U.S. Postal Service
Better Guidance Is Needed to Ensure an Appropriate Response to Anthrax Contamination Gao ID: GAO-04-239 September 9, 2004In September and October 2001, at least four letters containing anthrax spores were mailed to news media personnel and two U.S. Senators, leading to the first cases of bioterrorism-related anthrax in the United States. The contaminated letters, which were delivered through the U.S. mail system, caused 22 cases of anthrax, 5 of them fatal. Nine postal employees associated with two postal facilities that processed the letters--Trenton in New Jersey and Brentwood in Washington, D.C.--contracted anthrax and two Brentwood employees died. The U.S. Postal Service closed Trenton and Brentwood, but other contaminated postal facilities remained open. GAO's review covers Trenton, Brentwood, and three of these other facilities. As requested, this report describes (1) the factors considered in deciding whether to close the five facilities, (2) the information communicated to postal employees about health risk and the extent of the facilities' contamination, and (3) how lessons learned from the response to the contamination could be used in future situations.
According to Postal Service managers, public health officials, and union representatives, the Postal Service considered the health risks to its employees ahead of its mission to deliver the mail in deciding whether to close postal facilities. The Postal Service relied on public health agencies to assess the health risks to its employees. These agencies believed the risks to be minimal until the Centers for Disease Control and Prevention (CDC) confirmed cases of anthrax in postal employees at Trenton and Brentwood. The Postal Service then closed these facilities. Public health agencies underestimated the health risks to postal employees, in part, because they did not know that anthrax spores could leak from taped, unopened letters in sufficient quantities to cause a fatal form of anthrax. The Postal Service kept the three other facilities covered by GAO's review open because public health officials had advised the agency that employees at those centers were at minimal risk. CDC and the Postal Service have said they would have made different decisions if they had earlier understood the health risks to postal employees. The Postal Service communicated information to affected postal employees about the health risks posed by, and the extent of, anthrax contamination at the five facilities in GAO's review, but problems with accuracy, clarity, and timeliness led employees to question the information they received. Problems with accuracy stemmed from incomplete information about health risks, and problems with clarity occurred as information on the medical response to anthrax contamination changed with experience. Problems with timeliness occurred when the Postal Service delayed the release of quantitative data (anthrax spore counts) for one facility, in part because it was uncertain what the results meant for worker safety and public health. To communicate more effectively, the Postal Service has established a center to coordinate information within the postal system and has worked with other agencies to develop guidelines for responding to anthrax. The response to anthrax contamination revealed several lessons, the most important of which is that agencies need to choose a course of action that poses the least risk of harm when considering actions to protect people from uncertain and potentially life-threatening health risks. Because public health officials underestimated the health risks involved, actions to protect postal employees were delayed. In addition, agencies' guidance did not cover all of the circumstances that occurred. The Postal Service has since revised its guidance, but the revised guidance (1) does not define some key terms, including those that would trigger a decision to evacuate a facility, (2) includes some outdated references that could cause confusion during a future response, and (3) does not address certain issues, such as what steps would be taken during the interval between a diagnosis of anthrax in a postal employee and confirmation of the disease. In addition, the guidance does not reflect proactive measures, including facility closures, that the Postal Service has recently implemented in response to suspected contamination.
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-04-239, U.S. Postal Service: Better Guidance Is Needed to Ensure an Appropriate Response to Anthrax Contamination
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Report to Congressional Requesters:
September 2004:
U.S. POSTAL SERVICE:
Better Guidance Is Needed to Ensure an Appropriate Response to Anthrax
Contamination:
GAO-04-239:
GAO Highlights:
Highlights of GAO-04-239, a report to congressional requesters
Why GAO Did This Study:
In September and October 2001, at least four letters containing anthrax
spores were mailed to news media personnel and two U.S. Senators,
leading to the first cases of bioterrorism-related anthrax in the
United States. The contaminated letters, which were delivered through
the U.S. mail system, caused 22 cases of anthrax, 5 of them fatal. Nine
postal employees associated with two postal facilities that processed
the letters”Trenton in New Jersey and Brentwood in Washington, D.C.”
contracted anthrax and two Brentwood employees died.
