these infants will be infected with the virus. Successful management of these patients requires early initiation of antiretroviral treatment, which depends on Early Infant Diagnosis (EID). This requires a blood sample to be sent within eight weeks of birth to a central laboratory for molecular diagnostic testing. (Figure 1) EID is hindered by an expensive and slow system for sample transportation. Currently 640 sites offer EID testing for HIV-exposed children, primarily using Dried Blood Spot (DBS) sample collection, while 8 laboratories nationwide conduct the analysis using Central DNA Polymerase Chain Reaction (PCR). (Figure 2) The average time from date of sample collection to receipt in the laboratory is days (Table 1). The average turnaround time from sample collection until the test result is received by the care provider is over 36 days. Multiple delays impede getting results: transport of samples from health facilities to laboratories (road transport); delays in testing samples at the laboratory, delivery of results from labs to sites, and communication of results to the health care worker and patient or care provider.

2 The human costs of delayed or inadequate EID are catastrophic. Children initiated on HIV treatment early can live nearly normal lives, but without treatment, 30% will die before their first birthday; 50% will die before the age of two. 2 Currently only 5% of pediatric HIV cases in Malawi are diagnosed through EID. The remainder are recognized only when the child becomes ill and is diagnosed at a health center. Operational research has identified numerous factors that impede coordination and hinder an effective EID system, with sample transport being a consistent problem. 2,3 Figure 1 - Early Infant Diagnosis

3 Figure 2 - Malawi Health Facilities and EID Laboratories Table 1 - Transportation Time of Lab Samples for Early Infant Diagnosis of HIV, Malawi, Jan - Oct 2015 Receiving Laboratory Number of Samples Days from Sample Collection to Receipt in Lab Dream Lab Balaka Dream Lab BT Kamuzu Central Hospital Mzimba District Hospital

4 Mzuzu Central Hospital Partners In Hope Queen Elizabeth Central Hospital Zomba Central Hospital Total Transportation of laboratory samples for HIV (EID and Viral Load), tuberculosis and other diseases is a tremendous barrier in Malawi due to limited transportation infrastructure, poor roads (some of which are impassible during the rainy season), and the high cost of fuel (approximately USD 1.40 per liter). International donors and development partners are currently scaling up a dedicated system for laboratory sample transport in Malawi. Once complete, the annual operating cost is estimated to be USD 2 million per year, an amount which would be difficult for the Government of Malawi to afford due to limited domestic resources and multiple competing priorities within the health sector and elsewhere. As Unmanned Aerial Vehicles (UAVs) have become smaller, more reliable, and less expensive, they have been used to provide innovative solutions to challenges in a wide array of sectors from wildlife management, agriculture, humanitarian response 4, and health. There are several companies specializing in UAVs for the health sector and a consortium of non-profit, for-profit, academic, and international organizations working together on developing UAVs for health. 5 UAVs have been considered for delivering health commodities, and have been tested for transporting laboratory samples in Haiti, Lesotho, Papua New Guinea, and South Africa. 6 Among the various potential applications of UAVs in global health, the transportation of laboratory samples presents a compelling use-case, especially when considering the limited payload capacity and flight range of current UAV technology. Lab samples are routinely moved between known locations (clinics and laboratories), allowing flight paths to be assessed, cleared with civil aviation authorities, and programmed into UAVs ahead of time. Unlike medical commodities, lab samples have no inherent value, making theft of the UAV payload extremely unlikely. A DBS card used to collect samples is made of filter paper and measures less than 10 cm x 15 cm. A DBS sample consists of five drops of blood dried onto the card. Such cards are the current standard for molecular diagnostics for HIV and several other diseases. DBS samples are relatively temperature stable, less infectious than tubes of blood and weigh approximately four grams each. Current UAVs are capable of transporting hundreds of them at a time over distances of 15 to 60+ km, which makes UAVs a potentially valuable part of a transport network, particularly where road conditions or surface topography make traditional motor transport difficult. There is no scientific evidence documenting the cost of UAVs for laboratory sample delivery or their impact on transportation delays. The long delay in delivery of DBS samples in Malawi combined with the high cost of diesel fuel make it an ideal location to do such a scientific study. UNICEF has initiated a study to pilot the use of UAVs for transportation of dried blood spots. The study is being done in collaboration with the Government of Malawi, with VillageReach, an international NGO that focuses on last mile health solutions, conducting the cost analysis. It aims to achieve the following objectives: i) optimize the design of a UAV to serve as a robust laboratory sample transport vehicle; ii) demonstrate the capability of the UAV to safely transport simulated laboratory samples from the site of collection to the site of testing; iii) estimate the cost of this form of sample transportation and compare it to current standard forms of sample transport (motorbike and motor vehicles). For phase 1 of the study, simulated non-biologic DBS samples are being used. A vendor with experience in the use of UAVs in developing countries is providing, maintaining, and operating the vehicles. A public information campaign will be conducted to familiarize the local community with the UAVs and their purpose. The study consists of a series of automated flights between a high volume peri-urban health clinic and a central laboratory to test the ability of the UAVs to transport samples without damaging them. For each flight, information will be recorded on the time of flight, flight performance data, weather conditions, and the condition of the simulated samples.(table 2) Additional information is collected for coordination with the Malawi Civil Aviation Authority, and on the cost of the equipment, support systems, and operational costs for the cost analysis. (Table 3) The cost analysis will yield monthly estimated costs for sample transport by type, cost per health center by type of transport, and cost per sample transported by type of transport.

