Epidemics control and logistics operations- A review

Epidemics control and logistics operations:A reviewThomas K.Dasaklis n,Costas P.Pappis,Nikolaos P.RachaniotisUniversity of Piraeus,Department of Industrial Management and Technology,80Karaoli&Dimitriou Str.,18534Piraeus,Greecea r t i c l e i n f oArticle history:Received15September2010Accepted17May2012Available online28May2012Keywords:Epidemics controlEmergency supply chainsEpidemics control logisticsa b s t r a c tOutbreaks of epidemics account for a great number of municable or infectious diseases arealso a major cause of mortality in the aftermath of natural or man-made disasters.Effective control ofan epidemic outbreak calls for a rapid response.Available resources such as essential medical suppliesand well-trained personnel need to be deployed rapidly and to be managed in conjunction withavailable information andfinancial resources in order to contain the epidemic before it reachesuncontrollable or disastrous proportions.Therefore,the establishment and management of anemergency supply chain during the containment effort are of paramount importance.This paperfocuses on defining the role of logistics operations and their management that may assist the control ofepidemic outbreaks,critically reviewing existing literature and pinpointing gaps.Through the analysisof the selected literature a series of insights are derived and several future research directions areproposed.In conclusion,this paper provides both academics and practitioners with an overview ofliterature on epidemics control and logistics operations aiming at stimulating further interest in thearea of epidemics control supply chain management.&2012Elsevier B.V.All rights reserved.1.IntroductionAmong disasters,outbreaks of epidemics account for excessivedamages of human and material capital,including a great number ofdeaths.Polio,smallpox,cholera and HIV are among the diseases thatcontinue to pose a threat for many developing and developedcountries.Human history is full of public health incidents wherepandemics occurred in a certain period of time causing suffering anddeath.For example,plague epidemics in late Medieval Europecharacterized by high mortality rates caused many fatalities,whilethe1918–1919Spanish influenza pandemic killed an estimated20to50million people worldwide(Benedictow,1987;Tumpey et al.,2005).Epidemic outbreaks may occur in the context of naturalcauses such as the recent outbreak of novel influenza A(H1N1)viruswhere,according to the World Health Organization(WHO),from thestart of the pandemic until May28,2010,the virus had alreadyspread over214countries causing18,114deaths(http://www.who.int/csr/don/2010_05_28/en/index.html).Epidemic outbreaks arealso very common in the aftermath of natural disasters.Acuterespiratory infections,measles,malaria and diarrhea are the mostprevalent infectious diseases after natural disasters and all of themare closely related to unsanitary health conditions and malnutritionof the population affected(Watson et al.,2007).Finally,deliberatebioterrorist actions and the release of biological warfare agentscould also lead to epidemic outbreaks.According to Henderson(1999)smallpox and anthrax are considered to be among the twomost feared biological agents that could be used in a probablebioterrorist attack‘‘as they have the potential to be grown reason-ably easily and in large quantities and are sturdy organisms that areresistant to destruction’’.The anthrax attacks of2001in the UnitedStates demonstrated the threat of a possible bioterrorist action andits severe impacts.The importance of addressing epidemic outbreaks nowadays iseven greater as the general framework in which they may occurhas dramatically changed during the last years.New challengeshave arisen and certain drivers like climate change,populationdensity and urbanization could serve as catalysts for the accel-eration of pandemic incidents.Climate change is expected to playa crucial role in the birth and transmission of specific diseases(McMichael,2003).Many studies suggest that diseases such asyellow fever,dengue and cholera are re-emerging due to climatechange among other factors(Shope,1991).Specific arbovirusdiseases have recently emerged outside their usual endemicrange and this could be attributed to changes in climate patterns(Gould and Higgs,2009).Apart from climate change,the wit-nessed rapid urbanization of the world’s population along with asubstantial growth in general population could lead to acceler-ated epidemic outbreaks,rendering socioeconomic systems evenmore vulnerable.A possible outbreak combined with changes indemographic conditions like population distribution,size anddensity could potentially lead to a pandemic of unprecedentedContents lists available at SciVerse ScienceDirectjournal homepage:/locate/ijpeInt.J.Production Economics0925-5273/$-see front matter&2012Elsevier B.V.All rights reserved./10.1016/j.ijpe.2012.05.023n Corresponding author.Tel.:þ302104142150;fax:þ302104142629.E-mail addresses:dasaklis@unipi.gr(T.K.Dasaklis),pappis@unipi.gr(C.P.Pappis),nraxan@unipi.gr(N.P.Rachaniotis).Int.J.Production Economics139(2012)393–410proportion where available capacities and resources could be strained to their limits.The control of an epidemic’s outbreak calls for a prompt response.Certain control protocols should be followed and