The U.S. Postal Service closed Trenton and Brentwood, but other
contaminated postal facilities remained open. GAO‘s review covers
Trenton, Brentwood, and three of these other facilities. As requested,
this report describes (1) the factors considered in deciding whether to
close the five facilities, (2) the information communicated to postal
employees about health risk and the extent of the facilities‘
contamination, and (3) how lessons learned from the response to the
contamination could be used in future situations.
What GAO Found:
According to Postal Service managers, public health officials, and
union representatives, the Postal Service considered the health risks
to its employees ahead of its mission to deliver the mail in deciding
whether to close postal facilities. The Postal Service relied on public
health agencies to assess the health risks to its employees. These
agencies believed the risks to be minimal until the Centers for
Disease Control and Prevention (CDC) confirmed cases of anthrax in
postal employees at Trenton and Brentwood. The Postal Service then
closed these facilities. Public health agencies underestimated the
health risks to postal employees, in part, because they did not know
that anthrax spores could leak from taped, unopened letters in
sufficient quantities to cause a fatal form of anthrax. The Postal
Service kept the three other facilities covered by GAO‘s review open
because public health officials had advised the agency that employees
at those centers were at minimal risk. CDC and the Postal Service have
said they would have made different decisions if they had earlier
understood the health risks to postal employees.
The Postal Service communicated information to affected postal
employees about the health risks posed by, and the extent of, anthrax
contamination at the five facilities in GAO‘s review, but problems with
accuracy, clarity, and timeliness led employees to question the
information they received. Problems with accuracy stemmed from
incomplete information about health risks, and problems with clarity
occurred as information on the medical response to anthrax
contamination changed with experience. Problems with timeliness
occurred when the Postal Service delayed the release of quantitative
data (anthrax spore counts) for one facility, in part because it was
uncertain what the results meant for worker safety and public health.
To communicate more effectively, the Postal Service has established a
center to coordinate information within the postal system and has
worked with other agencies to develop guidelines for responding to
anthrax.
The response to anthrax contamination revealed several lessons, the
most important of which is that agencies need to choose a course of
action that poses the least risk of harm when considering actions to
protect people from uncertain and potentially life-threatening health
risks. Because public health officials underestimated the health risks
involved, actions to protect postal employees were delayed. In
addition, agencies‘ guidance did not cover all of the circumstances
that occurred. The Postal Service has since revised its guidance, but
the revised guidance (1) does not define some key terms, including
those that would trigger a decision to evacuate a facility, (2)
includes some outdated references that could cause confusion during a
future response, and (3) does not address certain issues, such as what
steps would be taken during the interval between a diagnosis of anthrax
in a postal employee and confirmation of the disease. In addition, the
guidance does not reflect proactive measures, including facility
closures, that the Postal Service has recently implemented in response
to suspected contamination.
What GAO Recommends:
GAO is making recommendations to help ensure that the Postal Service
has comprehensive, clear, accurate, and up-to-date guidance for any
future anthrax response. The Postal Service indicated that it had taken
or would take action on GAO‘s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-239.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Mark L. Goldstein at
(202) 512-2834 or goldsteinm@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Postal Service Primarily Considered Health Risks to Employees in
Deciding to Close Facilities:
Communication Problems Raised Employees' Concerns:
Several Lessons Emerged from the Response to Anthrax Contamination:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendixes:
Appendix I: Comparison of Medical Services and Reassignment Benefits
Provided to Postal Employees at Selected Facilities:
Similar Medical Services Were Provided to Employees at the Five