5 Table 2 - Data for Phase 1 Test Flights 1. Flight Plan a. Expected Time of Departure (ETD) from Area 25 Health Centre b. Expected time of Arrival (ETA) at KCH Hospital c. ETD from KCH Hospital d. ETA at Area 25 Health Centre 2. UAV and payload characteristics for flight to KCH Hospital a. Number, weight, and condition of simulated samples b. Battery voltage and data volume 3. Environmental Conditions a. Weather, wind speed, temperature 4. Pre-launch activities for the flight to KCH Hospital a. Time of beginning of prep activities b. Personnel involved in preparation c. Time of Departure d. Observed preparation issues or challenges 5. UAV landing at KCH and sample retrieval a. Time of Arrival b. Personnel involved in receipt of vehicle and samples c. Time of receipt activities d. Number, weight, and condition of simulated samples e. Battery voltage and data volume f. Observed receipt issues and challenges 6. Battery Exchange a. Time for battery exchange b. Personnel involved in Battery Exchange c. Source of electricity for battery charging Data similar to sections 2-5 are recorded for the return flight of simulated results to Area 25 Health Centre Table 3 - Inputs for Cost Analysis Input UAV Motorcycle Node locations List of labs and health centers served by each lab List of labs and health centers served by each lab Distances in km between health centers and labs (as traveled by air) Distances in km between health centers and labs (as traveled by road) Personnel requirements, time and cost[1] Cost of personnel time (HCW, UAV operator) Cost of driver time including per diem Estimated health worker time for: o Driver time allocable preparing for and receiving UAV to specific duties associated with swapping battery (if transport of samples applicable) loading samples triggering device Skillsets needed for: UAV programming, launch, and management Driving/flying the UAV o Can one person do both of above? What level of computer/technical literacy is needed? Vehicle costs[2] UAV (including battery) Motorcycle

