U.S. Postal Service
Clear Communication with Employees Needed before Reopening the Brentwood Facility Gao ID: GAO-04-205T October 23, 2003On October 21, 2001, the U.S. Postal Service closed its Brentwood mail processing facility after the Centers for Disease Control and Prevention (CDC) confirmed that an employee there had contracted inhalation anthrax, an often-fatal form of the disease. On October 21 and 22, two other Brentwood employees died of inhalation anthrax. The contamination was linked to a letter that passed through the facility on or about October 12, before being opened in the office of Senator Daschle in the Hart Senate Office Building on October 15. The Hart Building was closed the next day. The Brentwood facility has since been decontaminated and will soon reopen. This testimony, which is based on ongoing work, provides GAO's preliminary observations on the decisions made in closing the facility and problems experienced in communicating with employees, as well as lessons learned from the experience.
The Postal Service's decision to wait to close the Brentwood facility and refer employees for medical treatment until CDC confirmed that a postal employee had contracted inhalation anthrax was consistent with the advice the Postal Service received from public health advisers and the information about health risk available at the time. However, because circumstances differed at Brentwood and the Hart Building--an observed spill at the Hart Building and no observable incident at Brentwood--the Postal Service's response differed from the response at Capitol Hill, leading some Brentwood employees to question whether the Postal Service was taking adequate steps to protect their health. The Postal Service communicated information to its Brentwood employees during the anthrax incident, but some of the health risk information changed over time, exacerbating employees' concerns about the measures being taken to protect them. Notably, employees later learned that their risk of contracting the disease was greater than originally stated. Other factors, including difficulties in communicating the uncertainty associated with health recommendations and employees' distrust of postal managers, also challenged efforts to communicate effectively. Recently, the Postal Service informed employees that Brentwood, which has been tested and certified as safe for occupancy, is "100 percent free of anthrax contamination." However, in discussions with GAO, the Service agreed to revise future communications to acknowledge that although any remaining risk at the facility is likely to be low, complete freedom from risk cannot be guaranteed. The Postal Service and others have learned since the 2001 anthrax incidents that (1) the risk of contracting anthrax through the mail is greater than was previously believed and more caution is needed to respond to that greater risk and (2) clear, accurate communication is critical to managing the response to an incident and its aftermath. The Postal Service is revising its guidance to respond more quickly and to communicate more effectively to employees and the public in the event of a future incident.
GAO-04-205T, U.S. Postal Service: Clear Communication with Employees Needed before Reopening the Brentwood Facility
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Testimony:
Before the Committee on Government Reform, House of Representatives:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 1:30 p.m. EDT:
Thursday, October 23, 2003:
U.S. Postal Service:
Clear Communication with Employees Needed before Reopening the
Brentwood Facility:
Statement of:
Bernard L. Ungar, Director:
Physical Infrastructure:
Keith Rhodes, Chief Technologist:
Center for Technology and Engineering, Applied Research and Methods:
GAO-04-205T: Reopening the Brentwood Postal Facility:
GAO-04-205T:
GAO Highlights:
Highlights of GAO-04-205T, a testimony before the Committee on
Government Reform, House of Representatives
Why GAO Did This Study:
On October 21, 2001, the U.S. Postal Service closed its Brentwood mail
processing facility after the Centers for Disease Control and
Prevention (CDC) confirmed that an employee there had contracted
inhalation anthrax, an often-fatal form of the disease. On October 21
and 22, two other Brentwood employees died of inhalation anthrax. The
contamination was linked to a letter that passed through the facility
on or about October 12, before being opened in the office of Senator
Daschle (see fig.) in the Hart Senate Office Building on October 15.
The Hart Building was closed the next day. The Brentwood facility has
since been decontaminated and will soon reopen. This testimony, which
is based on ongoing work, provides GAO‘s preliminary observations on
the decisions made in closing the facility and problems experienced in
communicating with employees, as well as lessons learned from the
experience.
What GAO Found:
The Postal Service‘s decision to wait to close the Brentwood facility
and refer employees for medical treatment until CDC confirmed that a
postal employee had contracted inhalation anthrax was consistent with
the advice the Postal Service received from public health advisers and
the information about health risk available at the time. However,
because circumstances differed at Brentwood and the Hart Building”an
observed spill at the Hart Building and no observable incident at
Brentwood”the Postal Service‘s response differed from the response at
Capitol Hill, leading some Brentwood employees to question whether the
Postal Service was taking adequate steps to protect their health.
The Postal Service communicated information to its Brentwood employees
during the anthrax incident, but some of the health risk information
changed over time, exacerbating employees‘ concerns about the measures
being taken to protect them. Notably, employees later learned that
their risk of contracting the disease was greater than originally
stated. Other factors, including difficulties in communicating the
uncertainty associated with health recommendations and employees‘
distrust of postal managers, also challenged efforts to communicate
effectively. Recently, the Postal Service informed employees that
Brentwood, which has been tested and certified as safe for occupancy,
is ’100 percent free of anthrax contamination.“ However, in
discussions with GAO, the Service agreed to revise future
communications to acknowledge that although any remaining risk at the
facility is likely to be low, complete freedom from risk cannot be
guaranteed.
The Postal Service and others have learned since the 2001 anthrax
incidents that (1) the risk of contracting anthrax through the mail is
greater than was previously believed and more caution is needed to
respond to that greater risk and (2) clear, accurate communication is
critical to managing the response to an incident and its aftermath.
The Postal Service is revising its guidance to respond more quickly
and to communicate more effectively to employees and the public in the
event of a future incident.