huge amounts of supplies together with the necessary human resources(medical and other personnel)should be available in order to be utilized during the containment effort.For example,if a smallpox attack happens,vaccination of the affected population should take place within4days while in the case of an anthrax outbreak the distribution of antibiotics should take place within2 days of the event(Lee,2008).As a consequence,any control of an epidemic’s outbreak should rely on the establishment of an emergency supply chain as a plethora of logistics issues is raised according to the control strategy adopted and the very nature of the agent triggering the outbreak.All the logistics operations such as transportation of medical supplies and commodities or the deployment of medical personnel must be managed in conjunc-tion with available information andfinancial resources in order to contain the epidemic before it reaches critical proportions.This is the reason why leading international health organizations like World Health Organization and the Pan American Health Organi-zation explicitly recognize the importance of logistics operations to any successful health task undertaken for the control of an outbreak.A basic component of the World Health Organization’s Epidemic and Pandemic Alert and Response program addresses logistic issues in order‘‘to provide operational assistance in the ongoing management of logistics required for epidemic and pandemic preparedness and response and for the rapid deployment of medical and laboratory supplies,transport,communications as well as the rapid deployment of outbreak response teams’’(http://www.afro. who.int/en/divisions-a-programmes/ddc/epidemic-a-pandemic-a lert-and-response/programme-components/logistics.html).Inter-national aid organizations,like the United States Agency for International Development(USAID),also pay attention to logis-tical issues in the case of epidemic outbreaks control.The USAID9DELIVER PROJECT,Task Order2-Supply Chain Manage-ment for Outbreak Response supports USAID’s efforts to mitigate existing and emerging pandemic threats by procuring,stock-piling,and distributing outbreak response commodities(http:// /dhome/topics/health/outbreakresponse).Although logistics operations are very important for control-ling an epidemic’s outbreak,the scientific community has yet to produce a large amount of well-established approaches that explicitly incorporate epidemics logistics features.Even further, issues of appropriately managing epidemics logistics operations have been paid limited attention.So far,epidemics logistics operations have been seen through the lens of resource allocation or have been implicitly incorporated as qualitative variables into preparedness and response plans.For example,a considerable volume of scientific research has been conducted in the case of resources allocation for the control of infectious diseases (Brandeau,2005;Rachaniotis et al.,2012;Zaric and Brandeau, 2001,2002)or in the case of developing preparedness and response plans for health-care facilities to deal with epidemic outbreaks(Ammon et al.,2007;Ippolito et al.,2006;Rebmann et al.,2007;Savoia et al.,2009;Webby and Webster,2003).While resource allocation models and contingency plans provide a strong insight towards epidemics control,they often overlook some critical aspects:allocation of resources cannot be accom-plished unless the availability of these resources is assured at the right time,right place and right quantity.In addition,contingency plans often overlook critical logistical parameters like patient flow logistics and the availability of workforce and,therefore, several decision variables related to possible bottlenecks or workforce shortages are omitted.Results of many full-scale exercises have shown that logistics poses a real challenge when controlling an epidemic outbreak(Aaby et al.,2006).Logistical barriers could also be apparent even when establishing a simple quarantine program in terms of transferring supplies across quarantine lines,recruiting qualified medical personnel etc. (Barbera et al.,2001).The aforementioned gap in the literature concerning epidemics logistics operations and their management has been our main driver for conducting this review paper.Our scope is to shed light into the general context of emergency supply chain management in the case of epidemics containment.Thus the objectives of the paper may be summarized as follows:To define and inter-correlate the logistics operations taking place during the containment of an epidemic.Tofind to what extent literature has produced a critical mass of scientific work in terms of methodologies applied and research techniques utilized regarding the issues of epidemics control logistics.To determine whether the methodologies applied in business logistics problems could be utilized in the context of epidemics control logistics(e.g.Operational Research methods utilization etc.).To develop a more robust definition of the epidemics control supply chain and enhance its understanding.To look for trends in epidemics control supply chain manage-ment academic research and to propose areas for further investigation.The remainder of the paper is structured as follows:in Section2 some key concepts of emergency and humanitarian supply chain management are outlined.Section3provides