Preparations for the next influenza pandemic have captured a remarkable amount of attention, effort, and fiscal funding since 2004, when the scientific and public health communities became increasingly concerned about the emergence of a novel influenza virus (H5N1) infecting humans in Eurasia (1). Many feared the occurrence of an outbreak on the scale of the 1918–19 pandemic, during which one third of the world’s population became infected and as many as 100 million persons died (2)

Numerous guidance documents call for stockpiling certain supplies that might be needed to care for influenza patients during a pandemic (3–6). Just-in-time supply chains and standard operating procedures may be insufficient to meet demand as the number of cases increase (3–6). Healthcare systems have been challenged to determine the medical supplies that should be procured. Despite publication of numerous pandemic planning recommendations, little or no guidance has been available about this topic.

In December 2005, the US Department of Veterans Affairs (VA), which has governance over the largest integrated healthcare system in the United States, directed its medical centers to make detailed pandemic influenza preparations. This directive was ushered in by a guidance document (7) that broadly defined the goals and expectations of individual VA medical centers and provided a framework for planning and preparedness. Steps taken by medical centers, including decisions about stockpiling items, were determined by leaders at the local level.

To help our healthcare system prepare for a pandemic, a multidisciplinary group of experts drawn from within the VA system were empaneled to help bridge the gap between policy and procedure. Among the most challenging tasks was the development of a prioritized list detailing supplies and the essential quantities that should be stockpiled. This report aims to provide detailed example of 1 healthcare system’s approach to building a cache of supplies for the next influenza pandemic and to help identify critical gaps in knowledge that must be addressed for adequate preparedness.

The 1,400 medical facilities in the national VA healthcare system are decentralized into 23 Veterans Integrated Service Networks (VISNs), each representing a specific region of the nation. The concepts described in this report are based on actions taken by staff in VISN 8, which includes southern Georgia, most of Florida, and all of Puerto Rico, and provides healthcare for ≈500,000 veterans. Regional network offices help integrate the activities of the medical facilities included in each VISN. Local medical center leaders are primarily responsible for the activities at each hospital and its affiliated outpatient clinics.

Despite the numerous uncertainties posed by pandemic influenza, the types and quantities of essential items that should be stockpiled can be estimated by using a reasoned approach. What is offered in this report is a method to calculate the components of a stockpile by using assumptions that are drawn from previous pandemics. This method enables modification of figures, making them scalable and adaptable to any size population. By following the logic of the proposed calculations, it should be possible to modify the assumptions and other figures as needed for almost any community or healthcare system.

Perhaps the most important limitation with this method is a reliance on assumptions. No one knows what the next pandemic will bring. We believe that it is better to plan for a more severe event that will leave the system overprepared than to risk being underprepared. However, this approach may be viewed by some as unnecessary or too expensive. A stratified purchase plan, in which a fraction of essential items is purchased periodically, is recommended on the basis of availability of funds. Some may favor purchase of all items in 1 category before moving to the next category.

The formation and management of a pandemic supply cache would require considerable human and financial resources. The level of commitment may be viewed by some healthcare systems as too costly, especially in an era of economic instability and healthcare system instability likely requiring major reform. Some of the more resource-intensive components of the proposed approach, such as the storage of items in a staffed central facility, were facilitated by the large size of our healthcare system and available resources. Achieving a similar product in the private sector, where healthcare systems are typically much smaller than those in the federally managed VA, might require a partnership among multiple healthcare systems in a region.

One of the most common and widely held misconceptions we encountered was the notion that a healthcare system could be stressed to the breaking point, such that a large surge of patients could eventually render a hospital unable to function. It is our view that in reality, healthcare systems are designed to operate in a graded fashion. Although it is theoretically conceivable that a catastrophe could cause hospitals to cease functioning, it is much more likely that they will continue functioning, even under the most ominous circumstances (15–17). What will change is the standard of care that is delivered; many patients may have access to less resources than would normally be available (18,19). Stockpiling supplies should help prepare for a downgraded level of care that becomes inevitable as resources are increasingly stretched. A key message taken from our experiences was that supplies need to be ordered far in advance of a pandemic to avoid major problems with back orders and supply shortfalls.

The estimated cost of purchasing all supplies and medications needed to provide healthcare to a population of 500,000 during a wave of an influenza pandemic, including negotiated and contracted prices, was ≈$11 million, or approximately half that amount if one only considers purchasing priority A items. This amount is considerably higher than the amount estimated elsewhere (20). This difference may stem from the way we calculated our needs: we did not assume that we could reach a full capacity. Instead, we attempted to estimate the population that is likely to seek care and assumed that under the dire circumstances of a severe pandemic facilities would decrease standards of care, open alternate sites of care, and creatively care for those patients who came for treatment. We also did not assume that we would have a shortage of personnel to care for these patients. Through altered standards of care; emergency privileging and cross-training of healthcare workers, volunteers, and other persons willing and able to care for our patients, a temporary and substantially changed workforce would be expected to emerge.

Numerous gaps in knowledge were encountered. The mechanisms of human-to-human transmission of seasonal and pandemic influenza are poorly understood. Numerous articles have discussed the types of respiratory protection that should be considered and stockpiled (6,10) for healthcare workers. However, there has never been a definitive, prospective clinical trial that shows whether respirators are superior to surgical masks. Translational research funding to answer these questions should become a priority.

This report is an attempt to describe the challenges our healthcare system faced when preparing for an influenza pandemic. By no means are all the answers, or even the questions, reported here. Additional work is needed to further identify important questions and appropriate solutions. We hope these concepts will help guide the decisions of other healthcare systems as they work through this challenging task.