Bioterrorism
Public Health Response to Anthrax Incidents of 2001
Gao ID: GAO-04-152 October 15, 2003
In the fall of 2001, letters containing anthrax spores were mailed to news media personnel and congressional officials, leading to the first cases of anthrax infection related to an intentional release of anthrax in the United States. Outbreaks of anthrax infection were concentrated in six locations, or epicenters, in the country. An examination of the public health response to the anthrax incidents provides an important opportunity to apply lessons learned from that experience to enhance the nation's preparedness for bioterrorism. Because of its interest in bioterrorism preparedness, Congress asked GAO to review the public health response to the anthrax incidents. Specifically, GAO determined (1) what was learned from the experience that could help improve public health preparedness at the local and state levels and (2) what was learned that could help improve public health preparedness at the federal level and what steps have been taken to make those improvements.
Local and state public health officials in the epicenters of the anthrax incidents identified strengths in their responses as well as areas for improvement. These officials said that although their preexisting planning efforts, exercises, and previous experience in responding to emergencies had helped promote a rapid and coordinated response, problems arose because they had not fully anticipated the extent of coordination needed among responders and they did not have all the necessary agreements in place to put the plans into operation rapidly. Officials also reported that communication among response agencies was generally effective but public health officials had difficulty reaching clinicians to provide them with guidance. In addition, local and state officials reported that the capacity of the public health workforce and clinical laboratories was strained and that their responses would have been difficult to sustain if the incidents had been more extensive. Officials identified three general lessons for public health preparedness: the benefits of planning and experience; the importance of effective communication, both among responders and with the general public; and the importance of a strong public health infrastructure to serve as the foundation for responses to bioterrorism or other public health emergencies. The experience of responding to the anthrax incidents showed aspects of federal preparedness that could be improved. The Centers for Disease Control and Prevention (CDC) was challenged to both meet heavy resource demands from local and state officials and coordinate the federal public health response in the face of the rapidly unfolding incidents. CDC has said that it was effective in its more traditional capacity of supporting local response efforts but was not fully prepared to manage the federal public health response. CDC experienced difficulty in managing the voluminous amount of information coming into the agency and in communicating with public health officials, the media, and the public. In addition to straining CDC's resources, the anthrax incidents highlighted both shortcomings in the clinical tools available for responding to anthrax, such as vaccines and drugs, and a lack of training for clinicians in how to recognize and respond to anthrax. CDC has taken steps to implement some improvements. These include creating the Office of Terrorism Preparedness and Emergency Response within the Office of the Director, creating an emergency operations center, enhancing the agency's communication infrastructure, and developing databases of information and expertise on the biological agents considered likely to be used in a terrorist attack. CDC has also been working with other federal agencies and private organizations to develop better clinical tools and increase training for medical care professionals.
GAO-04-152, Bioterrorism: Public Health Response to Anthrax Incidents of 2001
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Report to the Honorable Bill Frist, Majority Leader, U.S. Senate:
United States General Accounting Office:
GAO:
October 2003:
Bioterrorism:
Public Health Response to Anthrax Incidents of 2001:
GAO-04-152:
GAO Highlights:
Highlights of GAO-04-152, a report to the Honorable Bill Frist,
Majority Leader, U.S. Senate
Why GAO Did This Study:
In the fall of 2001, letters containing anthrax spores were mailed to
news media personnel and congressional officials, leading to the first
cases of anthrax infection related to an intentional release of
anthrax in the United States. Outbreaks of anthrax infection were
concentrated in six locations, or epicenters, in the country. An
examination of the public health response to the anthrax incidents
provides an important opportunity to apply lessons learned from that
experience to enhance the nation‘s preparedness for bioterrorism.
Because of your interest in bioterrorism preparedness, you asked GAO
to review the public health response to the anthrax incidents.
Specifically, GAO determined (1) what was learned from the experience
that could help improve public health preparedness at the local and
state levels and (2) what was learned that could help improve public
health preparedness at the federal level and what steps have been
taken to make those improvements.
What GAO Found:
Local and state public health officials in the epicenters of the
anthrax incidents identified strengths in their responses as well as
areas for improvement. These officials said that although their
preexisting planning efforts, exercises, and previous experience in
responding to emergencies had helped promote a rapid and coordinated
response, problems arose because they had not fully anticipated the
extent of coordination needed among responders and they did not have
all the necessary agreements in place to put the plans into operation
rapidly. Officials also reported that communication among response
agencies was generally effective but public health officials had
difficulty reaching clinicians to provide them with guidance. In
addition, local and state officials reported that the capacity of the
public health workforce and clinical laboratories was strained and
that their responses would have been difficult to sustain if the
incidents had been more extensive. Officials identified three general
lessons for public health preparedness: the benefits of planning and
experience; the importance of effective communication, both among
responders and with the general public; and the importance of a strong
public health infrastructure to serve as the foundation for responses
to bioterrorism or other public health emergencies.
The experience of responding to the anthrax incidents showed aspects
of federal preparedness that could be improved. The Centers for
Disease Control and Prevention (CDC) was challenged to both meet heavy
resource demands from local and state officials and coordinate the
federal public health response in the face of the rapidly unfolding
incidents. CDC has said that it was effective in its more traditional
capacity of supporting local response efforts but was not fully
prepared to manage the federal public health response. CDC experienced
difficulty in managing the voluminous amount of information coming
into the agency and in communicating with public health officials, the
media, and the public. In addition to straining CDC‘s resources, the
anthrax incidents highlighted both shortcomings in the clinical tools
available for responding to anthrax, such as vaccines and drugs, and a
lack of training for clinicians in how to recognize and respond to
anthrax. CDC has taken steps to implement some improvements. These
include creating the Office of Terrorism Preparedness and Emergency
Response within the Office of the Director, creating an emergency
operations center, enhancing the agency‘s communication
infrastructure, and developing databases of information and expertise
on the biological agents considered likely to be used in a terrorist
attack. CDC has also been working with other federal agencies and
private organizations to develop better clinical tools and increase
training for medical care professionals.
In commenting on a draft of this report, DOD stressed the critical
role it played in the public health response, and HHS provided
additional examples of actions taken to enhance national preparedness
for bioterrorism and other public health emergencies.
www.gao.gov/cgi-bin/getrpt?GAO-04-152.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Janet Heinrich (202)
512-7119.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Local and State Public Health Officials Identified Strengths in Their
Responses as Well as Areas for Improvement:
Experience Showed Aspects of Federal Preparedness That Could Be
Improved:
Concluding Observations:
Agency Comments:
Appendix I: Timeline of Selected Key Events in the Anthrax Incidents:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Health and Human Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Table:
Table 1: People with Anthrax Infections, Letters Containing Anthrax
Spores, and Facilities Contaminated with Anthrax Spores in the Six
Epicenters:
Abbreviations:
AHRQ: Agency for Healthcare Research and Quality:
AMI: American Media Inc.:
CDC: Centers for Disease Control and Prevention:
DOD: Department of Defense:
EIS: Epidemic Intelligence Service:
EOC: Emergency Operations Center:
EPA: Environmental Protection Agency:
Epi-X: Epidemic Information Exchange:
FBI: Federal Bureau of Investigation:
FDA: Food and Drug Administration:
FEMA: Federal Emergency Management Agency:
HAN: Health Alert Network:
HHS: Department of Health and Human Services:
MMWR: Morbidity and Mortality Weekly Report:
NIH: National Institutes of Health:
USAMRIID: United States Army Medical Research Institute of Infectious
Diseases:
United States General Accounting Office:
Washington, DC 20548:
October 15, 2003:
The Honorable Bill Frist
Majority Leader
United States Senate:
Dear Senator Frist:
In the fall of 2001, letters containing anthrax spores were mailed to
news media personnel and congressional officials, leading to the first
cases of anthrax infection related to an intentional release of anthrax
in the United States.[Footnote 1] Outbreaks of the disease were
concentrated in six locations, or epicenters, in the country--Florida;
New York; New Jersey; Capitol Hill in Washington, D.C;[Footnote 2] the
Washington, D.C., regional area, which includes Maryland and Virginia;
and Connecticut--where individuals came into contact with spores from
the contaminated letters. The anthrax incidents caused illness in 22
people, 11 with the cutaneous (skin) form of the disease and 11 with
the inhalational (respiratory) form. Five people died, all from
inhalational anthrax. The anthrax incidents and the illness and deaths
they caused also had an impact on the country beyond the six
epicenters. Across the nation, even in areas far removed from the
epicenters, residents brought samples of suspicious powders to
officials for testing and worried about the safety of their daily mail.
The public health response to the anthrax incidents was complicated by
several factors. The incidents occurred in the turbulent period
following the terrorist attacks of September 11, 2001, when the focus
of the nation was centered on response to those events. In addition,
the anthrax
incidents were unprecedented. The response was coordinated by the
Department of Health and Human Services (HHS), primarily through its
Centers for Disease Control and Prevention (CDC), and CDC had never
responded simultaneously to multiple disease outbreaks caused by the
intentional release of an infectious agent. Anthrax was virtually
unknown in clinical practice, and many clinicians did not have a good
understanding of how to diagnose and treat it. As a result, public
health officials at the federal, state, and local levels were basing
their actions and recommendations to government officials, other
responders,[Footnote 3] and the public on information that was changing
rapidly. The response to the incidents has been characterized by
several public officials, academics, and other commentators as
problematic and an indication that the country was unprepared for a
bioterrorist event.
An examination of the response to the anthrax incidents provides an
important opportunity to apply lessons learned from that experience to
enhance the nation's preparedness for bioterrorism and other public
health emergencies. Because of your interest in bioterrorism
preparedness, you asked us to review the public health response to the
anthrax incidents. Specifically, you asked us to determine (1) what was
learned from the experience that could help improve public health
preparedness for bioterrorism at the local and state levels and (2)
what was learned that could help improve public health preparedness for
bioterrorism at the federal level and what steps have been taken to
make those improvements.
In studying the response of local and state public health departments,
we interviewed officials from the six epicenters. For a previous
report,[Footnote 4] we had conducted interviews about bioterrorism
preparedness with officials from seven cities and their respective
state capitals. These interviews were conducted from December 2001
through March 2002, and we used information from these interviews to
examine the public health response
to the anthrax incidents in localities that were not epicenters. To
study federal public health efforts, we interviewed officials from the
Department
of Defense (DOD) and HHS. These officials included representatives from
DOD's Armed Forces Institute of Pathology, Chemical Biological Incident
Response Force, Naval Medical Research Center, and U.S. Army Medical
Research Institute of Infectious Diseases (USAMRIID), and from HHS's
Agency for Healthcare Research and Quality (AHRQ), CDC, Food and Drug
Administration (FDA), National Institutes of Health (NIH), and Office
of the Assistant Secretary for Public Health Emergency Preparedness. To
determine the nature of the information provided by CDC during the
incidents, we examined the materials that CDC disseminated during
October 2001 through December 2001. For overall assessments of and
information on the local, state, and federal public health response, we
interviewed members of the academic community and officials of private
organizations representing groups affected by the incidents or involved
in the response, including the American Hospital Association, the
American Medical Association, the American Nurses Association, the
American Postal Workers Union, the American Public Health Association,
and the District of Columbia Hospital Association. We also reviewed
media reports of the incidents from television news services and
newspapers, retrospective analyses of the response published after the
incidents, relevant congressional hearings that were held between
October 2001 and December 2001, and materials provided to us by local,
state, and federal agencies and private organizations involved in
responding to the attack. To understand the scientific community's
analysis of the anthrax incidents, we searched the scientific
literature using the National Library of Medicine's PubMed service and
reviewed relevant articles. To determine what was learned from the
experience that could help improve public health preparedness for
bioterrorism, we analyzed these materials for common themes. We focused
on what could be learned from the anthrax incidents that could help
improve public health preparedness not specifically for anthrax or any
particular locality but for bioterrorism in general. To determine what
steps have been taken to make those improvements, we reviewed materials
from relevant federal agencies through October 2003. Although efforts
to decontaminate affected facilities are part of the public health
response, they are outside the scope of this report, as is the criminal
investigation associated with the incidents.[Footnote 5] We conducted
our work from May 2003 through October 2003 in accordance with
generally accepted government auditing standards.
