Our Legislators' Vision Good for Healthcare and National Security

The below blogpost was written with Professor Ladimer S. Nagurney, Professor of Electrical, Computer and Biomedical Engineering, University of Hartford, CT.

Several years ago, we became interested in the Supply Chain of the Medical Nuclear Isotope Molybdenum-99 (Mo-99) that decays into Technetium-99m (Tc-99m), which is used for countless medical tests, especially for cardiac symptoms and cancer diagnostics. At that time, no US reactor was generating Mo-99. As a result, this critical radioisotope that is used in over 50,000 procedures per day in the US with over 1000 procedures per year at Cooley Dickinson Hospital (our local hospital in Northampton, MA) had to be imported from reactors in Canada, Western Europe, and the former Eastern Bloc countries. In addition to the potential security problems caused by reliance on foreign sources, most of the isotope was generated in reactors using Highly Enriched Uranium (HEU) fuel, which could, if not properly secured, be diverted to nuclear weapons.

Concern about the security of the supply of this radioisotope from medical professionals, scientists, and nuclear security experts led the House of Representatives in the 111^th Congress to pass the American Medical Isotope Production Act, sponsored by Representative (now Senator) Ed Markey (D-MA) and co-sponsored by Representative James McGovern (D-MA), whose district, after the 2010 census, now includes Amherst and Northampton.

Just over two years later, the results of these efforts are closer to being realized. Their legislative initiatives were fulfilled with the passage of Public Law 112-239 in January 2013, which includes Subtitle F —American Medical Isotopes Production as part of the Department of Energy National Security Programs.

In September 2013, NorthStar Medical Technologies, of Madison, Wisconsin, a manufacturer and distributor of domestically-produced radioisotopes for the nuclear medicine industry, was able to raise $13.5 million from private investors to begin production of Mo-99 at the Missouri University Research Reactor. According to a recent article in Physics Today, production will begin, following FDA approval, in mid 2014 and, by late 2015, Northstar should be able to produce 3000 six-day curies of Mo-99 per week, approximately half of the US demand for this critical radioisotope.

In November 2013, NorthStar was awarded a $21.8 million cooperative agreement that included $10.9 millionfrom the Department of Energy’s (DOE) National Nuclear SecurityAdministration (NNSA) as part of its Global Threat ReductionInitiative. Currently, a large portion of Mo-99 is produced in reactors using Highly Enriched Uranium, HEU. The Global Threat Reduction Initiative aims to accelerate the development of a reliable, domestic supply of Mo-99 while reducing the use of highly enriched uranium (HEU) in civilian applications worldwide. NorthStar plans to develop non-uranium-based production of Mo-99 via neutron capture.

This funding will reduce potential supply shortages, address national security concerns associated with the use of HEU for civilian applications and reliance on foreign sources, and simplify the logistical complexities of the shipping and disposal of a highly radioactive isotope with long life byproducts. We discussed these issues in our book, Networks Against Time: Supply Chain Analytics for Perishable Products, co-authored with then UMass Isenberg School of Management doctoral students Min Yu and Amir Masoumi, and published in 2013.

As we look forward to the production of Mo-99 in Missouri and Northstar's new technology, we see the efforts of many scientists, engineers, medical professionals, public policy makers, and our outstanding elected officials bearing fruit (or Mo-99/TC99m, as it be). 

Our OpED of a few years ago, emphasized the severity of this issue.

Very glad to see such great progress made, thanks to our legislators in Massachusetts!

The Most Multidisciplinary Supply Chain -- The Medical Nuclear Supply Chain -- Where Operations Research, Physics, Chemistry, and Biology All Meet

Supply chains underpin our economy and are part of each and every industry.

To model and solve supply chain problems, one often has to take a multidisciplinary approach.

Never more so than in the case of medical nuclear supply chains, a topic that we have been researching for several years now and have even written an OpEd piece . These supply chains are especially vulnerable due to the aging of the nuclear reactors where the isotopes are irradiated. Each day, 41,000 nuclear medical procedures are performed in the U.S. using Technetium-99m, a radioisotope obtained from the decay of Molybdenum-99. The Molybdenum is produced by irradiating Highly Enriched Uranium (HEU) targets in research reactors. The radioisotopes are used in medical imaging and diagnostics ranging from cardiac problems to cancer.