What GAO Recommends:
Because the Postal Service agreed to inform Brentwood employees before
the facility is reopened that it could not guarantee that the facility
is completely risk free, GAO is making no recommendations at this
time.
www.gao.gov/cgi-bin/getrpt?GAO-04-205T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Bernard L. Ungar at
(202) 512-2834 or ungarb@gao.gov
[End of section]
Mr. Chairman and Members of the Committee:
We are pleased to be here to discuss issues related to the U. S. Postal
Service's response to the anthrax[Footnote 1] contamination at the
Washington D.C. Processing and Distribution Center, or Brentwood, as it
was commonly known.[Footnote 2] As you know, the facility was renamed
the Joseph Curseen Jr. and Thomas Morris Jr. Processing and
Distribution Center in memory of the two Brentwood employees who died
of inhalation anthrax on October 21 and 22, 2001. Inhalation anthrax is
the most lethal form of the disease. The facility is about to reopen
after being closed 2 years ago this week for decontamination and
renovation. My testimony today will focus on the (1) decisions made by
the Postal Service in closing the Brentwood facility and (2) problems
the Postal Service experienced in communicating to its employees as
well as (3) lessons that can be learned from the experience. While you
also asked us to address the effectiveness of the facility's
decontamination, we are unable to do so because this issue is outside
the scope of work that we have under way. However, we will relay our
observations about communication issues associated with the facility's
decontamination.
My testimony today is based largely on our ongoing work addressing the
treatment of postal employees at several postal facilities, including
the Brentwood facility, that were contaminated with anthrax spores in
late 2001. This work, which we expect to complete within the next
several months, is being done at the request of Senator Joseph I.
Lieberman and Representatives Christopher H. Smith and Eleanor Holmes
Norton. Our work thus far has involved interviews with individuals
involved in the response to the contamination, including
representatives from the Postal Service, the Department of Defense, the
Centers for Disease Control and Prevention (CDC), and state and local
public health agencies and postal unions as well as reviews of relevant
documents and literature related to the anthrax response. We are also
drawing from our completed work addressing anthrax contamination at a
postal facility in Connecticut,[Footnote 3] issues related to the
testing for anthrax in that facility,[Footnote 4] and the public health
response to the 2001 anthrax incidents.[Footnote 5] Our work is being
performed in accordance with generally accepted government auditing
standards. The observations that we are making are based on our ongoing
work and should be viewed as preliminary.
Before I discuss the decisions made in closing the Brentwood facility,
let me briefly place these decisions in context. When the Postal
Service learned that a letter contaminated with anthrax spores had been
sent through the mail and opened in the office of Senator Daschle
within the Hart Senate Office Building (Hart Building) on October 15,
2001, the Postal Service reports that it immediately understood that
the letter passed through its Brentwood facility. However, at that
point, the risk of contamination and its consequences at the facility
were uncertain. The Postal Service sought advice and guidance from CDC
and the District of Columbia (D.C.) Department of Health, provided
information to its employees, arranged for environmental tests of the
facility, and provided some protective equipment, but it did not close
the facility or refer the facility's employees for medical treatment
until October 21, when CDC confirmed that a Brentwood employee had
inhalation anthrax. The Postal Service's actions contrasted with those
taken by the Attending Physician for the U.S. Capitol--the individual
responsible for the health of public officials and other congressional
employees on Capitol Hill. The Attending Physician decided to make
antibiotics available to the most directly exposed congressional
employees on the same day the contaminated letter was opened and
advised closure of the Hart Building the following day.
In summary:
The Postal Service's decision to wait for CDC's confirmation of a case
of inhalation anthrax before closing Brentwood and referring its
employees for medical treatment was consistent with the advice it
received from CDC and the D.C. Department of Health as well as the
information about health risk available at the time. However, the
decision raised questions among Brentwood employees about whether their
health was being adequately protected. At the time, CDC advised waiting
for such confirmation before recommending closing a facility or
recommending medical treatment because CDC and local public health
authorities believed it unlikely that postal employees could contract
inhalation anthrax from exposure to contaminated mail. The Postal
Service's decision differed from the decision to close the Hart
Building, in large part, because there was an observable incident of
anthrax contamination there--which was immediately recognized as a
potentially high-risk situation--whereas there was no observable
incident at Brentwood. However, even before CDC confirmed the first
case of inhalation anthrax at Brentwood, some Postal Service employees
questioned whether the Postal Service's actions adequately protected
their health.
The Postal Service communicated health risk and other information to
its Brentwood employees during the anthrax incident, but some of the
information it initially provided changed as public health knowledge
evolved--exacerbating employees' concerns about the adequacy of the
measures being taken to protect them. Most significantly, employees
later learned that their risk of contracting the disease was greater
than originally stated. Other factors, including difficulties in
communicating the uncertainty associated with health recommendations,
the appearance of disparate treatment between Brentwood and
congressional employees, and employees' long-standing distrust of
postal managers, also challenged efforts to communicate effectively.
According to postal managers, the Postal Service has made additional
efforts to communicate with Brentwood employees since the facility's
closure, but challenges remain, including before the facility opens to
clearly communicate the impossibility of eliminating all risk of
contamination from the environment. Recently, for example, the Postal
Service informed employees that Brentwood, which has been tested and
certified as safe for occupancy, is "100 percent free of anthrax
contamination." However, following discussions with us about the
impossibility of eliminating all risk of contamination, the Postal
Service agreed to revise future communications to acknowledge that
although any remaining risk at the facility is likely to be low,
complete freedom from risk cannot be guaranteed.
The Postal Service, CDC, and others have learned a great deal from the
2001 anthrax incidents and have taken various steps to address the
problems that occurred and to enhance their preparedness for any future
incidents. One of the lessons learned is that the risk of employees
contracting anthrax through the mail is greater than was previously
believed and more caution is needed to respond to that greater risk.
Another important lesson learned is that clear and accurate
communication to employees is critical to managing the response to an
incident and its aftermath. The Postal Service, CDC, and others have
taken steps to revise their guidance to respond more quickly in the
event of a future anthrax incident and to communicate more effectively
about such an incident with employees and the public. The Postal
Service told us that it would inform Brentwood employees prior to
opening the Brentwood facility that while the facility is safe for
occupancy, it is impossible to guarantee that it is risk free.
