To the Editor— As the world prepared and responded to the coronavirus disease 2019 (COVID-19) pandemic in early 2020, a rapid increase in demand for personal protective equipment (PPE) led to severe shortages worldwide. The PPE demand rose as a result of panic purchasing, hoarding, and misinterpretation of public health information.^{Reference Battista, Ferraro, Piccioni, Malzaneni and Bussi1–Reference Cohen and van der Meulen Rodgers3} This led to shortages so wide that the World Health Organization released several memorandums regarding ‘rational use’ of PPE to try and reconcile the spike in utlization of PPE as well as the inevitable increase in prices.^{Reference Battista, Ferraro, Piccioni, Malzaneni and Bussi1,4} Our 151-bed safety-net hospital, like many other facilities, navigated a major rise in prices as part of our pandemic preparedeness and response. In this study, we performed a review of PPE market prices paid by our facility during the first surge of the pandemic (April–June 2020). Our hospital is located in Chicago, Illinois. We have reported cost and emphasized the importance of PPE supply resilience for pandemic preparedness. The maximum cost per unit (CPU) of PPE was tabulated and compared with prepandemic (April–June 2019) prices to establish an increase in CPU in US dollars for the various PPE items. The maximum CPU of PPE was tabulated for each week and the average cost throughout the first wave of COVID-19 pandemic was calculated. Disposable gowns, washable gowns, N95 respirators, face masks, and gloves were included in our analysis.

PPE prices were significantly higher during the first wave of the pandemic compared to prepandemic prices (Fig. 1). The CPU for gloves increased from $0.05 to $0.12; the CPU for face masks increased from $0.05 to $0.45; the CPU for N95 respirators increased from $0.98 to $7.4; and the CPU for disposable gowns increased from $0.87 to $6.60. The CPU for gloves averaged 2.5 times higher than prepandemic prices. The CPU for face masks peaked at $0.55, 11 times higher and an average of 9 times higher than the prepandemic price. N95 respirators had a peak CPU of $12, and the average CPU was 8 times higher than prepandemic prices. The average CPU for gowns was 7.5 times higher than prepandemic prices; the CPU for disposable gowns peaked at $12 during the first week of March 2020, a price 13.7 times higher than the prepandemic price.

Fig. 1. Cost of personal protective equipment per unit in US dollars.

Before the pandemic, hospitals were spending ∼$7 per patient on PPE, with an increase to $20.40 during the first wave of COVID-19 in the spring of 2020.⁵ The Society for Healthcare Organization Procurement Professionals conducted a study during the same period showing that PPE costs increased 1,064% in their 5,000 skilled nursing facilities and assisted living centers across the United States.^{Reference Berklan2} Multiple factors likely contributed to high prices, including demand shock, disrupted supply chains, and a rush to acquisition by healthcare systems and the general population alike. The global PPE supply chain did not properly operate to meet the demands of healthcare systems across the world during the first wave of the COVID-19 pandemic. In 2020, many factors such as the shortage of raw materials, export bans, and restraints in logistics contributed to 4–6 month backlogs for global supply orders of PPE.^{Reference Park, Kim and Roth6}

Several major sources of PPE backlogs were identified by the Asian Development Bank during the early wave of the pandemic in 2020. N95 mask surges led to shortages in nonwoven polypropylene. Export bans in 22 countries limited PPE access to millions of people worldwide. Transport and shipping constraints were implemented. Fewer workplace personnel were available due to COVID-19. Availability of various shipping containers was lower, and more.^{Reference Park, Kim and Roth6} Along with price gouging and competitive bidding among hospitals, these factors inevitably contributed to soaring PPE prices. Cohen et al^{Reference Cohen and van der Meulen Rodgers3} elaborated on 4 other contributing factors to PPE shortages: the way that hospitals budget for PPE, domestic demand shocks, federal government failures, and disruptions to global supply chain.^{Reference Cohen and van der Meulen Rodgers3}

The PPE supply challenges during COVID-19 led to several important conversations regarding policy changes and mitigation strategies. The International Journal of Operations and Production Management identified 4 specific strategies for pandemic-specific supply-chain management: global PPE standards, production changeover, joint procurement, and multiple sourcing.^{Reference Sigala, Sirenko, Comes and Kovács7} The Asian Development Bank also outlined several policy recommendations to ensure PPE preparedness for a global pandemic: monitoring PPE use and visibility of orders, improving supply systems and sharing responsibility, improving domestic manufacturing surge capacity during the event, strengthening trade finance programs for micro, small, and medium-sized enterprises, and more.^{Reference Park, Kim and Roth6} To develop resilient supply chains, local capacity for essential items should be developed, along with an increase and diversification in international production sites.^{Reference Gereffi8}

The COVID-19 pandemic has highlighted the need for policy reconciliation to prevent future supply chain failures and inevitably price surging for essential materials such as PPE.

The Society for Healthcare Epidemiology of America (SHEA) Outbreak Response and Incident Management guidelines provide a high-level overview of incident management for infectious diseases outbreaks.^{Reference Banach, Johnston and Al-Zubeidi9} Our facility navigated these challenges by centralizing and securing our PPE stocks, ensuring accountability and evidence-based use of our supplies, and diversifying our procurement as much as possible to ensure adequate stocks. Resilient supply chains and standardized guidelines for PPE reuse may be necessary for future pandemics.

This study had several limitations. For example, the data presented were limited to the geographic scope of Chicago, Illinois. Despite these limitations, the results of this study are generalizable to hospitals across the United States.