When I was an undergraduate at Brown University, and then a graduate student there, I remember being told that one might make use of subject matter in the future that one was studying even though it might not be apparent or even envisionable at that point.

I especially enjoy working on systems, notably, network systems, and, hence, my love of supply chains.

I would argue that medical nuclear supply chains are the most multidisciplinary supply chains and to capture their functionality (and, of course, vulnerability) and, hence, to improve their operation as well as their design, one has to be knowledgable about physics, chemistry, biology/medicine, and, of course, operations research. This may entail collaborations across disciplines but that is an approach that pushes knowledge forward.

Above we have composed a graphic that highlights some of the salient issues surrounding medical nuclear supply chains. Our most recent paper on the topic is: Securing the Sustainability of Global Medical Nuclear Supply Chains Through Economic Cost Recovery, Risk Management, and Optimization, Anna Nagurney, Ladimer S. Nagurney, and Dong Li, to appear in the International Journal of Sustainable Transportation. An earlier paper of ours: Medical Nuclear Supply Chain Design: A Tractable Network Model and Computational Approach, Anna Nagurney and Ladimer S. Nagurney, was published in the International Journal of Production Economics 140(2): (2012) pp 865-874.

A lecture given on the topic to biomedical engineers, which has additional background material, can be accessed here.  Another nice lecture on prezi, which cites our work, and has stunning graphics, can be viewed here.

Hence, do listen to your professors -- chemistry, physics, biology, and math, and operations research you may one day be using and applying and even integrating!

Our OpEd on Medical Nuclear Supply Chains Published Today

It is important not only to do research but also to speak about it at conferences and at other forums.

There are also topics that one may feel sufficiently passionate about and may wish to disseminate thoughts, ideas, and even research results on to a broader audience. Hence, it is also important for academics to contribute OpEd pieces to newspapers on timely topics.

Medical nuclear supply chains, which impact our healthcare security, are such a topic and their vulnerability needs to be addressed.

There is some movement in the US Congress in this direction but the criticality of such supply chains, which enable both cardiac and cancer diagnostics, needs to be emphasized.

Our OpEd piece on the subject: Viewpoint: Passage of American Medical Isotope Production Act of 2011 will help ensure U.S. nuclear medicine supply chain, was published in today's Springfield Republican newspaper, and may be read here.

We have begun to conduct serious research on the design and redesign of medical nuclear supply chains. Our first study on the subject can be accessed, in pdf format, here.

Medical Nuclear Supply Chains -- Where Physics Meets Operations Research for Healthcare Security

I came across an interesting presentation given to a pharmaceutical audience on medical nuclear supply chains in which my book, Supply Chain Network Economics, was cited.

This topic very much intrigued me so I began to research it.

For some background:

Each day, 41,000 nuclear medical procedures are performed in the United States using Technetium-99m, a radioisotope obtained from the decay of Molybdenum-99. The Molybdenum is produced by irradiating primarily Highly Enriched Uranium (HEU) targets in research reactors. Surprisingly, for over two decades, no irradiation and subsequent Molybdenum processing has occurred in the United States. All of the Molybdenum necessary for our nuclear medical diagnostic procedures, which include diagnostics for two of the greatest killers, cancer and cardiac problems, comes from foreign sources. Since Molybdenum-99 has a half-life of only 66.7 hours, continuous production is needed to provide the supply for the medical procedures. Thus, the US is critically vulnerable to Molybdenum supply chain disruptions that could significantly affect our healthcare security and is completely at the mercy of foreign suppliers.

Currently, about 60% of the supply of Molybdenum-99 (Mo-99) for the United States comes from a Canadian reactor, with the remainder coming from Western Europe, with its production taking place in Western Europe, the former Eastern-Bloc States, and South Africa. Worldwide, there are only 9 reactors used for the target irradiation and only 6 major processing plants. The shutdown of any of the reactors or processing plants, due to routine maintenance, upgrades, or, as occurred during 2009 and 2010, for emergency repairs, could significantly disrupt our Molybdenum supply and impact our medical facilities' abilities to perform the necessary imaging for cardiac and cancer diagnoses. The number of processors that supply the global market, however, is only four, and they are located in Canada, Belgium, The Netherlands, and South Africa. Australia and Argentina produce bulk for their domestic markets but are expected to be exporting smaller amounts in the future.