Background:
Anthrax is an acute infectious disease caused by the spore-forming
bacterium called Bacillus anthracis. The bacterium is commonly found in
the soil and forms spores (like seeds) that can remain dormant for many
years. Although anthrax can infect humans, it occurs most commonly in
plant-eating animals.
Human anthrax infections are rare in the United States and have
normally resulted from occupational exposure to infected animals or
contaminated animal products, such as wool, hides, or hair. Infection
can occur in three forms, two of which are relevant to this testimony.
They are (1) cutaneous, which usually occurs through a cut or
abrasion[Footnote 6] and (2) inhalation, which results from breathing
aerosolized anthrax spores into the lungs.[Footnote 7] Aerosolization
occurs when anthrax spores become airborne, thus enabling a person to
inhale the spores into the lungs. After the spores enter the body, they
can germinate into bacteria, which then multiply and secrete toxins
that can produce local swelling and tissue death. The symptoms are
different for each form of infection and are thought to appear within
about 7 days of exposure, although individuals have contracted
inhalation anthrax as long as 43 days after exposure. Depending on the
extent of exposure and its form, a person can be exposed to anthrax
without developing an infection. Before the 2001 incidents, the
fatality rate for inhalation anthrax was approximately 75 percent, even
with appropriate antimicrobial medications.[Footnote 8] People coming
in contact with anthrax in its natural environment have generally not
been at risk for inhalation anthrax, and before 2001, no cases of
inhalation anthrax had been reported in the United States since 1976,
although 224 cases of cutaneous anthrax were diagnosed between 1944 and
1994.[Footnote 9] Fatalities are rare for cutaneous anthrax.
Because so few instances of inhalation anthrax have occurred,
scientific understanding about the number of spores needed to cause the
disease is still evolving. Before the 2001 incidents, it was estimated
that a person would need to inhale thousands of spores to develop
inhalation anthrax. However, based on the cases that occurred during
the fall of 2001, experts now believe that the number of spores needed
to cause inhalation anthrax could be very small, depending on a
person's health status and the aerosolization capacity of the anthrax
spores.
In total, the contaminated letters caused 22 illnesses and resulted in
5 deaths from inhalation anthrax. Numerous postal facilities were also
contaminated. The first two cases of disease involved media employees
in Florida. The employees--one of whom died--contracted inhalation
anthrax and were thought to have contracted the disease through
proximity to opened letters containing anthrax spores. Media employees
also developed anthrax in New York--the second location known to be
affected. The initial cases in New York were all cutaneous and were
also thought to have been associated with opened envelopes containing
anthrax spores. The initial cases at the next site--New Jersey--
involved postal employees with cutaneous anthrax. The postal employees
were believed to have contracted the disease through handling the mail-
-as opposed to opening or being exposed to opened letters containing
anthrax spores. Unlike the incidents at other locations, which began
when cases of anthrax were detected, the incident at the Hart Building-
-the fourth location--began with the opening of a letter containing
anthrax spores and the resulting exposure to the contamination. The
discovery of inhalation anthrax in the first postal worker from
Brentwood revealed that even individuals who had been exposed only to
taped and sealed envelopes containing anthrax could contract the
inhalation form of the disease. Subsequent inhalation cases in
Washington, D.C; New Jersey; New York; and Connecticut--the sixth
location affected--underscored that finding and also demonstrated that
exposure and illness could result from cross contamination of
mail.[Footnote 10] (See app. I for a time line of selected events
related to the anthrax incident in the fall of 2001.):
On or about October 9, 2001, at least two letters containing anthrax
spores entered the U.S. mail stream--one was addressed to Senator
Thomas Daschle, the other to Senator Patrick Leahy. The letters were
mailed in Trenton, New Jersey, and forwarded to the Brentwood facility
in Washington, D.C., where they were processed on high-speed mail
sorting machines and further processed in the facility's government
mail section before delivery.[Footnote 11] On October 15, a staff
member in Senator Daschle's office opened the contaminated envelope.
The envelope contained a powdery substance, which the accompanying
letter identified as anthrax, that was released in a burst of dust when
the envelope was opened. The U.S. Capitol Police were notified, and the
substance was quickly tested and confirmed to be anthrax. Brentwood
managers analyzed the path of the letter through the facility. Although
the machine that processed the letter was reportedly shut off--at least
for a period of time--the facility itself was not closed or evacuated
at that time. Within days, a Brentwood employee was suspected of having
contracted inhalation anthrax. The Postal Service closed the facility
on October 21, 2001, after CDC confirmed that the employee had the
disease. Thereafter, two other Brentwood employees, Mr. Curseen, Jr.,
and Mr. Morris, Jr., died. Both were subsequently found to have died of
inhalation anthrax.
The Brentwood facility is a large 2-story facility that operated 24
hours a day, 7 days a week. About 2,500 employees worked at Brentwood,
processing mail on one of three shifts. Brentwood processed all the
mail delivered to addresses on Capitol Hill, including the Hart
Building. Brentwood was the second processing and distribution center
closed for an extended period because of anthrax contamination. The
Postal Service reported that it plans to reopen the facility in phases;
by late November administrative personnel will begin working in the
facility and limited mail processing operations will begin shortly
after that. Brentwood is expected to be fully operational by spring
2004. The other facility--the Trenton Processing and Distribution
Center--located in Hamilton, New Jersey, was closed 3 days before
Brentwood on October 18, 2001, after CDC confirmed that a New Jersey
postal employee had cutaneous anthrax. It is in the process of being
decontaminated.
Brentwood Employees Questioned Whether the Decision to Wait for
Confirmation of Inhalation Anthrax Adequately Protected Their Health:
The Postal Service's decision to wait for CDC's confirmation of a case
of inhalation anthrax before closing Brentwood and referring the
facilities' employees for medical treatment was consistent with the
public health advice the Postal Service received and the health risk
information available at the time. However, the Postal Service's
decision contrasted with the more immediate decision to close the Hart
Building after anthrax contamination occurred. As a result, postal
employees questioned whether the Postal Service's decision adequately
protected their health.