Results in Brief:
Local and state public health officials identified strengths in their
responses to the anthrax incidents of 2001 as well as areas for
improvement. These officials said that their planning efforts had
helped to promote a rapid and coordinated response, but they had not
fully anticipated the extent of coordination that would be needed
across both public and private entities involved in the response to the
anthrax incidents. Even though many aspects of their existing response
plans had been made operational, for example, by putting agreements
into place, the aspects that had not been operationalized affected
their ability to coordinate a rapid response to the anthrax incidents.
Local and state officials said that their responses also benefited from
previous experiences, whether gained through exercising their plans or
by responding to emergencies of various kinds. These experiences had
allowed them to build relationships and identify areas for improvement
in their plans and thus to be better prepared to respond to the anthrax
incidents. Local and state officials also stressed the importance of
effective communication throughout the incidents. They reported that
communication among response agencies was generally effective, but they
had difficulty reaching clinicians to provide them with needed
guidance. Local and state public health officials were concerned that
the capacity of their workforce and clinical laboratories was strained
and said that their responses would have been difficult to sustain if
the incidents had been more extensive.
The experience of responding to the anthrax incidents also showed
aspects of federal preparedness that could be improved. CDC was
challenged to both meet heavy resource demands from local and state
officials and coordinate the federal public health response in the face
of rapidly unfolding anthrax incidents. CDC has acknowledged that
although it was effective in its more traditional capacity of
supporting local response efforts, it was not fully prepared to manage
the federal public health response. CDC served as the focal point for
communicating critical information during the response to the anthrax
incidents and experienced difficulty in managing the voluminous amount
of information coming into the agency and in communicating with public
health officials, the media, and the public. In addition to straining
CDC's resources, the anthrax incidents highlighted both shortcomings in
the clinical tools available for responding to anthrax, such as
vaccines and drugs, and a lack of training for clinicians on how to
recognize and respond to anthrax.
CDC has reviewed its performance during the anthrax incidents,
identified areas for improvement, and taken steps to implement those
improvements. These include restructuring the Office of the Director,
building and staffing an emergency operations center, enhancing the
agency's communication infrastructure, and developing and maintaining
databases of information on and expertise in biological agents
considered most likely to be used in a terrorist attack. CDC has also
increased its collaborative efforts with others within and outside of
HHS, for example, by creating a permanent position of CDC liaison to
the Federal Bureau of Investigation (FBI). CDC has also been working
with other federal agencies as well as private organizations to support
the development of better clinical tools, including new vaccines and
treatments for anthrax and other potential agents of bioterrorism, and
increased training for medical care professionals.
In commenting on a draft of this report, DOD stressed the critical role
it played in the public health response, and HHS provided additional
examples of actions it has taken to enhance national preparedness for
bioterrorism and other public health emergencies.
Background:
Anthrax:
Anthrax is an acute infectious disease caused by the spore-forming
bacterium called Bacillus anthracis. The bacterium is commonly found in
the soil, and its spores can remain dormant for many years. Although
anthrax can infect humans, it occurs most commonly in plant-eating
animals. Human anthrax infections have usually resulted from
occupational exposure to infected animals or contaminated animal
products, such as wool, hides, or hair. Both human and animal anthrax
infections are rare in the United States.
Anthrax infection can take one of three forms: cutaneous, usually
through a cut or an abrasion; gastrointestinal, usually by ingesting
undercooked contaminated meat; or inhalational, by breathing airborne
anthrax spores into the lungs. After the spores enter the body through
any of these routes, they germinate into bacteria, which then multiply
and secrete toxins that can produce local swelling and tissue death.
The symptoms are different for each form and usually occur within 7
days of exposure. Depending on the extent of exposure and its form, a
person can be exposed to Bacillus anthracis without developing an
infection. There are several methods for detecting anthrax spores or
the disease itself, for example, nasal swabs for exposure to spores,
blood tests for infections, and wet swabs for environmental
contamination. CDC does not recommend the use of the nasal swab test to
determine whether an individual should be treated, primarily because a
negative result (no spores detected) does not exclude the possibility
of exposure. Confirmation of anthrax infection or the presence of
anthrax spores can require more than one type of test. The disease can
be treated with a variety of antimicrobial medications and is not
contagious.[Footnote 6] With proper treatment, fatalities are rare for
cutaneous anthrax. For gastrointestinal anthrax, between 25 and 60
percent of cases have resulted in death. For inhalational anthrax, the
fatality rate before the 2001 incidents had been approximately 75
percent, even with appropriate antimicrobial medications. An anthrax
vaccine is available, but it is indicated for use in individuals at
high risk of exposure to anthrax spores, such as laboratory personnel
who work with Bacillus anthracis.
Because so few instances of inhalational anthrax have occurred,
scientific understanding about the number of spores needed to cause
infection is still evolving. Before the 2001 incidents, it was
estimated that a person would need to inhale thousands of spores to
develop an infection. However, based on some of the cases that occurred
during the anthrax incidents, experts now believe that the number of
spores needed to cause inhalational anthrax could be fewer than that,
depending on a person's health and the nature of the spores.
Public Health Response to a Bioterrorist Attack:
In the existing model for response to a public health emergency of any
type, including a bioterrorist attack, the initial response is
generally a local responsibility. This local response can involve
multiple jurisdictions in a region, with states providing additional
support as needed. Having the necessary resources immediately available
at the local level to respond to an emergency can minimize the
magnitude of the event and the cost of remediation. In the case of a
covert release of a biological agent such as anthrax, it can be days
before exposed people start exhibiting signs and symptoms of the
disease. The model anticipates that exposed individuals would seek out
local clinicians, such as private physicians or medical staff in
hospital emergency departments or public clinics. Clinicians would
report any illness patterns or diagnostic clues that might indicate an
unusual infectious disease outbreak to their state or local health
departments. Local and state health departments would collect and
monitor data, such as reports from clinicians, for disease trends and
evidence of an outbreak. Environmental and clinical samples would be
collected for laboratorians[Footnote 7] to test for possible exposures
and identification of illnesses. Epidemiologists[Footnote 8] in the
health departments would use the disease surveillance systems[Footnote
9] to provide for the ongoing collection, analysis, and dissemination
of data to identify unusual patterns of disease. Public health
officials would provide needed information to the clinical community,
other responders, and the public and would implement control measures
to prevent additional cases from occurring. The federal government can
also become involved, as requested, by providing assistance with
testing of samples and epidemiologic investigations, providing advice
on treatment protocols and other technical information, and
coordinating a national response.
CDC's Bioterrorism Response Planning Efforts:
As early as 1998, CDC had begun its planning efforts to enhance its
capacity to respond effectively to bioterrorism. CDC said it was
responsible for providing national leadership in the public health and
medical communities in a concerted effort to detect, diagnose, respond
to, and prevent illnesses that occur as a result of bioterrorism. In
its strategic preparedness and response plan, CDC anticipated that it
would need to collaborate with local and state public health partners
and other federal agencies in order to strengthen components of the
public health infrastructure.[Footnote 10] As part of this
collaboration, CDC initiated a cooperative agreement program in 1999 to
enhance state and local bioterrorism preparedness. CDC's planning
efforts identified the importance of coordination with the Department
of Justice, including the FBI and the National Domestic Preparedness
Office. In addition, CDC said that there was ongoing coordination with
the Office of Emergency Preparedness within HHS, FDA, NIH, DOD, the
Federal Emergency Management Agency (FEMA), and many other partners,
including academic institutions and professional organizations. At the
time of the anthrax incidents, some of these collaborative efforts were
in the planning stage, some were in the form of working groups, and
others were limited in scope to areas such as laboratory preparedness,
training, or new vaccine research.
CDC was also working to make improvements in various aspects of
preparedness and prevention, detection and surveillance, and
communication and coordination. At the time of the anthrax incidents,
CDC was working on creating diagnostic and epidemiologic performance
standards for local and state health departments. In collaboration with
NIH and DOD, CDC was encouraging research for the development of new
vaccines, antitoxins, and innovative drugs. In addition, CDC had
developed a repository of pharmaceuticals and other supplies through
the Strategic National Stockpile.[Footnote 11] CDC was developing
educational materials and providing terrorism-related training to
epidemiologists, laboratory workers, emergency responders, emergency
department personnel, and other front-line health care providers and
health and safety personnel. Through cooperative agreements, CDC was
also working to upgrade the surveillance systems of the local and state
health departments and investing in the Health Alert Network
(HAN)[Footnote 12] and Epidemic Information Exchange (Epi-X)[Footnote
13] communication systems.
Fall 2001 Anthrax Incidents:
In October 2001, an employee of American Media Inc. (AMI) in Florida
was diagnosed with inhalational anthrax, the first case in the United
States in over two decades. By the end of November 2001, 21 more people
had contracted the disease, and 5 people, including the original
victim, had died as a result. Although the FBI confirmed the existence
of only four letters containing anthrax spores, by December 2001 the
Environmental Protection Agency (EPA) had confirmed that over 60 sites,
about one third of which were U.S. postal facilities, had been
contaminated with anthrax spores.
The cases of inhalational anthrax in Florida, the first epicenter, were
thought to have resulted from proximity to opened letters containing
anthrax spores, which were never found. (See table 1.) The initial
cases of anthrax detected in New York, the second epicenter, were all
cutaneous and were also thought to have been associated with opened
anthrax letters. The cases detected initially in New Jersey, the third
epicenter, were cutaneous and were in postal workers who presumably had
not been exposed to opened anthrax letters. Unlike the incidents at
other epicenters, which began when cases of anthrax were detected, the
incident on Capitol Hill, the fourth epicenter, began with the opening
of a letter containing anthrax spores and resulting exposure. The
discovery of inhalational anthrax in a postal worker in the Washington,
D.C., regional area, the fifth epicenter, revealed that even
individuals who had been exposed only to sealed anthrax letters could
contract the inhalational form of the disease. Subsequent inhalational
cases in Washington, D.C., New Jersey, New York, and Connecticut, the
sixth epicenter, underscored that finding. (For a list of key events in
the history of the anthrax incidents and the public health response to
the incidents, see app. I.):
Table 1: People with Anthrax Infections, Letters Containing Anthrax
Spores, and Facilities Contaminated with Anthrax Spores in the Six
Epicenters:
Epicenters: Florida; Number of infected people: Cutaneous anthrax: 0;
Number of infected people: Inhalational anthrax: 2; Letter
recovered within epicenter: No; Contaminated facilities: Yes.