Limitations in processing capabilities restrict the ability to produce the medical radioisotopes from regional reactors since long-distance transportation of the product raises safety and security risks, and also results in greater decay of the product. The number of generator manufacturers, in turn, with substantial processing capabilities, is under a dozen. In addition, several of the reactors currently used, including the Canadian one, are due to be retired by the end of this decade, with the majority of them being between 40 and 50 years of age.

Moreover, although most of the current production of Mo-99 uses HEU targets, all producing countries, where economically and technologically feasible, have agreed, in principle, to convert to low enriched uranium (LEU) according to the latest OECD Nuclear Energy Agency (2011) report. However, although the use of LEU targets for Mo-99 production has advantages over HEU, with proliferation resistance (and, hence, enhanced global security) being a primary one, along with easier availability of the target material and also easier compliance for its transportation and processing, the negatives, nonetheless, include: a lower production yield than HEU and a greater number of targets needed to be irradiated with associated increased volumes of waste. Hence, both production and processing pressures are raised as well as waste management issues.

Since Mo-99 decays with a 66.7 hour half-life, approximately 99.9% of the atoms decay in 27.5 days, making its production, transportation, and processing all extremely time-sensitive. In fact, its production is quantified in Six-day curies end of processing denoting the activity of the sample 6 days after it was irradiated to highlight this. In addition to the time-sensitivity, the irradiated targets are highly radioactive, significantly constraining transportation options between the reactor and the processing facilities to only trucks that can transport the heavily shielded transportation containers. While the extracted M0-99 continues to be constrained by its decay, its shielding requirements are reduced, allowing for transportation by modes other than trucks, including by air.

So what did we do?

We began to identify what a rigorous medical nuclear supply chain network model for this radioisotope should include.

For example, a proper model of this critical medical nuclear supply chain, which allows for appropriate economic cost quantification, heavily emphasized by policy-makers, must include the physics-based principles of the underlying radioactivity, and must incorporate multicriteria decision-making and optimization to capture the operational and waste management costs as well as risk management, subject to constraints of demand satisfaction at the hospitals and medical facilities. Moreover, it must be sufficiently flexible and robust in order to provide rigorous solutions as the technological landscape changes. Furthermore, it should enable the redesign of the supply chain network.

With the creation of such a medical nuclear supply chain network economic optimization model, decision-makers, policy-makers, as well as, healthcare providers, would have the ability to analyze the medical nuclear supply chain vulnerabilities, and synergies, as well as to explore the relevant costs and risks. In addition, the effects on costs and risks of changes in demand, which is expected to increase given the aging population, could be assessed. Moreover, the various stakeholders including the government, the medical firms, and the hospital and imaging facilities, through such a supply chain network economic optimization model, could determine the true costs of operating the reactors, and the same holds for the processing facilities, as well as the generator manufacturing facilities. Such a transparent framework would enhance healthcare security, would allow for more accurate pricing and cost recovery, and would enable the evaluation of disruptions to the medical nuclear supply chain.

We have developed such a model, which is a generalized network model, along with an algorithm, in the paper, Medical Nuclear Supply Chain Design: A Tractable Network Model and Computational Approach, which may be downloaded at:
http://supernet.som.umass.edu/articles/Medical_Nuclear_Supply_Chains.pdf

This paper, I co-authored with my husband, Professor Ladimer S. Nagurney, who holds a PhD in physics, so it represents a true meeting of physics and operations research.

I will be presenting this paper later this month at the Seventh Conference on Integrated Risk Management in Operations and Global Supply Chains. This year, this conference is being hosted by the Desautels Faculty of Management at McGill University, in Montreal, Canada, July 31st - August 1st, 2011. The goal of the conference is to bring together leading academic researchers and practitioners whose work strives to meet at the intersection of Finance, Economics, Operations, and Supply Chain Management. The conference web site is http://intrimatmcgill.wordpress.com.

According to the conference announcement, this two-day conference will feature a single track of presentations that combine technical presentations, industry practices, and discussions on relevant challenges and approaches in the topic area. There will be sixteen 90-minute sessions. Each session has two 30-minute presentations, followed by a discussant giving an overview of related research as well as facilitating a discussion with session participants. The format aims to stimulate discussion and interaction among speakers and participants.

I am very much looking forward to this conference and to presenting our work on medical nuclear supply chains.