Facilities, but the Timing of the Services Varied:
Employees at the Two Closed Facilities Received Various Reassignment
Benefits That Lasted for Different Periods of Time:
Appendix II: Objectives, Scope, and Methodology:
Appendix III: Time Line of Key Events, Fall 2001:
Appendix IV: Comments from the U.S. Postal Service:
Appendix V: Comments from the Centers for Disease Control and
Prevention:
Tables:
Table 1: Characteristics of the Five Processing and Distribution
Centers in Our Review, Fall 2001:
Table 2: Distribution of Anthrax Cases, Fall 2001:
Table 3: Key Events and Selected Medical Services Provided to Employees
at the Five Postal Facilities:
Table 4: Postal Facilities Closed for Other Emergencies, January 1,
1998, through December 31, 2002:
Figures:
Figure 1: Date in 2001, Type, and Location of Anthrax Cases:
Abbreviations:
ABC: American Broadcasting Company:
CBS: Columbia Broadcasting System:
CDC: Centers for Disease Control and Prevention:
FBI: Federal Bureau of Investigation:
GAO: Government Accountability Office:
HEPA: high efficiency particulate air:
NBC: National Broadcasting Company:
OSHA: Occupational Safety and Health Administration:
Letter September 9, 2004:
The Honorable Joseph I. Lieberman:
Ranking Minority Member:
Committee on Governmental Affairs:
United States Senate:
The Honorable Christopher H. Smith:
House of Representatives:
The Honorable Eleanor Holmes Norton:
House of Representatives:
The first cases of bioterrorism-related anthrax in the United States
occurred in September and October 2001 when at least four letters
containing anthrax[Footnote 1] spores were mailed to news media
personnel and two U.S. Senators. The contaminated letters, which were
delivered through the U.S. mail system, caused 22 cases of anthrax
during the fall of 2001--11 from inhalation anthrax, an often-fatal
form of the disease, and 11 from cutaneous (skin) anthrax, a readily
treatable form.[Footnote 2] Nine of the 22 cases of anthrax involved
postal employees, including two of the five individuals who died from
inhalation anthrax.
The U.S. Postal Service responded to this crisis by testing and closing
two heavily contaminated processing and distribution centers--the
Trenton facility in Hamilton, New Jersey, and the Brentwood facility in
Washington, D.C.[Footnote 3] Testing also identified contamination at
21 other postal facilities, including 3 processing and distribution
facilities in West Palm Beach, Florida; New York City, New York (the
Morgan facility); and Wallingford, Connecticut.[Footnote 4] Brentwood
was decontaminated and renovated and was fully operational as of
December 22, 2003.[Footnote 5] Trenton also has been decontaminated
and is expected to reopen in February 2005. Contaminated areas in the
three other processing and distribution centers were isolated and
decontaminated while operations continued elsewhere in the centers.
[Footnote 6]
We previously reported on the Postal Service's response to anthrax
contamination at the Wallingford processing and distribution center in
Connecticut[Footnote 7] and testified on specific issues related to the
reopening of the Brentwood facility.[Footnote 8] Our work at the
Wallingford facility identified communication difficulties and delays
in disclosing test results to employees. Our testimony identified other
communication problems associated with the reopening of the Brentwood
facility. As you requested, for this report, we reviewed the Postal
Service's response to anthrax contamination at five contaminated
processing and distribution centers--the Trenton, Brentwood, Morgan,
Wallingford, and West Palm Beach postal processing and distribution
centers.[Footnote 9] Specifically, you asked us to describe:
* the factors considered in deciding whether to close the five
facilities and the actions taken to protect postal employees;
* the information communicated to affected postal employees about the
health risks posed by, and the extent of, contamination in the five
facilities; and:
* how lessons learned from the response to the contamination could be
used in future situations.
You also asked us to determine what, if any, medical services and
reassignment benefits were provided to employees at the five facilities
and how these benefits compared across these facilities as well with
those provided to employees at facilities closed for other emergencies
between January 1, 1998, and December 31, 2002. A lesson learned
related to the need for an emergency medical plan is discussed toward
the end of this report, and a description of the medical services and
reassignment benefits is discussed in appendix I.