Epicenters: New York; Number of infected people: Cutaneous anthrax: 7;
Number of infected people: Inhalational anthrax: 1; Letter
recovered within epicenter: Yes; Contaminated facilities: Yes.
Epicenters: New Jersey; Number of infected people: Cutaneous anthrax:
4; Number of infected people: Inhalational anthrax: 2; Letter
recovered within epicenter: No[A]; Contaminated facilities: Yes.
Epicenters: Capitol Hill; Number of infected people: Cutaneous anthrax:
0; Number of infected people: Inhalational anthrax: 0; Letter
recovered within epicenter: Yes; Contaminated facilities: Yes.
Epicenters: Washington, D.C., regional area; Number of infected people:
Cutaneous anthrax: 0; Number of infected people: Inhalational anthrax:
5; Letter recovered within epicenter: No[A]; Contaminated
facilities: Yes.
Epicenters: Connecticut; Number of infected people: Cutaneous anthrax:
0; Number of infected people: Inhalational anthrax: 1; Letter
recovered within epicenter: No; Contaminated facilities: Yes.
Source: CDC.
[A] Although no letters were recovered within the New Jersey and
Washington, D.C., epicenters themselves, the letters found in the New
York and Capitol Hill epicenters have been determined to be the source
of the contamination in New Jersey and Washington, D.C.
[End of table]
Although the anthrax incidents were limited to six epicenters on the
East Coast, the incidents had national implications. Because mail
processed at contaminated postal facilities could be cross-contaminated
and end up anywhere in the country, the localized incidents generated
concern about white powders found in locations beyond the epicenters
and created a demand throughout the nation for public health resources
at the local, state, and federal levels.
Local and State Public Health Officials Identified Strengths in Their
Responses as Well as Areas for Improvement:
Local and state public health officials across the epicenters
emphasized the benefits of their planning efforts for promoting a rapid
and coordinated response, stressed the importance of effective
communication throughout the incidents, and reported that their
response capacity was strained and the response would have been
difficult to sustain if the incidents had been more extensive.
Local and State Public Health Officials Relied on Plans for
Coordinating with a Wide Range of Entities and Identified Areas for
Improvement:
Local and state public health officials were challenged to coordinate
their responses to the anthrax incidents across a wide range of public
and private entities, often across more than one local jurisdiction.
Officials reported that anticipating local needs in emergency response
plans, making those plans operational with formal contracts and
agreements, and having experience with other public emergencies or
large events improved their ability to mount a rapid and coordinated
response. When pieces of this planning process were missing, had not
been operationalized, or had not been tested by experience,
coordination of the local response was often more difficult.
Epicenters Had Engaged in Some Response Planning but Had Not
Anticipated the Full Extent of Coordination That Would Be Needed:
Local and state public health officials reported that they had
typically planned for coordination of their emergency response but had
not fully anticipated the extent to which they would have to coordinate
with a wide range of both public and private entities involved in the
response to the anthrax incidents, both locally and in other
jurisdictions. Among others, public health departments had to
coordinate their responses with those of local and federal law
enforcement, emergency responders, the postal community, environmental
agencies, and clinicians.
Most response plans anticipated the need for public health officials to
coordinate with law enforcement and emergency response officials, both
within their community and across jurisdictions. In one epicenter, for
example, a regional organization of local governments had developed
planning guidance that outlined collaborative networks between the
public health and emergency response communities needed to strengthen
the region's response to an event such as the anthrax incidents.
In contrast, the need to link the public health response with the
responses of other public entities affected by the anthrax incidents,
such as environmental agencies, military response teams, and the U.S.
Postal Service, was less likely to have been anticipated in local
response plans. During the response, standard practices for clinical
and environmental testing and use of proper protective clothing and
equipment needed to be coordinated among public health officials,
postal officials, police, firefighters, environmental specialists, and
teams from DOD. However, officials reported that in some cases
personnel from environmental and military groups were meeting with
public health officials for the first time as the response unfolded.
When the need for consistency in testing procedures and standards for
protective clothing and equipment had not been anticipated, officials
sometimes had difficulty agreeing on which procedures and standards to
follow. In addition, some plans had not anticipated the need to forge
quick relationships between public health departments and local groups
affected by the incidents but not expressly mentioned in the plans.
During the anthrax incidents, the absence of such a measure proved to
be a particular problem for postal officials and postal union
representatives. In part due to this absence of proactive plans,
coordination between public health and postal officials on many of the
details of the response was problematic, and there were difficulties
communicating critical information, such as decisions on how and when
to provide prophylactic, or preventive, treatment to postal workers.
The need for coordination between public health and private groups
affected by the emergency--such as the hospital community--was also not
always fully anticipated in local response plans. Public health
officials in several areas had to work with local hospitals and other
facilities to set up screening and postexposure prophylaxis clinics
rapidly, sometimes in less than 24 hours. In this time they had to
identify an appropriate site location, design patient flow plans,
outline staff needs and responsibilities (medical, pharmacy,
counseling, administrative, and facilities operation components), and
obtain medications (including dealing with the logistics of breaking
down and repackaging bulk medications). Few locations had formally
addressed all of these issues before the anthrax incidents, but those
that had addressed at least some of them reported being able to respond
more rapidly.
Some Aspects of Response Plans Had Been Made Operational and Increased
Officials' Ability to Coordinate a Rapid Response:
Officials relied on a variety of formal agreements, such as memoranda
of understanding and legal contracts, to address the needs identified
in their planning documents. These needs included coordination across
disciplines and jurisdictions, access to scientific information, and
human resources support. Local officials reported that putting
agreements and contracts into place to address these needs strengthened
their preparedness both by solidifying links with their public and
private partners and by helping them identify weaknesses that could be
addressed prior to an emergency. When systems had not been put into
place to support plans, coordination of response efforts was more
difficult.
Formal agreements had often been put into place to support coordination
among officials within communities and across jurisdictions, but some
aspects of plans that were important for coordinating the response had
not yet been made operational. For example, one official reported
having arranged to link surveillance and environmental health personnel
with law enforcement officials during criminal investigations in the
event of an anthrax attack. Another official had already established
agreements with local counterparts to provide access to prophylaxis.
Officials reported that when formal contacts between officials had not
been established, coordination with counterparts in their community and
other jurisdictions during the incidents often relied on personal
relationships.
While some public health departments reported having systems in place
to ensure ready access to the scientific information needed to make
decisions and provide information to the media and the public, many
reported that they did not. Officials reported that planning ahead and
then taking the necessary steps to compile available scientific
information--including what was known about anthrax, procedures for
testing exposure to anthrax, treatment protocols, and standards for the
types of protective clothing and equipment that are appropriate for
first responders--were important for responding rapidly and reducing
confusion across the parties involved in the response.
Officials stated that during the response they relied on existing
mutual aid agreements or contracts that gave them access to staff for
screening and mass care clinics, allowed the state to pull local
epidemiologists to support the state response, and addressed licensure
issues for staff brought in from other states. However, these
agreements were not always in place, or only partially covered the
needs of the situation, and some officials had to spend time dealing
with issues that could have been addressed before the event. For
example, an official in one epicenter reported that because a state of
emergency had not been declared in the jurisdiction, there was no
system to pay for food for staff who were working 24-hour shifts in
prophylaxis clinics. Several officials in other localities reported
that systems had not been put into place to authorize payment for
overtime work in both public health departments and laboratories. In
addition, one health department received offers of volunteer help from
many physicians, pharmacists, nurses, epidemiologists, and other
concerned citizens. However, it could not use the volunteers because it
did not have a volunteer management system to train providers and
verify credentials.
Experience with Drills and Responding to Emergencies Allowed Officials
to Identify Areas for Improvement in Their Plans:
Experience with drills and responding to public health emergencies
helped officials identify weaknesses in their plans. These officials
stated that drills ranging from tabletop to full-scale exercises were
useful for testing coordination and response capacities both locally
and regionally. Public health officials also reported that their
experience in dealing with hoax letters and false alarms proved useful,
particularly in supporting coordination with the law enforcement
community. In major metropolitan areas, experience with large events,
such as political conventions, forced local public health departments
to develop their emergency response plans and put the necessary
agreements in place to support those plans. Experience with public
health emergencies--including natural disasters and outbreaks of
infectious disease such as West Nile virus--also allowed officials to
work on coordinating their responses across multiple sites, test their
surveillance systems, and establish links with other public and private
entities.
Where previous experience had not allowed officials to identify and
address shortcomings of their plans, the anthrax incidents tended to
uncover weaknesses. For example, one local public health official
reported that although the agency had planned how to set up a
prophylaxis clinic it had not actually exercised getting people through
the testing and prophylaxis process. During the anthrax response, it
took significantly longer than the agency had anticipated to obtain
test results from overwhelmed laboratories. This official said that if
the agency had known how long it was going to take to get laboratory
results, it would have provided the first doses of prophylaxis for a
longer duration to take into account the additional time required to
obtain test results. Another official reported that the agency's
experience with setting up a prophylaxis clinic during the anthrax
response taught the agency how to select more appropriate sites for
mass vaccination or prophylaxis clinics in emergency situations.
Experience also revealed shortcomings in regional coordination. Several
officials noted that although some plans for coordination across
jurisdictions were in place, they had not been exercised, and so the
relationships to support coordination had not been formed or tested.
Communicating Effectively during the Incidents Was Challenging:
Local officials identified communication among responders and with the
public during the anthrax incidents as a challenge, both in terms of
having the necessary communication channels and in terms of making the
necessary information available for distribution. Good communication
can minimize an emergency, improve response, and reassure the public.
Officials reported that although communication among local responders
was generally effective, there were problems in communicating with some
hospitals and physicians. They also reported that dealing with the
media and communicating messages to the public were also challenging.
Communication among Response Agencies Was Generally Viewed as
Effective:
Communication among local and state response agencies was generally
perceived to be effective and helped keep agency officials informed and
the public health response coordinated. Channels of communication
between public health agencies and other responders--including law
enforcement and emergency management agencies, hazardous material
units, and neighboring state public health agencies--were already in
existence at the time of the anthrax incidents. Regular conference
calls, which were initiated during the incidents, were used to
distribute information, raise issues, and answer questions.
In addition to telephone calls, local and state public health offices
relied on fax machines and the Internet to send and receive information
during the incidents. Most local health departments, however, noted
that they did not have backup communication systems that could be used
in case everyday systems became unavailable. In addition, public health
workers did not generally have cell phones, pagers, or laptop
computers, which could provide the means to keep working if it became
necessary to vacate a building during a crisis. In one epicenter, when
an agency had to evacuate its quarters during the incidents and workers
could not be at their desks, many of its communication systems (in
addition to the information stored in the office in electronic formats)
became unavailable. Several local agencies that did not have backup
systems available at the time of the anthrax incidents told us they
have concluded that it is important to invest in such systems to be
prepared for any future public health emergencies.
