U.S. Postal Service
Better Guidance Is Needed to Improve Communication Should Anthrax Contamination Occur in the Future Gao ID: GAO-03-316 April 7, 2003In 2001, letters contaminated with anthrax resulted in 23 cases of the disease, 5 deaths, and the contamination of numerous U.S. Postal Service facilities, including the Southern Connecticut Processing and Distribution Center in Wallingford, Connecticut (the Wallingford facility). GAO was asked to address, among other matters, whether (1) the Postal Service followed applicable guidelines and requirements for informing employees at the facility about the contamination and (2) lessons can be learned from the response to the facility's contamination.
The Wallingford facility first tested positive for anthrax in early December 2001. The contamination was found in samples collected from four mail-sorting machines in November. Analyses of the samples produced quantified results, including about 3 million anthrax colonies, or living anthrax cells, in one of the samples. While this was far more than the amount needed to cause death, none of the employees at the facility became sick from the anthrax contamination. The Postal Service's decision not to inform workers about the number of anthrax colonies identified in December 2001 appears consistent with its guidelines because, according to the Service, it could not validate the results, as required. However, its subsequent decision not to release the results after an employee union requested all the facility's test results in January and February 2002, was not consistent with the Occupational Safety and Health Administration's (OSHA) requirement for disclosing test results that are requested. An OSHA investigation resulted in the Service's release of the quantitative test results in September 2002--about 9 months after the results were first known. Although OSHA did not issue a regulatory citation, it expressed concern about communication deficiencies. In retrospect, the Service's decision not to release the quantitative test results in December 2001 was understandable given the challenging circumstances that existed at the time, the advice it received from public health officials, an ongoing criminal investigation, and uncertainties about the sampling methods used. However, numerous lessons can be learned from the experience, such as the need for more complete and timely information to workers to maintain trust and credibility and to help ensure that workers have essential information for making informed health decisions. Federal guidelines developed in 2002 by GSA and the National Response Team suggest that more--rather than less--information should be disclosed. However, neither the Service's guidelines nor the more recent federal guidelines fully address the communication-related issues that developed in Wallingford. For example, none of the guidelines specifically require the full disclosure of quantified test results. Likewise, OSHA's regulations do not require employers to disclose test results to workers unless requested, which assumes that workers are aware of the test results and know about this requirement.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-316, U.S. Postal Service: Better Guidance Is Needed to Improve Communication Should Anthrax Contamination Occur in the Future
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Report to the Ranking Minority Member Committee on Governmental Affairs
U.S. Senate:
United States General Accounting Office:
GAO:
April 2003:
U.S. Postal Service:
Better Guidance Is Needed to Improve Communication Should Anthrax
Contamination Occur in the Future:
GAO-03-316:
GAO Highlights:
Highlights of GAO-03-316, a report to the Ranking Minority Member,
Committee on Governmental Affairs, U.S. Senate
Why GAO Did This Study:
In 2001, letters contaminated with anthrax resulted in 23 cases of the
disease, 5 deaths, and the contamination of numerous U.S. Postal
Service facilities, including the Southern Connecticut Processing and
Distribution Center in Wallingford, Connecticut (the Wallingford
facility). GAO was asked to address, among other matters, whether (1)
the Postal Service followed applicable guidelines and requirements for
informing employees at the facility about the contamination and (2)
lessons can be learned from the response to the facility‘s
contamination.
What GAO Found:
The Wallingford facility first tested positive for anthrax in early
December 2001. The contamination was found in samples collected from
four mail-sorting machines in November. Analyses of the samples
produced quantified results, including about 3 million anthrax
colonies, or living anthrax cells, in one of the samples. While this
was far more than the amount needed to cause death, none of the
employees at the facility became sick from the anthrax contamination.
The Postal Service‘s decision not to inform workers about the number of
anthrax colonies identified in December 2001 appears consistent with
its guidelines because, according to the Service, it could not validate
the results, as required. However, its subsequent decision not to
release the results after an employee union requested all the
facility‘s test results in January and February 2002, was not
consistent with OSHA‘s requirement for disclosing test results that are
requested. An OSHA investigation resulted in the Service‘s release of
the quantitative test results in September 2002”about 9 months after
the results were first known. Although OSHA did not issue a regulatory
citation, it expressed concern about communication deficiencies.
In retrospect, the Service‘s decision not to release the quantitative
test results in December 2001 was understandable given the challenging
circumstances that existed at the time, the advice it received from
public health officials, an ongoing criminal investigation, and
uncertainties about the sampling methods used. However, numerous
lessons can be learned from the experience, such as the need for more
complete and timely information to workers to maintain trust and
credibility and to help ensure that workers have essential information
for making informed health decisions. Federal guidelines developed in
2002 by GSA and the National Response Team suggest that more”rather
than less”information should be disclosed. However, neither the
Service‘s guidelines nor the more recent federal guidelines fully
address the communication-related issues that developed in Wallingford.
For example, none of the guidelines specifically require the full
disclosure of quantified test results. Likewise, OSHA‘s regulations do
not require employers to disclose test results to workers unless
requested, which assumes that workers are aware of the test results and
know about this requirement.
What GAO Recommends:
To help prevent a reoccurrence of communication problems, GAO
recommends that the Postal Service, OSHA, GSA, and the National
Response Team”a group chaired by the Administrator of EPA and
comprising 16 federal agencies with responsibilities for planning,
preparing, and responding to activities related to the release of
hazardous substances”work together to revise their existing guidelines
or regulations to, among other things, require prompt communication of
available test results, including quantitative results, to workers and
others, as applicable. The Service, EPA, and GSA generally agreed with
our recommendations, indicating that they would work together to revise
their guidelines. OSHA did not comment on our recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-316
To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Bernard L. Ungar, (202) 512-2834,
ungarb@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Anthrax Contamination Was First Identified at Wallingford in December
2001 after an Extensive Multiagency Investigation:
Quantitative Test Results Were Provided to Workers in April 2002--but
Not in December 2001:
Disclosure of Anthrax Test Results:
Lessons Learned at the Wallingford Facility Suggest the Need for More
Complete and Timely Information to Workers:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Summary of Anthrax Testing at the Wallingford
Facility between November 2001 and April 2002:
Appendix III: Comments from the Environmental Protection Agency:
Appendix IV: Comments from the U.S. Postal Service:
Appendix V: Comments from the American Postal Workers Union:
Table:
Table 1: Summary of Sampling for Anthrax Contamination between November
2001 and April 2002 and the Associated Test Results:
Abbreviations:
CDC: Centers for Disease Control and Prevention
EPA: Environmental Protection Agency
FBI: Federal Bureau of Investigation
GSA: General Services Administration
HEPA: High Efficiency Particulate Air
HHS: Department of Health and Human Services
OSHA: Occupational Safety and Health Administration:
This is a work of the U.S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce
copyrighted materials separately from GAO‘s product.
[End of section]
United States General Accounting Office:
Washington, DC 20548:
April 7, 2003
The Honorable Joseph I. Lieberman
Ranking Minority Member
Committee on Governmental Affairs
United States Senate:
Dear Senator Lieberman:
In September and October 2001, letters containing anthrax spores were
mailed to news media personnel and congressional officials, leading to
the first bioterrorism-related cases of anthrax in the United
States.[Footnote 1] The contaminated letters caused 23 illnesses and
resulted in 5 deaths from inhalation anthrax and the contamination of
numerous postal facilities. The U.S. Postal Service initially responded
to this crisis by collecting and testing samples from over 280 of its
facilities, including the Southern Connecticut Processing and
Distribution Center in Wallingford, Connecticut (the Wallingford
facility). The facility was first tested on November 11, 2001, and no
contamination was found.
In late November 2001, the death of a Connecticut woman--1 of the 5
people who died--spurred an extensive investigation by a multiagency
team to determine, among other things, how she had been exposed to
anthrax. Believing that the woman may have died from exposure to mail
that had been contaminated as it passed through the Wallingford
facility, federal and state investigators conducted more extensive
testing of the facility. Facility workers received antibiotics on
November 21, 2001--the day that the elderly woman died. The antibiotics
were provided as a precautionary measure, since the Postal Service‘s
earlier testing of the facility had not identified any contamination.
At about the same time, the Postal Service also initiated a medical
surveillance program to monitor the health of the facility‘s employees.
The investigative team sampled the facility on numerous occasions
between November and December 2001 and, in early December, identified
anthrax on four mail-sorting machines. Anthrax also was identified in
areas above the mail-sorting machines in April 2002.[Footnote 2] On
both occasions, the affected areas were decontaminated, while mail
processing continued in other areas of the facility.
Perhaps because the facility‘s workers had been provided with
antibiotics, none of the employees at the Wallingford facility became
sick from anthrax. However, you requested that we review the Postal
Service‘s disclosure of anthrax test results to the facility‘s workers.
As agreed, in this report, we address (1) how and when contamination
was identified at the Wallingford facility, (2) what and when
information was communicated to facility workers, (3) whether the
Postal Service followed applicable guidelines and requirements for
informing facility workers about the contamination, and (4) whether
lessons can be learned from the response to contamination at the
facility. As agreed, our future work will compare the treatment of
postal workers at the Wallingford facility with the treatment of
employees at other postal facilities contaminated with anthrax in the
fall of 2001.
To address our reporting objectives, we interviewed federal and state
officials involved in investigating and responding to anthrax
contamination at the Wallingford facility, including officials from the
Postal Service‘s headquarters office, its Connecticut district, and the
Wallingford facility; the Connecticut Department of Public Health; and
numerous federal agencies. We also interviewed representatives of
employees at the facility, including the national American Postal
Workers Union and its Greater Connecticut Area Local Union. We
discussed, among other matters, the officials‘ roles and involvement in
responding to the crisis and lessons that can be learned from the
response. We obtained and reviewed documentation related to the
sampling and testing of the facility, including laboratory test
results; information about when and how test results and associated
health risks were communicated to facility workers; the Postal
Service‘s guidelines for releasing and communicating test results; the
Occupational Safety and Health Administration‘s (OSHA) regulatory
requirements for disclosing test results to workers; more recent
federal guidelines developed in 2002 by the General Services
Administration (GSA) and the National Response Team--a group chaired by
the Administrator of the Environmental Protection Agency (EPA) and
comprising 16 federal agencies with responsibility for planning,
preparing, and responding to activities related to the release of
hazardous substance; and other documents related to the facility‘s
contamination. Additional information on our scope and methodology
appears in appendix I.
:
Results in Brief:
Following a series of negative test results in November 2001, the
Wallingford facility first tested positive for anthrax in early
December. The positive results were found in samples collected from
four mail-sorting machines on November 28, 2001. Subsequent analyses of
the samples identified two quantitative results, including about 3
million colony-forming units of anthrax in a sample collected from one
of the mail-sorting machines.[Footnote 3] This finding was far more
than the 8,000 to 10,000 spores considered harmful, at that time, if
inhaled in a fine powder form. Although district postal managers said
they received written confirmation of the test results from the Chief
Epidemiologist for the Connecticut Department of Public Health (Chief
Epidemiologist) on December 10, 2001, available documentation indicates
that Postal Service headquarters may have received the results 2 days
earlier. In April 2002, after the mail-sorting machines had been
decontaminated and returned to operation, anthrax was found in samples
collected from areas above the machines. Following both the December
2001 and April 2002 test results, the contaminated areas were isolated
and decontaminated and, thereafter, returned to operation.
On December 2, 2001--when anthrax contamination was first identified in
the facility--Postal Service managers and a physician under contract
with the Postal Service met with workers to inform them that ’trace“
amounts of anthrax had been found in samples collected on November 28.
Knowing that the laboratory initially identified a small number (1 or 2
colony-forming units) of anthrax spores, the Chief Epidemiologist--who
helped lead the investigation--told district postal managers that it
would be accurate to use the term ’trace“ to describe the extent of
contamination. On December 2, postal managers also relayed the Chief
Epidemiologist‘s health-related recommendations to the facility‘s
employees. For example, although the Chief Epidemiologist viewed the
health risk as ’minimal,“ workers were advised, as a precautionary
measure, to continue taking the antibiotics they received on November
21, 2001--the day that the Connecticut woman died from inhalation
anthrax. On December 12, 2001--2 days after district postal managers
said they received written confirmation of the presence of about 3
million spores in a sample collected on November 28 and, possibly, 4
days after headquarters postal managers received the results--postal
managers once again relayed the Chief Epidemiologist‘s views and
health-related recommendations to employees at the facility.
Specifically, district postal managers told us that they informed
workers that, while trace amounts of anthrax existed on three mail-
sorting machines, a ’concentration“ of spores had been identified in a
sample collected from a fourth machine. Although the extent of
contamination was much greater than initially believed, following the
assurances of the Chief Epidemiologist, postal managers said they
informed workers that there was ’no additional risk“ to employees
because all of the steps needed to protect them had already been taken.
In April 2002, the Postal Service provided employees with the actual
quantitative test results (1 to 18 colony-forming units) from the
samples collected in April from areas above the previously contaminated
mail-sorting machines.
