Targeted Applications of Unmanned Aerial Vehicles (Drones) in Telemedicine

Abstract

Introduction:

Advances in technology have revolutionized the medical field and changed the way healthcare is delivered. Unmanned aerial vehicles (UAVs) are the next wave of technological advancements that have the potential to make a huge splash in clinical medicine. UAVs, originally developed for military use, are making their way into the public and private sector. Because they can be flown autonomously and can reach almost any geographical location, the significance of UAVs are becoming increasingly apparent in the medical field.

Materials and Methods:

We conducted a comprehensive review of the English language literature via the PubMed and Google Scholar databases using search terms “unmanned aerial vehicles,” “UAVs,” and “drone.” Preference was given to clinical trials and review articles that addressed the keywords and clinical medicine.

Results:

Potential applications of UAVs in medicine are broad. Based on articles identified, we grouped UAV application in medicine into three categories: (1) Prehospital Emergency Care; (2) Expediting Laboratory Diagnostic Testing; and (3) Surveillance. Currently, UAVs have been shown to deliver vaccines, automated external defibrillators, and hematological products. In addition, they are also being studied in the identification of mosquito habitats as well as drowning victims at beaches as a public health surveillance modality.

Conclusions:

These preliminary studies shine light on the possibility that UAVs may help to increase access to healthcare for patients who may be otherwise restricted from proper care due to cost, distance, or infrastructure. As with any emerging technology and due to the highly regulated healthcare environment, the safety and effectiveness of this technology need to be thoroughly discussed. Despite the many questions that need to be answered, the application of drones in medicine appears to be promising and can both increase the quality and accessibility of healthcare.

Introduction

The Unmanned Aerial Vehicles (UAVs), also commonly referred to as drones, have recently become a household name in the United States and around the world.¹ Their use in the military and appearance on many headlines have spurred nationwide interest and debate.² UAVs are defined as aircraft vehicles that can be flown autonomously without the need of a pilot on board.³ The origins of UAVs can be traced back almost 100 years dating back to World War I.⁴ While UAVs were originally created for the military, they are now being used for a wide variety of applications. The rise in popularity and application of UAVs, especially in the public sector, can be attributed to their ability to perform a wide range of tasks, which include delivering products faster than ground transportation, traversing rough terrain, and capturing aerial images. Companies such as Amazon and Domino's are heavily studying and developing drones as a modality to improve delivery services and decrease costs.^5
–7 They are also being used by researchers to study pollution, plant ecology, and marine biology.^8

–11

While UAVs have been actively used in the military and recently by many companies and researchers, the application of drones in medicine is a novel and emerging concept. UAVs have an enormous potential to revolutionize the way physicians and patients interact with each other. UAVs offer an inexpensive solution to expand the accessibility of healthcare to patients who are restricted by distance or infrastructure. Examples include critically ill patients who live in rural areas or in areas affected by natural disasters. Some of the medical applications of UAVs include the delivery of automated external defibrillators (AEDs), medical specimens, and vaccines.^12

–18 They also can function as a public health surveillance tool.^19
–21 UAVs have also been tested as a communication hotspot for surgeons to operate in military battlefields using telesurgery to reduce latency.²² While the use of UAVs in the medical field holds a promising future, several ethical, technical, and clinical questions need to be addressed first.

To the best of our knowledge, there are no comprehensive reviews that have integrated and presented research that has been published on the application of UAVs in medicine. This article discusses current UAV feasibility projects as well as several limitations that need to be addressed before drones can be used on a large scale.

Methods

To complete a review of the literature, the PubMed database was queried with the following search terms: “Unmanned Aerial Vehicles,” “UAVs,” and “Drone.” Search results were further limited to English language studies. Boolean operators and medical subject headings (MeSH) were used to combine search terms. Further literature was discovered using the Google Scholar database with the same search terms and using the reference section of articles found through the PubMed search. Preference for selection was given to clinical trials and review articles that assessed the utility of UAVs in clinical medicine.