Local response agencies generally got the information they requested
from other local agencies. For example, in one epicenter, police and
fire departments were given specific protocols for handling suspicious
samples and triaging them for the laboratory. However, there were
instances in which they did not get needed information. For example, a
local emergency response official stated that the local fire department
did not know what protective equipment (such as masks and gloves)
firefighters should wear when responding to a suspected anthrax
incident. The fire department turned to the local health department for
answers, but the health department took weeks to release the protocol.
Flow of Information to Clinicians Was Problematic:
State and local officials reported difficulty providing needed
information to some hospitals and physicians in a timely way, and
members of the medical community expressed concern about the timeliness
of the information they received. Physicians recognized that they
lacked experience with anthrax and were particularly concerned about
missing a diagnosis because of its high fatality rate. They expected to
be given rapid and specific instructions from public health officials
about how to recognize and treat people who had been exposed. They
wanted guidelines, for example, on how to diagnose inhalational anthrax
and how to advise individuals who worked in post offices. Hospitals in
one epicenter reported receiving daily influxes of people with flulike
symptoms. Because these hospitals were seeking guidance on how to
distinguish between influenza and anthrax symptoms, the hospital
association in the area initiated daily conference calls with concerned
clinicians. The purpose of these calls was to collect questions to ask
other organizations, such as CDC, to coordinate consistent answers to
questions from the public, and to share information about clinical
approaches.
Some of the ways in which local public health agencies tried to
communicate with hospitals and physicians were regarded as relatively
effective by the agencies, but no method worked well for all targeted
recipients. Health departments used various means to make relevant
materials available to hospitals and physicians, including sending
faxes or e-mail messages, posting relevant information on their Web
sites, distributing CD-ROMs, and setting up hotlines. In one state,
which had no confirmed anthrax infections but numerous false alarms,
the state public health department faxed critical information to
hospitals throughout the state. Officials in the department reported
that while this system was useful in disseminating information it was
insufficient because it did not provide a means of receiving
information from the hospitals. E-mail worked well for institutions,
but it was an ineffective way of communicating with physicians,
especially those who did not have a hospital-based practice. Several
local public health officials told us that many private physicians did
not have e-mail or Web access. Because electronic messages were not a
feasible way of communicating with many clinicians, there was no way to
get timely information about anthrax to them. Some primary care
physicians were difficult to reach by any mass communication method or
even individually because public health officials sometimes did not
have up-to-date rosters of their telephone numbers. Officials in one
state said they realized during the incidents that they did not have a
way to send information directly to dermatologists, a group of
specialists who were especially important for detecting the cutaneous
form of anthrax infection. Because localities were unable to reach all
physicians directly, government agencies relied on physicians and
associations who did receive the information to serve as conduits.
However, government and association officials agreed that this method
did not provide complete coverage of all physicians.
Criminal Investigation Sometimes Hindered Flow of Information to
Officials and the Public:
Local officials reported that the criminal investigation of the anthrax
incidents sometimes hindered their ability to obtain information they
needed to conduct their public health response. For example, public
health officials in one epicenter said that they were unable to get
certain information from the FBI because the local public health
officials lacked security clearances. They said that if they had
received more detailed information earlier about the nature of the
anthrax spores in the envelopes, it might have affected how their
agencies were responding. In addition, a laboratory director in one of
the epicenters reported that the criminal investigation led to
constraints on his ability to communicate laboratory results to
clinicians.
Just as information was not provided to government agencies because of
law enforcement considerations, officials stated that criminal aspects
of the incidents complicated the distribution of information to the
public. Officials expressed concern about the necessity of withholding
some information from the public. One official reported that
communication with the public was constrained when the situation became
a criminal investigation. She was concerned that information the public
needed to understand its risk was no longer being provided. Officials
in one epicenter told us that they were concerned that constraints on
the ability of local public health departments to communicate could
lead to a loss of credibility. More generally, officials reported that
fear in the community could have been reduced if they had been able to
release more information to the media and the public.
Supplying Information to Meet Needs of Media and Local Public Was
Challenging:
Local and state officials reported that although they were generally
successful in persuading people to seek treatment, they encountered
difficulties in providing needed information to the media and local
public during the anthrax incidents. Because the incidents were taking
place in many locations, local communications were complicated by the
public's exposure to information about other localities and from the
national media.
Local and state officials realized that they needed to use the media to
disseminate information to the public and that they needed to be
responsive to the media so that the information the media were
providing was accurate. Public health and other government officials in
the epicenters held regular press conferences to keep the public
informed about local developments, made officials available to respond
to media requests, and developed informational materials so that the
media and the public could be better informed. Several officials stated
that the media helped in publicizing sources of information such as
hotlines and specific information such as details about who should seek
treatment and where to go for it. However, media analysts have also
noted that the media were sometimes responsible for providing incorrect
information. For example, one official said that when the media
reported that nasal swabbing was the test for anthrax, individuals
sought unnecessary nasal swab testing from emergency rooms, physicians,
and the health department, and thereby diverted medical and laboratory
resources from medical care that was required elsewhere.
Communication with the public was further complicated by the evolving
nature of the incidents and the local public's exposure to information
from other localities and the national media. Comparisons of actions
taken by officials at different points in time and in different areas
caused the public to question the consistency and fairness of actions
taken in their locale. For example, the affected public in some
epicenters wondered why they were being given doxycycline for
prophylaxis instead of ciprofloxacin, which had been heralded in the
media as the drug of choice for the prevention of inhalational anthrax
and used earlier in other epicenters. CDC's initial recommendation for
ciprofloxacin was made because ciprofloxacin was judged to be most
likely to be effective against any naturally occurring strain of
anthrax and had already been approved by FDA for use in postexposure
prophylaxis for inhalational anthrax. However, when it was determined
that doxycycline was equally effective against the strain of anthrax in
the letters and following FDA's announcement that doxycycline was
approved for inhalational anthrax, the recommendation was changed. This
change was made because of doxycycline's lower risk for side effects
and lower cost and because of concerns that strains of bacteria
resistant to ciprofloxacin could emerge if tens of thousands of people
were taking it. In epicenters where prophylaxis was initiated after the
recommendation had changed, officials followed the new recommendation
and gave doxycycline to affected people. Local officials were
challenged to explain the switch and address concerns raised by
affected groups about apparently differential treatment. One local
official described the importance of explaining that the switch was
also taking place even in locations that had started with
ciprofloxacin.
Response Capacity Was Strained and Would Have Been Difficult to
Sustain:
Elements of the local and state public health response systems--
including the public health department and laboratory workforce as well
as laboratories--were strained by the anthrax incidents to an extent
that many local and state officials told us that they might not have
been able to manage if the crisis had lasted longer. The anthrax
incidents required extended hours for many public health workers
investigating the incidents, as well as the assignment of new tasks,
including the staffing of hotlines, to some workers. Aside from
problems of workforce capacity, some clinical laboratories were not
prepared in terms of equipment, supplies, or available laboratory
protocols to test for anthrax, and most of them were unprepared for and
overwhelmed by the large number of environmental samples they received
for testing. The systems experienced these stresses in spite of
assistance from CDC and DOD, and temporary transfers of local, and in
some cases regional, resources.
Public Health Workers Were Overwhelmed with Work:
During the anthrax incidents, the workload increased greatly at local
and state health departments and laboratories and across the country.
The departments heightened their disease surveillance, investigated
false alarms and hoaxes as well as potential threats, tested large
numbers of samples, and performed other duties such as answering calls
on telephone hotlines that were set up to respond to questions from the
public. Health departments across the nation received thousands of such
calls. For example, officials at one location told us that they
received 25,000 calls over a 2-week period during the crisis. Nine
states--Colorado, Connecticut, Louisiana, Maryland, Montana, North
Dakota, Tennessee, Wisconsin, and Wyoming--reported to CDC that during
the week of October 21 to 27, 2001, they received a total of 2,817
bioterrorism-related calls. These nine states also reported that during
that week they conducted approximately 25 investigations per state and
had from 8 to 30 state personnel engaged full-time in the responses in
each state.
Some local and state health departments had to borrow workers from
other parts of their agencies or from outside of their agencies, such
as from CDC and DOD, to meet the greater demands for surveillance,
investigation, laboratory testing, and other duties related to the
incidents. Several agencies realized that they lacked staff in
particular specialties, such as environmental epidemiology. Some state
public health departments did not have enough epidemiologists to
investigate the suspected cases in their localities and had to borrow
staff from other programs. Health workers were pulled from other jobs
to work in the field or to staff the telephone hotlines. Staff borrowed
from other parts of the agency were sometimes unable to fulfill their
traditional public health duties, such as working on prevention of
sexually transmitted diseases, and some routine work was delayed. In
spite of the borrowing, staff at some agencies worked long hours over a
number of weeks. In some cases, state laboratories had to borrow staff
from various parts of their health department because laboratory
workers were overwhelmed and the laboratories required staffing for 24
hours a day, 7 days a week. In some locations, CDC provided
epidemiologists and laboratorians to help fill gaps in staff.
Some borrowed workers had to be trained for their new duties while the
incidents were ongoing. Some workers had to be trained or cross-trained
in two fields, requiring additional time from other staff and resources
from the department. Some borrowed staff had to be trained for the
specific tasks required by the incidents. Finding sufficient numbers of
people who were appropriately trained or could be efficiently trained
to staff the telephone hotlines effectively was also a challenge. Local
officials reported that even if sufficient staff were found, calls were
not always handled effectively, especially when the caller needed
mental health services.
Many officials we interviewed were concerned about their ability to
deal with demand on staff in future crises. Since the anthrax
incidents, some states have sent members of their staff for additional
training. Some officials emphasized that surge capacity should be
flexible to ensure preparedness for various types of future
bioterrorism incidents.
Laboratories Handled Huge Volumes of Samples, and Some Were
Underequipped to Do So:
In addition to overwhelming the laboratory workforce, the large influx
of samples strained the physical capacity of the laboratories. Public
health laboratories around the country tested thousands of white
powders and other environmental samples as well as clinical samples.
According to CDC, during the anthrax incidents, laboratories within the
Laboratory Response Network[Footnote 14] tested more than 120,000
samples, the bulk of which were environmental samples. Officials from
one state told us that its laboratories did not have the capacity to
handle the volume of work they received. Some local and state public
health laboratories could not analyze anthrax samples because of
limitations of equipment, supplies, or laboratory protocols. For
example, in some states there were a limited number of biological
safety cabinets, which were needed to prevent inhalation of anthrax
spores by laboratory workers during the testing of samples. Some
laboratories did not have the chemicals needed to conduct the
appropriate tests. In some states, none of the state laboratories could
conduct an essential diagnostic test for anthrax, the polymerase chain
reaction test. In another state, only one of three state laboratories
could perform this test. Some state and local laboratories were not
prepared to take the safety precautions required to test samples for
anthrax. Local laboratories were even less capable of doing anthrax
testing. Samples for confirmatory testing were sent to CDC or to DOD's
USAMRIID. In addition to performing confirmatory testing, DOD also
provided other laboratory support to state and local officials. For
example, the samples from one epicenter were sent to DOD, and the
department sent mobile laboratories to two other epicenters to assist
with testing samples.