Although the Postal Service‘s communication of anthrax test results
appears consistent with its guidelines, its decision not to provide the
December 2001 quantified results (i.e., the number of colony-forming
units found in the positive samples)--after being requested to do so by
an employee union--did not satisfy OSHA‘s disclosure requirements. The
Postal Service generally provided the facility‘s test results to
workers within 1 day of receiving the test results. Such timely
disclosure is consistent with the Postal Service‘s guidelines to notify
workers ’as soon as possible.“ However, for a period of 2 days,
district managers delayed informing the facility‘s workers about the
documented test results that the district postal managers received on
December 10, 2001. According to the Postal Service, the additional time
was needed to obtain advice from public health officials about the
meaning of the results, particularly the result indicating the presence
of about 3 million spores in a sample collected from one mail-sorting
machine. According to Postal Service managers, the December 2001
decision not to release the quantitative results--even after being
requested to do so by a union leader--was also consistent with the
Postal Service‘s guidelines because, according to the managers, the
Postal Service could not ensure that the sampling had been done in
accordance with procedures specified in its guidelines, and, thus, it
could not validate the results, as required by its guidelines. However,
the Postal Service‘s decision not to release the December 2001
quantitative test results after a union leader requested all of the
facility‘s test results on January 29, 2002, and February 6, 2002, was
not consistent with OSHA‘s regulations for disclosing test results that
are requested by workers or their designated representatives. OSHA‘s
regulations require employers to disclose test results within 15
working days of the request or explain the delay and provide the
requester with a time frame for releasing the results. OSHA‘s
subsequent investigation into this matter resulted in the Postal
Service‘s release of the December 2001 quantitative test results in
September 2002--more than 7 months after the union leader first
requested the results and about 9 months after the test results were
known by the Postal Service. OSHA did not cite the Postal Service for
not disclosing the quantitative test results earlier; however, in an
October 7, 2002, letter to the Postal Service, OSHA noted that a
’failure to effectively communicate issues which can have an effect on
a worker‘s health and safety, can lead to fear and mistrust.“:
While the Postal Service‘s decision not to release the quantitative
test results in December 2001 is understandable given all of the
circumstances that existed at the time, the lessons learned from this
experience suggest the need for more complete and timely information to
workers to maintain trust and credibility. Officials from OSHA and
members of the investigative team did not specifically fault the Postal
Service for not releasing the quantified results when they were first
known in December 2001. However, they said full and timely disclosure
of test results is the best method for communicating with employees and
others. Two federal guidelines developed in 2002 by GSA and the
National Response Team suggest that more--rather than less--information
should be disclosed. For example, GSA‘s guidelines emphasize the need
for ’timely, clear, consistent, and factual“ information, including any
limitations associated with the information, so that people can make
informed decisions. The other set of guidelines, developed by the
National Response Team, warns agencies not to withhold information
because it could affect the agency‘s credibility. However, neither the
Postal Service‘s guidance nor the more recent federal guidelines fully
address the anthrax communication-related issues that developed at the
Wallingford facility. For example, none of the guidelines specifically
require the full disclosure of all test results, including quantitative
test results. Likewise, OSHA‘s regulations for communicating test
results to workers do not address the need for full, immediate, and
proactive disclosure. We are making several recommendations to minimize
the likelihood that the communication-related problems at the
Wallingford facility will reoccur elsewhere.
The Postal Service, EPA, and GSA generally agreed with our findings and
recommendations and indicated that they would work together to revise
their respective guidelines. The union also agreed with our
recommendations to better coordinate communication between federal
agencies when events occur. However, the union said that our report did
not adequately reflect the union‘s perspective of the facts and that a
number of our conclusions were not supported by the facts. We disagree.
We believe that our conclusions are fully supported by the evidence
presented in this report and that the report presents a fair,
objective, and balanced depiction of the facts as best we could
determine them.
Background:
Anthrax is an acute infectious disease caused by the spore-forming
bacterium called Bacillus anthracis. Anthrax is found in the soil in
many parts of the world and forms spores (like seeds) that can remain
dormant in the environment for many years. Anthrax can infect humans;
however, the disease occurs most commonly in herbivores.[Footnote 4]
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: (1) cutaneous, usually through a cut or an
abrasion; [Footnote 5] (2) gastrointestinal, by ingesting undercooked
contaminated meat; and (3) inhalation, by breathing aerosolized anthrax
spores into the lungs. Aerosolization occurs when anthrax spores become
airborne, thus enabling a person to inhale the spores into the lungs.
Symptoms depend on how the disease is contracted and, on the basis of
experiences in the fall of 2001, are now thought by medical experts to
typically appear within 4 to 6 days of exposure, although individuals
have contracted the disease as long as 43 days after exposure. The
disease can be treated with a variety of antibiotics and is not
contagious.
Persons who come in contact with anthrax spores are described as having
been ’exposed.“ Depending on the extent of contamination and its form,
a person can be exposed without developing the disease. Anthrax spores
are dormant cells that can germinate and, if viable, replicate under
suitable environmental conditions, such as in the human body. A person
can die if the anthrax spores grow and the bacteria multiply and spread
throughout the body. There is a range of laboratory tests for detecting
anthrax in a person‘s body and in the environment. Laboratories report
anthrax test results either qualitatively (e.g., as ’positive“ or
’negative“) or quantitatively (e.g., as a specific number of colony-
forming units per gram or square inch of material sampled or in
milligrams per microliter).
Before the fall of 2001, outbreaks of inhalation anthrax in the United
States had been linked mainly to occupational exposure. However,
according to the Centers for Disease Control and Prevention (CDC),
there was a release of anthrax in 1979 from a military bioweapons
facility in Sverdlovsk in the Former Soviet Union. The release of
anthrax, which had been prepared in a powder form, reportedly caused
the death of 66 people and demonstrated the lethal potential of
aerosolized anthrax as a weapon.[Footnote 6]
Because so few instances of inhalation anthrax have occurred,
scientific understanding about the number of spores needed to cause the
disease is still evolving. According to the contract physician
responsible for providing medical advice to postal employees at the
Wallingford facility in the fall of 2001, her literature search
revealed that a person would need to inhale 8,000 to 10,000 spores to
contract the disease.[Footnote 7] However, given that anthrax spores
were never discovered in the Connecticut woman‘s home or places that
she frequented,[Footnote 8] experts we consulted 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.
The Postal Service‘s infrastructure includes, in part, its headquarters
office in Washington, D.C.; 8 area offices; the Capital Metro
Operations office; approximately 350 mail processing and distribution
centers, including the Wallingford facility; and about 38,000 post
offices, stations, and branches. The area offices are further divided
into 85 postal districts throughout the United States, including the
Connecticut district in Hartford, which oversees operations at the
Wallingford facility. The Wallingford facility is operated by a
facility manager and is under the jurisdiction of the District Manager
in Hartford.
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. Before being sent
to the Brentwood facility in Washington, D.C.--the facility that
processed mail to the Senators--the letters were processed on high-
speed mail-sorting machines at a postal facility in Hamilton, New
Jersey. The Hamilton facility--also known as the Trenton postal
facility--processed mail that was to be transported to Wallingford for
further processing.[Footnote 9]
The Wallingford facility covers about 350,000 square feet and has over
1,100 employees. The facility handles nearly 3 million pieces of mail
per day and operates 24 hours a day with employees who work one of
three 8-hour shifts. Two unions--the Greater Connecticut Area Local
American Postal Workers Union, in New Haven, Connecticut, and the Mail
Handlers Union in Boston, Massachusetts--represent workers at the
facility.
In October 2001, the Postal Service established a Unified Incident
Command Center (the Command Center) in Washington, D.C., to, among
other things, manage the Postal Service‘s response to anthrax
contamination in its facilities. The Command Center was staffed by
Postal Service employees and supported by several agencies, including
EPA; CDC; the U.S. Army Corps of Engineers; the U.S. Postal Inspection
Service; OSHA; and the Federal Bureau of Investigation (FBI).
On November 20, 2001, a team of representatives from state and federal
government agencies with responsibilities for law enforcement (the
Connecticut State Police and the FBI); environmental safety (the
Connecticut Department of Environmental Protection); public health (the
Connecticut Department of Public Health, local health departments, and
CDC); and the Postal Service was formed to investigate and formulate
the public health response to the case of the elderly woman who
contracted and subsequently died from inhalation anthrax. The Chief
Epidemiologist for the Connecticut Department of Public Health (Chief
Epidemiologist),[Footnote 10] an on-site CDC team leader, and a CDC
team leader in Atlanta, jointly led the on-site investigation team. The
team communicated with one another largely through twice-daily
confidential telephone conference calls during which information was
shared, possible actions were discussed, and decisions were made. Once
contamination was identified in the Wallingford facility, a facility-
specific response team was formed consisting of the National Institute
for Occupational Safety and Health, the Agency for Toxic Substances and
Disease Registry, and CDC--all within the Department of Health and
Human Services (HHS); the Corps of Engineers; the Postal Service; EPA;
and the Connecticut Department of Public Health. The team was led by
the Postal Service‘s Command Center. OSHA--an agency within the
Department of Labor that enforces safety and health standards in the
workplace--was not part of the response team.
The Postal Service requested and the investigative team agreed that the
Postal Service would be the sole party responsible for communicating
test results and other information to the workers at the facility. In
this regard, the physician under contract with the Postal Service
informed the facility‘s workers that, according to her research,
inhalation of 8,000 to 10,000 spores would likely be needed to cause
inhalation anthrax.
Anthrax Contamination Was First Identified at Wallingford in December
2001 after an Extensive Multiagency Investigation:
The Wallingford facility was tested on numerous occasions between
November 2001 and April 2002 (see table 1). The first sampling was
performed by a Postal Service contractor on November 11, 2001, as part
of the Postal Service‘s effort to identify facilities that may have
been contaminated with anthrax. The contractor collected 53 samples
using dry swabs.[Footnote 11] The laboratory found no contamination and
provided the negative results to Postal Service managers on November
14. A second Postal Service contractor sampled the facility on November
21, 2001--the day the Connecticut woman died. The 64 samples, collected
using dry swabs, tested negative, and the results were verbally
provided to Postal Service officials on November 23. (App. II
summarizes additional information about sampling at the facility,
including the dates of the samples, the agencies involved in the
sampling, the date and content of information provided to workers. This
appendix also provides information about decontamination activities at
the facility.):
Table 1: Table 1: Summary of Sampling for Anthrax Contamination between
November 2001 and April 2002 and the Associated Test Results:
Sampling date: 11/11/01; Type (Number of samples): Dry swabs (53);
Result: Negative; Agency that collected the samples[[A]]: Postal
Service.
Sampling date: 11/21/01; Type (Number of samples): Dry swabs (64);
Result: Negative; Agency that collected the samples[[A]]: Postal
Service.
Sampling date: 11/25/01; Type (Number of samples): Wet swabs (60);
Result: Negative; Agency that collected the samples[[A]]: CDC.
Sampling date: 11/28/01; Type (Number of samples): Wet wipes and HEPA
vacuums (212); Result: Positive; Agency that collected the
samples[[A]]: CDC.
Sampling date: 12/02/01; Type (Number of samples): Wet wipes (200);
Result: Positive; Agency that collected the samples[[A]]: CDC.
Sampling date: 4/21/02; Type (Number of samples): HEPA vacuums (101);
Result: Positive; Agency that collected the samples[[A]]: Postal
Service.
Sources: GAO (summary) and Postal Service and CDC (data).
Legend:
CDC - Centers for Disease Control and Prevention
HEPA - High Efficiency Particulate Air:
[A] The Postal Service used a contractor; CDC was assisted by the
Agency for Toxic Substances and Disease Registry.
[End of table]
Following confirmation on November 20, 2001, that the elderly
Connecticut woman had contracted inhalation anthrax, the multiagency
state and federal investigative team targeted mail as one possible
source of her exposure. Having found no contamination at the
Wallingford facility or at the woman‘s home and other places she
frequented in the 2 months preceding her death, CDC and the Agency for
Toxic Substances and Disease Registry resampled the facility on
November 25, 2001, using wet swabs--not dry swabs. These 60 samples
also tested negative. The laboratory informed the Chief Epidemiologist
of the results, and he, in turn, called district postal managers to
relay the results.
Determined to ascertain the role that mail may have played in the
woman‘s exposure to anthrax, on November 28, 2001, CDC and the Agency
for Toxic Substances and Disease Registry, with the full support of the
Postal Service, performed what officials termed a ’targeted“ and
’extensive“ sampling of the facility. The team collected 212 samples,
the majority of which were from machines that could have been used to
process mail to the deceased woman‘s home. The team also used different
collection methods than had been used earlier--that is, the team
collected samples using two methods: wet wipes and HEPA vacuums rather
than dry swabs or wet swabs alone.[Footnote 12] The use of these
sampling methods resulted in the identification of anthrax on 4 of the
facility‘s 13 mail-sorting machines.
The Chief Epidemiologist first knew the results of the November 28,
2001, sampling effort on December 2, when samples collected from three
of the mail-sorting machines tested ’positive“ for anthrax. Shortly
thereafter, a fourth machine--which also had been sampled on November
28, 2001--also tested positive for anthrax.[Footnote 13] The laboratory
analyzed the November 28, 2001, samples and provided two quantified
results. The results indicated that although all four of the machines
were contaminated, one of the machines was heavily contaminated.
Specifically, on the basis of the laboratory‘s quantified results, the
Chief Epidemiologist identified 2.9 million colony-forming units of
anthrax--about 3 million spores--in a sample of 0.55 grams of material
(dust) collected from the heavily contaminated machine.[Footnote 14] A
second sample identified 370 colony-forming units per gram of material
collected from another mail-sorting machine. The two samples were
collected using HEPA vacuums.[Footnote 15]
The laboratory e-mailed the quantitative results to CDC officials and
the Chief Epidemiologist on December 6. After subsequent discussions
with the laboratory concerning the results as well as related
discussions over the next few days with members of the investigative
and response teams, the Chief Epidemiologist faxed the results on
December 9 to the Postal Service‘s district Human Resource Manager,
who, according to the manager, received them on December 10. Precisely
when Postal Service headquarters and district managers first became
aware of the quantified test results is unclear. According to CDC
officials and the Chief Epidemiologist, they began discussing the
quantitative results with team members, which they believe included a
district postal manager, on December 6, 2001. However, district postal
managers said that they were not involved in discussions about the
quantitative results until December 9. District postal managers
confirmed that the Chief Epidemiologist faxed the quantitative results
to the district on December 9 (a Sunday) and that district postal
managers received the fax on December 10. However, a chronology of the
events prepared in January 2002 by Postal Service employees and shared
with CDC indicates that postal managers at headquarters may have
received the documented results on or about December 8, 2001. We
discussed the chronology with postal headquarters managers in March
2003 and they told us that, according to their recollections, there
were errors in the chronology that were not corrected. They also said
that they do not otherwise recall precisely when they received the
documented quantitative results. Absent definitive documentation of
when Postal Service headquarters received the test results and
documentation of the discussions between public health and postal
managers, we were unable to determine when Postal Service headquarters
managers first learned of the quantitative test results.