To address our reporting objectives, we analyzed, among other things,
pertinent reports, studies, scientific literature, and guidance for
responding to anthrax, including public health and postal guidance for
closing postal facilities. We also interviewed federal, state, and
local officials involved in investigating and responding to anthrax
contamination at the five postal processing and distribution centers in
our review.[Footnote 10] We discussed, among other matters, the roles,
responsibilities, activities, and lessons learned by the U.S. Postal
Service, the Centers for Disease Control and Prevention (CDC) and its
National Institute for Occupational Safety and Health within the
Department of Health and Human Services, the Federal Bureau of
Investigation (FBI) within the Department of Justice, the Environmental
Protection Agency, the Occupational Safety and Health Administration
(OSHA) within the Department of Labor, and the U.S. Army Medical
Research Institute of Infectious Diseases within the Department of
Defense. We also interviewed local public health officials, postal
managers, and union representatives associated with each of the five
processing and distribution centers. In addition, we met with
representatives of a group of employees who worked at the Brentwood
facility prior to its closure. We did not examine issues related to the
other 18 postal facilities that tested:
positive for anthrax or matters that are being litigated.[Footnote 11]
Likewise, we did not assess the response to the anthrax contamination
at the Hart Senate Office Building in Washington, D.C., because these
activities were also outside the scope of our work. However, a previous
GAO report provides information on this topic,[Footnote 12] which we
incorporated in this report as appropriate. We performed our work from
January 2003 through July 2004 in accordance with generally accepted
government auditing standards. Further details about our scope and
methodology appear in appendix II.
Results in Brief:
According to postal managers, public health officials, and union
representatives, the Postal Service considered the health risks to its
employees ahead of its mission to deliver the mail in deciding whether
to close postal facilities. Although the Postal Service had guidance
that called for closure following the discovery of a suspicious letter
or a powder spill at a facility, it did not consider this guidance
applicable because neither a suspicious letter nor a powder spill was
discovered at Trenton or Brentwood. As a result, the Postal Service
relied on public health agencies to assess the health risks to its
employees, and as long as these agencies advised the Postal Service
that the health risks were minimal, it kept the facilities open. When
CDC confirmed that employees at Trenton and Brentwood had contracted
cutaneous and inhalation anthrax, respectively, the Postal Service
closed these facilities within hours. At the time, CDC recommended that
facilities be closed for inhalation anthrax, but not for cutaneous
anthrax, since this form of the disease is considered readily
treatable. Nevertheless, New Jersey public health officials recommended
that Trenton be closed to facilitate environmental testing. The Postal
Service kept the three other processing and distribution centers open
because public health officials had advised the agency that employees
at those centers were at minimal risk. During the anthrax response, the
Postal Service took steps to protect its employees, such as providing
gloves and disposable masks and reminding employees to wash their hands
with soap and water if they encountered a suspicious letter or package.
Later, the Postal Service began testing and installing detection
systems at some of its processing facilities. While union leaders
acknowledged the Postal Service's efforts during the response, some
postal employees maintain that the Postal Service should have taken
earlier action to protect them. However, critical information that
could have alerted public health agencies and the Postal Service to the
health risks that postal employees faced, such as the way the spores
were prepared and the potential for anthrax spores to leak from taped,
unopened envelopes in sufficient quantities to cause inhalation
anthrax, was not available to them until after Brentwood's closure.
According to CDC and the Postal Service, they would have made different
decisions if they had understood the health risks to postal employees
earlier.
The Postal Service communicated information to affected postal
employees about the health risks posed by, and the extent of, anthrax
contamination at the five facilities in our review, but problems with
the accuracy, clarity, and timeliness of the information provided led
employees to question the information they received. Problems with
accuracy occurred because the early health risk information public
health officials provided was based on their existing knowledge and
experience that proved to be far more uncertain than the officials
initially recognized and which resulted in underestimating the health
risks to postal employees. Problems with clarity occurred because
information on the medical response to anthrax contamination changed as
knowledge evolved. For example, the Postal Service published and then
corrected treatment-related information, and CDC revised its treatment
recommendations as it gained more experience with anthrax. Problems
with the accuracy and clarity of information communicated were
exacerbated by (1) postal employees' perceptions of unequal treatment
between the responses to anthrax contamination on Capitol Hill and at
postal facilities and (2) long-standing distrust of postal management.
Problems with timeliness occurred when the Postal Service delayed the
release of quantitative data (anthrax spore counts) from environmental
tests at one of the five facilities. A union representative had
requested this information, and the Postal Service was required to
disclose it, but the Postal Service delayed disclosure in part because
it was uncertain what the results meant for worker safety and public
health. The Postal Service has taken steps aimed at communicating more
effectively, including establishing a center to coordinate information
within the postal system and working with other agencies to develop
guidelines for responding to anthrax.