The Postal Service's Decision Was Based on CDC's Advice and Available
Health Risk Information:
The Postal Service's decision to wait for CDC's confirmation of a case
of inhalation anthrax before closing Brentwood and referring its
employees for medical treatment was consistent with the advice provided
by CDC and the D.C. Department of Health, as well as the available
health risk information. CDC called for such confirmation before
closing a facility or recommending medical treatment because, at the
time, public health authorities believed postal employees were unlikely
to contract inhalation anthrax from exposure to contaminated mail.
Postal officials reported that they consulted CDC and the D.C.
Department of Health about the possible health risks to Brentwood
employees after learning that Senator Daschle's letter--opened on
October 15, 2001--contained anthrax. Even though the letter would have
passed through Brentwood, the public health authorities said that they
did not consider the facility's employees at risk, given the results of
ongoing investigations of anthrax incidents in Florida and New York and
the scientific understanding at that time. Specifically, as discussed,
no postal employees were known to have developed symptoms of anthrax
after contaminated letters had passed through the postal system on the
way to destinations in Florida and New York, and anthrax spores were
not considered likely to leak out, or escape from, a taped and well-
sealed envelope in sufficient quantities to cause inhalation anthrax.
Accordingly, the Postal Service reported that it kept the Brentwood
facility open in order to keep the mail moving. This goal was important
to managers whom we interviewed, who cited the psychological importance
of keeping the mail flowing in the aftermath of the September 11
terrorist attacks.
On October 18, 2001, CDC confirmed that a postal employee in New Jersey
had cutaneous anthrax. On that day, the Postal Service, in consultation
with the New Jersey Department of Health and Senior Services, closed
the Trenton Processing and Distribution Center. According to New Jersey
public health officials, the facility was closed to facilitate
environmental testing of the Trenton facility. While the contaminated
letters to Senator Daschle and Senator Leahy were both processed
through the Trenton and Brentwood facilities, it is not clear why the
Postal Service did not take the same precautionary measures at
Brentwood. We are pursuing this issue as part of our ongoing work.
Although the Postal Service followed CDC's advice and kept Brentwood
open until CDC confirmed a case of inhalation anthrax, the Postal
Service took interim steps to protect its employees. First, the Postal
Service arranged for a series of environmental tests at the Brentwood
facility, even though it reported that CDC had advised the Postal
Service that it did not believe such testing was needed at that time.
The results of the first test--taken and available on October 18, 2001-
-were from a quick test conducted by a local hazardous materials
response team. The results were negative. Three days later, on October
21, 2001, CDC confirmed that a Brentwood employee had inhalation
anthrax, and the Postal Service closed the facility and referred its
employees for medical treatment. The positive results of more extensive
environmental testing--also conducted on October 18, 2001--were not
available until October 22--after the facility had already closed. In
addition, Postal Service managers said they asked the D.C. Department
of Health three times before October 21 for nasal swabs and antibiotics
for Brentwood employees; however, the health department said the swabs
and antibiotics were unnecessary. We have not yet been able to confirm
this information with the D.C. Department of Health. Finally, the
Postal Service took actions to protect its employees from low-level
environmental risks. For example, it provided protective equipment such
as gloves and masks and, according to postal managers, shut down the
mail-sorting machine that processed the Daschle letter, at least for a
time. Additionally, the Postal Service provided information on handling
suspicious packages and required facility emergency action plans to be
updated.
In 1999, the Postal Service developed guidance for responding to
anthrax and other hazardous incidents. The guidance, which was
developed in response to hundreds of hoaxes, includes steps for
notifying first responders, evacuating employees, and providing
information and medical care to employees. The Postal Service reported
that the guidance deals with observable events--specifically, spills--
not events that are not observable, such as aerosolization of powders.
As a result, the Postal Service said that it did not view the guidance
as being applicable to the situation that occurred at Brentwood.
Given that the situation at Brentwood differed from the situation
contemplated in its guidance, the Postal Service sought advice from CDC
and others. According to CDC officials, the health and safety of postal
employees was always the first concern of postal managers during
discussions with CDC. Furthermore, they said that the Postal Service
was receptive to their advice about the need to close Brentwood to
protect postal employees after a diagnosis of inhalation anthrax was
confirmed.
The Decisions Made at Brentwood and Capitol Hill Differed Because the
Circumstances and Decisionmakers Differed:
The Postal Service's decision to wait for a confirmed case of
inhalation anthrax before closing the facility and referring employees
for medical treatment differed from the decision to implement
precautionary measures immediately after anthrax contamination was
identified at the Hart Building. The decisions differed, in part,
because there was an observable incident at the Hart Building, but not
at Brentwood. In addition, different parties made the decisions. At
Brentwood, the Postal Service made the decision in consultation with
CDC and the D.C. Department of Health. These parties were not involved
in the decision-making at the Hart Building. Instead, because the Hart
Building is one of many congressional offices surrounding the U.S.
Capitol, the Attending Physician for the U.S. Congress--who functions
independently from the District of Columbia--provided advice and made
decisions about how to deal with the contamination there.[Footnote 12]
The incident at the Hart Building was immediately viewed as high risk
to employees there because the envelope opened in Senator Daschle's
office contained a visible white powder that the accompanying letter
identified as anthrax, which was quickly confirmed by testing of the
substance. Consequently, the Office of the Attending Physician of the
U.S. Congress arranged for congressional employees to receive
antibiotics immediately and advised closure of the Hart Building the
following day.
Since 2001, the Postal Service has developed new guidance to address
security risks in the mail. Its Interim Guidelines for Sampling,
Analysis, Decontamination, and Disposal of Anthrax for U.S. Postal
Service Facilities--first issued in November 2001--states that postal
facilities will be closed if a confirmed case of inhalation anthrax is
identified or when evidence suggests that anthrax has been aerosolized
in a postal facility. The Postal Service said that it plans to complete
an update to these guidelines soon, and we plan to determine whether
the new guidelines will adequately address the situation that occurred
at Brentwood as part of our ongoing work. In addition, the Postal
Service has tested and begun to install new biodetection technology in
postal facilities. This technology is designed to enhance safety by
quickly identifying unobservable evidence of aerosolized anthrax,
thereby allowing for a prompt response. We plan to review the guidance
associated with this technology as we complete our work.