On December 9, 2001, the Chief Epidemiologist also relayed the results
of other samples collected at the facility. The samples were collected
on December 2--hours before the four contaminated mail-sorting machines
were to be enclosed and decontaminated--by CDC and the Agency for Toxic
Substances and Disease Registry. The 200 samples were collected using
wet wipes to establish the extent of contamination on the machines. The
results identified unspecified amounts of contamination (i.e.,
’positives“) on (1) 30 of 52 samples collected from the heavily
contaminated machine, (2) 3 of 52 samples from a second machine, and
(3) 1 of 48 samples from each of the two other mail-sorting machines.
A Postal Service contractor under the guidance of CDC and the Corps of
Engineers decontaminated the four mail-sorting machines. To test the
effectiveness of the decontamination, follow-up samples were collected
between December 7 and December 18, 2001. The laboratory informed the
Chief Epidemiologist of the negative results on December 20. The Chief
Epidemiologist relayed the results to district postal managers who,
shortly thereafter, returned the machines to operation. The facility
remained open throughout the period in part because, according to
public health officials, there was no evidence that the anthrax was
airborne, workers had already received antibiotics, no one had
contracted the disease, and action had already been taken to isolate
the contaminated machines from workers on December 2, 2001--the day
that anthrax contamination was first reported.[Footnote 16]
On April 21, 2002, a Postal Service contractor, in consultation with
CDC, OSHA, EPA, and the Connecticut Department of Public Health,
sampled areas above the previously contaminated machines using HEPA
vacuums. The sampling was performed because of a Postal Service
requirement for testing prior to the routine cleaning of elevated areas
in facilities that had previously tested positive for anthrax. The
effort was undertaken to protect workers from the possibility of
exposure to spores that may have blown into these areas as a result of
the Postal Service‘s prior use of compressed air to clean its
facilities. The laboratory relayed the results from the April 21
sampling effort to district postal managers on April 24. The results
revealed from 1 to 18 colony-forming units in 3 of 101 samples
collected from the elevated areas.[Footnote 17] The contaminated areas
were subsequently encapsulated and decontaminated. A Postal Service
contractor collected follow-up samples to test the effectiveness of the
decontamination between May 1 and June 3, 2002. The laboratory reported
negative results in all of the samples directly to district postal
managers on June 6 and, on June 7, the facility was returned to full
operation.[Footnote 18]
Quantitative Test Results Were Provided to Workers in April 2002--but
Not in December 2001:
The Postal Service typically provided nonquantitative (i.e., ’positive“
or ’negative“) results from samples collected between November 2001 and
April 2002 to employees on each of the facility‘s three work shifts.
The specific content of the information disclosed varied. The Postal
Service began communicating the results of the first samples--which
were collected on November 11, 2001--on November 15, the day after the
Postal Service received the negative results. The Facility Manager
informed supervisors and union officials of the results, and the
supervisors, in turn, informed employees at the facility. According to
a district manager, the test results also were posted on designated
bulletin boards at the facility. The Postal Service began relaying the
results of the November 21, 2001, sampling effort, which were also
negative, to employees in a briefing on November 23, the day that
district postal managers were notified of the results. On November 27,
the day that district managers received the results from the third
sampling done on November 25, 2001, the Facility Manager once again
began briefing employees about the negative results.
According to district postal managers, they began informing employees
about contamination at the facility on December 2, 2001, the same day
they learned that the facility was contaminated. The positive results
were identified from samples collected on November 28, 2001, and were
relayed to district postal managers in a telephone call from the Chief
Epidemiologist. The Chief Epidemiologist met with district postal
facility managers, union representatives, and a physician under
contract with the Postal Service on December 2, 2001, to discuss the
results. District postal managers told us that no documentation of the
meeting exists; however, according to several of the individuals
present, the Chief Epidemiologist described the extent of contamination
as ’trace“ amounts on three mail-sorting machines.[Footnote 19]
According to the Chief Epidemiologist, although the laboratory
initially reported only a positive finding, his subsequent discussions
with laboratory personnel indicated that the samples contained ’one or
two“ colony-forming units of anthrax. Thus, he said, he used the term
to denote a small amount of contamination. Also, he said, ’trace“
seemed appropriate given the number of sampling efforts undertaken
before any contamination was found in the facility.
According to officials present at the December 2, 2001, meeting, they
pressed the Chief Epidemiologist about any possible risk to workers at
the facility and were assured that for a variety of reasons, there was
no additional health risk. First, as a precautionary measure, workers
had been provided antibiotics on November 21, the day the Connecticut
woman died from inhalation anthrax. Second, even if workers had not
chosen to take the antibiotics, the results of the Postal Service‘s
medical surveillance program indicated that none of the facility‘s
workers had contracted the disease. Further, in the view of the Chief
Epidemiologist and CDC officials, workers were not expected to contract
the illness because the contamination was found weeks after what public
health officials considered the likely incubation period for the
disease.[Footnote 20] Third, the contaminated machines were being
isolated and decontamination was scheduled to begin the next day.
Fourth, there was no evidence that the anthrax was airborne because no
spores had been found in the facility‘s heating, ventilating, and air
conditioning systems. Finally, related to this last issue, the Chief
Epidemiologist told us that the likelihood of spores being blown within
the facility (becoming airborne) had been greatly reduced by the Postal
Service‘s decision on October 23, 2001, to stop using compressed air to
clean its facilities. Nevertheless, as a precautionary measure, the
Chief Epidemiologist recommended that the Postal Service advise
facility workers to continue taking antibiotics.
According to district postal managers, after their December 2, 2001,
meeting with the Chief Epidemiologist; the physician and postal
managers, including the Facility Manager, began briefing employees on
each of the facility‘s three shifts. The managers relayed the Chief
Epidemiologist‘s views that there was no additional health risk
associated with the test results. According to the managers, they also
informed workers about planned actions to remediate the
contamination.[Footnote 21]
As previously discussed, district postal managers recall being notified
of the quantitative test results on December 9, 2001, which is the date
they told us that the Chief Epidemiologist first called them to relay
the results of additional laboratory analyses that he and CDC had
received on December 6, 2001. The results were from the two samples
collected on November 28, 2001, including the sample involving 2.9
million colony-forming units per 0.55 grams of sample material (dust)
collected from one of the four contaminated mail-sorting machines. The
Chief Epidemiologist told us that he discussed the results with
laboratory personnel and, after these discussions, concluded that the
results revealed the presence of ’about 3 million spores.“ According to
district postal managers, the test results were discussed at length in
teleconferences between them, the Chief Epidemiologist, and other
members of the investigation team on December 9 and 10. District postal
managers said that they were concerned about the test results and asked
whether the facility‘s employees were at risk. Although we were told
that no documentation exists about the advice the Postal Service
received at the time, according to district postal managers, the Chief
Epidemiologist informed them that there was ’no additional risk“ to
employees for the same reasons previously cited--the contaminated
machines had already been isolated and were being decontaminated; the
anthrax was not believed to be airborne; employees at the facility had
already been offered antibiotics; and, in the view of public health
officials, the incubation period for the disease had already passed
without illness. Nevertheless, as a precautionary measure, the Chief
Epidemiologist recommended that the Postal Service managers advise
workers to continue taking their antibiotics. CDC concurred with the
Chief Epidemiologist‘s recommendation and assessment about the health
risk.
According to participants in the teleconferences, they also discussed
how to communicate the quantitative test results to workers at the
facility. As a result of these conversations, we were told, the
participants agreed that using the term ’trace“--after the finding of
about 3 million spores in a sample from one of the four mail-sorting
machines--was no longer appropriate in describing the extent of
contamination at the facility. As a result, district managers asked the
Chief Epidemiologist how the results could be communicated to employees
and others. According to district postal managers, the Chief
Epidemiologist advised them that it would be accurate to characterize
the contamination as a ’concentration of spores“ on one mail-sorting
machine and ’trace“ amounts on three others. The Chief Epidemiologist
agreed that he used the terms ’trace“ and ’concentration“ to describe
contamination at the facility. However, he subsequently informed us
that he did not provide a single description of the extent of
contamination in the facility but, instead, told postal managers that
this was one way to discuss the extent of contamination to facility
workers. According to the Chief Epidemiologist, it was up to the Postal
Service to determine how to communicate the test results. A district
postal manager told us that he relayed information about the
concentration of spores in the facility--one of the interpretations
provided by the Chief Epidemiologist--to the Facility Manager, without
any information about the actual quantitative results. The Chief
Epidemiologist and district postal managers agree that they never
discussed whether the Postal Service should disclose the quantified
test results to employees.
According to the Chief Epidemiologist, at the invitation of district
postal managers, he met with facility managers and union leaders on
December 12 to discuss the test results and to answer questions about
his health recommendations.[Footnote 22] The terms ’concentration of
spores“ and ’heavily contaminated machine“ were used, he said, but no
quantitative results were presented or discussed. Union representatives
and Postal Service officials we spoke to do not recall this meeting.
However, district postal managers issued a press release on December 12
containing the terminology that the Chief Epidemiologist said he had
used. Further, district postal managers told us that supervisors on
each of the facility‘s three work shifts began relaying the Chief
Epidemiologist‘s views and health-related recommendations directly to
the facility‘s employees on December 12. Union representatives told us
that they did not recall any supervisory briefings on December
12.[Footnote 23] Although no documentation of these briefings is
available, postal headquarters officials said that the December 12
press release would have been made widely available per the Service‘s
standard operating procedures and that a local Connecticut newspaper
reported the information contained in the press release on December 13.
According to the district managers, during follow-up testing later that
month, workers were routinely advised of the qualitative (e.g.,
negative/positive) test results when the Postal Service received them
from the laboratory. Beginning on December 20, 2001, workers were
briefed that all of the follow-up samples had tested negative for
contamination. On December 21, the Postal Service issued a press
release stating that the four mail-sorting machines had been completely
decontaminated and returned to service.
In contrast to its actions in December 2001, the Postal Service fully
released all test results related to its April 21, 2002, sampling of
the facility‘s elevated areas. An OSHA official involved in sampling
the facility‘s elevated areas--OSHA was not involved in December 2001-
-recommended immediate disclosure of all of the results. The results,
which included the finding of from 1 to 18 colony-forming units in
several samples, were provided to union representatives in a meeting on
April 24, the same day that postal managers were notified of the
results. Later that day, facility managers and the Chief Epidemiologist
began briefing employees about the results, indicating that 3 of 101
samples collected from 71 locations were contaminated.[Footnote 24]
According to the President of the Greater Connecticut Area Local
American Postal Workers Union, the quantitative results were also
posted on bulletin boards in the facility. There is little
documentation of these briefings or the advice that the Postal Service
received from public health officials. However, we were told that
postal managers relayed the views and recommendations of the
Connecticut Department of Public Health officials, who had advised them
that there was no immediate health risk to workers and, therefore, that
the employees would not need to take antibiotics. This decision was
based, in part, on the view that the contaminated areas had already
been isolated and, in consultation with CDC, OSHA, and EPA, were to be
decontaminated. The managers also assured workers that testing would be
performed to ensure that no contamination was present before the areas
were returned to operation.[Footnote 25] The elevated areas were
resampled in a series of tests and, on June 6, 2002, the final
laboratory report indicated that all samples were negative for anthrax.
Postal Service managers met daily with union representatives to provide
and discuss test results and the status of decontamination efforts. The
Postal Service posted the final results on bulletin boards in the
facility on June 7, informing employees that decontamination had been
completed.
Disclosure of Anthrax Test Results:
Consistent with its guidelines, the Postal Service generally provided
the facility‘s test results to workers within 1 day of receiving the
results. The one exception to this practice involved the December 2001
quantitative test results. In this case, there was a delay of at least
2 days between the date that the Postal Service received documentation
of the quantified test results and the date that it notified its
workers about the ’concentration of spores“ on one mail-sorting
machine. It is not clear precisely when in December 2001 the Postal
Service first received the documented test results. While the Postal
Service informed workers of the results in a qualitative manner, it did
not disclose the actual quantitative results to workers until September
2002. The Postal Service‘s decision not to release the quantitative
test results in December 2001 appears to have been consistent with its
guidelines because the sampling methods used could not be validated, as
required. However, its decision not to release the December 2001
quantitative test results in response to two requests by a local union
leader in January 2002 and February 2002 was not consistent with OSHA‘s
regulations for disclosing test results that are requested by workers
or their designated representatives. OSHA‘s subsequent investigation
into this matter resulted in the Postal Service‘s release of the
December 2001 quantitative test results in September 2002--more than 7
months after the union leader first requested the results and about 9
months after the results were first known by the Postal Service. OSHA
did not cite the Postal Service for its decision not to disclose the
results earlier; however, in a October 7, 2002, letter to the Postal
Service, OSHA noted that a ’failure to effectively communicate issues
which can have an effect on a worker‘s health and safety, can lead to
fear and mistrust.“:
The Postal Service‘s Release of the December 2001 Test Results Appears
Consistent with Its Guidelines:
Following the anthrax contamination of several postal facilities, the
Postal Service, in consultation with public health and other
organizations that were members of the Postal Service‘s Command Center,
issued--in December 2001--policies and procedures for, among other
things, releasing and communicating anthrax test results.[Footnote 26]
The guidelines specify, among other things, how and when test results
will be communicated to employees and the public. The guidelines state
that results cannot be released until confirmed data are received from
CDC or a state public health laboratory. Also, all confirmed data have
to be validated before being sent to the Command Center.[Footnote 27]
Once data are confirmed and validated, the guidelines state that the
Manager of the Command Center is to release the data to affected
district and facility managers, the affected state health
department(s), and the CDC liaison at the Command Center. According to
the guidelines, when a Facility Manager receives the results, he or she
is to ensure that employees, union representatives, and other affected
parties are notified ’as soon as possible.“ An earlier version of the
guidelines, dated November 16, 2001, has identical requirements.