The response to anthrax contamination afforded multiple lessons, two of
which are key. First, it is important for agencies to err on the side
of caution--meaning that agencies should choose a course of action that
poses the least risk of harm to individuals--when considering actions
to protect people from uncertain and potentially life-threatening
health risks. Because public health officials underestimated the health
risks involved and did not communicate any uncertainty associated with
the inferences they made based on scientific knowledge and experience,
actions to protect postal employees were delayed. Furthermore, existing
guidance did not address certain circumstances, such as the
unobservable contamination that the Postal Service faced at the Trenton
and Brentwood facilities in 2001. The Postal Service twice revised its
guidance to address some of the circumstances it faced; however, the
most recent guidance--issued in December 2003--(1) does not define some
key terms, including those that would trigger a decision to evacuate a
facility, (2) includes some outdated references that could cause
confusion during a future response, and (3) does not address some of
the circumstances that the Postal Service faced and could face again,
such as what steps would be taken in the period between a diagnosis of
inhalation anthrax in a postal employee and confirmation of the
disease. Additionally, the revised guidance does not reflect the
proactive measures that the Postal Service has recently taken, such as
closing 11 postal facilities in November 2003 after a preliminary test-
-not a confirmed result--from a routine air sample at a U.S. Navy mail-
processing facility indicated the possibility of anthrax contamination.
The second key lesson is that agencies need to share information in a
timely manner. Collocating liaisons from CDC and the Postal Inspection
Service with FBI headquarters officials--who were in charge of the
investigation--facilitated timely information sharing. Nevertheless,
agencies reported that information was not always shared within and
among public health agencies and the Postal Service. Several factors
may have hindered the prompt exchange of information, including unclear
responsibilities for decision making and postal employees' distrust of
postal management. Agencies have taken steps to improve information
sharing. Additionally, the Postal Service is working with the
Department of Homeland Security and other entities responsible for
dealing with terrorist activity to formulate governmentwide policies
and procedures for, among other things, paying for emergency medical
services. While these policies and procedures should help avoid future
confusion about such matters as where employees should go for emergency
medical services and who will pay for them, it is not known when they
will be available. As a result, if another emergency arises in the
interim, confusion--such as occurred in New Jersey--could again cause
delays in payments to providers and/or disputes over payments.
We are making several recommendations to help ensure that the Postal
Service has accurate, clear, comprehensive, and up-to-date guidance for
responding to a future anthrax emergency. Specifically, we are
recommending that the Postal Service revise its December 2003
guidelines to (1) define key terms, including those that would trigger
a decision to evacuate a facility; (2) ensure that any references to
earlier guidance are still applicable; and (3) clarify the actions that
the Postal Service would take under various scenarios, such as when it
receives preliminary evidence of anthrax contamination. In addition, to
ensure timely payment to medical providers for emergency medical
services provided to postal employees exposed to anthrax or other life-
threatening substances, we are recommending that the Postal Service
establish and meet a definitive time frame for developing interim
policies and procedures on paying for such services.
We requested comments on a draft of this report from the Postal
Service, CDC, the FBI, the U.S. Army Medical Research Institute of
Infectious Diseases, and representatives of three postal unions (the
American Postal Workers Union, the National Postal Mailhandlers Union,
and the National Association of Letter Carriers). Most of these
organizations provided technical comments, which we incorporated as
appropriate.
The Postal Service's written response to our draft report agreed with
the thrust of our recommendations. For example, the Postal Service said
that it either (1) had revised or (2) would revise and clarify its
guidance, and we eliminated one proposed recommendation to reflect its
action. The Postal Service also said that it was taking alternative
action to address our recommendation about the need for policies and
procedures for paying providers of emergency medical services. Finally,
although the Postal Service said that we concluded that its decisions
in 2001 were appropriate under the circumstances, we did not draw
conclusions on this issue. As stated in our report, our first objective
was to describe the factors considered in deciding whether to close the
five postal facilities and the actions taken to protect postal
employees--not to assess the appropriateness of the Postal Service's
actions and decisions.
