Pandemic drug distribution: dealing with a ‘slow motion hurricane’

Following right behind the intense buzz around vaccines for Covid-19 is the buzz for how approved vaccines (and therapies) will get to 330 million American patients overnight. That is, of course, an oversimplification: sufficient product won’t be available all at once on one day and, if precedents are followed, there will be some type of preference, for healthcare workers first and others coming behind. In whatever manner this is worked out, the next step will be physically moving product from manufacturing sites to clinics or pharmacies to administer to patients. And for that step, says Paul Dickson, president of Morris & Dickson drug distributors, the summary feeling is, “No problem. We (US distributors) do this all the time.”

Dickson says that there are two important precedents for dealing with the coming tsunami of drug demand: how the drug-distribution industry (and Morris & Dickson in particular, being based in Louisiana) learned from the Katrina hurricane in 2005); and the business practices it has established to deal with the annual runup to flu season as well as customary product launches. How drug distributors make a difference, says Dickson, is that they are already plugged into the majority of dispensing outlets (hospitals, pharmacies, long term care, alternate care, etc.). Based on demand, products are delivered to those outlets daily, and distributors know how to handle both surges in demand and shortages of supply through a variety of allocation processes.

Katrina was a wakeup call for the entire industry: once a region of the country was shut down and residents displaced, getting needed medicines became a crisis. (One outcome of Katrina was the creation of HealthcareReady, a cross-industry collaboration to identify critical needs and coordinate delivery.) The State of Louisiana turned to Morris & Dickson to figure out how to resupply the healthcare system across the region, and its trucks were quickly on the move.

“FEMA [the Federal Emergency Management Agency] has been used to draw product from the Strategic National Stockpile for emergency response,” says Dickson, “but in the case of Katrina, they were geared up to deliver trauma materials, while what patients really needed was their daily blood-pressure medication,” he says. In the aftermath of Katrina, the state of Louisiana developed a longterm arrangement with Morris & Dickson, whereby the company keeps a stockpile on hand for emergencies, and can distribute them quickly and effectively where they are needed. “We know where the health centers are and how to deliver to them, and we can manage the inventory to keep fresh product on hand,” he says. “The Strategic National Stockpile can’t do that.”

Morris & Dickson, whose roots in Louisiana go back to 1841, is generally regarded as the No. 4 distributor in the US, behind McKesson, AmerisourceBergen and Cardinal Health (as it is privately held, its revenues are not publicly reported). It operates throughout the South and much of the Midwest. In addition to being M&D president, Dickson is on the executive committee of the Healthcare Distribution Alliance.

Gearing up for Covid-19

In Dickson’s view, his company—and the rest of the distribution industry—can take lessons learned from Katrina and apply them to the ongoing pandemic. “The response to Covid-19 has been just like responding to a hurricane, only in slow motion,” he says. Drugs for patients on ventilators or with respiratory disorders suddenly skyrocketed in demand, and the industry had to figure out both how to increase supplies and get the products to where they were most needed.

Gilead Sciences’ remdesivir, as a newly identified treatment, represents something of an intermediate point between pre-pandemic and when vaccines will be available. A set quantity of the drug was made available by Gilead (and was distributed to states by AmerisourceBergen); now production is ramping up and the drug will flow into the industry’s distribution centers.

HHS sent out a request for proposals for how to distribute vaccines in mid-June, and M&D was one of the organizations who responded. Its proposal emphasizes a “public/private partnership” in which vaccines (and other products in the Strategic National Stockpile) are distributed from the national network of wholesaler distribution centers. Somewhat controversially, the company recommends using only the Top 3 distributors plus M&D—something that would leave numerous small distributors out of the mix. In essence, M&D is recommending that the arrangement it has with the State of Louisiana be expanded to other states, and with more distributors. Data on both health system demand, and available supply, would be centralized and reported to HHS, which could intervene to reallocate dosages.

There are parallels with how flu vaccine shipments have been handled (coincidentally, the distribution system is gearing up right now for flu season with an expected 168 million dosages eventually to be distributed during the flu season that begins in October). Flu vaccine goes from manufacturers to wholesalers, while a supplementary effort is conducted by the Centers for Disease Control to make vaccine available late in the season where needed. Additionally, both one of the two forms of remdesivir (the injectable) and just about every currently publicized Covid-19 vaccine in development are cold chain products, requiring refrigeration during transport and storage.

It’s worth noting, says Dickson, that with the exceptions of shortages of personal protective equipment (PPE) and drugs specific to Covid-19 treatment early on as the pandemic took hold, the US pharma distribution system held up reasonably well—there were few reports of empty pharmacy shelves (unlike, say, grocery stores). “There’s a lot of hyperbole in the media that when a Covid-19 vaccine becomes available, we won’t have the resources to distribute it efficiently,” concludes Dickson. “We know how to do this, and we’ve been doing it for a long time.”