The Postal Service, with one exception, began disclosing the laboratory
test results for samples collected from the facility within 1 day of
receiving the qualitative results. Such prompt disclosure is consistent
with the Postal Service‘s guidelines, which require facility managers
to notify workers of sample results ’as soon as possible“ if the
results are confirmed and validated. The one exception to this practice
appears to have occurred after the Postal Service received written
confirmation of the results from the two quantified samples collected
on November 28, 2001. According to district postal managers, they began
relaying the results to facility workers on December 12, 2001--2 days
after district postal managers said they first received written
confirmation of the laboratory‘s quantified results from the Chief
Epidemiologist. District postal managers provided several reasons for
their 2-day delay in notifying workers of the results.[Footnote 28]
First, they said they needed time to consult with public health
officials from Connecticut‘s Department of Public Health and CDC about
(1) the meaning and implications of the quantitative results and (2)
how to describe the results and associated health risks to employees at
the facility. Second, the managers said that they needed additional
time to obtain advice from Postal Service headquarters and to draft a
press release. Although the district did not receive the quantitative
results until December 10, as previously discussed, a chronology of
events prepared in January 2002 by Postal Service employees and shared
with CDC indicates that postal managers at headquarters may have
received the documented results on or about December 8, 2001--4 days
before workers were informed of the test results.[Footnote 29] The
length of the delay in informing workers cannot be specifically
determined because postal headquarters managers do not recall when they
first obtained the written test results.
According to Postal Service managers, the decision to withhold the
actual quantified results from facility workers also was consistent
with the guidelines because the Postal Service could not ensure that
the contractor‘s sampling procedures were consistent with the
procedures and protocols specified in the guidelines. As a result,
according to the Postal Service, it was unable to validate the results
as required by its guidelines. More specifically, the Postal Service
indicated that the results could not be validated, in part, because the
team that collected the samples--individuals from the Agency for Toxic
Substances and Disease Registry and CDC--did not always measure and
record the extent of the surface area that they sampled.[Footnote 30]
Also, the team used various sampling methods, and there was no way to
correlate the results from the various methods used.[Footnote 31] The
Postal Service also indicated that the laboratory that produced the
results was not hired by or working directly for the Postal Service, as
had been expected when the Postal Service developed its
guidelines.[Footnote 32]
Aside from the requirements in its guidelines, district postal managers
said two other factors influenced their decision not to disclose the
quantified results in December 2001. First, district postal managers
said that they were uncertain about whether they could release the
results given the ongoing FBI criminal investigation related to the
facility‘s contamination.[Footnote 33] Although acknowledging that
they did not consult the FBI or others about releasing the quantitative
results, district postal managers noted that the investigative team was
subject to strict rules and had agreed not to disclose information
exchanged during its twice-daily conference calls. Second, they said
that there was considerable uncertainty about what the results meant
from the standpoint of worker safety and public health. The District
Manager explained that in December 2001, interpretations about the
meaning of the results were changing by the hour, depending on the
views of individuals involved at the time. As a result, according to
members of the investigative team, there was considerable daily
discussion within the team about what the test results actually
meant.[Footnote 34] CDC pointed out that it ’did not and still does not
know how to interpret quantitative results such as the high spore count
from a health risk standpoint.“ Nevertheless, CDC noted that the
actions taken by the Postal Service when the contamination was found
were ’very cautionary and prudent.“:
The Postal Service‘s Delay in Disclosing the December 2001 Quantitative
Test Results Was Not Consistent with OSHA‘s Disclosure Requirements:
To help ensure that employees have safe and healthy work places, OSHA
enforces a variety of standards that it developed to eliminate
foreseeable and preventable hazards, such as worker exposure to
asbestos, lead, and carbon monoxide. The risk of contamination from
anthrax was not anticipated when these standards were developed. Thus,
there is no specific OSHA standard governing the timing and disclosure
of test results for anthrax and a host of other unanticipated
substances that could harm workers. However, regardless of the
contamination, OSHA regulations require employers to disclose exposure-
related test results ’whenever an employee or designated representative
requests access to a record. . . .[Footnote 35] Employers are required
to provide access to the records ’in a reasonable time, place, and
manner.“ If access is not provided within 15 working days, employers
must explain the delay and indicate when the record can be made
available.[Footnote 36] OSHA has considerable discretion in enforcing
this requirement and, depending upon the seriousness of the situation,
can cite and even fine an employer for noncompliance.[Footnote 37]
The President of the Greater Connecticut Area Local American Postal
Workers Union--a designated representative of many of the facility‘s
employees--triggered the OSHA requirement on January 29, 2002, when he
requested postal facility managers to provide copies of all test
results and all supporting and relevant documents for all anthrax
testing conducted at the Wallingford facility in the fall of
2001.[Footnote 38] The request was made pursuant to the union‘s
collective bargaining agreement with the Postal Service. The Postal
Service responded on February 6, 2002, with a summary listing of tests
performed at the Wallingford facility, including information about
whether the test was positive or negative for anthrax. The Postal
Service did not (1) provide any of the actual laboratory reports for
the tests or (2) inform the union leader that it had not disclosed all
of the relevant records. According to the Postal Service, it viewed the
union leader‘s request, like others it receives from the union, in the
context of its collective bargaining agreement with the union, not
within the context of OSHA‘s disclosure requirement. As a result, the
Postal Service did not provide him with the earliest date when the
other records would be made available, as required by OSHA‘s
regulations.
Noting that the Postal Service had not provided him with certain test
results, including results related to the decontamination of the four
mail-sorting machines in December 2001, the union leader submitted an
identical request for all of the records to the Postal Service on
February 28, 2002--again under the collective bargaining agreement. The
Postal Service provided the results of tests performed on November 11,
2001, as well as the results of the December 2001 decontamination
efforts. However, once again, according to the headquarters‘ manager
responsible for establishing and overseeing the Command Center, the
Postal Service did not view the request within the context of the OSHA
disclosure requirement. As a result, the Postal Service did not apprise
the union leader of the reason for the delay in disclosing all of the
records or the earliest date when the records would be made available.
According to the union leader, he believed that the Postal Service had
provided him with all of the relevant information and did not pursue
the matter further until April 2002--after he learned from a newspaper
article that at least one of the facility‘s test results had been
quantified.[Footnote 39] According to the union leader and the Postal
Service physician who had been responsible for providing medical advice
to workers at the facility in December 2001, this was the first time
that they were aware that any of the facility‘s test results had been
quantified.
The union leader told us that the news article alarmed him; as a
result, he initiated action to obtain the quantified test results under
the Freedom of Information Act. Specifically, on April 23, 2002, the
union leader requested OSHA, the Connecticut Department of Public
Health, and CDC to supply ’any and all documents regarding any and all
investigations of hazardous conditions, or suspected hazardous
conditions, including, but not limited to, all documents related to any
and all investigations of contamination, or suspected contamination, of
the anthrax virus at the [Wallingford facility] in 2001 and 2002.“:
OSHA responded to the request but indicated that it did not have the
test results and, therefore, it could not release the information.
Second, while the Commissioner of the Connecticut Department of Public
Health had discussed the December 2001 quantified results with the
union leader on April 22, 2002, and the Chief Epidemiologist had
briefed the facility‘s workers about the quantitative results on April
24, 2002, the department subsequently declined to release the actual
results because of state prohibitions on releasing epidemiological
investigative data.[Footnote 40] Finally, although CDC had previously
(1) released the quantitative test results for the Wallingford facility
at a March 2002 conference and (2) published some quantitative test
results for the Brentwood facility in Washington, D.C.,[Footnote 41] it
did not release the results to the union until March 28, 2003, because,
according to a CDC official, the FBI had only recently notified CDC
that it did not need to review CDC‘s records before the release of
’anthrax-related information.“[Footnote 42]
Unsuccessful in obtaining the facility‘s test results, the union leader
filed a formal complaint with OSHA. The May 29, 2002, complaint alleged
that the Postal Service had ’intentionally failed to properly and
timely disclose to the employees working at [the facility] and to their
union representatives the actual level of anthrax contamination found
on four (4) automated processing machines back in December 2001.“ The
letter noted that the Postal Service was aware of the quantified test
results ’on or about December 12, 2001“ yet did not inform the
facility‘s workers. Absent knowledge of the actual amount of
contamination at the facility, the union leader charged that employees
had inadequate information for making informed decisions, such as
decisions about whether to continue (1) taking antibiotics and (2)
working in the facility. The union leader and other union
representatives subsequently explained to us that, according to their
discussions with workers at the facility, many of the employees either
(1) did not take their antibiotics or (2) stopped taking their medicine
prematurely on the basis of the Postal Service‘s use of ’trace“ and
’concentration“ to characterize the extent of contamination in the
facility.
The complaint resulted in an OSHA investigation and the Postal
Service‘s subsequent release of test results from samples collected in
November and December 2001. This included the actual laboratory record
for the sample that identified about 3 million spores in a sample
collected from one mail-sorting machine on November 28, 2001. The
Postal Service provided the quantified results to union representatives
and to members of the facility‘s Safety and Health Committee on
September 4, 2002, along with a letter describing the Postal Service‘s
reasons for not releasing the results earlier. Specifically, the Postal
Service indicated that the results could not be validated because ’the
laboratory that produced the results was not hired by or working
directly for the Postal Service.“ As a result, the letter cautioned
recipients not to use the information to interpret the risk to
employees who had been working in the facility in December 2001.
At the conclusion of the inspection, OSHA‘s area office in Bridgeport,
Connecticut, reported that its inspection had ’revealed conditions of
significant findings,“ which--while not warranting a citation for a
regulatory violation--were of ’sufficient importance to require [the
Facility Manager‘s] attention.“ OSHA‘s October 7, 2002, letter to the
Postal Service also stressed the importance of timely communication of
test results and stated that a ’failure to effectively communicate
issues which can have an effect on a worker‘s health and safety, can
lead to fear and mistrust.“ Furthermore, the letter informed the Postal
Service that ’effective and forthright communication of any and all
information relating to exposure records, both quantitative and
qualitative, to toxic substances and harmful physical agents should
take place in a timely manner.“:
According to OSHA officials, OSHA typically sends a letter of
significant findings when the employer has disclosed information
requested by an employee or his or her designated representative while
the complaint is still open--as the Postal Service did on September 4,
2002, prior to the end of OSHA‘s investigation. Although OSHA did not
believe that a citation was warranted, OSHA officials stated that they
used a letter of significant findings to establish a basis for a future
violation if the problem reoccurs.
Dissatisfied with OSHA‘s decision not to take regulatory action, on
October 17, 2002, the union leader requested that OSHA‘s Regional
Administrator in Boston, Massachusetts, review the matter. The request
was based, in part, on the fact that the Postal Service did not release
the quantified results until September 4, 2002--more than 3 months
after the union filed its complaint with OSHA and more than 7 months
after the union had first requested all test results directly from the
Postal Service. The request also cited conflicting information that had
been received by OSHA about whether postal managers were still in
possession of the December 2001 quantified results in June 2002, when
OSHA initiated its investigation, and thus whether the Postal Service
could have supplied the information to the union earlier.[Footnote 43]
In his request, the union leader argued that a regulatory citation was
needed because, otherwise, there would be no incentive for the Postal
Service to prevent a similar situation from reoccurring. OSHA‘s
Regional Administrator reviewed the matter and, by a letter dated
November 26, 2002, affirmed OSHA‘s prior decision not to issue a
regulatory citation.
We discussed OSHA‘s findings with officials responsible for the
inspection. They noted that OSHA was not involved at the facility until
April 2002--well past the December 2001 period in question.
Nevertheless, they cited the emergency situation that had existed at
that time and indicated that, on the basis of their subsequent
knowledge of the events that had transpired, they believed the Postal
Service had taken ’reasonable and prudent“ actions to protect its
employees throughout the period of the facility‘s contamination. As a
result, any hazard associated with the Postal Service‘s nondisclosure
of the quantitative test results had been eliminated in December 2001-
-about 6 months before OSHA‘s investigation began. Also, the OSHA
officials noted that because the Postal Service had subsequently
released the requested data, in their view, it would not be appropriate
to issue a regulatory citation.
In a February 2003 letter to the union leader, OSHA‘s Regional
Administrator reaffirmed OSHA‘s decision not to cite the Postal
Service. According to the Regional Administrator, the agency‘s decision
was influenced by several factors, including the (1) national panic
about the anthrax threat in the fall of 2001; (2) lack of information
about the significance, in terms of employee exposure, of anthrax
spores found in the facility; and (3) existence of an ongoing criminal
investigation into the source of the anthrax spores that involved
several federal agencies.[Footnote 44] Nevertheless, she emphasized the
need for better communication by the Postal Service and reaffirmed
OSHA‘s concern about the ’failure of communication and openness“
exhibited by the Postal Service in this case.
Lessons Learned at the Wallingford Facility Suggest the Need for More
Complete and Timely Information to Workers:
Although OSHA and members of the investigative team in December 2001
were not critical of the Postal Service‘s decision not to release the
December 2001 quantified results when they were first known, in
hindsight and within the context of lessons learned, they said there
was no reason why the results and any limitations associated with the
results could not have been disclosed at that time. They explained that
from their perspectives, full and timely disclosure of laboratory
results is the best method for communicating test results. For example,
the Chief Epidemiologist from the Connecticut Department of Public
Health emphasized that it is important to ’put the information out
there frankly and then discuss it.“ Similarly, CDC officials stated
that the principle is to get all of the information out to employees
regarding their health risks. Finally, although not a member of the
investigative team, an OSHA official who was involved in the facility‘s
decontamination in April 2002 told us that he advised the Postal
Service to provide employees with the ’raw data sheets“ of test results
to avoid miscommunication, confusion, and concern about how the data
may have been interpreted.