Communication Problems Exacerbated Postal Service Employees' Concerns:
The Postal Service communicated health risk and other information to
its Brentwood employees during the anthrax crisis, but some of the
information it initially provided changed as public health knowledge
evolved, intensifying employees' concerns about whether adequate
measures were being taken to protect them. Most significantly,
information on the amount of anthrax necessary to cause inhalation
anthrax and the likelihood of postal employees' contracting the disease
turned out to be incorrect. Other factors, including difficulties in
communicating the uncertainty associated with health recommendations
and employees' long-standing distrust of postal managers, also
challenged efforts to communicate effectively. The Postal Service has
made additional efforts to communicate with Brentwood employees since
the facility's closure, but challenges remain, particularly the need to
effectively communicate information on any possible residual risks.
Some Information Communicated to Postal Employees Changed:
The Postal Service used a wide variety of methods to communicate
information to employees;[Footnote 13] however, some of the information
it initially provided changed with changes in public health knowledge.
For example, on the basis of the science at that time, the Postal
Service and CDC initially informed employees that an individual would
need to be exposed to 8,000 to 10,000 spores to contract inhalation
anthrax. This view turned out to be incorrect when two women in New
York and Connecticut died from inhalation anthrax in October and
November 2001 without a trace of anthrax spores being found in their
environments. Their deaths caused experts to conclude that the number
of spores needed to cause the disease could be very small, depending on
a person's health status and the aerosolization capacity of the spores.
Postal employees were also told that they were at little risk of
contracting inhalation anthrax because, in the view of public health
officials, anthrax was not likely to escape from a taped and well-
sealed envelope in sufficient amounts to cause inhalation anthrax. In
addition, on October 12, 2001, CDC issued a health advisory, which the
Postal Service distributed to its employees, indicating that it is very
difficult to refine anthrax into particles small enough to permit
aerosolization. This information also proved to be incorrect when the
U.S. Army Medical Research Institute of Infectious Diseases' analyses
of the anthrax in Senator Daschle's letter in mid-October 2001 revealed
that the substance was not only small enough to escape from the pores
of a taped and well-sealed envelope but also highly refined and easily
dispersed into the air.[Footnote 14]
Finally, an error occurred on October 10, when the Postal Service
instructed employees to pick up suspicious letters and isolate them in
sealed containers. The message was corrected within a few days when
employees were instructed not to touch suspicious letters.
Nevertheless, Brentwood employees we spoke with cited the
miscommunication as an indication that the Postal Service was not
concerned about their safety. As a result of these and other issues,
union and management officials report lingering bitterness between
Brentwood employees and postal management.
Communicating Information Proved Challenging:
Communicating information proved challenging for several reasons.
First, the incidents occurred in the turbulent period following the
terrorist attacks of September 11, 2001, when the nation was focused on
the response to those events. In addition, the anthrax incidents were
unprecedented. The response was coordinated by the Department of Health
and Human Services, primarily through CDC, and CDC had never responded
simultaneously to multiple disease outbreaks caused by the intentional
release of an infectious agent. Furthermore, when the incidents began,
CDC did not have a nationwide list of outside experts on anthrax, and
it had not yet compiled all of the relevant scientific literature.
Consequently, CDC had to do time-consuming research to gather
background information about the disease before it could develop and
issue guidance. Moreover, since anthrax was virtually unknown in
clinical practice, 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 health-related
actions and recommendations on information that was constantly
changing. According to the testimony of CDC's Associate Director for
Science, National Institute for Occupational Safety and Health, before
a Subcommittee of this Committee last year, CDC "clearly did not know
what we did not know last October [2001] and this is the cardinal sin
that resulted in tragic deaths.":
Effective communications were further complicated by the evolving
nature of the incidents and the media's extensive coverage of the
response to anthrax at other localities. Comparing the various actions
taken by officials at different points in time and in different
locations confused postal employees and the public and caused them to
question the consistency and fairness of actions being taken to protect
them. For example, when employees at the Brentwood postal facility
received doxycycline for prophylaxis instead of ciprofloxacin, they
incorrectly concluded that they were receiving an inferior drug. In
part, this was because the media had characterized ciprofloxacin as the
drug of choice for the prevention of inhalation anthrax. Ciprofloxacin
also had been used as the primary medication in earlier responses,
including the response to anthrax atthe Hart Building. CDC initially
recommended ciprofloxacin for several reasons;[Footnote 15] however,
when CDC subsequently determined that the anthrax was equally
susceptible to doxycycline and other drugs, it began:
recommending the use of doxycycline instead.[Footnote 16] The switch to
doxycycline was considered desirable for a variety of reasons,
including its (1) lower risk for side effects, (2) lower cost, and (3)
greater availability. Local and CDC officials we spoke with told us
that they were challenged to explain the switch in medications and to
address perceptions of differential treatment.
Additional misunderstandings arose over the administration of nasal
swabs to postal employees. Nasal swabs are samples taken from the nasal
passages soon after a possible exposure to contamination to determine
the location and extent of exposure at a site, but not to diagnose
infection. Nasal swabs were administered to congressional employees on
October 15 after the contaminated letter was opened to determine which
employees might have been exposed and based on this where and how far
the aerosolized anthrax spores had spread. Some Brentwood employees
questioned why they did not also receive nasal swabs at this time and
saw this difference as evidence of disparate medical treatment. As
noted, the Postal Service reported requesting nasal swabs for its
employees, but the CDC and the D.C. Department did not consider them
necessary. Nasal swabs were then provided to at least some employees
after Brentwood was closed on October 21. However, further confusion
appears to have occurred about the purpose of the nasal swabs when
employees who were tested did not receive the results of the swabs. The
confusion occurred partly because the Postal Service issued a bulletin
dated October 11, 2001, that incorrectly indicated that nasal swabs
were useful in diagnosing anthrax and the media described nasal swabs
as the "test" for anthrax. The bulletin was subsequently corrected, but
the media continued to refer to the swabs as a test. Public health
officials acknowledged that this confusion about the purpose of the
nasal swabs created a great deal of anxiety within the postal community
and the public. As a result, public health entities continued to
collect the samples when people asked for them, simply to allay the
individuals' fears.