Moreover, although some laboratories were relatively well prepared to
test clinical samples, they were not expecting the hundreds of
environmental samples they received and did not have protocols prepared
for testing them. It was the volume of these environmental samples,
rather than the volume of the clinical samples, that overwhelmed the
laboratories. Among the environmental samples, there were white powder
samples that arrived without any assessment by law enforcement as to
the level of threat they posed. At least one state laboratory developed
protocols so that law enforcement personnel could triage samples,
thereby increasing the likelihood that only those samples with a
relatively high threat level would be forwarded to the laboratory for
further testing. Even where protocols for testing these samples were
available, it was a time-consuming and unfamiliar task for the
laboratory to label them, track their progress, and ensure that their
results were reported to the appropriate authority.
Experience Showed Aspects of Federal Preparedness That Could Be
Improved:
CDC led the federal public health response to the anthrax incidents,
and the experience showed aspects of federal preparedness that could be
improved. During the anthrax incidents, CDC was designated to act on
behalf of HHS in providing national leadership in the public health and
medical communities. As the lead agency in the federal public health
response, CDC had to not only provide public health expertise but also
manage the public health response efforts across epicenters and among
other federal agencies. While local and state officials reported that
CDC's support of their responses to the rapidly unfolding anthrax
incidents at the local and state levels was generally effective, CDC
acknowledged that it was not fully prepared for the challenge of
coordinating the public health response across the federal agencies.
CDC experienced difficulty serving as the focal point for communicating
critical information during the response. In addition to straining
CDC's resources, the anthrax incidents highlighted shortcomings in the
clinical tools available for responding to anthrax, such as vaccines
and drugs, and a lack of training for clinicians on how to recognize
and respond to anthrax.
CDC Provided Support to Meet Heavy Resource Demands from Local and
State Officials:
CDC effectively responded to heavy resource demands from state and
local officials to support the local responses. CDC reported that its
support activities included surveillance; clinical, epidemiologic, and
environmental investigation; laboratory work; communications;
coordination with law enforcement; medical management; administration
of prophylaxis; monitoring of adverse events; and decontamination. As
new epicenters became involved, CDC dispersed additional agency staff
to assist local and state health departments and other groups playing a
role in the response efforts, eventually deploying more than 350
employees to the six epicenters. In addition, because even the
perception of danger required a public health response, CDC also
provided assistance as requested in localities beyond the epicenters.
From October 8 to 31, 2001, CDC's emergency response center received
8,860 telephone inquiries from all 50 states, the District of Columbia,
Puerto Rico, Guam, and 22 foreign countries. CDC's callers included
health care workers, local and state health departments, the public,
and police, fire, and emergency departments and included requests for
information about anthrax vaccines, bioterrorism prevention, and the
use of personal protective equipment. Thus CDC not only provided
resources to the epicenters but also had to coordinate local efforts
nationwide.
Local public health offices required varying levels of assistance from
CDC. For example, in one epicenter local officials looked to CDC to
lead the epidemiologic investigation and relied primarily on CDC staff.
In contrast, local officials in another epicenter led the local disease
outbreak investigation and control effort and CDC staff supplemented a
large local team. In most of the epicenters, the team sent by CDC
included Epidemic Intelligence Service (EIS) officers, who are
specially trained epidemiologists, to help with the investigation. The
team's epidemiologic investigation used the traditional two-pronged
approach in which it completely investigated either the case or the
circumstance of a confirmed exposure and conducted intensive
surveillance to identify any other anthrax cases or exposures.
Laboratory testing proved to be an important tool in the epidemiologic
investigation, and the CDC team also included laboratorians, who
assisted with laboratory testing. In one epicenter, CDC also sent one
of its anthrax experts to provide guidance and assist the local and
state officials.
CDC Reported It Was Not Fully Prepared to Coordinate the Federal Public
Health Response:
In addition to playing its traditional role of supporting local and
state public health departments, CDC also was confronted with the
challenge of coordinating the public health activities of multiple
federal agencies involved in the response, a task for which it
acknowledged it was not wholly prepared. CDC described having to create
an ad hoc emergency response center in an auditorium from which to
manage the federal public health response, which involved numerous
agencies. These included FDA, which, among other activities, provided
guidance on treatment and addressed drug and blood safety issues. In
addition, NIH provided scientific expertise on anthrax. CDC also
coordinated with federal agencies working on the environmental and law
enforcement aspects of the response efforts. DOD was responsible for
testing all of the anthrax letters that were recovered and was involved
in the transportation and testing of environmental samples as well as
the cleanup of contaminated buildings. EPA was in charge of the cleanup
of contaminated sites. FEMA assisted the President's Office of Homeland
Security in establishing and supporting an emergency support team. The
FBI led the criminal investigation.
Although CDC's planning efforts prior to the anthrax incidents had
identified the importance of coordination with other federal agencies
for an effective response to bioterrorism, and CDC had developed some
working groups among federal agencies, CDC sometimes had to adjust its
response as events unfolded to facilitate coordination of more
practical issues such as conducting simultaneous investigations in the
field. For example, CDC told us that in one epicenter both CDC and the
FBI, which needed to collect samples for the forensic investigation,
identified the need to gain a better understanding of one another's
work. During the incidents, CDC provided a liaison to the FBI, and the
agencies worked together to collect laboratory samples. Since the
anthrax incidents, CDC has held joint training with the FBI to discuss
what they learned from their experience that could facilitate working
together in the future.
CDC has made several efforts to improve coordination since the anthrax
incidents, including major structural changes within the agency,
creation of a permanent emergency operations center (EOC), and
increased collaborative efforts with others within and outside of HHS.
Officials point to the creation of the Office of Terrorism Preparedness
and Emergency Response, which is part of the Office of the Director, as
a major change. The primary services of this office are to provide
strategic direction for CDC to support terrorism preparedness and
response efforts, secure and position resources to support activities,
and ensure that systems are in place to monitor performance and manage
accountability. The office manages the cooperative agreement program to
enhance local and state preparedness and jointly manages the Strategic
National Stockpile with the Department of Homeland Security. The office
also manages the EOC, which was created to promote quicker and better-
coordinated responses to public health emergencies across the country
and around the globe. The EOC is staffed 24 hours a day, 7 days a week,
and the staff includes officials from FEMA, DOD, and other agencies.
CDC also created a permanent position of CDC liaison to the FBI to
increase collaboration with that agency.
CDC Experienced Difficulty Serving as Focal Point for Communicating
Critical Information during Response to Anthrax Incidents:
CDC served as the focal point for information flow during the anthrax
incidents, but experienced some difficulty in fulfilling that role. In
addition to the varied responsibilities involved in leading the public
health response, the agency concurrently had to collect and analyze the
large amount of incoming information on the anthrax incidents, assemble
and analyze the available scientific information on anthrax, and
produce guidance and other information based on its analyses for
dissemination to officials, other responders, the media, and the
public. CDC officials reported that the agency had difficulty producing
and disseminating this guidance rapidly as well as difficulty conveying
information to the media and the public.
CDC Had Difficulty Managing the Influx of Information to Produce and
Disseminate Guidance Rapidly:
CDC officials acknowledged that the agency was not always able to
produce guidance as quickly as it would have liked. When the incidents
began, it did not have a nationwide list of outside experts on anthrax,
and it had not compiled all of the relevant scientific literature on
anthrax. Consequently, CDC had to do time-consuming research to gather
background information to inform its decisions, which slowed the
development of its guidance. CDC has since compiled background
information and lists of experts not only for anthrax but also for the
other biological agents identified as having the greatest potential for
adverse public health impact with mass casualties in a terrorist
attack, and it has made the background information available on its Web
site.[Footnote 15]
CDC officials reported that CDC also had difficulty compiling the
information it received during the incidents. Although CDC's role as
focal point for information was a familiar one, the magnitude of
information it received was unusual. CDC received a tremendous amount
of information via e-mail, phone, fax, and news media reports from such
sources as the agencies and organizations in the epicenters of the
incidents, public health departments not in the epicenters, other
federal agencies, and international public health organizations. CDC
also received information from its staff in the field, but encountered
some problems in those communications. Agency officials have said there
were communication problems between epidemiologic staff in the field
and at headquarters, which CDC attempted to address by holding "mission
briefings" through its emergency response center; however, these
briefings were not conducted regularly. CDC's efforts to manage all of
this incoming information and associated internal communication
problems were complicated by its concurrent responsibility for
coordinating the day-to-day activities involved in the federal public
health response to the unfolding incidents.
According to CDC, both clinical and environmental guidance was
developed during the incidents by using working groups of six to eight
employees who were subject matter experts. Keeping up with the influx
of new information that was being acquired daily proved to be a
challenge for these working groups. CDC officials told us that no group
at CDC was responsible for collecting and analyzing all of the data
that were coming in and that few people at CDC had time to read their
e-mail messages during the incidents. Since the incidents, CDC has
established teams of scientists from inside and outside CDC whose only
role is to review and analyze information during a crisis; CDC does not
intend for these teams to be involved in day-to-day response
operations.
As the working groups incorporated new information into their analyses,
the guidance they were producing changed accordingly. For example, as
the epidemiologic investigation expanded, CDC had to revise its
assessment of the risk of developing inhalational anthrax from letters
containing anthrax spores. Early on, CDC was acting on the theory that
there was little risk of contracting inhalational anthrax from sealed
letters. The incidents in the Washington, D.C., regional area, the
fifth epicenter, represented a turning point in the epidemiologic
investigation. The discovery of inhalational anthrax in a postal worker
who presumably had been in contact only with sealed anthrax letters
required CDC to revise its assessment. From this point on, CDC presumed
that any exposure would put an individual at risk and changed its
recommendation regarding who should get prophylaxis accordingly. CDC
began to recommend prophylaxis for all individuals who had been in
contact with sealed as well as unsealed anthrax letters, whereas
earlier the agency had not been recommending such treatment unless an
individual had been exposed to an opened letter.
Initially, CDC relied on the HAN communication system and its Morbidity
and Mortality Weekly Report (MMWR) publication to disseminate its
guidance and other information; however, during the incidents there
were difficulties with both of these methods. At the time of the
incidents, all state health departments were connected to the HAN
system. However, only 13 states were connected to all of their local
health jurisdictions, and therefore HAN messages could not reach many
local areas. Some states were satisfied with the information they
received via HAN, but others claimed they did not get much information
from HAN and what they did get was incomplete. During the incidents,
CDC expanded its list of HAN recipients to include additional
organizations, including medical associations. MMWR is issued on a
weekly basis, and so the information in the latest issue was not always
completely up-to-date for incidents that were unfolding by the hour.