Two recent guidelines developed by GSA and the National Response Team
stress the importance of complete and timely information. The
guidelines are intended to disseminate information learned from the
response to anthrax contamination at postal and nonpostal facilities in
the fall of 2001, including lessons relating to the communication of
test results. GSA released its guidelines in July 2002.[Footnote 45]
The guidelines are written in the form of a policy advisory--not as
regulations or explicit directives--and primarily apply to the
operation of mail centers located in federal agencies in the
Washington, D.C., area. While not requirements, GSA‘s recommendations
for communicating test results to workers, in our view, are relevant to
the Postal Service and others. The guidelines emphasize the importance
of the integrity of the information communicated to workers and stress
the need for ’timely, clear, consistent, and factual“ information about
risk levels and any limitations associated with the information. The
guidelines conclude that people need ’solid“ information to have the
’confidence to make informed choices.“:
The National Response Team developed the other guidelines, which are
still in draft. The most recent version of the guidelines is dated
September 30, 2002, and is entitled Technical Assistance for Anthrax
Response.[Footnote 46] Although not a member of the National Response
Team, the Postal Service assisted in the development of the guidelines.
The guidelines (1) suggest that more--rather than less--information
should be disclosed and (2) provide a number of recommendations about
communicating information during emergency situations. For example, the
guidelines advise agencies to consider that ’different audiences (e.g.,
employees, reporters, local politicians) may need different types of
information“ and to ’anticipate what information people need and in
what form.“ Further, although the guidelines caution against passing on
’everything you know,“ it points out the consequences of not fully
disclosing information. Specifically, the guidelines warn, ’. . . do
not withhold information . . . it is very likely that the withheld
information will be found out, which will cripple your credibility. . .
.“ Finally, the guidelines advise agencies to ’admit when you have made
a mistake or do not know the information.“:
Although helpful in ensuring the integrity of information to be
released, neither of the two recent guidelines nor the Postal Service‘s
guidelines explicitly address all of the communication issues that
arose at the Wallingford facility.[Footnote 47] None of these
guidelines:
* explicitly require disclosure of quantitative test results, when
available, or specify the terminology (e.g., number of colony-forming
units per gram or square inch of material sampled) that should be used
to communicate the results to workers or others, along with any
limitations associated with the results, or:
* specify the actions that should be taken if test results cannot be
validated, including a strategy for communicating unvalidated test
results to workers.
Furthermore, the Postal Service‘s guidelines do not define the meaning
of ’validation“ or specify the steps that must be taken to validate
test results. The Postal Service headquarters‘s manager who was
responsible for establishing and overseeing the Command Center told us
that the term was intended to describe a method for ensuring that work
had been done in accordance with the Postal Service‘s sampling and
testing procedures and, therefore, for coordinating the release of
validated results. However, the guidelines do not specify who is to do
the validation or how it is to be done, particularly when the testing
is not done or sponsored by the Postal Service.
The experts whom we consulted (1) told us that the sampling method
(HEPA vacuums) used to collect the samples that were quantified was
appropriate and (2) agreed that the lack of documentation about the
extent of surface area sampled, especially given the complexity of the
facility‘s mail-sorting machines, could have made interpretations about
the results difficult.[Footnote 48] Nevertheless, they noted that the
method of counting colony-forming units is a long-standing, definitive,
and universally accepted microbiological technique for determining the
amount of bacteria in a given sample, including anthrax. The results
show how many spores have replicated to form colonies, which can be
seen by the naked eye. Thus, regardless of the sampling issues at
Wallingford, none of the agencies involved provided any evidence
indicating that the number of colony-forming units identified by the
laboratory was incorrect. Accordingly, although the sampling issues may
have hindered the interpretation of the test results,[Footnote 49]
according to these experts, the use of the term ’concentration“ to
convey the finding of about 3 million spores in one sample may have
been misleading because it did not adequately convey the health risk
associated with the sample. According to the experts with whom we
talked, providing information about the actual test results to workers
would have given them better information for making informed medical
decisions.
In this case, according to the experts we consulted, an appropriate way
to communicate the results to workers would have been to indicate that
2.9 million colony-forming units (from 0.55 grams of dust) were found
in a sample from one machine, along with appropriate limitations
regarding the sampling procedures used. Although a precise
interpretation of the health risks associated with the quantitative
test results was problematic, providing the quantitative results would
have given workers a framework for evaluating the information they were
previously given regarding the 8,000 to 10,000 spores believed--at that
time--to be needed to cause inhalation anthrax and would have provided
some indication of the magnitude of the anthrax present in the
facility. According to CDC, although the number of anthrax colonies can
be counted, it is not possible to count the exact amount of anthrax in
the environment because of uncertainties about how well a sample picks
up anthrax. In other words, there could be more anthrax in the
environment than can be picked up by a sample.
An additional problem relating to the existing guidelines is that none
of them (1) specify who should be involved in deciding what to
communicate to workers and others, as appropriate; (2) describe the
documentation agencies should maintain, including the advice agencies
receive from public health officials or others about the communication
of test results to workers; or (3) discuss the actions that should be
taken if test data are requested by an employee or a designated
representative. As previously discussed, OSHA representatives were not
involved in the December 2001 discussions about what to communicate to
workers. This deprived the Postal Service of the insights and
suggestions that OSHA could have offered. Furthermore, although the
Postal Service representatives cited uncertainty over what information
could be released given the ongoing criminal investigation, the Postal
Service did not consult with the FBI on this issue. According to FBI
officials we interviewed in Connecticut, the test results were of no
value to their investigation and, had they been consulted, they said
that they would have allowed the results to be released.
As previously discussed, another issue that arose in the Wallingford
case involved differing recollections among the various parties
regarding who participated in certain discussions and about what advice
was given. For example, in contrast to the recollections of officials
from CDC and the Connecticut Department of Public Health, postal
managers told us that they did not participate in a December 6, 2001,
telephone conversation in which the quantitative test results were
first discussed. Further, postal managers have different recollections
about the advice they received from the Chief Epidemiologist than the
information that he recalls. Also, in the Wallingford case, the Postal
Service said that it did not associate the union leader‘s request for
the test results with OSHA‘s regulatory requirement and, therefore, did
not realize that it was obligated to either provide the results within
15 days or provide the reasons for the delay along with a time frame
for providing the results. Related to this, OSHA‘s disclosure
requirements do not fully address the emergency situation that arose at
Wallingford, where workers were exposed to an unanticipated and
externally introduced hazard capable of causing serious health
problems, including death. The regulations are not applicable until an
employee or a designated representative requests test results and, even
then, the employer has up to 15 days to provide the information or
explain why it is not providing the information. The 15-day time frame
is far more than the number of days needed to contract inhalation
anthrax.
We discussed OSHA‘s regulatory requirements with OSHA‘s Director of
Enforcement Programs. The Director told us that OSHA‘s standards were
written for airborne exposure to chemical and physical agents in the
workplace, and, at the time they were drafted, OSHA did not envision
biological hazards, such as anthrax. According to the Director, OSHA‘s
current regulatory agenda do not include any planned modifications to
its requirements, including any changes to require the immediate and
proactive disclosure of records related to an employee‘s exposure to
unforeseen hazards, such as anthrax, regardless of whether the records
are requested by workers or their designated representatives.
Conclusions:
In retrospect, the Postal Service‘s decision not to release the
quantitative test results in December 2001 was understandable given (1)
the circumstances that existed at that time, (2) the advice it received
from public health officials, (3) an ongoing criminal investigation,
and (4) uncertainties surrounding the validation of the sampling
methods used and the meaning of the test results. However, the decision
deprived facility employees of information that may have been useful in
making informed decisions about whether to take or continue taking
antibiotics and whether to continue working in the facility.
Furthermore, in hindsight, it is clear that not fully disclosing
quantified test results can affect an agency‘s credibility and lead to
worker distrust. It is also apparent now that not consulting relevant
agencies--in this case, OSHA and the FBI--regarding its December 2001
decision about what to disclose to employees deprived the Postal
Service of information that could have been useful in deciding what to
communicate to its workers. Finally, the Postal Service‘s failure to
document the discussions that it had with other agency personnel on
communication issues makes it difficult to resolve discrepancies in
recollections that arose. As demonstrated at Wallingford, documentation
of the advice and recommendations received from others, either at the
time they are received or shortly thereafter for emergencies, could
help resolve questions that may arise later about what was done and
why.
The agencies involved in the investigation and response to anthrax at
Wallingford have learned a number of lessons from their experiences,
including the need for more effective sampling methods and more
explicit and consistent guidance concerning the communication of test
results for hazardous substances, such as anthrax. However, the
guidelines developed by the Postal Service, GSA, and the National
Response Team are still too general to prevent problems like those that
occurred at the Wallingford facility. Specifically, the current
guidelines do not (1) require the prompt disclosure of all available
test results, using specified terminology; (2) define how test results
should be validated or the actions that should be taken when results
cannot be validated; (3) specify which agencies should be involved in
deciding what to communicate to workers and others; or (4) require
documentation of the advice and recommendations from other
organizations involved in deciding the actions to be taken during a
crisis. Moreover, since employees and their designated representatives
may not know that test results are available or that they can be
requested, it appears incumbent upon employers to, in emergency
situations, immediately disclose test results without waiting for an
employee or representative to request them. Because current OSHA
regulations require the disclosure of test results only when an
employee or representative requests them, such as occurred in the
Wallingford case, organizations can still decide to withhold essential
information. Lastly, agency officials dealing with an anthrax situation
or similar emergency may not be aware of, or associate an employee‘s
request for test data with, OSHA‘s regulations, which can result in
penalties for noncompliance.
Recommendations for Executive Action:
To help prevent the reoccurrence of the communications problems that
occurred at the Wallingford facility, we recommend that the Postmaster
General; the Administrator of GSA; and the Administrator of EPA, as
Chairperson of the National Response Team, work together to, where
applicable, revise guidelines to:
* require prompt communication of test results, including quantified
results when available, to workers and others;
* specify the terminology that should be used to communicate
quantitative test results to employees and others (e.g., the number of
colony-forming units per gram or square inch of material sampled) and
any limitations associated with the test results;
* define what is meant by the validation of test results and explain
the steps that must be taken to validate sampling or testing methods
that are undertaken by the agency itself or by another organization;
* specify the actions that should be taken if test results cannot be
validated, including a strategy for communicating unvalidated results;
* specify the agencies that should be involved in deciding what to
communicate to workers and others, as appropriate;
* require documentation of the basis for decisions made, including the
(1) advice the organization receives from public health officials and
others about the communication of health-related information to workers
and others, as appropriate, and (2) specific content of what the
organizations communicate to workers and others; and:
* reflect OSHA‘s regulations for disclosing test results requested by
workers or their designated representatives.
In light of new concerns about the possibility and impact of future
terrorist actions using unforeseen hazardous substances, we also
recommend that the Assistant Secretary for Occupational Safety and
Health consider whether OSHA regulations should require--in emergency
situations--full and immediate disclosure of test results to workers,
regardless of whether the information is requested by an employee or
his or her designated representative.
Agency Comments and Our Evaluation:
We requested comments on a draft of this report from the Postmaster
General; the Commissioner of the Connecticut Department of Public
Health; the Secretaries of HHS, Labor, and Homeland Security; the
Attorney General--for the FBI; the Administrators of EPA and GSA; and
the President of the American Postal Workers Union. EPA, the Postal
Service, GSA, the union, and the FBI provided comments on our
conclusions and/or recommendations. Their comments are summarized
below.
EPA‘s Assistant Administrator provided comments on March 21, 2003, in
EPA‘s capacity as the Chair for the National Response Team. According
to the EPA Assistant Administrator, OSHA, GSA, HHS (specifically the
National Institute of Occupational Safety and Health), and the Postal
Service were consulted in preparing the response. EPA indicated that
the members of the National Response Team believe that our draft report
provided a balanced presentation of anthrax testing and communications
with employees at the Wallingford postal facility. While stating that
the National Response Team agrees with our references and
recommendations regarding the content of its guidelines--Technical
Assistance for Anthrax Response--EPA stated that the guidelines had
been carefully written as a technical resource document, as opposed to
a directive or guidance, and that knowledge on anthrax is evolving
rapidly. Thus, EPA noted that each response situation is unique. As a
result, EPA stated that the guidelines were intended to provide
scientific background and viable options for responders to consider in
addressing specific circumstances. Nevertheless, EPA indicated that
’certain improvements“ could be made to the guidelines that would be
responsive to our recommendations. The letter did not specify the
nature of the planned improvements. EPA also provided technical
comments, which we included, as appropriate. EPA‘s letter is reproduced
in appendix III.
In his March 31, 2003, comments on our draft report, the Postal
Service‘s Chief Operating Officer and Executive Vice President stressed
that the safety and security of its employees and its customers were
then and now of the utmost importance. The Postal Service also
emphasized that, when the anthrax crisis unfolded in the fall of 2001,
there were no guidelines and no designated regulatory agency for
dealing with the crisis. While stating that the Postal Service acted
quickly and prudently to communicate pertinent information to its
employees, the Postal Service acknowledged that there are always
opportunities to improve communications regarding anthrax and other
biohazards. In this regard, the Postal Service stated that it is
committed to working with the National Response Team to revise the
team‘s technical assistance guidelines for anthrax and, when completed,
that it planned to ensure that its guidelines are consistent with the
team‘s updated guidelines. The Postal Service also noted that it agreed
with many of our specific recommendations. For example, the Postal
Service agreed that test results, including quantified results, should
be released to employees and others as quickly as possible. The Postal
Service also agreed that any limitations associated with the results
should be explained. Further, the Postal Service recognized the
importance of developing and maintaining sufficient records concerning
its communication of health-related information to employees and
others. Finally, the Postal Service indicated that it is aware of its
obligation to release testing information to employees and their
unions, when requested to do so. The Postal Service‘s letter, which is
reproduced in appendix IV, did not comment on our other
recommendations. The Postal Service also provided technical comments,
which we included, as appropriate.