Another area of confusion relates to the process used to administer the
anthrax vaccine to interested postal employees. When the vaccine used
by the military became available in sufficient quantities that it could
be provided to others, CDC offered it to postal employees and
congressional staff. While considered safe, it had not been approved
for use in postexposure situations. Consequently, the Food and Drug
Administration required CDC to administer the vaccine using extensive
protocols related to the distribution of an "investigational new drug."
These protocols required postal employees to complete additional
paperwork and undergo additional monitoring which, according to some
Brentwood employees, gave some employees the impression that they were
being used as "guinea pigs" for an unsafe treatment. CDC officials
acknowledged that CDC did not effectively communicate information about
the vaccine program and that, in hindsight, these deficiencies probably
resulted in the "wrong perception.":
CDC officials have also acknowledged that they were unsuccessful in
clearly communicating the degree of uncertainty associated with the
health information they were providing, which was evolving during the
incidents. For example, although there were internal disagreements
within CDC over the appropriate length of prophylaxis, this uncertainty
was not effectively conveyed to postal employees and the public.
Consequently, in December 2001, when postal employees and others were
finishing their 60-day antimicrobial regimen called for in CDC's
initial guidance, they questioned CDC's advice about the need to
consider taking the drugs for an additional 40 days. CDC officials have
since acknowledged the need to clearly state when uncertainty exists
about the information distributed to the public and appropriately
caveating the agency's statements.
Long-Standing Labor Relations Issues Compounded Communication Issues:
CDC, local public health officials, union representatives, and postal
officials told us that employees' mistrust of postal managers
complicated efforts to communicate information to them. According to
these parties, postal employees were often suspicious of management's
motives and routinely scrutinized information they received for
evidence of any ulterior motives. This view appears consistent with the
results of our past work, which has identified persistent workplace
problems exacerbated by decades of adversarial labor-management
problems. These problems were so serious that in 2001, we reported that
long-standing and adversarial labor-management relations affected the
Postal Service's management challenges.[Footnote 17] The need to
address this long-standing issue was also raised in the July 2003
report of the President's Commission on the U. S. Postal
Service.[Footnote 18]
The Postal Service Has Made Additional Efforts to Improve Communication
with Employees, but Challenges Remain:
According to postal managers, the Postal Service has made additional
efforts to communicate with the employees who were at Brentwood,
including holding "town hall" meetings to explain the facility's
decontamination process to postal employees and the public. The Postal
Service has reported that it is also updating its 1999 guidance for
responding to anthrax and other hazardous materials. At present,
however, the revision of the guidance has not yet been completed and it
is, therefore, unclear whether the revisions will address the issues
that occurred at Brentwood. Nevertheless, the Postal Service assisted
the National Response Team--a group of 16 federal agencies with
responsibility for planning, preparing, and responding to activities
related to the release of hazardous substances--in the development of
improved guidance entitled Technical Assistance for Anthrax Response.
This guidance provides a number of recommendations about communicating
information during emergency situations, including the need for
agencies to "admit when you have made a mistake or do not know the
information.":
While information on the process and outcome of decontamination efforts
is technically complex and therefore challenging to present clearly to
the public, the revised guidelines may be helpful in future discussions
about the safety of a facility. We have not reviewed the details of the
facility's decontamination or its subsequent testing and, therefore,
cannot comment on the effectiveness of decontamination efforts.
However, in general, discussions about the success of decontamination
and any residual risk to individuals center on two related topics. The
first topic entails a discussion of the degree to which contamination
has been reduced, bearing in mind that all sampling and analytical
methods have a limit of detection below which spores may be present but
undetected. Against that backdrop, it is also important to discuss how
many anthrax spores are required to infect humans and to explain that
the number is variable, depending upon the route of infection (e.g.,
skin contact or inhalation) and the susceptibility of each individual
to infection. In light of this, it is particularly important to
properly communicate to Brentwood employees a clear understanding of
the decontamination approach that was undertaken at the facility and
the nature and extent of any residual risk there. Likewise, the Postal
Service's communications to employees must be clear and unbiased to (1)
clearly communicate the limitations of testing and the associated risks
while, at the same time, (2) avoid inducing unnecessary fear or
concern. If provided with clear and unbiased information, employees
will be able to make informed decisions about their health and future
employment. In this regard, the Postal Service has given employees who
worked at Brentwood an opportunity to be reassigned to certain other
mail processing centers in the region if they do not want to return to
Brentwood.
In our view, providing complete information to employees is important
for them to make informed decisions about working at Brentwood.
According to recent information that the Postal Service provided to its
employees, the facility, which public health authorities have certified
as safe for occupancy, is "100 percent free of anthrax contamination"
and there is "no remaining health risk" at the facility. This latter
information is not consistent with what CDC's Associate Director for
Science, National Institute for Occupational Safety and Health, told
this Committee's Subcommittee on the District of Columbia in July 2002.
Specifically, she said that while a science-based process can allow
workers to safely return to Brentwood, it is not possible to eliminate
risk entirely or to guarantee that a building is absolutely free of
risk. We discussed our concerns with Postal Service officials about
their characterization of the facility as completely free of anthrax
contamination, and they agreed to revise their statements to indicate
that it is not possible to guarantee that a building is absolutely risk
free. According to the Postal Service, a misunderstanding resulted in
the incorrect information being distributed to employees before the
document had been fully reviewed. The Postal Service said that it would
correct the information and distribute the new information to employees
who worked at Brentwood within the next 2 weeks.