Prehospital emergency care

Out-of-hospital cardiac arrests (OHCAs) remain an enormous health concern in the United States. Based on a 2017 American Heart Association report, approximately 356,000 people are affected annually with an 11.4% survival rate after emergency medical services (EMS) treatment.²³ The five links to the chain of survival include the early recognition of OHCA, immediate cardiopulmonary resuscitation (CPR), defibrillation, advanced cardiac life support, and postresuscitative care.²⁴ If any of these links are broken, the chance of survival substantially decreases. Survival can decline by as much as 5% every minute if no treatment is applied to the patient.²⁵

According to the Cardiac Arrest Registry to Enhance Survival Summary Report by the Centers for Disease Control and Prevention, half of all OHCAs are either witnessed by bystanders or EMS personnel.²⁶ In these cases, it is important for these individuals to start CPR, locate an AED, and call for emergency services. Even though the placement of AEDs in public places has helped some patients survive cardiac arrests, if response time is reduced then survival may improve. Low survival rates can be attributed to the lack of accessibility of defibrillators within the first few minutes of an arrest.²⁷ In a survey conducted by Research!America, approximately two-thirds of respondents have never seen AEDs in public places.²⁸ To increase the rates of survival of OHCAs, it is important to address the problem of AED accessibility.

UAVs have been demonstrated on a theoretical scale to improve response time for OHCAs as well as survival rates by having the capacity to deliver AEDs directly to bystanders. UAVs equipped with AEDs can be dispatched as soon as calls are made to the 911 call center, deliver AEDs using a Global Positioning System, assist bystanders to perform CPR, and apply an AED through video and audio feedback.^29,30 Three studies have looked at how a theoretical network of UAVs would help to delivery AEDs faster than ambulances in three separate regions. These studies used mathematical and geographic modeling to determine the best placement of drone stations.^12
–14

Current data show that less than 5% of all OHCA patients are reachable by emergency services within 1 min in Salt Lake County.¹² Pulver et al. reported if UAVs existed at every EMS station in the county, more than 80% of OHCA patients would potentially have access to an AED within 1 min.¹² This complements another study that applied a similar geographic and mathematical model to OHCA data in Sweden. Claesson et al. showed that UAVs delivered AEDs faster than the ambulance in more than 90% of the rural cases, ultimately shaving off 19 min in response time.¹³ In another study, Boutilier et al. predicted that drones would reduce the response time of delivering an AED by approximately 10 min in some parts of the Greater Toronto metropolitan region.¹⁴

It is important, however, to note that UAVs would only be helpful to those patients who have their OHCAs witnessed by bystanders who are able to retrieve the AEDs from the UAV. In addition, there are several factors to consider in the use of a network map of UAVs. The response time of the drones depend on the speed, altitude, and acceleration of the drones, as well as their capacity to carry an AED and safely release it to a bystander. In addition, the number of drones and stations needed to adequately cover a certain region as well as the costs to build and maintain them needs to be compared with current EMS. Nonetheless, these three recent studies show promise of AED drones to deliver prehospital emergency care. These UAVs have the potential to increase the accessibility of AEDs and improve the survival rate of patients by giving bystanders an opportunity to apply a shock before ambulances arrive at the scene (Table 1).

Table 1.

Characteristics of the Three Studies Demonstrating the Efficacy of UAVs to Deliver AEDs

STUDY	DESIGN	FINDINGS	CONCLUSION
Pulver et al.¹²	Geographic and mathematical model	AED coverage within 1 min of OHCAs can be substantially increased by UAVs compared to ground EMS transportation in Salt Lake County, Utah	A drone network capable of delivering AEDs has the potential to increase survival rates for patients with OHCAs
Claesson et al.¹³	Geographic and mathematical model	AEDs delivered via UAVs arrived faster than ground EMS transportation in more than 30% of urban settings averaging a reduction of 1.5 min and in more than 90% of rural settings averaging a reduction of 19 min in Stockholm County, Sweden	UAVs appear to be a practicable approach to deliver AEDs faster than EMS in rural regions
Boutilier et al.¹⁴	Geographic and mathematical model	Delivery of AEDs by UAVs compared to EMS ground transportation was significantly reduced in both rural and urban areas in the Greater Toronto metropolitan region	UAVs that deliver AEDs can improve survival rates for patients with OHCAs

AED, automated external defibrillators; EMS, emergency medical services; OHCA, out-of-hospital cardiac arrest; UAV, unmanned aerial vehicle.