The Postal Service‘s commitment to work with the National Response Team
in revising the team‘s anthrax-related guidelines and, thereafter, to
ensure that its guidelines are consistent with the revisions made to
the team‘s Technical Assistance for Anthrax Response, should go a long
way in ensuring that the Postal Service‘s employees have all of the
information they need to make informed decisions about their health and
safety in a timely manner. However, because the National Response Team
did not specify the nature of its planned revisions to its technical
assistance, we believe that the Postal Service should also revise its
guidelines to address any recommendations that are not eventually
included in the National Response Team‘s revised technical assistance,
particularly with respect to issues related to the meaning of
’validation,“ the steps that must be taken to verify sampling methods
or test results, and the release of test results that cannot be
validated.
On March 31, 2003, GSA‘s Associate Administrator provided oral comments
on our draft report. GSA said that it had consulted with the National
Response Team and with key members of an Interagency Working Group that
had participated in the development of GSA‘s anthrax-related
guidelines. According to GSA, the other members of the working group
had similar comments. Overall, GSA said that our draft report provided
a balanced presentation of anthrax testing and communications with
employees at the Wallingford facility and that it generally agrees with
our references to, and recommendations regarding, its guidelines. Like
the comments we received on behalf of the National Response Team, GSA
also emphasized that its guidelines were written as a policy advisory
and that they were not intended to prescribe specific actions that
should be taken in every case. Instead, GSA indicated that its
guidelines are intended to provide background information and viable
options for managers who operate federal mail centers in the
Washington, D.C., area. GSA also explained that its guidelines deal
primarily with the actions that these managers should take to prepare
for possible anthrax threats and to determine whether an anthrax threat
is credible. Once a credible threat has been identified, responsibility
for managing the situation passes from the manager of the mail center
to law enforcement, public health, and other authorities. As a result,
GSA emphasized that the guidelines developed by the National Response
Team should be the primary source of advice for anyone managing a
credible threat.
GSA noted that it needs to consult with the entire Interagency Working
Group before implementing specific changes to its guidelines. However,
GSA informed us that it agreed with three of our recommendations and
indicated that it would work with other members to revise its
guidelines related to (1) the prompt disclosure of all test results,
including any available quantified results; (2) the need for adequate
documentation of the advice an agency receives from public health
officials and others and its related communications with employees and
others; and (3) OSHA‘s regulations for disclosing test results
requested by workers or their designated representatives.
GSA also said that it would address the issues covered in three of our
other recommendations somewhat differently than in the manner that we
suggested. Nevertheless, GSA indicated that it would work with the
Interagency Working Group to address the concerns raised in our report.
The three recommendations in question relate to the need for (1) common
terminology in communicating quantitative test results, (2)
understanding what is meant by the ’validation“ of sampling methods and
test results, and (3) specifying the actions to be taken if test
results cannot be validated. Specifically, while GSA commented that it
agrees that all test results should be conveyed to workers promptly, it
said that it does not believe that quantitative test results should be
used in all cases. GSA explained that appropriate testing methods vary
according to site-specific circumstances and the ability to quantify
results depends on the testing methods used. GSA also noted that the
term validation has various meanings. Rather than promote confusion or
add unnecessary detail to distinguish the different types of
validation, GSA said that it would address our recommendations by
adding a statement in its guidelines that recommends sharing all
available test results; specifying the testing methods used; and
explaining the limitations, if any, of the results and the testing
methods.
We appreciate GSA‘s commitment to address the concerns raised in our
report. From GSA‘s comments, it appears that further clarification of
our view may be warranted. We did not mean to imply that quantitative
results should be used in all cases. As indicated in our report,
quantitative results are not always available, depending on the
sampling methods used. In fact, in the case of the Wallingford
facility, quantified results were rarely available. However, when
quantitative results are available, like GSA, we continue to believe
that it is important to disclose them to all affected parties. We
clarified our recommendation to avoid any misunderstandings in this
area.
Regarding our final recommendation, GSA indicated that parties involved
in responding to anthrax may change over time and, as a result, it
believes that its guidelines--in a general fashion--adequately identify
the types of parties that should be involved in deciding what to
communicate to workers and others. Nevertheless, GSA said that, in
consultation with the Interagency Working Group, it would look for ways
to enhance this part of its guidelines.
The President of the American Postal Worker‘s Union commented on our
draft report in a letter dated March 25, 2003. The union said that it
agreed with our recommendations to better coordinate communication
between federal agencies when events occur. However, the union said
that our report did not adequately reflect the union‘s perspective of
the facts and that a number of our conclusions were not supported by
the facts. We disagree. We believe that our conclusions are fully
supported by the evidence presented in this report and that the report
presents a fair, objective, and balanced depiction of the facts as best
we could determine them. We also disagree that the report does not
adequately reflect the union‘s perspective. Our report clearly
concludes that the Postal Service‘s December 2001 decision not to
disclose the quantitative results deprived workers of essential
information for making informed decisions related to their health and
safety. In addition, the report lays out a number of lessons that can
be learned to avoid similar problems in the future. Furthermore, the
report contains several recommendations for improving communication
with postal and other workers in the future if another bioterrorist
attack occurs. The union‘s letter is reproduced in appendix V.
The union disagreed with a number of our conclusions. First, the union
disagreed that the Postal Service‘s decision not to release the
quantitative results to workers in December 2001 appeared consistent
with its guidelines. The union reiterated the requirements in the
Postal Service‘s guidelines which, as discussed in this report, specify
that confirmed test results must be validated before being sent to the
Postal Service‘s Command Center and, once the data are confirmed and
validated, the guidelines state that the Manager of the Command Center
is to release the data to, among other parties, affected postal
managers and state health departments. Thus, in the union‘s view, the
test results are considered to be validated when they are reported by
the Manager of the Command Center. However, this is not what happened
in Wallingford. In the Wallingford case, the laboratory reported the
quantitative results directly to the Connecticut Department of Public
Health and CDC--not to the Postal Service‘s Command Center--and the
Chief Epidemiologist provided the test results directly to the Postal
Service‘s district office. Thus, the results were not reported by the
Command Center as anticipated by the guidelines. According to the
Postal Service, the December 2001 quantitative results could not be
validated, within the context of the Postal Service‘s guidelines,
because the party that collected the samples did not work for the
Postal Service and the Postal Service could not ensure that the samples
had been collected in accordance with procedures set forth in its
guidelines. While we believe that the Postal Service‘s decision not to
release the quantitative test results in December 2001 appears
consistent with its guidelines on the basis of its interpretation of
the validation requirement, we also believe that the use of the term
’validation“ in the context of anthrax testing can be problematic.
Therefore, our report contains a recommendation to define what is meant
by validation and explain the steps that must be taken to validate test
results.
Second, the union stated that, in its view, it is unacceptable to
withhold exposure information under any circumstances. While we agree
in principle, our conclusion that the Postal Service‘s decision not to
release the quantified test results in December 2001 was understandable
is based on the particularly challenging and difficult circumstances
that existed at that specific point in time. As discussed in this
report, these circumstances included an ongoing investigation of the
bioterrorist attack; the advice that the Postal Service received from
public health officials; uncertainties surrounding the validation of
the sampling methods used and the meaning of the test results. In
addition, while the Postal Service‘s existing guidelines do not address
all of the conditions that existed at the Wallingford facility, the
decision not to disclose the quantified results in December 2001
appears consistent with the existing guidelines. Furthermore, neither
OSHA nor the members of the investigative team, including CDC, the
Connecticut Department of Public Health, the FBI, and EPA, specifically
faulted the Postal Service for not releasing the quantitative results
at that time. Nevertheless, our report clearly states that, in
hindsight, not disclosing test results can be problematic and that the
decision not to disclose the December 2001 quantified results deprived
workers of important information. Consequently, we are making several
recommendations to improve future communication of test results,
including the prompt disclosure of available qualitative and
quantitative results, and any limitations associated with the sampling
methods or test results.
Third, the union stated that our report concluded that it was
understandable and acceptable that the Postal Service failed to follow
OSHA‘s regulatory disclosure requirements and, as a result, that it was
acceptable to withhold the quantitative results for 9 months. We
disagree with the union‘s characterization of our conclusion. Our
report clearly states that the Postal Service‘s decision not to release
the test results in response to two union requests in January and
February 2002 was not consistent with OSHA‘s regulations. To help
ensure that similar situations do not occur in the future, we are
recommending that EPA, the Postal Service, and GSA revise their
guidelines to reflect OSHA‘s regulations for disclosing test results
requested by workers. Related to this, we are also recommending that
OSHA consider strengthening its regulatory requirements to require--in
emergency situations--full and immediate disclosure of test results to
workers, regardless of whether the information is requested by an
employee or his or her designated representative.
Finally, the union said that the report concluded that the Postal
Service followed its guidelines ’with one exception,“ without
explaining that the exception involved the sample containing about 3
million spores on one heavily contaminated mail-sorting machine.
According to the union, this exception placed employees at considerable
risk. As discussed in this report, we agree that the Postal Service‘s
decision not to release the quantitative results in December 2001
deprived the facility employees of information that may have been
useful to them in making informed decisions about whether to take or
continue taking antibiotics and whether to continue working in the
facility. However, we disagree that we have not adequately explained
the circumstances associated with this situation. Throughout the report
we discuss the results in question as well as the fact that the
quantitative test results were not communicated to workers.
Furthermore, the report clearly discusses the actual finding of about
’3 million spores,“ the ’concentration“ of spores that was communicated
to workers, as well as the fact that exposure to 3 million spores is
far more than the amount considered necessary to contract the disease.
On March 27, 2003, we received technical comments from an FBI unit
chief responsible for dealing with threats from weapons of mass
destruction. The FBI noted conditions that existed in the fall of 2001
that it believes might have contributed to some of the problems that we
identified at the Wallingford facility. These conditions included
uncertainties about anthrax testing and the interpretation of test
results and conflicting information about (1) what constituted a lethal
dose of anthrax and (2) the amount of spores needed to contract
inhalation anthrax. The FBI also commented on our recommendation that
agency guidelines specify the terminology that should be used to
communicate quantitative test results. Specifically, the FBI noted that
it believes that quantitative test results are not as helpful to
employees as qualitative information. The FBI also said that, in its
view, quantitative data are less applicable to the health and safety of
employees than qualitative information. As a result, the FBI suggested
that we revise our recommendation to specify that qualitative--rather
than quantitative--test results should be disclosed to workers.
While we agree that the prompt disclosure of qualitative test results
is important, we continue to believe that available guidelines need to
be revised to ensure that any quantitative test results are properly
disclosed. Thus, we have not revised our recommendation in this area.
Experts that we interviewed believe that, when available, quantitative
test result data can be helpful to employees. Further, CDC, the
Connecticut Public Health Department, and OSHA officials told us that
the full disclosure of test results is appropriate and that full
disclosure can help avoid misunderstandings, miscommunication,
confusion, and mistrust. Similarly, the experts we consulted--including
the former Director and Chief Executive Officer of the British Center
for Applied Microbiology Research--said that if the actual results had
been provided to postal employees, they would have had better
information for making informed medical decisions, particularly since
the amount of anthrax in the facility was much higher than the 8,000 to
10,000 spores that postal employees had been advised would likely be
needed to contract inhalation anthrax. A final reason for not revising
our recommendation is that by not providing quantitative test results
when requested by employees or their designated representatives, an
agency could be found in violation of OSHA regulations and, therefore,
subject to penalties for noncompliance.
OSHA and two HHS components--CDC and the Agency for Toxic Substances
and Disease Registry--provided technical comments via E-mail, which we
incorporated, as appropriate. OSHA did not comment on our
recommendation that the Assistant Secretary for Occupational Safety and
Health consider whether OSHA regulations should require--in emergency
situations--full and immediate disclosure of test results to workers,
regardless of whether the information is requested by an employee or
his or her designated representative. We also received technical
comments from the Chief Epidemiologist of the Connecticut Department of
Public Health in which he stated that, overall, the report accurately
portrays his role as well as the role of the Connecticut Department of
Public Health as it relates to the situation at the Wallingford
facility. He suggested a number of revisions to clarify this report,
which we incorporated. In a March 31, 2003, letter, HHS‘s Acting
Principal Deputy Inspector General said that the department had no
comments aside from the technical comments provided by two of its
components. Finally, we requested comments from the Secretary of
Homeland Security, but we did not receive any.
:
As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after the date of this letter. At that time, we will send copies to the
Chairman of the Senate Committee on Governmental Affairs; the Chairman
and Ranking Minority Member of the House Committee on Government
Reform; the Postmaster General; the Secretaries of HHS, Labor, and
Homeland Security; the Administrators of EPA and GSA; the Assistant
Secretary for Occupational Safety and Health; the Attorney General; the
Connecticut Department of Public Health; CDC; the Agency for Toxic
Substances and Disease Registry; the national American Postal Workers
Union; and other interested parties. Copies will be made available to
others on request and are also available at no charge on our Web site
at http://www.gao.gov.
If you have any questions about this report, please contact me on (202)
512-2834 or at ungarb@gao.gov. Key contributors to this assignment
were Don Allison, Hazel Bailey, Bert Japikse, Latesha Love,
Cady Summers, and Kathleen Turner. Jack Melling and Sushil K. Sharma
provided technical expertise.
Sincerely yours,
Bernard L. Ungar
Director, Physical Infrastructure Issues:
Signed by Bernard L. Ungar:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
Our objectives for this report were to determine (1) how and when
contamination was identified at the U.S. Postal Service‘s Southern
Connecticut Processing and Distribution Center in Wallingford,
Connecticut (Wallingford facility); (2) what and when information about
contamination was communicated to facility workers; (3) whether the
Postal Service followed applicable guidelines and requirements for
informing facility workers about the contamination; and (4) whether
lessons can be learned from the response to contamination at the
facility.