Lessons Learned and Implications for Reopening the Facility:
The Postal Service, CDC, and others have learned a great deal from the
2001 anthrax incidents and have taken various steps to address the
problems that occurred and to enhance their preparedness for any future
incidents. Among the lessons learned are that the risk to employees of
contracting anthrax through contaminated mail is greater than was
previously believed and more caution is needed to respond to that
greater risk. It is now clear, for example, that anthrax spores can be
released in the air, or aerosolized, when sealed letters pass through
the Postal Service's processing equipment and that a limited number of
anthrax spores can cause inhalation anthrax in susceptible individuals.
This increased risk of contracting inhalation anthrax indicates that
decisions about closing facilities need to consider other factors as
well as the presence of an observable substance, such as a powder. The
Postal Service and CDC have responded to this need for greater caution
by developing guidance for closing a facility that establishes evidence
of aerosolization, as well as confirmation of a diagnosis of inhalation
anthrax, as a criterion for closure. We have not yet evaluated this
guidance to determine whether it is specific enough to make clear the
circumstances under which a postal facility should be closed to
adequately protect employees and the public. We recognize that
developing such guidance is difficult, given that the Postal Service
experiences many hoaxes and needs to accomplish its mission as well as
ensure adequate protection of its employees' health.
Another important lesson learned during the 2001 anthrax incidents is
that clear and accurate communication is critical to managing the
response to an incident. Because the risk information that was provided
to employees changed over time and some of the information was
communicated in ways that employees reportedly found confusing or
difficult to understand, the fears that would naturally accompany a
bioterrorism incident were intensified and distrust of management,
which already existed in the workplace, was exacerbated. CDC, in
particular, has recognized the importance of communicating the
uncertainty associated with scientific information to preserve
credibility in the event that new findings change what was previously
understood. In this regard, our work on the sampling and analytical
methodologies used to test for and identify anthrax contamination
addresses the uncertainty involved in these efforts. The Postal Service
agrees that although the Brentwood facility has been tested and
certified as safe for occupancy, the Postal Service cannot assert that
the building is 100 percent free of anthrax contamination. Accordingly,
the Postal Service stated that it would inform Brentwood employees
before opening the facility that the Postal Service cannot guarantee
that the building is absolutely risk free.
This concludes my prepared statement. I will be happy to respond to any
questions you or other members of the Committee may have.
Contacts and Acknowledgments:
Should you or your staff have any questions concerning this report,
please contact me at (202) 512-2834 or Keith Rhodes at (202) 512-6412.
I can also be reached by e-mail at ungarb@gao.gov. Individuals making
key contributions to this testimony were Don Allison, Hazel Bailey,
Jeannie Bryant, Derrick Collins, Dwayne Curry, Elizabeth Eisenstadt,
and Kathleen Turner. Drs. Jack Melling and Sushil Sharma provided
technical expertise.
[End of section]
Appendix I: Time Line of Selected Events Related to the Anthrax Incident
in the Fall of 2001:
[End of section]
Date: Tuesday, 9/11/01; Events Occurring on That Date: Terrorist
attacks on the World Trade Center and Pentagon prompt heightened
concerns about possible bioterrorism.
Date: Tuesday, 10/02/01; Events Occurring on That Date: In Florida, an
American Media Inc. (AMI) employee is admitted to the hospital with a
respiratory condition; The Centers for Disease Control and Prevention
(CDC) issues an alert about bioterrorism, providing information about
preventive measures for anthrax.
Date: Thursday, 10/04/01; Events Occurring on That Date: CDC and the
Florida Department of Health announce that AMI employee has inhalation
anthrax.
Date: Friday, 10/05/01; Events Occurring on That Date: AMI employee
dies of inhalation anthrax.
Date: Monday, 10/08/01; Events Occurring on That Date: The Postmaster
General announces that Postal Inspection Service is working with other
law enforcement agencies on the Florida incident.
Date: Wednesday, 10/10/01; Events Occurring on That Date: The Postal
Service 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: In NY, the New
York City Department of Health (NYCDOH) announces the confirmation of a
case of cutaneous anthrax in an NBC employee; The Postal Service says
that it will offer gloves and masks to all employees who handle mail;
(On or about) Daschle letter passes through Brentwood; Boca Raton post
office, which had direct access to the AMI mail, is tested for anthrax
and Palm Beach County Department of Health administers nasal swabs and
offers a 15-day supply of ciprofloxacin to postal employees.
Date: Monday, 10/15/01; Events Occurring on That Date: On Capitol
Hill, an employee opens a letter addressed to Senator Daschle. Staff in
that office, an adjacent office, and first responders are given nasal
swabs and a 3-day supply of antibiotics; In NJ, State Department of
Health and Senior Services (NJDHSS) assures Trenton employees that they
have a low risk of contracting anthrax; Anthrax is confirmed at Boca
Raton post office.
Date: Tuesday, 10/16/01; Events Occurring on That Date: Part of the
Hart Senate Office Building is closed in the morning, and the remainder
of the building is closed in the evening. Over the next 3 days, all
Hart building and other Capitol Hill employees who request them are
given nasal swabs and a 3-day supply of antibiotics.
Date: Wednesday, 10/17/01; Events Occurring on That Date: The Postal
Service arranges for environmental testing at Brentwood.
Date: Thursday, 10/18/01; Events Occurring on That Date: A local
hazardous materials response team conducts "quick tests" of Brentwood,
which are negative for anthrax. A contractor conducts more extensive
testing in the evening; Postmaster General Potter holds a press
conference at Brentwood, in part to reassure employees they are at low
risk; CDC confirms cutaneous anthrax in New Jersey postal employee,
and a second suspected case is identified; In NJ, the Trenton facility
is closed. Employees are sent home; In NY, NYCDOH announces another
case of cutaneous anthrax, in a CBS employee; In Florida, the Postal
Service cleans two postal facilities contaminated with anthrax spores;
CDC distributes a press release announcing that the Food and Drug
Administration has approved doxycycline for postexposure prophylaxis
for anthrax; In the DC, a postal employee who works at the Brentwood
facility seeks medical attention.