an overview of the research methodology utilized for the purposes of the review and the boundaries of our research.In Section4an inventory of the logistics operations taking place during the control of an epidemic is developed.Section5deals with the analysis and classification of the selected literature regarding epidemics logistics operations.In Section6the mainfindings of the review are discussed.Finally,the paper ends with some concluding remarks and suggestions for future research directions.2.Epidemics control and emergency supply chain managementThe control of infectious diseases may be based on measures adopted at international,national,provincial or even community level.Reducing the rate by which susceptibles become infected, reducing the mortality rate for those already infected and increas-ing the immunization capacity of the population comprise the main objectives of any containment effort.Such control measures demand the launching of vaccination or quarantine programs over certain geographic regions.They also call for interventions that will ensure the provision of medical supplies like antiretro-viral drugs,antibiotics,clean water/adequate sanitation and better nutrition conditions in order that the multiplication of the infectious agent be reduced.Control measures could be adopted with the aim either to prevent the spread after the initiation of an infectious disease(as pre-event measures)or to control a confirmed outbreak(post-event measures).In thefirst case,a certain level of medical supplies should be kept in order to be utilized immediately at the initiation of an epidemic.In the second case the deployment of all the available resources should rapidly take place providing either treatment to those already infected or prophylaxis to those susceptible to the agent triggering the outbreak.T.K.Dasaklis et al./Int.J.Production Economics139(2012)393–410 394It is therefore evident that the control of any epidemic out-break should be based on the establishment of an emergency supply chain as physical movement of large amounts of medical supplies takes place.For example,manufacturers should produce vaccines,antiretroviral drugs and complementary medical ernments and public health institutions should pur-chase and stockpile well in advance a plethora of such supplies for a possible outbreak.During the containment effort transportation and distribution of these supplies from central warehouses to regional store sites and then to local Points of Dispensing(POD) will have to take place.In the case of vaccines,a cold supply chain must be established to assure that vaccines are transported, stored and packed in accordance with manufacturers’instructions (stable temperature).Affected people will proceed to treatment centers where patientflow operations along with dispensing activities of the medical supplies should be managed appropri-ately.Reverse logistics activities should also take place as dan-gerous wastes must be treated carefully or disposed of in such a way that they do not pose a threat for the medical personnel and people engaged in the containment effort.In addition,coordina-tion issues across the entire emergency supply chain arise. Manufacturers,governments,primary health care institutes and possibly military agencies are few among many players that should be coordinated during the control effort.Finally,managing the information regarding the demand for medical supplies as well as theflow of funds is also critical.In Fig.1an End-to-End approach of the epidemics control supply chain is depicted.Note that the reverseflow may refer to only a part of the medical supplies.The outbreak of an epidemic can be related to a high rate of mortality,thus it may be characterized as a disaster.Disaster Operations in general are a set of activities that are performed before,during and after a disaster with the goal of preventing loss of human life,reducing its impact on the economy and returning to a state of normalcy(Altay and Green Iii,2006).Disaster management is‘‘an applied science which seeks,by the systematic observation and analysis of disasters,to improve measures relating to prevention,mitigation,preparedness,emergency response and recov-ery’’(Pettit and Beresford,2005).Recent studies have demonstrated the contribution of appro-priate management of disasters to save or offer relief to as many people as possible.According to Kovacs and Spens(2007)an emergency or humanitarian supply chain encompasses a range of activities,including preparedness,planning,procurement,trans-port,warehousing,tracking and tracing and customs clearance. Humanitarian logistics is an umbrella term for a mixed array of operations,from disaster relief to continuous support for devel-oping regions,and could be defined as the process of planning, implementing and controlling the efficient,cost effectiveflow and storage of goods and materials as well as related information from the point of origin to the point of consumption for the purpose of alleviating the suffering of vulnerable people.As an example,one of the notable aspects of the relief effort following the2004Asian tsunami was the public acknowledgment of the role of logistics in effective relief(Thomas and Kopczak,2007).The management of emergency and/or humanitarian supply chains has recently attracted the attention of both