CDC provided detailed written comments to clarify portions of the draft
report. For example, in its general comments, CDC objected to our use
of the term "assumptions" to describe how it arrived at its public
health recommendations. CDC noted that its recommendations were based
on the best available science as well as its "inferences from previous
experience and [its] epidemiological observations in Florida and New
York, where no disease occurred among postal workers." We revised the
report to more clearly describe the limitations of available knowledge
and experience in the fall of 2001 and how these limitations led to the
development of incorrect inferences and working assumptions about the
health risk to postal employees. We also addressed CDC's technical
comments, as appropriate, in the body of the report.
Background:
Health Effects of Anthrax:
Anthrax is an acute infectious disease that is caused by the Bacillus
anthracis bacterium, which is commonly found in the soil and forms
spores (like seeds) that can remain dormant for many years. Although
anthrax can infect humans, it occurs most commonly in plant-eating
animals. Human anthrax infections are rare in the United States and
have usually resulted from occupational exposure to infected animals or
contaminated animal products, such as wool, hides, or hair. Infection
can occur in three forms, two of which are relevant to this report--
cutaneous anthrax, which occurs from exposure to spores through a cut
or abrasion,[Footnote 13] and inhalation anthrax, which results from
breathing airborne spores into the lungs.[Footnote 14] After anthrax
spores enter the body, they can germinate into vegetative cells, which
then multiply and secrete toxins that can produce local swelling and
tissue death. The symptoms differ for each form of infection. According
to a June 4, 2004, CDC Morbidity and Mortality Report, the incubation
period for anthrax is usually less than 2 weeks; however, because
spores can remain dormant for a long time and may be slow to clear from
the lungs, the incubation period for inhalation anthrax can be
prolonged for months.
People exposed to anthrax in its natural environment generally do not
contract inhalation anthrax. Before the fall of 2001, no cases of
inhalation anthrax had been reported in the United States since
1976.[Footnote 15] In the fall of 2001, information on the effects of
exposure to refined anthrax was limited,[Footnote 16] but some
information was available about a suspected release in 1979 of anthrax
from a bioweapons facility in the former Soviet Union. According to
published accounts, the release--which U.S. authorities believe was
accidental--resulted in 79 cases of inhalation anthrax, 68 of which
were fatal. The effects of exposure depend on the amount and form of
exposure as well as the health of the individual exposed. A person can
be exposed to anthrax and not develop the disease.
Anthrax is treatable with a variety of antibacterial drugs, such as
amoxicillin, ciprofloxacin, and doxycycline. The optimal duration of
preventive treatment for anthrax, known as prophylaxis, is uncertain;
however, because of prolonged incubation--when inhaled spores can
remain in the lungs and then germinate and cause disease--CDC currently
recommends at least 60 days of antibacterial drugs and enrollment in an
investigational new drug protocol to receive the anthrax vaccine.
Fatalities are rare for cutaneous anthrax.[Footnote 17] Inhalation
anthrax is far more lethal. According to CDC, the reported fatality
rate was approximately 75 percent for the 18 cases of inhalational
disease detected in the United States in the 20th century. In 2001,
with antibacterial drugs and aggressive care, about half the cases
ended in death.
A diagnosis of anthrax is based on a review of a person's symptoms and
the results of initial tests, which are confirmed by additional
laboratory testing. While a range of laboratory tests exists for
detecting anthrax in the environment and in a person's body, analysis
of the bacteria's growth in a culture is considered the most reliable
method for confirming the presence of anthrax.
CDC classifies illness as "confirmed" or "suspected." According to CDC,
a confirmed case of anthrax is clinically compatible with the disease
and was either (1) confirmed by isolating anthrax bacteria cultured
from a patient's clinical specimens or (2) associated with other
laboratory evidence of anthrax infection obtained from at least two
supportive tests. A suspected case is clinically compatible with
anthrax but cannot be definitively confirmed by laboratory tests--
possibly because the person has begun taking medication.[Footnote 18]
According to CDC, a case would be classified as "suspected" if there
was no alternative diagnosis and no anthrax bacteria were isolated, but
there was either (1) laboratory evidence of anthrax obtained from one
supportive laboratory test or (2) an epidemiological link to an
environmental anthrax exposure.[Footnote 19]
The U.S. Mail System:
The mission of the Postal Service is to provide affordable, universal
mail service. As of May 28, 2004, the Postal Service had over 800,000
employees who process more than 200 billion pieces of mail per year.