Date: Friday, 10/19/01; Events Occurring on That Date: In NJ, the
NJDHSS refers postal employees to their private physicians for medical
treatment. Employees begin seeking treatment at a local hospital; In
DC, a postal employee who works at Brentwood is admitted to a hospital
with suspected inhalation anthrax; In NJ, laboratory testing confirms
cutaneous anthrax in a second postal employee who works at the Trenton
postal facility.
Date: Saturday, 10/20/01; Events Occurring on That Date: In DC,
another postal employee who works at the Brentwood facility is admitted
to a hospital with a respiratory condition; CDC arrives at the
Brentwood facility to meet with Postal Service management.
Date: Sunday, 10/21/01; Events Occurring on That Date: In DC, the
postal employee who was admitted to the hospital on 10/19/01 is
confirmed to have inhalation anthrax; In DC, Brentwood is closed.
Evaluation and prophylaxis of employees begin; In DC, a Brentwood
employee who had initially sought medical attention on 10/18/01 is
admitted to a hospital with suspected inhalation anthrax and becomes
the first postal employee (and second anthrax victim) to die; In DC,
another postal employee who worked at the Brentwood 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: In DC, the
postal employee who worked at the Brentwood facility and who sought
medical attention on 10/21/01 and was discharged is readmitted to the
hospital with suspected inhalation anthrax, and becomes the second
postal employee (and third anthrax victim) to die; In DC, prophylaxis
is expanded to include all employees and visitors to nonpublic areas at
the Brentwood facility; The postal employee who was admitted to the
hospital on October 20 is confirmed to have inhalation anthrax; The
Postal Service learns that environmental tests of Brentwood are
positive for anthrax.
Date: Sunday, 10/28/01; Events Occurring on That Date: In NJ, a postal
employee at Trenton is confirmed to have inhalation anthrax.
Date: Monday, 10/29/01; Events Occurring on That Date: In NY,
preliminary tests indicate anthrax in a hospital employee who was
admitted with suspected inhalation 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 Trenton 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
inhalation anthrax, in a Trenton postal 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: In NY, the
hospital employee becomes the fourth anthrax victim to die.
Date: Friday, 11/2/01; Events Occurring on That Date: In NY, NYCDOH
announces another case of cutaneous anthrax, in a New York Post
employee.
Date: Wednesday, 11/21/01; Events Occurring on That Date: In
Connecticut, an elderly woman, who was admitted to the hospital for
dehydration on 11/16/01, becomes the fifth anthrax victim to die; The
Connecticut Department of Public Health, in consultation with CDC,
begins prophylaxis for postal employees working in the Wallingford
postal facility.
Date: Friday, 12/27/01; Events Occurring on That Date: CDC offers the
anthrax vaccine to postal employees.
Source: Information provided by U.S. Postal Service, Centers for
Disease Control and Prevention, Connecticut Department of Public
Health, D.C. Department of Health, Food and Drug Administration,
Florida Department of Health, New Jersey Department of Health and
Senior Services, New York City Department of Health, and Office of the
Attending Physician of the U.S. Congress.
[End of table]
FOOTNOTES
[1] Technically, the term "anthrax" refers to the disease caused by
Bacillus anthracis and not the bacterium or its spores. In this report,
we use the term "anthrax" for ease of reading and to reflect
terminology commonly used in the media and by the general public.
[2] In this report, we refer to the facility as Brentwood.
[3] 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).
[4] 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).
[5] U.S. General Accounting Office, Bioterrorism: Public Health
Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.:
Oct. 15, 2003).
[6] Cutaneous means of, relating, to or affecting the skin. Cutaneous
anthrax is characterized by lesions on the skin.
[7] The third form of anthrax infection is gastrointestinal, which
results from ingesting undercooked contaminated meat.
[8] An antimicrobial medication either kills or slows the growth of
microbes. Antibiotics are an example of antimicrobial medications.
[9] Journal of American Medical Association, Anthrax as a Biological
Weapon: Medical and Public Health Management, May 12, 1999. Volume 281,
No. 18.
[10] Cross contamination occurs when other pieces of mail or equipment
come in contact with the original source of the anthrax.
[11] The letter addressed to Senator Leahy was never delivered.
Instead, it was recovered in November 2001 in mail that had been
quarantined on Capitol Hill on October 17, 2001.
[12] The Office of the Attending Physician, U.S. Congress, is an office
of the U.S. Navy. It serves as the local health department for Capitol
Hill and is responsible for about 30,000 public officials and other
congressional staff, as well as tourists, on Capitol Hill.
[13] Methods for communicating information included briefings,
newsletters, fact sheets, videos played on closed circuit televisions
in its facilities, and a toll-free information line. In addition, the
Postal Service regularly updated its Web site and, after the facility
closed, it mailed information to its employees' homes.
[14] According to the Postal Service, it learned the results of the
Army's analysis after the Brentwood closure.
[15] The first reason for recommending ciprofloxacin was that, absent
information about the strain's susceptibility to various drugs, CDC
considered it most likely to be effective against any naturally
occurring strain of anthrax. Also, as the newest antimicrobial
available, CDC considered it less likely that terrorists would have had
time to engineer a resistant strain of anthrax. Finally, the Food and
Drug Administration had already approved ciprofloxacin for the
postexposure prophylaxis for inhalation anthrax.
[16] The recommendation to use doxycycline also followed the Food and
Drug Administration's approval of the drug for inhalation anthrax.
[17] U.S. General Accounting Office, Major Management Challenges and
Program Risks: U.S. Postal Service, GAO-01-262 (Washington, D.C.: Jan.
2001).
[18] Report of the President's Commission on the United States Postal
Service, Embracing the Future: Making the Tough Choices to Preserve
Universal Mail Service, July 31, 2003.