To address these objectives, we identified and, with Postal Service
headquarters, district, and facility managers, discussed the roles of
the agencies involved in investigating and responding to anthrax at the
Wallingford facility. We met with officials from the Postal Service,
the Connecticut Department of Public Health, the Centers for Disease
Control and Prevention (CDC), the Agency for Toxic Substances and
Disease Registry, the Occupational Safety and Health Administration
(OSHA), the Environmental Protection Agency, the Federal Bureau of
Investigation, the national American Postal Workers Union, and its
Greater Connecticut Area Local Union. We also requested and reviewed
agency documentation related to the testing of the facility and the
subsequent finding of anthrax contamination as well as documentation
about how, when, and what information the Postal Service communicated
to workers about the extent of contamination at the facility. The
information documented, among other things, the various roles of the
agencies involved, the laboratories‘ test results, sampling plans and
testing protocols, press releases, information about the content of
employee briefings, the Postal Service‘s guidelines for testing and
communicating anthrax test results, OSHA requirements for disclosing
records related to employee health risks, and more recent anthrax
guidelines developed by the General Services Administration and the
National Response Team.
We also interviewed officials from involved agencies to determine their
views and the extent of their involvement in the response to the
facility‘s contamination between November 2001 and June 2002.
Specifically, (1) what information was provided to employees at the
facility and when, and by whom, it was provided and (2) what lessons
can be learned about the response to contamination at the facility.
Finally, we reviewed published literature, including technical reports
on anthrax, and consulted several experts. We did not independently
assess or verify any of the laboratory test results, sampling plans, or
testing protocols to determine their accuracy or adequacy. Moreover,
because the Postal Service did not document all of the advice that it
received from public health officials or the precise information it
communicated to workers at the facility, we largely relied on the
recollections of Postal Service, public health, and other officials to
reconstruct these events. We conducted our review from September 2002
through March 2003 in Hartford, North Haven, New Haven, and Bridgeport,
Connecticut; Washington, D.C.; and Atlanta, Georgia, in accordance with
generally accepted government auditing standards.
[End of section]
Appendix II: Summary of Anthrax
Testing at the Wallingford Facility between November 2001 and April
2002:
[See PDF for image]
[End of figure]
[A] A fourth machine was suspected of being positive for anthrax on
December 2 but was not confirmed to be positive until later.
[B] Precisely when Postal Service headquarters and district managers
first became aware of the quantified test results is unclear. According
to CDC officials and the Chief Epidemiologist, they began discussing
the quantitative results with investigative team members, which they
believe included a district postal manager, on December 6, 2001.
However, district postal managers said that they were not involved in
discussions about the quantitative results until December 9. Absent
documentation, we were unable to reconcile these views.
[C] According to CDC, although the number of anthrax colonies can be
counted, it is not possible to count the exact amount of anthrax in the
environment because of uncertainties about how well a sample picks up
anthrax. In other words, there could be more anthrax in the environment
than can be picked up by a sample.
[D] District postal managers confirmed that the Chief Epidemiologist
faxed the quantitative results to the district office on December 9 (a
Sunday), and that district managers received the fax on December 10.
However, other documentation suggests that postal managers at
headquarters may have received the documented results on or about
December 8. Postal headquarters managers said that they do not recall
precisely when they received the documented results, and absent
definitive documentation, we were unable to determine when they first
knew about the quantitative test results.
[End of section]
Appendix III: Comments from the Environmental Protection Agency:
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY:
WASHINGTON, D.C. 20460:
MAR 21 2003:
OFFICE OF SOLID WASTE AND EMERGENCY RESPONSE:
Bernard L. Ungar:
Director, Physical Infrastructure Issues:
United States General Accounting Office (GAO) Washington, D.C. 20548:
Dear Mr. Ungar:
Thank you for the opportunity to review and comment on the draft report
entitled ’ U.S. Postal Service: Better Guidance is Needed to Improve
Communication Should Anthrax Contamination Occur in the Future ’ (GAO-
03-316). The Environmental Protection Agency (EPA), as Chair of the
National Response Team (NRT), provides this statement. The NRT
consulted with its members, including the Occupational Safety and
Health Administration (OSHA), the General Services Administration
(GSA), the Department of Health and Human Services (specifically, the
National Institute of Occupational Safety and Health), and the U.S.
Postal Service in preparing this letter.
The NRT believes the report provides a balanced presentation on anthrax
testing and communications with employees at the Wallingford,
Connecticut postal facility. We appreciate GAO efforts to produce an
accurate report. In general, the NRT agrees with the references and
recommendations regarding the content of the NRT‘ s Technical
Assistance for Anthrax Response (TAD). It is important to note,
however, that the TAD was carefully written as a technical resource
document, as opposed to a directive or guidance. Knowledge on anthrax
response is evolving rapidly, and each situation is unique. As a
result, the TAD does not prescribe specific actions that should be
taken in every case, but provides scientific background and viable
options for responders to consider in addressing specific
circumstances. However, we believe that we can make certain
improvements to the TAD that will be responsive to GAO‘ s
recommendations.
The enclosure provides EPA‘s technical comments for GAO‘s consideration
when preparing the final report. If you have questions about any of
these comments, please contact Karen Burgan at (703) 603-9917.
Sincerely,
Marianne Lamont Horinko
Assistant Administrator
Signed by Marianne Lamont Horinko
Enclosure:
Enclosure:
EPA Comments on Technical Accuracy of the GAO Report:
1) The total number of cases of anthrax resulting from the 2001 attacks
was 23, not 22 as stated in the Highlights section and in the first
paragraph of the letter to Senator Lieberman. There were 11 cases of
inhalational anthrax and 12 cases of cutaneous anthrax. The last case
of cutaneous anthrax occurred in a laboratory worker who was handling a
sample known to contain anthrax spores from the bioterrorism attack.
The worker cut himself shaving earlier in the day in which he was
working with the anthrax sample. He failed to follow proper precautions
in handling the material and thereafter developed cutaneous anthrax at
the site of the cut.
2) On page 3, it is not specified whether the area containing the
contaminated sorting machines was re-opened for mail sorting after the
December 2001 cleanup and before the April 2002 sampling event in which
anthrax spores were found in the samples taken above the cleaned
machines. This information should be included in the final report as it
pertains to both risk assessment and risk communication to the affected
postal workers.
3) On page 6, second paragraph, line 4, add ’ undercooked ’ between ’
ingesting ’ and ’ contaminated meat. ’:
4) On page 7, second paragraph, it should be noted that anthrax spores
were also not found in the home or workplace of the female hospital
worker in New York City who died of inhalational anthrax in October
2001. This fact is also relevant to the potential number of spores
needed to cause disease/death in exposed persons.
5) Table 1, page 9, would be enhanced by including the number of
samples taken in each of the six sampling events at Wallingford. The
numbers of samples taken for the last three events are given in the
text, but no numbers are presented for the first three sampling events.
These numbers are relevant to the risk assessment/risk communication
activities at Wallingford and should be included in the final report,
both in the text and in Table 1.
6) On page 12, second paragraph, summary information on the manner in
which the contaminated machines were cordoned off to prevent migration
of contamination from that area to other parts of the facility should
be included in the final report.
[End of section]
Appendix IV: Comments from the U.S. Postal Service:
PATRICK R. DONAHOE CHIEF OPERATING OFFICER AND ExECUTIVE VICE
PRESIDENT:
UNITED STATES POSTAL SERVICE:
March 31, 2003:
Mr. Bernard L. Ungar:
Director, Physical Infrastructure Issues United States General
Accounting Office Washington, DC 20548-0001:
Dear Mr. Ungar:
Thank you for providing the United States Postal Service the
opportunity to review and comment on the GAO draft report, U.S. Postal
Service: Better Guidance Is Needed to Improve Communication Should
Anthrax Contamination Occur in the Future. This report examined events
relating to the anthrax contamination of the Southern Connecticut
Processing and Distribution Center located in Wallingford, Connecticut.
We stress that the safety and security of our employees and customers
were at the time, and continue to be, of the utmost importance to the
Postal Service. The Postal Service made every effort to move quickly to
protect its employees and to safeguard the mail commencing November 20,
2001, when notified that a Connecticut resident was suspected of having
contracted inhalation anthrax. The Postal Service immediately began
testing at the facility, informing its employees of the situation, and
ensuring that antibiotics were provided to them. We note, as did GAO in
its draft report, that none of the employees at the facility became ill
as a result of the anthrax contamination.
We appreciate GAO‘s acknowledgement that decisions made by the Postal
Service relating to events that transpired at the facility were
understandable, given the circumstances at the time, advice received
from public health agencies, an ongoing criminal investigation, and
uncertainties surrounding the sampling methods used. It should be noted
that, at the time, there were no guidelines and no designated
regulatory agency for dealing with this type of situation. The Postal
Service acted quickly and prudently to communicate pertinent
information to its employees, rely-ing upon the advice of public health
experts. We understand, however, that there are always opportunities
for improvement in our future communication efforts regarding anthrax
or other biohazards.
We realize that recollections of events occurring in a difficult
atmosphere may vary, particularly after more than a year has passed.
Nonetheless, our focus has been and will remain on provid-ing complete
and accurate information to our employees as promptly as possible
regarding any situation that may affect their health and safety.
With regard to GAO‘s specific recommendations, the Postal Service is
committed to working with the National Response Team (NRT) in making
appropriate revisions to the Technical Assistance Document (TAD) for
Anthrax Response. The Postal Service fully realizes the challenges
faced by the NRT in going forward on this issue. We plan to revise
Postal Service guidelines in this area so that they are consistent with
the TAD. We agree that test results, including quantified results if
available, should be released to employees and others as quickly as
possible. We further agree that in communicating available test
results, the testing methods used should be specified and any
limitations of either the testing methods or the test results should be
explained. The Postal Service will make every effort, as it did at
Wallingford, to consult with appropriate federal, state, and local
agencies in deciding on appropriate communications to employees and
others. Also, we acknowledge the importance of attempting to develop
and maintain sufficient records concerning communications on health-
related information to employees and others. The Postal Service is
aware of its obligations to release testing information to employees
and their unions when requested.
If you or your staff would like to discuss any of these comments, I am
available at your convenience.
Sincerely,
Patrick R. Donahoe
Signed by Patrick R. Donahoe
[End of section]
Appendix V: Comments from the American Postal Workers Union:
American Postal Workers Union, AFL-CIO:
1300 L Street, NW, Washington, DC 20005:
March 25, 2003:
William Burrus President:
(202) 842-4246:
Mr. Bernard L. Ungar:
Director, Physical Infrastructure Issues General Accounting Office:
441 G Street, N.W., Mailroom #2T23B Washington, D.C. 20548:
Re: Review of Draft GAO-Pub No. (GAO-03-316):
Report to the Ranking Minority Member Committee on Government Affairs
United States Senate:
Titled:
U.S. Postal Service:
Better Guidance Is Needed To Improve Communication Should Anthrax
Contamination Occur in the Future:
Dear Mr. Ungar:
The following is presented as comments after APWU‘s review of the above
referenced document. We viewed the document as very generous toward the
USPS response to the events and lacks considerably in presenting the
union‘s perspective of the facts. One of the most disturbing items is
that the report portrays the events as acceptable based upon the
circumstances, but fails to highlight that the actions were
inconsistent with both Postal Service practice/policy and OSHA
regulations.
The report provides a number of facts about the circumstances
surrounding the events at the anthrax contamination Wallingford, CT
facility, but a number of conclusions are not fully supported by the
facts.
The claim by the Postal Service that the results had not been validated
is not supported by the facts. The Manager of the Command center
reported the results and the Postal Services own guideline required the
reporting of validated results. (2-4.2.1 Noting Key Agencies and U.S.
Postal Service Officials. Results from anthrax sampling and analysis
are not released to the affected facility or the public until the
confirmed data is received from the CDC and/or State Public Health
Laboratories. All confirmed data must be validated before it. is sent
directly to the Managers, Safety Performance Management and
Environmental Management Policy, at U.S. Postal Service Headquarters.
In turn these managers will notes the U.S. Postal Service Headquarters
Unified Incident Command Center managing all anthrax sampling,
analysis, and decontamination work. The Headquarters Unified Incident
Command Center Manager (or his/her designee) will release validated
data simultaneously via FAX and phone to the following agencies, union
representatives, management representatives, and the contractors‘
representatives] The conclusions must be that the results were
considered validated when reported by the Manager of the Command
Center. Further, the decision not to report the quantitative results
even after a formal request by the local union president was made in
spite of OSHA regulation requiring the employer to provide exposure
data to employees and employee representatives. The Postal Services
requirements are that the facility manager notifies employees and
unions of the results. In essence the GAO concludes that it is
understandable and even acceptable that the Postal Services, given the
circumstances, failed to follow the law (OSHA Standards) providing
essential worker protection.
The report concludes that the Postal Service followed its guidelines
’with one exception“ without noting that the exception involved those
samples showing significant concentrations of anthrax spores. This
exception placed the employees of the facility at considerable risk. It
is very disturbing that the report draws the conclusion that ’under the
circumstances it is understandable“ that the Postal Service did not
report the quantitative results for nine months. We are unaware of any
circumstances under which it is understandable to ignore statuary
worker protection standards. The OSHA regulation 29 CFR 1910.1020 is
clear in stating that exposure data must be provided to employees and
employee representatives. It does not imply nor state that the employer
may withhold exposure data if they so choose. If there were any
question as to the accuracy or ’validity“ of the results it should have
been explained not withheld.
The report states that the Postal Service followed the advice of the
Chief Epidemiologist. This fact demonstrates that the Postal Service
received validated information from an acceptable source, a local
health department, to the postal guidance document. Further, the
responsibility for worker protection in the workplace falls to OSHA,
not CDC nor Local Health departments. Although advice was provided by a
Local Health Department, it was nothing more than advice, and did not
in any way relieve the Postal Service from compliance with workplace
standards.
GAO has recommended that additional effort be made to better coordinate
communication between Federal agencies when events occur. We agree, but
strongly believe that the Union must be an intrigual part of this
process. Unions represent the worker and workers better understand the
work process as it is performed if they and their representatives are
informed.
As a statement of findings, the report concludes that ’none of the
employees at the facility became sick from anthrax contamination.“ This
statement without explanation is misleading. Employees were being
treated with antibiotics since early in the process and this treatment
was most likely a significant contributing factor in the lack of
reported illness.