Expediting laboratory diagnostic testing

Individuals who live in rural communities are subjected to some barriers that may hinder proper access to healthcare. Often, individuals are unable to receive the care they need due to the lack of means of transportation. Either hospitals or clinics may be too far or the roads may not be suitable for transportation. In addition, clinics that are nearby often depend on other means to transport medical supplies and samples to far away laboratories for testing purposes. Despite almost half of the world's population living in rural communities, only a small fraction is near professional health workers.³¹ In the United States, only about 11% of physicians work in rural communities.³² Factors such as the shortage of physicians, lack of proper diagnostic testing equipment, and poor infrastructure are major limitations to healthcare. In addition, the lack of communication, Internet, or phones may prevent health workers from reaching out to specialists or laboratories that are far away, ultimately negatively impacting patient care.³³

Drones may offer a unique and inexpensive way to transport medical supplies, medications, and specimens faster than ground transportation. Organizations and companies such as the United Parcel Service of America (UPS), Deutsche Post DHL Group, and the National Aeronautics and Space Administration (NASA) have already experimented with the idea of delivering medical supplies as an initiative to increase access to care.^34
–36 However, for drones to be effective, the effects of flight must not alter medical supplies. These parameters include but are not limited to changes in temperature, pressure, and forces of gravity. Several studies have been published looking at the effects of flight on various laboratory samples.^15
–17 These initial studies conclusively point out that drones are a safe modality for the delivery of medical supplies.

Chemistry and hematology delivery

Amukele et al. examined the chemistry, hematology, and coagulation laboratory specimens that were drawn from healthy individuals. One set of specimens was flown via a drone, while the other set was kept stationary at the test site. Following the flight, the laboratory diagnostic tests showed that there were no significant differences in the results from the two modes of transportation.¹⁵

Transfusion delivery

As opposed to chemistry, hematology, and coagulation specimens, the delivery of blood products can be very complicated because they are larger in size and must be maintained under strict guidelines. Currently, UAVs are being used as part of a partnership between the Rwandan government and Zipline, a Silicon Valley-based company, to transport blood between hospitals and clinics as an initiative to make blood more accessible for patients in emergency situations.³⁷ To determine the effectiveness of the transport of blood products via drones, Amukele et al. compared sets of red blood cells, platelets, and plasma units frozen within 24 h of collection that were flown via a drone or held stationary. Following the flights, the blood products were compared with the stationary samples. Observations showed that the specimens were fully intact and no significant changes were detected between the samples from the two modes of transportation.¹⁶

Microbiology delivery

A different study looked at how growth patterns of microbes may be impacted by drone flight. In this study, Amukele et al. looked at growth patterns of microbes as they were being flown by a drone as opposed to being held stationary. Researchers inoculated these organisms (Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Bacteroides fragilis) in blood culture bottles. Researchers also inoculated sputa with S. aureus and S. pneumoniae. Researchers concluded that there were no significant differences in growth pattern or count in the blood or sputum from the samples that were flown versus the samples that were held stationary¹⁷ (Table 2).

Table 2.

Characteristics of the Three Studies Demonstrating the Efficacy of UAVs to Deliver Medical Laboratory Products

STUDY	DESIGN	FINDINGS	CONCLUSION
Amukele et al.¹⁵	Randomized control trial	No significant difference was observed among the chemistry, hematology, and coagulation specimens that were flown via UAVs and held stationary.	UAVs may effectively deliver chemistry laboratory products without affecting the integrity of the specimens
Amukele et al.¹⁶	Randomized control trial	No significant difference was observed between the red blood cell, platelet, and plasma unit specimens that were flown via UAVs and held stationary.	UAVs may effectively deliver blood products without affecting the integrity of the specimens
Amukele et al.¹⁷	Randomized control trial	No significant difference was observed between the microbiological specimens that were flown via UAVs and held stationary.	UAVs may effectively deliver microbiological products without affecting the integrity of the specimens

Vaccine delivery

In a study involving the delivery of medical products, researchers assessed the effectiveness of drones to deliver vaccines to make them more accessible for individuals in rural regions. Vaccine accessibility remains a major issue due to two main reasons: the lack of resources to supply the vaccines and the price of the vaccines.³⁸ The price of the vaccines encompasses the cost of production and transportation.³⁹

Haidari et al. created a virtual representation of the vaccine supply chain in Gaza, a province in Mozambique. In this supply chain, the provincial store was responsible for picking up vaccines from a national warehouse and delivering the vaccines to district stores, which in turn delivered them to health centers to be dispensed to patients using ground transportation. The study looked at whether UAVs would be more effective by delivering the vaccines from three drone hub sites, which would receive the vaccines from the provincial store and deliver them directly to the health centers in Gaza. With this model, vaccine availability can be increased by 2% and produce a $0.08 savings per dose administered.¹⁸

Surveillance

Over the past few years, UAV technology has evolved rapidly. Drones are now being equipped with all sorts of cameras and sensors. While drones have historically been used in the military, the addition of this type of equipment paves the way for these drones to be used for a wide array of applications. For example, police departments have recently used drones as surveillance tools to locate criminals.⁴⁰ The use of drones as surveillance tools in public health is a new concept, but one that has the potential to save many lives.