practitioners and researchers.Such supply chains have much in common with commercial supply chains but at the same time they pose significant challenges as they operate under uncertain,and many times,chaotic conditions.Research methodologies widely utilized in solving business logistics problems could be adopted in the context of emergency supply chain operations.Similarities exist-ing between commercial and emergency supply chains offer the opportunity of transferring knowledge from the business sector to humanitarian organizations(Maon et al.,2009).Even at a long-term level,strategies adopted in commercial supply chains could be also adopted in the case of emergency and/or humanitarian supply chains in an effort to match supply with demand (Oloruntoba and Gray,2006;Taylor and Pettit,2009).A very comprehensive description towards the issues of humanitarian logistics can be found in Van Wassenhove(2006).Research conducted so far towards emergency and/or huma-nitarian supply chain operations has been targeted towards inventory management,facility location,transportation problems and performance measurement.For example,Beamon and Kotleba(2006)and Clay Whybark(2007)examined the problem of inventory management in case of response to emergencies. Balcik and Beamon(2008)examined the facility location problem of a humanitarian relief chain responding to quick-onset disas-ters.Balcik et al.(2008)studied the‘‘last mile’’distribution problem of the relief chain,which refers to the distribution of emergency supplies from local distribution centers tofinal ben-eficiaries affected by disasters.Issues of performance measure-ment in humanitarian supply chains are examined in Beamon and Balcik(2008)and Van Der Laan et al.(2009).Finally,coordination and knowledge sharing issues or even the role of all the players taking part in an emergency and/or humanitarian supply chain have also been the subject of research(Balcik et al.,2010;Kova´cs and Spens,2010;Pettit and Beresford,2005).3.Research methodology and boundariesThe literature regarding epidemics containment is vast.Three basic streams of research conducted so far may be identified.The first stream consists of research addressing pharmaceutical inter-ventions for the control of an epidemic.In this case,public health treatment programs(like vaccination campaigns)take place where limited resources are utilized.These resources couldbe Fig.1.Materialsflow of the epidemics control supply chain(End-to-End approach).T.K.Dasaklis et al./Int.J.Production Economics139(2012)393–410395either discrete(like vaccines,antibiotics or antiretroviral drugs, etc.)or continuous(like funds).The second stream consists of research approaches addressing non-pharmaceutical interven-tions like the closure of schools,voluntary quarantines over a wide area,social distancing and travel limitations.Finally,the third stream consists of research approaches where the pharma-ceutical and non-pharmaceutical interventions are combined and harmonized control actions are proposed.From the aforementioned literature our focus has been on pharmaceutical and harmonized approaches where certain logis-tics operations features are incorporated into the decision making process(either quantitative or qualitative).Therefore,this review covers the logistical aspects that support the pre-event as well as post-event logistics operations in the case of emergencies like an unprecedented pandemic outbreak,a bioterrorist attack,epi-demic outbreaks during mass gatherings or epidemic outbreaks in the aftermath of natural or man-made disasters.As a conse-quence,this review does not take into consideration logistics aspects arising in the context of seasonal influenza outbreaks or relevant diseases’outbreaks which may be expected,anticipated or last for a long period of time(like HIV outbreaks).It is worth mentioning that this review focuses on the opera-tional issues arising in relation to the control of epidemics.Thus papers addressing problems such as resource allocation or general contingency plans have not been included in the main reference list.For the interested reader an additional reference list can be found after the main reference list,where several resource allocation papers as well as contingency plan papers are cited. Furthermore,modeling approaches not calibrated to the epi-demics control context have not been included in the classifica-tion framework of this review.A relevant survey regarding modeling approaches in the generic context of emergency supply chain management can be found in Caunhye et al.(2012).Apart from the aforementioned limitations,in this review two exemp-tions have been made regarding the papers of Chick et al.(2008) and Ak et al.(in press).The justification of these exemptions is provided in the relevant section where both papers are cited. Finally,this review cannot by any means be considered as an exhaustive one.In order to review the available literature ourfirst task was to define our sources and to establish the appropriate search criteria. Epidemics control handbooks and relevant information from several databases(governmental and international agencies such as the World Health Organization,the Pan-American Health Organization and the European Centre for Disease Prevention and Control etc.)were studied in order to determine the logistics operations taking place during the control of an outbreak.Key-word searches were made through several scientific databases including Springer,Science Direct and Scopus.During the selec-tion process all abstracts or list of references from the papers were examined in order to locate additional relevant research works.A total number of73papers werefinally selected.We are aware of at least one review regarding OR/MS research in disaster operations management(Altay and Green Iii,2006),in which epidemics control issues were excluded and one review regarding bioterrorism response logistics(Bravata et al.,2004a). In addition,Brandeau et al.