In closing, we thank you for your efforts in gathering the facts and
reporting findings. We question the conclusions and most particular
that GAO could find that under any circumstances it would be acceptable
to withhold exposure information from the workers. In this time of
heightened alert, the employer must provide adequate and timely
information that the employee is afforded adequate protection from
harm. It is never understandable that an employer can deny or inhibit
this opportunity for self protection.
Sincerely,
William Burrus
President
WB:hfa:
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[End of section]
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] The elevated areas of the facility--known as the ’high bay“--
include pipes, ducts, lights, joists, beams, and overhead conveyors.
[3] The term ’colony-forming units“ refers to the number of living
cells in a sample and is typically reported per gram of material
sampled for High Efficiency Particulate Air vacuum samples and per
square inch for samples collected using wipes.
[4] Herbivores are animals that eat plants.
[5] Cutaneous means of, relating to, or affecting the skin. Cutaneous
anthrax is characterized by lesions on the skin.
[6] The last cases of anthrax from this release occurred 43 days after
the individuals‘ exposure.
[7] According to CDC, the estimate of 8,000 to 10,000 spores is from a
Department of Defense, Defense Intelligence Agency publication entitled
Soviet Biological Warfare Threat, DST-161OF-057-86 (Washington, D.C.:
1986).
[8] In commenting on our draft report, EPA noted that anthrax spores
also were not found in the home or workplace of a female hospital
worker who died from inhalation anthrax in October 2001 in New York
City.
[9] Two other contaminated letters were sent to a television news
anchor and the editor of The New York Post in New York City on or
around September 18, 2001. Although the letters were processed through
the Hamilton/Trenton facility, it is not known whether the letters
contaminated the Wallingford facility.
[10] Epidemiology is a branch of medical science that investigates the
incidence, distribution, and control of disease in a population.
[11] Swabs can be either wet or dry and have small surface areas
(similar to Q-tipsŪ). Swabs are typically used to sample small,
nonporous surface areas (less than 100 sq. cm) that do not have a large
accumulation of dust. Depending upon the circumstances, wet swabs may
attract more particles of sample material than dry swabs.
[12] Wet wipes are sterile gauze pads, approximately 3 inches square.
Wet wipes are typically used for sampling larger (more than 100 sq.
cm), nonporous surface areas.
[13] This machine was suspected of being positive for anthrax on
December 2, but that suspicion was not confirmed until later.
[14] The sample collected 0.55 grams of material (dust) from the
heavily contaminated machine. The laboratory adjusted its analyses to
reflect a full gram of sample and reported the presence of 5.5 million
colony-forming units per gram of material sampled. The Chief
Epidemiologist subsequently determined, through extrapolation, that
the 0.55 grams of material sampled contained approximately 2.9 million
colony-forming units of anthrax. According to the Chief Epidemiologist,
this finding was equivalent to about 3 million spores. In this report,
we refer to the 2.9 million colony-forming units for the 0.55 grams of
material actually sampled.
[15] The number of colony-forming units was not provided for any of the
other positive samples. The other samples were collected using wet
wipes, which, according to the Chief Epidemiologist, did not allow for
measuring the amount of dust collected.
[16] According to the contractor‘s report on the decontamination, the
mail-sorting machines were enclosed in ’6-mil polyethylene sheeting“
supported by wood frames. Further, according to the report, air
filtration devices, with exhausts to the outside, were installed to
maintain negative air pressure inside each of the four enclosures.
[17] Specifically, the test results indicated (1) 1 colony from 7.50
grams of material sampled, (2) 10 colonies and 11 colonies from 7.69
grams of material sampled, and (3) 13 colonies and 18 colonies from
5.67 grams of material sampled.
[18] During the period of decontamination, many of the facility‘s mail
processing operations were transferred to other postal facilities.
[19] As previously discussed, a fourth machine also tested positive for
anthrax on the basis of samples collected on November 28, 2001.
However, the positive results were not confirmed until after December
2, 2001.
[20] Although individuals have contracted inhalation anthrax 43 days
after their exposure to the disease, according to the Chief
Epidemiologist and CDC literature, individuals exposed in the 2001
anthrax incidents typically contracted inhalation anthrax within 4 to 6
days. In the view of public health officials, the letters to Senators
Daschle and Leahy entered the mail stream on or about October 9, 2001-
-weeks before contamination was identified at the facility and, thus,
well after the period they viewed as the likely period of maximum risk
of exposure to the disease.
[21] The Postal Service also issued a statement to the news media on
December 2, 2001. Referring to the November 28 sampling, the press
release stated that ’trace amounts“ of anthrax had been identified on
three mail-sorting machines in the facility. The press release quoted
the Connecticut Commissioner of Public Health as saying that, ’This is
a very small amount of anthrax.“ The press release further indicated
that, according to public health officials, the contamination posed ’no
health risk“ to postal employees or their customers, in part because
the machines had already been isolated and were to be decontaminated.
[22] In commenting on our draft report, postal headquarters officials
also indicated that, on December 12, 2001, the District Manager and the
Inspector in Charge for the Northeast Area met with the Chief
Epidemiologist, the Commissioner of the Connecticut Department of
Public Health, and the Connecticut Governor and his staff.
[23] The President of the Greater Connecticut Area Local American
Postal Workers Union indicated that there is no record or evidence
indicating that the union leadership or workers were ever advised about
the change in the level of contamination from ’trace amounts“ to a
’concentration of spores“ on one of the mail-sorting machines.
[24] According to the Chief Epidemiologist and district postal
managers, the Chief Epidemiologist also informed workers about the
December 2001 quantified results, including the finding of about 3
million spores on one mail-sorting machine.
[25] The Postal Service also issued a press release communicating
similar information.
[26] U.S. Postal Service, Interim Guidelines for Sampling, Analysis,
Decontamination, and Disposal of Anthrax for U.S. Postal Service
Facilities (Dec. 4, 2001). The guidelines were developed as the anthrax
crisis unfolded with input and guidance from several federal agencies,
including CDC and OSHA, and the national unions that represent postal
workers.
[27] The Postal Service‘s guidelines do not define the meaning of the
terms ’confirmed“ and ’validated.“
[28] Although the Postal Service began relaying information about the
concentration of spores on one machine on December 12, we were unable
to determine whether the Postal Service also relayed the specific
results of samples collected on December 2. As discussed in appendix
II, the Postal Service received these results on or around December 9.
The results identified unspecified amounts of contamination (i.e.,
’positives“) on (1) 30 of 52 samples collected from the heavily
contaminated machine, (2) 3 of 52 samples from a second machine, and
(3) 1 of 48 samples from each of the two other mail-sorting machines.
[29] As previously discussed, in March 2003, postal headquarters
managers told us that there were errors in this chronology that they
believe were not corrected and that they do not recall precisely when
they received the documented results. Absent definitive documentation
of when Postal Service headquarters received the test results and
documentation of the discussions between public health and postal
managers, we were unable to determine when Postal Service headquarters
managers first learned of the quantitative test results.
[30] In its technical comments on our draft report, CDC noted that the
HEPA vacuum sample, which identified 2.9 million colony-forming units
of anthrax, had been taken on the feeder mechanism of a mail-sorting
machine. While the precise surface area of the feeder mechanism would
be difficult to measure, CDC noted that the mechanism is an important
part of the mail‘s pathway through the machine. Thus, even though there
are limitations in the ability to measure such areas, CDC pointed out
that there is value in sampling these types of complex mail processing
surfaces.
[31] For additional information about the rationale for the sampling
methods used at Wallingford as well as information about related
validation issues, see CDC, Environmental Sampling for Spores of
Bacillus anthracis. Emerging Infectious Diseases. Vol 8. No. 10.
(October 2002).
[32] Unlike its actions in December 2001, the Postal Service
immediately provided all of the test results, including the quantified
results of from 1 to 18 colony-forming units, to employees at the
facility in April 2002. Full and immediate disclosure of the April 2002
test results had been recommended by an OSHA official to avoid
miscommunication, confusion, and workers‘ concern about how the data
may have been interpreted. The decision to release the results also
appears consistent with the Postal Service‘s guidelines because,
according to the Postal Service, the sampling and analyses were
performed by a Service contractor in accordance with the Service‘s
procedures and protocols for sampling. According to the Manager of the
Command Center, this allowed the Postal Service to validate the
results.
[33] In addition to its participation on the investigation team at
Wallingford, the FBI also was conducting a separate criminal
investigation related to the facility‘s contamination. The U.S. Postal
Inspectors, the U.S. Attorney‘s Office, the Connecticut Department of
Public Health, and CDC were also members of the criminal investigation
team.
[34] Since the amount of surface area collected for the sample
containing about 3 million spores was not recorded, investigators could
not determine whether the spores had been spread over the sample area
or clumped together in one spot. Also, according to a team member, it
was not clear how to extrapolate the result from the surface sample
into its potential for existing in the air. (Additional information on
the interpretation of surface sampling results is contained in CDC‘s
MMWR Weekly, December 21, 2001, and in its fact sheet entitled
Comprehensive Procedures for Collecting Environmental Samples for
Culturing Bacillus anthracis (revised April 2002).
[35] Within the context of the regulation, ’records“ include exposure
and medical records. More specifically, records include ’environmental
workplace monitoring or measuring of a toxic substance or harmful
physical agent, including personal, area, grab, wipe, or other form of
sampling, as well as related collection and analytical methodologies,
calculations, and other background data relevant to interpretation of
the results obtained.“
[36] 29 C.F.R. § 1910.1020 (e)(1)(i).
[37] OSHA may cite the following violations with or without a fine:
’Other than Serious,“ ’Serious,“ ’Repeated,“ ’Failure to Abate,“ and
’Willful.“
[38] The union leader also requested test results from the post office
in Seymour, Connecticut--the post office that delivered mail to the
deceased woman‘s home.
[39] A March 26, 2002, article in The New York Times discussed a
presentation by the Chief Epidemiologist about contamination at the
facility, including the finding of ’about 3 million spores“ from a
sample collected in November 2001. The Chief Epidemiologist told us
that he presented this information at an international conference on
emerging infectious diseases because he wanted to emphasize the
importance of maintaining the Postal Service‘s restriction on the use
of compressed air to clean its facilities to ensure that any residual
spores at Wallingford and other postal facilities are not blown
elsewhere in the facilities.
[40] The Commissioner told us that he was not aware that his department
had not provided the requested test results. We did not evaluate state
laws related to the release of epidemiological data because doing so
was outside the scope of our work.
[41] Sampling performed by CDC investigators and Postal Service
contractors at the Brentwood facility in October 2001 identified from
8,700 to 2 million colony-forming units per gram of material collected
from high-speed mail-sorting machines and areas near the machines. CDC
published the results in December 2001. See MMWR Weekly, December 21,
2001/50(50); 1129-1133.
[42] According to CDC, it consulted with the FBI to determine whether
the request was subject to 45 C.F.R. § 568, which permits CDC to
withhold information that would interfere with ongoing law enforcement
proceedings.
[43] According to a November 26, 2002, OSHA letter to the union leader,
the Postal Service did not have a copy of the December 2001 quantified
results until August 13, 2002. Our work showed that the Postal Service
headquarters may have received documentation of the quantified test
results on or about December 8, 2001, and that the district had the
written results on December 10. Further, both of the offices maintained
copies of the results throughout the period in question. Postal Service
officials told us they did not know why OSHA was unaware that they had
the results. Although OSHA provided us with documentation associated
with its investigation, the source of misinformation about the Postal
Service‘s possession of the quantitative test results could not be
discerned from the material provided. Furthermore, our discussions with
postal and OSHA officials did not enable us to resolve this issue.
[44] According to the Postal Service, district postal managers--through
the U.S. Postal Inspection Service--contacted the FBI before releasing
the December 2001 quantified test results in September 2002. According
to the Postal Service, the FBI told a member of the Inspection Service
that the quantified data could be released since the information
already had been discussed at a CDC conference and reported in the
newspapers.
[45] GSA is responsible for providing workspace and security for many
federal agencies. The agency also offers guidance and policies for
various government functions, including mail management. These
guidelines are entitled GSA Policy Advisory: Guidelines for Federal
Mail Centers in the Washington, DC Metropolitan Area for Managing
Possible Anthrax Contamination.
[46] GSA emphasized that the guidelines developed by the National
Response Team should be the primary source of advice for anyone
managing a credible threat situation. GSA explained that its guidelines
deal primarily with actions that managers of federal mail centers in
the Washington, D.C., area should take to prepare for possible anthrax
threats and to determine whether an anthrax threat is credible. As a
result, once a credible threat has been identified, responsibility for
managing the situation passes from the manager of the mail center to
law enforcement, public health, and other authorities.
[47] GSA and EPA--as the Chair for the National Response Team--
explained that, by design, their guidelines were not intended to
prescribe specific actions because knowledge about how to respond to
anthrax is evolving rapidly, and each situation is unique. Instead, the
agencies indicated that their guidelines provide background information
and viable options for individuals who, in the case of GSA‘s
guidelines, operate and manage federal mail centers or, in the case of
guidelines developed by the National Response Team, respond to anthrax
attacks.
[48] We consulted with numerous experts in the field of microbiology,
including Dr. Jack Melling, former Director and Chief Executive Officer
of the British Center for Applied Microbiology Research; Dr. Paul Keim,
Professor in Microbiology, Northern Arizona University; Col. Eric
Henchal, Department of the Army; and Dr. Barbara Johnson, former Safety
Officer at the Dugway Proving Grounds, Department of the Army.
[49] The National Response Team‘s September 2002 draft guidelines agree
that methods have not been validated for a variety of sampling
techniques. Accordingly, the guidelines recommend that agencies use ’a
multi-disciplinary team“ to help them interpret anthrax test results.
Relating to this, according to CDC, it is important to scrutinize new
sampling techniques, such as the HEPA vacuum, to understand the
strengths and limitations of the methods so that the methods can be
subsequently validated.
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