For example, information published in MMWR on October 26, 2001,
contained the notice that the information was current as of October 24,
2001. In addition to these structural barriers to getting information
out quickly to those who needed it, CDC's internal process of clearing
information before issuance through HAN or MMWR was time-consuming. CDC
has since changed its clearing process so that information can get out
faster. The agency also made a number of other changes during the
incidents to address some of the difficulties it encountered in
providing information to the public health departments and clinicians.
These included bringing in professionals from other communication
departments in CDC to help get information out quickly, issuing press
releases twice a day, and holding telebriefings. Since the incidents,
CDC has taken actions to expand its communication capacity, including
developing an emergency communication plan, increasing the number of
health experts on staff, and establishing a pressroom, in which the
Director of CDC gives press briefings on public health efforts. In
addition, it has developed, and posted to its Web site, information to
assist local and state health officials in detecting and treating
individuals infected with agents considered likely to be used in a
bioterrorist attack.
CDC Had Difficulty Conveying Information to Media and Public:
During the anthrax incidents, the media and the public looked to CDC as
the source for health-related information, but CDC was not always able
to successfully convey the information that it had. Media analysts and
other commentators have asserted that although CDC officials were the
most authoritative spokespersons they were not initially the most
visible. In an October 2001 nationwide poll, respondents indicated that
they considered the Director of CDC and the U.S. Surgeon General to be
better sources of reliable information about the outbreak of disease
caused by bioterrorism than other federal officials mentioned in the
survey.
Another problem CDC encountered in its efforts to communicate messages
to the public was difficulty in conveying the uncertainty associated
with the messages, that is, the caveat that although the messages were
based on the best available information, they were subject to change
when new facts became known. As a bioterrorist event unfolds and new
information is learned, recommendations about who is at risk and how
people should be treated may change, and the public needs to be
prepared that changes may occur. Local officials and academics have
criticized CDC's communication of uncertainty during the anthrax
incidents. CDC officials have acknowledged that they were unsuccessful
in clearly communicating their degree of uncertainty as knowledge was
evolving during the incidents. For example, although there were
internal disagreements at CDC over the appropriate length of
prophylaxis, this uncertainty was not effectively conveyed to the
public. Consequently, in December 2001, when many people were finishing
the 60-day antimicrobial regimen called for in CDC's guidance, the
public questioned CDC's announcement that patients might want to
consider an additional 40 days of antimicrobials. Since the incidents,
CDC officials have acknowledged the necessity of expressing uncertainty
in terms the public can understand and appending appropriate caveats to
the agency's statements.
Anthrax Incidents Strained Some Aspects of Federal Response Capacity:
The anthrax incidents highlighted some of the strengths of the federal
public health response capacity, while also reflecting some of its
limitations. CDC's experience with epidemiologic investigations was
drawn on extensively and effectively, and the Laboratory Response
Network played an important role. Not all the clinical tools that were
needed to identify, treat, and prevent anthrax infection were
available, and those that were available had shortcomings. Although
CDC's bioterrorism preparedness training program for clinicians had
begun at the time of the incidents, most clinicians had not yet been
trained to recognize and report anthrax infection.
CDC's Epidemiologic and Laboratory Resources Were Strained:
CDC's skills in disease investigation were heavily relied on during the
anthrax incidents. CDC teams worked with local and state public health
departments and law enforcement to determine what happened with each
case. CDC's EIS was an important component of the agency's response.
The availability of trained epidemiologists enabled CDC to send numbers
of them to each epicenter to provide temporary staff to help
investigate the nature and extent of the local incident. CDC reported
that because of the number of epicenters and calls for assistance from
other localities, its staff, both at headquarters and in the field,
were spread thin. The level of assistance provided by CDC depended on
the needs of the local public health departments and therefore varied
considerably by location. For example, while CDC epidemiologists
augmented the staff of some local and state health departments who
would have been severely overtaxed without CDC's help, the agency
characterized its role in one epicenter as supplementary to that
epicenter's team of epidemiologists.
The Laboratory Response Network proved to be an asset, and some state
and local officials told us they were satisfied with the laboratory
response during the anthrax incidents. At that time, CDC laboratories,
like many of the laboratories in the network, were inundated with
samples and operated 24 hours a day to help epidemiologists determine
exposure and risk by testing samples to confirm cases. From October
2001 to December 2001, the network laboratories processed more than
120,000 samples for Bacillus anthracis. Public health laboratories
other than those at CDC tested 69 percent of these samples, DOD
laboratories tested 25 percent, and CDC laboratories tested 6 percent.
In addition to testing samples at its laboratories, DOD also assisted
the epicenters by providing personnel for laboratories in the
epicenters and at CDC and operating portable laboratories to support
local investigations. In addition to testing samples, CDC laboratories
distributed chemicals needed for testing samples to network
laboratories and developed a new testing method that permitted better
diagnostics from biopsy samples. CDC used the network to send
information to state bioterrorism response coordinators in local and
state laboratories. State laboratories also communicated with each
other and with CDC by using the network.
However, there were signs of strain in the Laboratory Response Network.
USAMRIID officials told us that USAMRIID, as well as other military and
civilian laboratories, is set up to process clinical samples and was
unprepared to process the volume and types of environmental samples
that it received. They noted that many of the procedures for obtaining
environmental samples from objects, such as keyboards and telephones,
had never been standardized. Officials reported that they spent a great
deal of time developing and validating these procedures as the
incidents unfolded. In addition, DOD laboratory officials told us that
they had to process overflow samples from overwhelmed laboratories at
CDC and in the epicenters. DOD officials expressed concern about
dependence on DOD laboratory resources for civilian emergencies, noting
that in wartime DOD's laboratories are needed to support military
operations.
The Strategic National Stockpile was also an asset in CDC's response
efforts. The anthrax incidents underscored the benefits of having a
system in place to transport antimicrobials and vaccines quickly to
areas that need them during emergencies. The Strategic National
Stockpile program delivered antimicrobial medications for postexposure
prophylaxis and provided for the transportation of anthrax vaccine,
clinical and environmental samples, and CDC personnel, including
epidemiologists, laboratory scientists, pathologists, and special
teams of researchers.
Available Clinical Tools Had Shortcomings:
Not all of the clinical tools that physicians needed to identify,
treat, and prevent anthrax infection were available, and those that
were had shortcomings. Clinicians did not suspect and had difficulty
promptly diagnosing anthrax because of their inexperience with the
disease and because of the nonspecific nature of its presenting
symptoms. Cutaneous anthrax can be confused with cellulitis or a spider
bite. Inhalational anthrax is difficult to distinguish from other
respiratory illnesses, such as pneumonia or influenza. Routine
laboratory and radiological testing did not always clearly signal
anthrax infection, and, even after physicians did suspect it, the
laboratory tests needed to confirm it were time-consuming, laborious,
and required that samples be sent to specialized laboratories.
Diagnostic tests that are more accurate and can yield results more
quickly are in development.
Treatment for anthrax infection was available, but it was not effective
in almost half of the inhalational cases. Both inhalational and
cutaneous anthrax, once diagnosed, were treated with a combination of
intravenous antimicrobial medications. All of the patients with
cutaneous anthrax recovered, but 5 of the 11 patients with inhalational
anthrax did not. The drugs worked by killing the bacteria that develop
from anthrax spores following germination of those spores in the body.
However, anthrax bacteria produce toxins, and no treatments were
available that could destroy these toxins. For this reason, the
antimicrobial drugs used to treat inhalational anthrax were ineffective
in those patients in whom the bacteria had already produced too much
toxin by the time treatment was initiated. CDC is working with other
agencies within HHS, such as NIH, and other federal agencies, including
DOD, to support the development of new treatments for anthrax and other
potential agents of bioterrorism.
Methods of prophylaxis for people exposed to anthrax spores were
available and apparently effective, but there were several difficulties
with these methods. There was uncertainty about how to assess exposure
to determine who should be given prophylaxis; initially only one drug
had been approved for prophylaxis, and it was approved only for
prophylaxis of inhalational anthrax; the optimal length of prophylaxis
for those thought to have been exposed to anthrax spores was unknown;
prophylactic drugs had to be taken for months and had side effects; and
the anthrax vaccine requires more than one dose, had not been approved
for postexposure prophylaxis, and was in short supply. Nasal swabs and
blood tests were used early in the investigation to assess exposure,
but these were not reliable methods. When there was uncertainty about
who was exposed or how great their risk from exposure was, prophylaxis
was sometimes recommended for all workers in a facility with some
contamination, regardless of how close to the contamination the workers
had been. This prophylaxis often started with an initial supply of
medication while test results were awaited. For example, some people
were given a 10-day supply of drugs and asked to return within 10 days
to learn whether they needed to continue taking the drugs. Initially,
CDC, with advice from NIH, recommended prophylaxis for 60
days.[Footnote 16] The drugs had side effects, and the rate of
compliance with the regimen was typically about 40 percent. Since the
incidents, federal agencies have been developing and evaluating tools
for detecting anthrax spores. Such tests could enable field workers to
make better initial assessments of exposure at particular locations to
determine who should get prophylaxis. CDC is working with other federal
agencies to support the development of new methods of prophylaxis for
anthrax and other potential agents of bioterrorism.
HHS reported that at the time of the anthrax incidents no system or
data collection instruments existed for monitoring the nearly 10,000
people who were receiving prophylaxis and thus it did not have a way to
collect information on the compliance with, adverse events from, or
effectiveness of prophylaxis. CDC attempted to collect this information
retrospectively, but acknowledged that this method is not optimal. To
improve preparedness for future incidents, CDC and FDA have created a
post-event surveillance working group that is responsible for
developing a system capable of collecting this kind of data.
Few Clinicians Had Been Trained to Recognize Anthrax:
During the anthrax incidents, it became apparent that few clinicians
had been trained to recognize anthrax infections. In November 2000, CDC
had created a national training plan for bioterrorism preparedness and
response. The plan outlined training required to implement the agency's
Bioterrorism Event Response Operational Plan and strategies for
training public health and medical professionals in collaboration with
partners (chiefly public health organizations and professional groups
such as the American Medical Association). At the time of the anthrax
incidents, CDC had been implementing the plan for less than a year, and
relatively few people had been trained: CDC reports that by October
2001 about 12,000 physicians, nurses, and other medical professionals
had completed the programs. However, CDC estimated that during the
incidents more than one million medical professionals participated in
its anthrax-related training programs via satellite, Web, video, and
phone. In addition to CDC's training programs, which continue to be
available, CDC collaborates with professional organizations, such as
the American Medical Association and the American Nurses Association,
to provide training for their members, and other federal agencies
present training programs on bioterrorism (for example, AHRQ) or fund
training programs on bioterrorism (for example, the Health Resources
and Services Administration).
Concluding Observations:
The anthrax incidents of 2001 required an unprecedented public health
response. The specific nature of the incidents and the nature of the
response varied across the epicenters and other localities across the
country. In each epicenter, local officials had to coordinate responses
that were a combination of local, state, and federal efforts. In
addition, local public health officials in the epicenters were
challenged to mount an intensive response that included identifying and
treating people already infected with anthrax as well as people who had
been exposed and could become infected, identifying contaminated areas
and preventing additional people from being exposed, processing
thousands of samples suspected of containing anthrax, and responding to
thousands of calls from concerned members of their communities.