(2009)made an inventory of health sector disaster response models in which logistical constraints were incorporated in the case of epidemic outbreaks,while Ferguson et al.(2003)reviewed the usage of available mathema-tical models when planning for smallpox outbreaks.The need for a more integrated incorporation of logistical constraints into existing modeling approaches was among thefindings of the review.For the classification of the selected literature all the logistical variables and relevant logistics aspects of each reference were initially identified.Our classification scheme was based on a three-level assessment framework presented in Fig.2.In thefirst level of assessment the various logistical features incorporated in each reference are classified according to the time framework in which they take place(pre-event or post-event).In the second level of assessment a context-specific classification is made where the logistics features are correlated to the nature of the epidemic’s outbreak.Finally,in the third level of assessment the logistical features and the methodologies applied(qualitative or quantita-tive)for solving the problem tackled are classified.It is worth mentioning that in the classification scheme the incorporated logistical features of each reference have been utilized as the main driver for the classification process.Such an approach not only provides the means for better synthesizing and analyzing the selected literature but also gives us the opportunity t o better understand the interdependencies between logistics operations and the general control context in which they take place.As a consequence,the classification scheme highlights several attri-butes of epidemics logistics operations and enables us to develop a more robust research agenda towards epidemics control supply chain management.4.Epidemics control and logistics operationsGovernmental agencies and health institutions should be prepared in advance for the control of epidemic outbreaks.This means that they should have in place robust contingency plans addressing issues like the availability of emergency medical stocks and well-trained personnel,their appropriate deployment, the availability of different types of vehicles for the transportation of essential medical supplies and commodities etc.Generally,it remains very difficult to define whether the needs for producing and distributing vaccines in the case of e.g.a possible pandemic influenza outbreak can be met(Fedson,2003;Webby and Webster,2003)by existing capacities.Consequently,any attempt to contain an epidemic outbreak demands real-time solutions that should ensure the effective management of all the logistics activities taking place,since sometimes these activities may become a real nightmare if not managed properly(Osterholm, 2001).In the sequence,an inventory of all the logistics operations taking place during the various phases of an epidemic’s contain-ment effort is provided.Generally,these phases could be classi-fied as follows(John Hopkins Bloomberg School of PublicHealth Fig.2.A framework for epidemics logistics literature classification.T.K.Dasaklis et al./Int.J.Production Economics139(2012)393–410 396and the International Federation of Red Cross and Red Crescent Societies,2008;World Health Organization,2005):PreparednessOutbreak investigationResponseEvaluation.4.1.PreparednessMany organizations around the world have established prepa-redness plans in the case of epidemic or pandemic outbreaks.Such plans range from community to national level and they include all the measures required for the successful containment of an out-break.The World Health Organization has published several pan-demic preparedness guidelines since1999and it updates them in the light of new developments regarding increased understanding of past pandemics,strengthened outbreak communications,greater insight on disease spread etc.(World Health Organization,2009).Epidemic preparedness aims at maintaining a certain level of available resources so as to reduce morbidity and mortality when an epidemic outbreak occurs.This means that pharmaceuticals and supplies should remain accessible or kept in large quantities (Richards et al.,1999)in order to assist a prompt response,if necessary.Procurement of vaccines and medical supplies and their exact storing location play a crucial role for the outcome of any containment effort.For instance,the Strategic National Stock-pile(SNS)program in the United States is an indicative prepared-ness program with the objective to maintain large quantities of medicine and medical supplies and to provide these materials to states and communities within twelve hours in the event of a large-scale public health