in state and local TB programs. Of the respondents, 64 percent reported problems with MDR TB drug procurement in the preceding 5 years.21
Cegielski reported that the most common reasons for the shortages were nationwide shortages (95 percent), lack of funding and drug price (62 percent), shipping delays (71 percent), regulatory delays (50 percent), and payer issues (~30 percent). The number of shortages22 increased from 70 to 211 between 2006 and 2010, and as of September 2011, kanamycin was not available, streptomycin was out of stock, and capreomycin and amikacin were very difficult to procure. The shortages had direct negative effects on patients, according to the same survey, including delays in treatment initiation (58 percent), treatment lapses and interruptions (32 percent), and the need to be prescribed a suboptimal treatment regimen (26 percent). Cegielski stressed that dealing with these shortages depletes the time and human resources of clinic management.
• National regulation of SLDs is essential, as there is no international mechanism to monitor for and ensure QA.
• The SLD supply chain is characterized by a negative cycle arising from the limited number of suppliers of API and FPP coupled with decreased demand for QA SLDs from certain areas.
• There is a need for better demand forecasting, and there is a need to distinguish between aspirational forecasting and realistic forecasting.
• Innovations in information management may offer improvements across many aspects of the SLD supply chain, from tracking of treatment to demand forecasting to reduction of stock-outs.
a Identified by individual speakers.
21 Cegielski cautioned that only 33 of 61 reporting areas responded, so the results might not be generalizable.
22 Including isoniazid, rifampicin, cycloserine, ethambutol, rifabutin, amikacin, kanamycin, and streptomycin.