The public health response to the anthrax incidents both demonstrated
the benefit of public health preparedness measures already in place or
under way at the local, state, and federal levels and emphasized the
need to reinforce or expand on those measures. The specific strengths
and weaknesses of the public health response identified by local and
state public health officials varied. Nonetheless, public health
officials from all locations identified general lessons learned for
public health preparedness. The lessons identified fall into three
general categories: the benefits of planning and experience; the
importance of effective communication, both among those involved in the
response efforts and with the general public; and the critical
importance of a strong public health infrastructure to serve as the
foundation from which response efforts can be mounted for bioterrorism
or other public health emergencies.
CDC was instrumental in supporting local and state efforts throughout
the anthrax incidents, for example, by sending epidemic investigators
into the field and providing laboratory expertise. DOD resources and
expertise were also required to support several epicenters. CDC was
challenged with the unfamiliar task of coordinating the extensive
federal public health response efforts. Before the incidents began, CDC
officials had recognized that the agency was not fully prepared to
coordinate a major public health response effort and indeed had
identified areas that needed improvement in testimony before Congress
on the day before it confirmed the first case of inhalational anthrax
in Florida. CDC officials have acknowledged that the agency did not
perform as well as it would have liked during the incidents. The agency
has taken steps to improve future performance, including creating the
Office of Terrorism Preparedness and Emergency Response within the
Office of the Director, building and staffing an emergency operations
center, enhancing the agency's communication infrastructure, and
developing and maintaining databases of information and expertise on
the biological agents the federal government considers most likely to
be used in a terrorist attack.
Agency Comments:
We obtained comments on our draft report from DOD and HHS. (See apps.
II and III.) DOD highlighted that lessons learned from its support of
the public health response could aid in the development of expanded
capabilities within the civilian sector to improve the nation's public
health preparedness. DOD emphasized its capabilities that were vital to
the success of the public health response, including environmental
assessment, transportation of contaminated articles, laboratory
testing, and cleanup of contaminated locations. The environmental
cleanup was beyond the scope of this report.
HHS found the report to be informative and provided additional examples
of actions taken to enhance national preparedness for bioterrorism and
other public health emergencies. These examples included the
establishment of the Office of Public Health Emergency Preparedness;
the accelerated acquisition of antimicrobial drugs for the Strategic
National Stockpile; and the expansion of basic and targeted research
and upgrading of research facilities focused on the pathogens most
likely to be used as bioterrorism agents.
DOD and HHS also made technical comments, which we incorporated where
appropriate.
We are sending copies of this report to the Secretary of DOD, the
Secretary of HHS, and other interested officials. We will also provide
copies to others upon request. In addition, the report will be
available at no charge on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please call
me at (202) 512-7119. Another contact and key contributors are listed
in appendix IV.
Sincerely yours,
Janet Heinrich
Director, Health Care--Public Health Issues:
Signed by Janet Heinrich:
[End of section]
Appendix I: Timeline of Selected Key Events in the Anthrax Incidents:
Table 2:
Date: Tuesday, 9/11/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* Terrorist attack on World Trade Center and Pentagon prompts
heightened epidemiologic surveillance activities in some areas.
Date: Wednesday, 9/26/01 through Monday, 10/01/01; Events Occurring on
That Date: Events Determined Retrospectively to Have Occurred on That
Date (in italics): * In New York (NY), two NBC employees, a New York
Post employee, and the child of an ABC employee and in New Jersey (NJ),
two U.S. Postal Service (USPS) employees, one from the West Trenton
postal facility and one from Hamilton postal facility, seek medical
attention for skin conditions; * In Florida, an American Media Inc.
(AMI) employee is admitted to the hospital with a respiratory
condition.
Date: Tuesday, 10/02/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* The Centers for Disease Control and Prevention (CDC) issues a Health
Alert Network (HAN) alert regarding preparedness for bioterrorism,
acknowledging the public's concern about smallpox and anthrax and
providing information about preventive measures; * In Florida, a
second AMI employee is admitted to the hospital, with a diagnosis of
meningitis.
Date: Thursday, 10/04/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* CDC and the Florida Department of Health announce confirmation of a
case of inhalational anthrax. The infected person is an AMI employee,
and the cause of the infection is unknown.
Date: Friday, 10/05/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In Florida, an AMI employee becomes the first anthrax victim to die.
Date: Sunday, 10/07/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In Florida, the AMI building is closed after anthrax spores are
found.
Date: Monday, 10/08/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In Florida, prophylaxis of AMI employees begins.
Date: Wednesday, 10/10/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* Because the source of the AMI employee's anthrax exposure is believed
to have been a letter, USPS begins nationwide employee education on
signs of anthrax exposure and procedures for handling mail to avoid
anthrax infection.
Date: Friday, 10/12/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NY, the New York City Department of Health (NYCDOH) announces the
confirmation of a case of cutaneous anthrax in an NBC employee; * USPS
says that it will offer gloves and masks to all employees who handle
mail.
Date: Monday, 10/15/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* On Capitol Hill, an employee opens a letter addressed to Senator
Daschle thought to contain anthrax spores. People thought to be in the
vicinity of the letter when it was opened are treated with
ciprofloxacin, at the time the only drug approved for postexposure
prophylaxis for anthrax; * In Florida, CDC confirms a second case of
inhalational anthrax in an AMI employee; * In NY, NYCDOH announces a
second case of cutaneous anthrax, in a child of an ABC employee.
Date: Thursday, 10/18/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In the Washington, D.C., regional area (DC),[A] USPS reports that
although it believes that the Daschle letter, which was processed at
the Brentwood postal facility, was extremely well sealed and that there
was a minute chance that anthrax spores escaped into the facility, it
is testing the facility for anthrax contamination; quick tests are
negative, other tests are sent to the laboratory; * In NJ, laboratory
testing confirms cutaneous anthrax in two USPS employees, one from the
West Trenton postal facility and one from the Hamilton postal
facility; * In NY, NYCDOH announces a third case of cutaneous anthrax,
in a CBS employee; * In Florida, USPS closes two postal facilities
contaminated with anthrax spores for cleaning; * In a telebriefing,
the Director of CDC provides information about anthrax, including risk
of exposure, availability of vaccines and antimicrobial medications,
screening tests, symptoms, and what to do with suspicious mail and also
explains CDC's role in the investigation; * CDC broadcasts part one of
a live satellite and Web broadcast on anthrax for clinicians; * FDA
announces that it has approved doxycycline for postexposure prophylaxis
for anthrax; * In DC, a USPS employee who works at the Brentwood
postal facility seeks medical attention.
Date: Friday, 10/19/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In DC, a USPS employee who works at both the Brentwood postal
facility and a Maryland postal facility is admitted to a hospital with
suspected inhalational anthrax; * In NJ, the Hamilton and West Trenton
postal facilities are closed, and the New Jersey Department of Health
and Senior Services recommends that all USPS employees from both
facilities receive prophylaxis; * In NJ, laboratory testing confirms
cutaneous anthrax in a second USPS employee who works at the Hamilton
postal facility; * In NY, NYCDOH announces a fourth case of cutaneous
anthrax, in a New York Post employee.
Date: Saturday, 10/20/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In DC, a third USPS employee who works at the Brentwood postal
facility is admitted to a hospital with a respiratory condition.
Date: Sunday, 10/21/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In DC, the USPS employee who worked at the Brentwood and Maryland
postal facilities and was admitted to the hospital on 10/19/01 is
confirmed to have inhalational anthrax; * In DC, the Brentwood and
Maryland postal facilities, are closed. Evaluation and prophylaxis of
employees begin; * In DC, a USPS employee who worked at the Brentwood
postal facility and who initially sought medical attention on 10/18/01
is admitted to a hospital with suspected inhalational anthrax and
becomes the second anthrax victim to die; * In DC, a fourth USPS
employee who worked at the Brentwood postal facility seeks medical
attention at a hospital. His chest X-ray is initially determined to be
normal, and he is discharged.
Date: Monday, 10/22/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In DC, the USPS employee who worked at the Brentwood postal facility
and who sought medical attention on 10/21/01 and was discharged is
admitted to the hospital with suspected inhalational anthrax, and
becomes the third anthrax victim to die; * In DC, the USPS employee
who was admitted to the hospital on 10/20/01 is confirmed to have
inhalational anthrax; * In DC, prophylaxis is expanded to include all
employees and visitors to nonpublic areas at the Brentwood postal
facility; * CDC rebroadcasts part one of the live satellite and Web
broadcast on anthrax for clinicians.
Date: Wednesday, 10/24/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NY, USPS begins giving prophylaxis to employees at six New York
City postal facilities where contaminated letters may have been
processed.
Date: Thursday, 10/25/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In DC, a State Department mail facility employee is called back to
the hospital for admission; test taken the previous day is positive for
inhalational anthrax; * In NY, NYCDOH announces a fifth case of
cutaneous anthrax, in a second NBC employee; * CDC initiates daily
telebriefings to provide updates on the anthrax incidents.
Date: Saturday, 10/27/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NY, NYCDOH announces the sixth case of cutaneous anthrax, in a
second New York Post employee.
Date: Sunday, 10/28/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NJ, laboratory testing confirms inhalational anthrax in a USPS
Hamilton employee who was admitted to a hospital with suspected
inhalational anthrax on 10/19/01.
Date: Monday, 10/29/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NY, preliminary tests indicate anthrax in a hospital employee who
was admitted with suspected inhalational anthrax on 10/28/01. The
hospital where she works is temporarily closed, and NYCDOH recommends
prophylaxis for hospital employees and visitors; * In NJ, laboratory
testing confirms cutaneous anthrax in a woman who receives mail
directly from the Hamilton facility. The woman originally sought
medical attention on 10/18/01 and was admitted to the hospital on 10/
22/01 for a skin condition; * In NJ, laboratory testing confirms a
second case of inhalational anthrax, in a USPS Hamilton employee who
initially sought medical attention on 10/16/01 and was admitted to the
hospital on 10/18/01 with a respiratory condition.
Date: Wednesday, 10/31/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In NY, the hospital employee becomes the fourth anthrax victim to
die.[B].
Date: Thursday, 11/01/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* CDC broadcasts part two of the live satellite and Web broadcast on
anthrax for clinicians.
Date: Friday, 11/2/01; Events Occurring on That Date: Events Determined
Retrospectively to Have Occurred on That Date (in italics): * In NY,
NYCDOH announces the seventh case of cutaneous anthrax, in a third New
York Post employee.
Date: Wednesday, 11/21/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* In Connecticut, an elderly woman, who was admitted to the hospital
for dehydration on 11/16/01, becomes the fifth anthrax victim to
die.[B]; * The Connecticut Department of Public Health, in consultation
with CDC, begins prophylaxis for USPS employees working in the Seymour
and Wallingford postal facilities.
Date: Friday, 12/21/01; Events Occurring on That Date: Events
Determined Retrospectively to Have Occurred on That Date (in italics):
* CDC expands the options for those on prophylaxis to include extending
the duration of drug therapy and adding the anthrax vaccine.