6 Other Vehicle and Infrastructure Requirements Quantity of samples transported and frequency of transport Infrastructure needs for launching and controlling vehicles during flight (internet, power, etc.) Estimated maintenance costs and frequency (battery replacements, spare part costs) Energy usage per KM (or expected power consumption per flight) Cost of recharging equipment at health center Payload capacity (actual versus est. utilized) Flight details (speed, maximum distance traveled) Expected useful lifetime of vehicle Insurance costs Frequency of transport (modeled based on # of samples estimated per facility and time requirements for sample processing) Payload of UAV Dimensions of payload carrier (to determine volume of tests that can be carried) Communication costs Devices for triggering UAV (if applicable) Data and/or SMS costs (if applicable) Per km fuel costs Maintenance costs and frequency Vehicle capacity (actual versus est. utilized) Speed or time needed to travel from HC to lab Expected useful lifetime of vehicle Insurance costs Volume and frequency of transport (extrapolated from existing data and future transport plans) Communication costs for dispatching motorcycles (if applicable) [1] The model assumes that the costs of sample preparation are the same regardless of transport mode, so human resource time to prepare the sample for transport will not be compared. Only the human resource time required to actually move samples (e.g., the driver) will be considered in this model. [2] For the purpose of the model, these costs will be amortized over an appropriate lifespan. Should the study demonstrate that UAVs are both cost favourable and feasible for transporting laboratory samples for EID, Phase 2 of the study will be conducted to determine acceptability of UAVs among clinic staff, patients and communities; identify training, operation and maintenance issues; and determine the impact on timeliness of testing, delivery of results, and clinical care. The expected outcomes are to i) understand the training needs for health care workers and facility staff to use UAVs to transport samples and/or receive results; ii) identify technical and regulatory challenges before UAVs can be used more broadly for sample transport; and iii) determine the potential impact of UAVs on cost and health outcomes. Both phases of this study will also inform the Government of Malawi s regulatory framework for UAVs. This study will be the first to document the feasibility and cost of UAVs for sample transport. As such, it is a critical step in moving UAV transport systems from concept to implementation. Although pilot tests have been done in multiple countries, there is no data on the impact that UAVs could have on a health system at scale. Countries such as Malawi depend on development partners to fund their health infrastructure. Major donors such as the World Bank, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and bilateral donors will be reluctant to commit funds to UAVs for global health until well-designed scientific studies can provide rigorous unbiased data to support their use. Phase 1 of this study will provide data for the first stage of a technology assessment. (Error! Reference source not found.) If UAVs prove to be complementary to motor vehicle transport either in cost or health system performance, future studies and longer-term testing would be required to determine additional costs including personnel costs associated with maintenance, routing, and management of UAVs, long-term maintenance, repair and disposal costs, training, extra vehicle capacity to account for loss of capacity due to maintenance or damage, cost of retrieving broken vehicles, and cost of maintaining charging stations (if applicable). The introduction of UAVs into a developing country health system to augment existing sample transport will also require further policy development on integration with civil and military aviation, a topic which many developed countries are already considering.

7 There are established methods for planning sample transport networks for EID. 7 Integration of UAVs into these networks can be modeled by use of discrete-event simulation software to provide sensitivity analysis, identify ideal scenarios, and guide optimal integration of traditional and UAV transport platforms. Once UAVs are deployed for routine use, data from monitoring and evaluation can be used for operational research on long-term performance including estimates of accident rates vs traditional transport and studies of efficiencies of scale. Understanding and modeling the potential impact of UAVs on health systems in developing countries is complicated by the rapid rate at which UAV technology improves, as well as the introduction of health technologies such as point of care testing. The core elements of this study will need to be repeated in the future to validate the methodology, to evaluate the technology in settings outside of Malawi, and to update the findings in light of improved capabilities and progressively lower costs. Figure 3 - Generic Stages of Technology Assessment 8 References WorldBank data available at Accessed January 20, Ghadrshenas A1, Ben Amor Y, Chang J, Dale H, Sherman G, Vojnov L, Young P, Yogev R; et al. (2013) Improved access to early infant diagnosis is a critical part of a child-centric prevention of mother-to-child transmission agenda. AIDS. Nov;27 Suppl 2:S Braun M, Kabue MM, McCollum ED, Ahmed S, Kim M, Aertker L, Chirwa M, Eliya M, Mofolo I, Hoffman I, Kazembe PN, van der Horst C, Kline MW, Hosseinipour MC. (2011) Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi. J Acquir Immune Defic Syndr. Apr 15;56(5):e Drones to the Rescue, UNICEF Connect blog, Accessed August 8, IDEO.org. How can Drones improve global health? ; accessed July 17, Mendelow B,Muir P, Boshielo B T, Robertson J. (2007) Development of e-juba, a preliminary proof of concept unmanned aerial vehicle designed to facilitate the transportation of microbiological test samples from remote rural clinics to National Health Laboratory Service laboratories. SAMJ, 97(11): Kiyaga C1, Sendagire H, Joseph E, McConnell I, Grosz J, Narayan V, Esiru G, Elyanu P, Akol Z, Kirungi W, Musinguzi J, Opio A. (2013) Uganda's new national laboratory sample transport system: a successful model for improving access to diagnostic services for Early Infant HIV Diagnosis and other programs. PLoS One. Nov 13;8(11):e78609

8 8 VillageReach and HERMES Logistics Modeling Team. Presentation on an Initial Technology Assessment Using HERMES Simulation Modeling; May 13, 2015; Seattle, WA.