A recent study was done in Sweden to use drones as a monitoring device for individuals at beaches. Drones can be helpful in identifying drowning victims allowing lifeguards to retrieve them and perform CPR much faster. Drones can be launched when an incident is reported and search the water through video surveillance. Claesson et al. conducted a randomized simulation study comparing the time it takes lifeguards and drones to locate a manikin placed in water. A median time of 3 min and 38 s was saved using drones.¹⁹ A similar type of study was conducted that looked at identifying victims stranded on mountains. While the search party could identify victims by a median time of about 60 min, the drones were able to identify these same victims by a median time of about 10 min.²¹

As part of another drone surveillance project, drones were tested to identify mosquito habitats as part of an effort to eradicate malaria. Drones can be useful because of their ability to identify bodies of water with mosquito habitats through video/photo surveillance. In a study, Hardy et al. compared the effectiveness of drones to ground/field teams in identifying bodies of water that may contain mosquito habitats. The researchers looked at mosquito habitats on the Zanzibar Archipelago. The study showed that the drone effectively identified more bodies of water than the field team for all the sites.²⁰

Limitations

Before drones are used widely in medicine and public health, many questions need to be addressed. An adequate discussion examining the ethical, legal, environmental, and clinical issues needs to occur. While the issues described in this article do not represent the full extent of barriers, they paint a picture of some of the fundamental obstacles. First, and most importantly, unlike the use of drones by Amazon for commercial delivery, medical drones must be Health Insurance Portability and Accountability Act (HIPAA) compliant. HIPAA is a set of regulations established to protect the confidential and private information of patients.⁴¹ HIPAA may be violated if individuals who are not involved in the direct care of patients view patient information on the labels of medical specimens or medications.

Second, current Federal Aviation Administration (FAA) guidelines on drones are very strict. Existing FAA guidelines state that drones must always be in the line of sight of the pilot. In addition, drones cannot exceed an altitude of 400 feet and cannot go faster than 100 miles per hour.⁴² Furthermore, drone usage is fully restricted in many areas such as Washington, D.C.⁴³ Because of these rigid guidelines, medical drones currently can only be used for experiments and research studies. However, for drones to be used in practical health related scenarios in the United States, the FAA needs to establish clear guidelines for medical drones.

Third, with any emerging technology, we need to be wary of any technical or computing malfunctions. Because some drones are operated autonomously, computing errors may not be resolvable while the drone is in flight. In addition, drones may be susceptible to hacks. In these circumstances, drones can be at risk of crashing into obstacles, birds, buildings, or even other unmanned or manned aircrafts or be rerouted to other places other than the target destination. The weather conditions during a flight also can impact the success of a drone mission. Inclement weather conditions or significant differences in ambient temperatures may cause drones to lose their functionality.

Fourth, the cost of building and maintaining drones needs to be carefully reviewed. A cost–benefit analysis needs to be conducted to determine if drones are more cost-effective than ground transportation to deliver medical supplies. In addition, the weight of medical supplies may increase the production cost of a drone. Therefore, more effort may need to be focused on decreasing the weight of the drones or packages for them to be cost-effective.

Conclusions

UAVs in the medical field have a promising future. This technology, originally developed for the military, can be used as a delivery modality or surveillance tool to increase the accessibility of care, especially to those who live in rural communities. However, before UAVs are used on a global scale, several key obstacles, which include the security and privacy of patient information, FAA regulations, computing errors, and cost, need to be discussed and tackled. We aspire that researchers from across the world continue researching the efficacy of drones as they are invaluable pieces of technology, having the potential to revolutionize the way health professionals and patients interact.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Weissbach

, Tebbe

. Drones in sight: Rapid growth through M&A's in a soaring new industry. Strateg Dir, 2016; 32:37–39.

IKV Pax Christi. Does unmanned make unacceptable? exploring the debate on using drones and robots in warfare. Available at www.paxvoorvrede.nl/media/files/does-u-make-ulowspreads_0.pdf; 2011 (last accessed July 22, 2017 ).