emergency(Esbitt,2003).In addition,a certain amount of vaccines should be available for the immuniza-tion of control teams and health-care workers.This is of great importance as medical personnel will treat the veryfirst infected persons and should be protected against the disease that causes the outbreak.Among the most important logistics operations taking place and relevant logistics-oriented decisions to be made during the phase of preparedness are the following(John Hopkins Bloomberg School of Public Health and the International Federation of Red Cross and Red Crescent Societies,2008;World Health Organization,2005,2008):Identification of sources for the procurement of medical supplies and relevant commoditiesContract management for all the materials procuredInventory management for all the essential medical supplies (vaccines,antibiotics,antiretroviral drugs)and supplementary medical commodities(personal protective supplies)keptPeriodical review and updating of medical suppliesFacility location and capacity determination for stockpiling centersNetwork design for transportation/distribution activities and selection of appropriate means for transportation/distribution activitiesSelection of appropriate vaccination facilities/health care sys-tems and their capacity(size,availability of rooms and designated areas,availability and scheduling of personnel etc.) Availability of funds.4.2.Outbreak investigationOutbreak investigation consists of the detection of any sus-pected outbreak and its confirmation through laboratory testing.In order to detect and confirm a suspected outbreak,surveillance systems must be put in place in order to provide the decision makers of the health agencies in charge with the essential information regarding any unexplained infection increases seen over a period of time through the systematic analysis of data collected.Surveillance systems provide adequate information that facilitates the development of an initial response framework where the type and magnitude of the containment effort could be determined once epidemic thresholds have been reached.The term epidemic threshold refers to the level of disease above which an urgent response is required.It is specific for each disease and depends on the infectiousness,other determinants of transmission and local endemicity levels(World Health Organization,2005).Leading world health organizations have developed surveillance systems covering cases like pandemic outbreaks(European Centre for Disease Prevention and Control,June,2009),epidemic out-breaks following natural disasters(World Health Organization, 2005)or even possible disease outbreaks during mass gatherings (World Health Organization,2008).Additionally,surveillance sys-tems have been developed by the scientific community(Dato et al., 2004;Krause et al.,2007;Lombardo et al.,2003)and many researchers have studied relevant issues arising during the detec-tion and confirmation of diseases outbreaks attributed to bioter-rorist attacks(Bravata et al.,2004b;Buehler et al.,2003;Lober et al.,2002;Pavlin et al.,2003;Platt et al.,2003)or epidemic outbreaks related to specific agents(Arita et al.,2004;Dietz et al., 1990;Jansson et al.,2005).It is worth mentioning that the development of a surveillance system to detect epidemic outbreaks that occur during emergency situations(like a humanitarian crisis) may necessitate taking into consideration some context-specific features like the target population,the political context,the poor infrastructure and,finally,the presence of multiple partners in the field(M’ikanatha et al.,2007).Among the logistics activities that support the detection and confirmation mechanisms of a suspected outbreak are(U.S.Agency for International Development,2009; World Health Organization,2005):The provision of all the appropriate materials like report sheets to hospitals,emergency medical services and local public health departments that will be used for the collection of primary data regarding initial casesThe training of clinical workers to recognize unexpected patterns of the occurrence of specific diseases and to promptly identify and report suspected cases using standard definitions The provision of all the necessary commodities and resources to the outbreak response team that will facilitate and ensure its operational deploymentThe collection of specimens and their labelingThe secure transportation of specimens to the appropriate laboratory(using cold boxes and coolant blocks)The appropriate storage of specimens in the laboratory(kept within a specific temperature range)The procurement,handling,storing and distribution of labora-tory commodities,their classification,their quality assurance and quality control etc.It is clear that any successful attempt to contain an epidemic outbreak is closely related to the services provided by labora-tories.These services rely on a huge number of materials and commodities that laboratories utilize and they necessitate increased inventory management capabilities.Additionally,dur-ing epidemic outbreaks laboratories must ensure that they have the capacity to cope with increased testing demands(Crawford et al.,2010).A good reference regarding laboratory logistics can be found in U.S.Agency for International Development(2009).T.K.Dasaklis et al./Int.J.Production Economics139(2012)393–410397。