Source: CDC, Connecticut Department of Public Health, District of
Columbia Department of Health, FDA, Florida Department of Health, New
Jersey Department of Health and Senior Services, NYCDOH, Office of the
Attending Physician of the U.S. Congress, and USPS.
[A] The Washington, D.C., regional area includes Washington, D.C.,
Maryland, and Virginia.
[B] As of September 30, 2003, the source of exposure had not been
confirmed.
[End of table]
[End of section]
Appendix II: Comments from the Department of Defense:
HOMELAND DEFENSE:
Ms. Janet Heinrich, Director Health Care - Public Health Issues U.S.
General Accounting Office Washington, DC 20548:
1 4 OCT 2003:
Dear Ms. Heinrich:
This is the Department of Defense (DoD) response to the GAO final
report, "Bioterrorism: Public Health Response to Anthrax Incidents of
2001" dated October 6, 2003 (Code 290288/ GAO-04-152).
DOD acknowledges receipt of the final report and notes it contains no
specific recommendations for departmental action, however, we believe
the report should be amended for two specific purposes. First, the
report should highlight the significant role the Department played in
supporting civilian public health response during this unprecedented
biological attack on American soil. In addition, amending the report to
reflect the lessons learned from DOD's support can aid the development
of expanded capabilities within the civilian sector to help improve the
nation's public health preparedness. Specific technical comments for
your consideration are also attached.
During the period from October 2001 through January 2002, DOD supported
civilian public health and law enforcement authorities by employing its
unique weapons of mass destruction (WMD) response capabilities to
perform environmental assessments, transportation of contaminated
articles, laboratory confirmation testing and cleanup of locations
suspected of anthrax contamination. These capabilities were vital to
the success of the public health response.
Immediately following the Fall 2001 anthrax attacks, the United States
Capitol Police contacted DOD and requested assistance to conduct
environmental assessments, testing and evaluation of air and source
samples for anthrax spores in the House and Senate office spaces. DOD
responded by dispatching the Marines and sailors of the Chemical
Biological Incident Response Force (CBIRF), 4th Marine Expeditionary
Brigade (Anti-Terrorism) to address this threat. Subsequently, CBTRF
was assigned in direct support of the Federal Bureau of Investigation -
Hazardous Materials Response Unit at the United States Postal Service
Mail P Street Facility to conduct biological-hazard reconnaissance and
collection and over packing of congressional mail.
Additionally, the laboratories of the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRID) and the U.S. Navy Naval
Medical Research Center (NMRC), were also pressed into service to
support the Center of Disease Control to conduct confirmation testing
of contaminated samples for the presence of anthrax.
These capabilities were unique to the DoD and resulted from the
Department's past contingency planning for WMD response in an overseas
warfighting environment. At the time of the attacks, no other Federal
government agency then possessed the capability and requisite
experience for addressing biological agent contamination across the
full range of activities from:
assessment to confirmation testing and subsequent decontamination and
cleanup. Accordingly, with this extensive biological defense
experience, training and expertise, DoD is fully prepared to assist
civilian public health officials in the future to expand their
development of WMD response capabilities.
DoD appreciates the opportunity to provide this additional information
on its role and we look forward to working with you on improving our
nation's future bioterrorism preparedness.
Sincerely,
Paul McHale:
Signed by Paul McHale:
Attachments a/s:
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES office of Inspector General:
Washington, D.C. 20201:
OCT 10 2003:
Ms. Janet Heinrich:
Director, Health Care - Public Health Issues United States General
Accounting Office Washington, D.C. 20548:
Dear Ms. Heinrich:
Enclosed are the Department's comments on your draft report entitled,
"Bioterrorism: Public Health Response to Anthrax Incidents of 2001."
The comments represent the tentative position of the Department and are
subject to reevaluation when the final version of this report is
received.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed by:
Dara Corrigan:
Acting Principal Deputy Inspector General:
The Office of Inspector General (OIG) is transmitting the Department's
response to this draft report in our capacity as the Department's
designated focal point and coordinator for General Accounting Office
reports. OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services on the General
Accounting Office's Draft Report. "Bioterrorism: Public Health Response
to Anthrax Incidents of 2001" (GAO-04-152):
The Department of Health and Human Services (HHS) appreciates [lie
opportunity to comment on the above-referenced draft report. The report
provides an informative account of a) the role of the Centers for
Disease Control and Prevention (CDC) in responding to the public health
emergency engendered by the anonymous, surreptitious, and malicious
distribution of wcaponized Bacillus anthracis (B. anthracis) through
the U.S. mail system during October 2001; b) the lessons learned from
that unique experience; and c) actions to enhance CDC's readiness for
further bioterrorisin incidents and other public health emergencies.
The report should become a valuable reference document for policy
makers, public health professionals, and members of the general public
concerned with U. S. national preparedness in the ever-present threat
of bioterrorism and its myriad potential manifestations.
The U.S. General Accounting Office could enhance the utility ol the
report by making explicit that the CDC role, invaluable as it was, is
only part of the story. During the weeks following the appearance of
the letters laced with B. anthracis spores, the Office of the Secretary
of Health and Human Services maintained an ad hoc emergency operations
center under the personal direction of the Deputy Secretary with a view
toward ensuring appropriate direction and coordination of all HHS
assets deployed during the crisis, including those of CDC. To cite but
one example, HHS deployed 325 U. S. Public Health Service Commissioned
Officers to help effect mass distribution of antibiotics, triaging,
assessment, patient education, and counseling of 37,000 persons at risk
of exposure to B. anthracis:
Moreover, in the wake of the anthrax incidents, HHS undertook a host of
significant actions - including but going well beyond those CDC-based
activities noted in the report - to enhance preparedness for
bioterrorism and other public health emergencies. "these other actions
include a) the Secretary's creation of the Office of Public Health
Preparedness (subsequently codified in statute and renamed the Office
of Public Health Emergency Preparedness) and, through it, the
establishment of the Secretary's Command Center and the Secretary's
Emergency Response Teams; b) an unprecedented increase of support for
public health departments, hospitals, other health care entities, and
communities throughout the nation to enhance Stale mid local
preparedness for public health emergencies; c) accelerated acquisition
of antibiotics for the National Pharmaceutical Stockpile (subsequently
renamed in statute as the Strategic National Stockpile) to improve
preparedness for further anthrax attacks or other bioterrorism
incidents; d) accelerated acquisition of enough closes of smallpox
vaccine to cover the entire TI. S. population in the event of a
terrorist-induced smallpox outbreak; e)significant expansion of basic
and targeted research and upgrading of research facilities focused on
the pathogens most. likely to be used as bioterrorism agents; and f) in
view of the potential for food to be a medium for terrorism,
substantial augmentation of efforts to protect the security and safety
of the T J. S. food supply.
Technical and Other Comments:
We have also provided technical and other comments on the draft for
your consideration and use in finalizing the report; these comments are
being submitted separately.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Michele Orza, (202) 512-6970:
Acknowledgments:
In addition to the contact named above, Robert Copeland, Charles
Davenport, Donald Keller, Nkeruka Okonmah, and Roseanne Price made key
contributions to this report.
[End of section]
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FOOTNOTES
[1] Anthrax is a serious disease caused by Bacillus anthracis, a
bacterium that forms spores. A bacterium is a very small organism made
up of one cell. A spore is a dormant bacterium cell that can be revived
under certain conditions.
[2] In this report, we identify Capitol Hill, the complex of
congressional office buildings centering on the U.S. Capitol, as an
epicenter distinct from the Washington, D.C., regional area epicenter
because Capitol Hill functions independently from the District of
Columbia. The Office of the Attending Physician, U.S. Congress, which
is an office of the U.S. Navy, serves as the local health department
for Capitol Hill and is responsible for the health of about 30,000
public officials and staff, as well as tourists, on Capitol Hill.
[3] In this report, the term responder refers to any organization or
individual that would respond to a bioterrorist incident. These include
physicians, nurses, hospitals, laboratories, public health
departments, emergency medical services, emergency management
agencies, fire departments, and law enforcement agencies.
[4] U.S. General Accounting Office, Bioterrorism: Preparedness Varied
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.:
Apr. 7, 2003).
[5] For information on aspects of the response to the anthrax incidents
that are outside the scope of this report, see our reports on those
topics: U.S. General Accounting Office, U.S. Postal Service: Better
Guidance Is Needed to Improve Communication Should Anthrax
Contamination Occur in the Future, GAO-03-316 (Washington, D.C.: Apr.
7, 2003); U.S. General Accounting Office, Capitol Hill Anthrax
Incident: EPA's Cleanup Was Successful; Opportunities Exist to Enhance
Contract Oversight, GAO-03-686 (Washington, D.C.: June 4, 2003); and
U.S. General Accounting Office, U.S. Postal Service: Issues Associated
with Anthrax Testing at the Wallingford Facility, GAO-03-787T
(Washington, D.C.: May 19, 2003). For a list of our other work related
to bioterrorism preparedness, see the list of related products at the
end of this report.
[6] An antimicrobial medication either kills or slows the growth of
microbes.
[7] A laboratorian is one who works in a laboratory; in the medical and
allied health professions, a laboratorian examines or performs tests
(or supervises such procedures) with various types of chemical and
biologic materials, chiefly to aid in the diagnosis, treatment, and
control of disease, or as a basis for health and sanitation practices.
[8] An epidemiologist is a specialist in the study of how disease is
distributed in populations and the factors that influence or determine
this distribution.
[9] Disease surveillance systems provide for the ongoing collection,
analysis, and dissemination of health-related data to identify,
prevent, and control disease.
[10] Public health infrastructure is the foundation that supports the
planning, delivery, and evaluation of public health activities and is
composed of a well-trained public health workforce, effective program
and policy evaluation, sufficient epidemiology and surveillance
capability to detect outbreaks and monitor incidence of diseases,
appropriate response capacity for public health emergencies, effective
laboratories, secure information systems, and advanced communication
systems.
[11] At the time of the anthrax incidents, the Strategic National
Stockpile was known as the National Pharmaceutical Stockpile.
[12] HAN is a nationwide program designed to ensure communication
capacity at all local and state health departments (including full
Internet connectivity and training), ensure capacity to receive
distance learning offerings from CDC and others, and ensure capacity to
broadcast and receive health alerts at every level.
[13] Epi-X is a secure, Web-based communication system to enhance
bioterrorism preparedness efforts by facilitating the sharing of
preliminary information about disease outbreaks and other health events
among public health officials across jurisdictions and provide
experience in the use of secure communications.
[14] The Laboratory Response Network was established in 1999 by CDC,
DOD, and the Association of Public Health Laboratories to maintain
state-of-the-art capabilities for biological agent identification and
characterization. The network is a multilevel system designed to link
local and state public health laboratories with advanced capacity
clinical, military, veterinary, agricultural, water, and food-testing
laboratories. About 100 laboratories participate in the network, with
at least one network laboratory in each state.
[15] These agents, which are labeled Category A agents, are anthrax,
botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers.
[16] Later, CDC recommended expanding prophylaxis for those already on
it to include an additional 40 days of antimicrobial drugs, with or
without three doses of the anthrax vaccine.
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