Boucher

. Domesticating the Drone: The Demilitarisation of Unmanned Aircraft for Civil Markets. Sci Eng Ethics, 2015; 21:1393–1412.

Keane

, Carr

. A brief history of early unmanned aircraft. Johns Hopkins APL Tech Digest, 2013; 32:558–571.

Wallace

. CNN Wire. Amazon says drone deliveries are the future. Available at http://money.cnn.com.proxygw.wrlc.org/2013/12/01/technology/amazon-drone-delivery/index.html (last accessed July 22, 2017 ).

Condliffe

. MIT Technology Review. An amazon drone has delivered its first products to a paying customer. Available at www.technologyreview.com/s/603141/an-amazon-drone-has-deliveredits-first-products-to-a-paying-customer (last accessed July 22, 2017 ).

McFarland

. CNN Wire. Domino's delivers pizza by drone in New Zealand. Available at http://money.cnn.com.proxygw.wrlc.org/2016/08/26/technology/dominos-drone-new-zealand/index.html (last accessed July 22, 2017 ).

, Wang

, Lu

, Peng

, Lu

, Li

, et al. Three-dimensional investigation of ozone pollution in the lower troposphere using an unmanned aerial vehicle platform. Environ Pollut, 2017; 224:107–116.

Messinger

, Silman

. Unmanned aerial vehicles for the assessment and monitoring of environmental contamination: An example from coal ash spills. Environ Pollut, 2016; 218:889–894.

10.

Cruzan

, Weinstein

, Grasty

, Kohrn

, Hendrickson

, Arredondo

, et al. Small unmanned aerial vehicles (micro-UAVs, drones) in plant ecology. Appl Plant Sci, 2016; 4:apps.1600041.

11.

Hodgson

, Peel

, Kelly

. Unmanned aerial vehicles for surveying marine fauna: Assessing detection probability. Ecol Appl, 2017; 27:1253–1267

12.

Pulver

, Wei

, Mann

. Locating AED Enabled Medical Drones to Enhance Cardiac Arrest Response Times. Prehosp Emerg Care, 2016; 20:378–389.

13.

Claesson

, Fredman

, Svensson

, Ringh

, Hollenberg

, Nordberg

, et al. Unmanned aerial vehicles (drones) in out-of hospital-cardiac-arrest. Scand J Trauma Resusc Emerg Med, 2016; 24:124

14.

Boutilier

, Brooks

, Janmohamed

, Byers

, Buick

, Zhan

, et al. Optimizing a drone network to deliver automated external defibrillators. Circulation, 2017; 135:2454–2465.

15.

Amukele

, Sokoll

, Pepper

, Howard

, Street

. Can unmanned aerial systems (Drones) be used for the routine transport of chemistry, hematology, and coagulation laboratory specimens?. PLoS One, 2015; 10:e0134020.

16.

Amukele

, Ness

, Tobian

, Boyd

, Street

. Drone transportation of blood products. Transfusion, 2017; 57:582–588

17.

Amukele

, Street

, Carroll

, Miller

, Zhang

. Drone transport of microbes in blood and sputum laboratory specimens. J Clin Microbiol, 2016; 54:2622–2625.

18.

Haidari

, Brown

, Ferguson

, Bancroft

, Spiker

, Wilcox

, et al. The economic and operational value of using drones to transport vaccines. Vaccine, 2016; 34:4062–4067

19.

Claesson

, Svensson

, Nordberg

, Ringh

, Rosenqvist

, Djarv

, et al. Drones may be used to save lives in out of hospital cardiac arrest due to drowning. Resuscitation, 2017; 114:152–156

20.

Hardy

, Makame

, Cross

, Majambere

, Msellem

. Using low-cost drones to map malaria vector habitats. Parasit Vectors, 2017; 10:29:1–13

21.

Karaca

, Cicek

, Tatli

, Sahin

, Pasli

, Beser

, et al. The potential use of unmanned aircraft systems (drones) in mountain search and rescue operations. Am J Emerg Med, 2017; pii: S0735-6757(17)30750-7.

22.

Harnett

, Doarn

, Rosen

, Hannaford

, Broderick

. Evaluation of unmanned airborne vehicles and mobile robotic telesurgery in an extreme environment. Telemed J E Health, 2008; 14:539–544.

23.

Benjamin

, Blaha

, Chiuve

, Cushman

, Das

, Deo

, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2017 Update: A Report from the American Heart Association. Circulation, 2017; 135:e146–e603.

24.

Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions. Available at www.ncbi.nlm.nih.gov/books/NBK321513 2015 (last accessed October 2, 2017 ).

25.

Larsen

, Eisenberg

, Cummins

, Hallstrom

. Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med, 1993; 22:1652–1658.

26.

Centers for Disease Control and Prevention. Cardiac arrest registry to enhance survival (CARES) national summary report. Available at https://mycares.net/sitepages/uploads/2015/CARES%20IOM%20Formatted.pdf 2016. (last accessed July 22, 2017 ).

27.

Sun

, Demirtas

, Brooks

, Morrison

, Chan

. Overcoming spatial and temporal barriers to public access defibrillators via optimization. J Am Coll Cardiol, 2016; 68:836–845.

28.

Research!America. Taking our pulse: The PARADE/research!america health poll. Available at www.researchamerica.org/sites/default/files/uploads/poll2005paradeheart.pdf; 2005 (last accessed July 22, 2017 ).

29.

Van de Voorde

, Gautama

, Momont

, Ionescu

, De Paepe

, Fraeyman

. The drone ambulance [A-UAS]: Golden bullet or just a blank?. Resuscitation, 2017; 116:46–48

30.

Claesson

, Bäckman

, Ringh

, Svensson

, Nordberg

, Djärv

, et al. Time to delivery of an automated external defibrillator using a drone for simulated out-of-hospital cardiac arrests vs emergency medical services. JAMA, 2017; 317:2332–2334

31.

World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations. Available at www.searo.who.int/nepal/mediacentre/2010_increasing_access_to_health_workers_in_remote_and_rural_areas.pdf; 2010. (last accessed July 22, 2017 ).

32.

University of Washington School of Medicine; Department of Family Medicine. The future of family medicine and implications for rural primary care physician supply. Available at https://depts.washington.edu/uwrhrc/uploads/RHRC_FR125_Rosenblatt.pdf; 2010 (last accessed July 22, 2017 ).

33.

Anticona Huaynate

, Pajuelo Travezaño

, Correa

, Mayta Malpartida

, Oberhelman

, Murphy

, Paz-Soldan

. Diagnostics barriers and innovations in rural areas: Insights from junior medical doctors on the frontlines of rural care in Peru. BMC Health Serv Res, 2015; 15:454

34.

Atherton

. Watch Popular Science. A UPS drone deliver medical supplies to an island. Available at www.popsci.com/ups-tests-drone-deliveries-to-island; 2016 (last accessed July 22, 2017 ).

35.

Hackman

, Nicas

. Wall Street Journal. Drone delivers medicine in Virginia. Available at www.wsj.com/articles/drone-delivers-medicine-to-rural-virginia-clinic-1437155114; 2015 (last accessed July 22, 2017 ).

36.

Nicas

, Sloat

. Wall Street Journal. Deutsche post DHL to deliver medicine via drone. Available at www.wsj.com/articles/deutsche-post-dhl-to-deliver-medicine-via-drone-1411576151;2014 (last accessed July 22, 2017 ).

37.

Preimesberger

. eWeek. Drones will soon be dropping medicines to save lives in Rwanda. Available at www.eweek.com/mobile/drones-will-soon-be-dropping-medicines-to-save-lives-in-rwanda; 2016 (last accessed July 22, 2017 ).

38.

Doctors without Borders. An overview of vaccine access and R&D. Available at www.doctorswithoutborders.org/sites/usa/files/MSF-Oxfam-Vaccine-Report.pdf; 2010 (last accessed July 22, 2017 ).

39.

Lydon

, Gandhi

, Vandelaer

, Okwo-Bele

. Health system cost of delivering routine vaccination in low- and lower-middle income countries: What is needed over the next decade?. Bull World Health Organ, 2014; 92:382–384

40.

Bennett

. Los Angeles Times. Police employ predator drone spy planes on home front. Available at http://articles.latimes.com/2011/dec/10/nation/la-na-drone-arrest-20111211; 2011 (last accessed July 22, 2017 ).

41.

U.S. Department of Health and Human Services. Your rights under HIPPAA. Available at www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html; 2017 (last accessed October 1, 2017 ).

42.

Federal Aviation Administration. Getting started. Available at www.faa.gov/uas/getting_started/; 2017 (last accessed October 1, 2017 ).

43.

Federal Aviation Administration. No drop zone. Available at www.faa.gov/uas/where_to_fly/no_drone_zone/; 2017 (last accessed October 1, 2017 ).