The Postal Service's infrastructure includes its headquarters office in
Washington, D.C; 9 area offices; approximately 350 mail processing and
distribution centers, including the 5 facilities in our review; and
about 38,000 post offices, stations, and branches. The processing and
distribution centers vary widely in size and capacity, as illustrated
by the differences among the facilities in our review (see table 1).
Table 1: Characteristics of the Five Processing and Distribution
Centers in Our Review, Fall 2001:
Facility: Trenton;
Size (in square feet): 282,000;
Mail volume/capacity per day: 4 million;
Number of employees: 960.
Facility: Brentwood;
Size (in square feet): 684,000;
Mail volume/capacity per day: 5 million;
Number of employees: 2,490.
Facility: Morgan;
Size (in square feet): 2.1 million;
Mail volume/capacity per day: 12.5 million;
Number of employees: 5,000.
Facility: West Palm Beach;
Size (in square feet): 185,000;
Mail volume/capacity per day: 6 million;
Number of employees: 930.
Facility: Wallingford;
Size (in square feet): 350,000;
Mail volume/capacity per day: 3 million;
Number of employees: 1,120.
Source: GAO presentation of Postal Service data.
Note: Numbers are approximate.
[End of table]
Mail processing facilities use several types of high-speed machines to
process letters. First, at the facility that initially receives a
letter for mailing, an Advanced Facer-Canceller System cancels the
postage stamp, among other functions. Other machines with optical
character readers apply bar codes and markings to the envelopes for
identification and sorting. The bar codes and markings identify, among
other things, the time and date of processing, the machine and facility
that processed the envelope, and the delivery destination. During the
fall of 2001, the Postal Service used this information to track the
path of contaminated envelopes through the U.S. mail system.
Subsequently, a Delivery Bar Code Sorter machine sorts the mail using
the bar codes. These machines process about 37,000 letters per hour,
using belts and rollers that repeatedly squeeze the letters. During
processing, paper dust accumulates, particularly on pinch rollers that
move the mail through the machines. These rollers are hard to access
using vacuum nozzles and, as a result, compressed air was typically
used to blow debris out of the machines until it was banned in October
2001, due to concerns about the potential for spreading anthrax in mail
processing facilities.
The Postal Service provides for the security of the mail and the
enforcement of federal postal laws through its Postal Inspection
Service, which employs approximately 1,970 fact-finding and
investigative postal inspectors and 1,100 uniformed postal police
officers.
Fall 2001 Anthrax Incidents:
During the fall of 2001, at least four letters containing anthrax
spores were sent through the U.S. mail--two to media personnel and two
to U.S. Senators. The first two recovered letters were sent on
September 18, 2001, to a television news anchor at the National
Broadcasting Company (NBC) and to the editor of the New York Post in
New York City. At about the same time, investigators suspect that other
letters containing anthrax were mailed to employees at the American
Broadcasting Company (ABC) and the Columbia Broadcasting System (CBS)
in New York City and at American Media Incorporated--a company that
publishes the National Enquirer in Boca Raton, Florida--although no
contaminated envelopes were recovered from these locations.[Footnote
20] About 3 weeks later--on October 9--a letter containing anthrax
spores was sent to Senator Thomas Daschle. The letter was opened in the
Hart Senate Office Building on October 15 and was immediately viewed as
high risk to Senator Daschle's staff and first responders because the
envelope contained a visible white powder that the accompanying letter
identified, and testing quickly confirmed, as anthrax. Another letter
containing anthrax spores was mailed to Senator Patrick Leahy at about
the same time; however, it was not discovered until November 16, 2001.
The letter was found unopened in a barrel of government mail that the
FBI had impounded following the release of anthrax contained in Senator
Daschle's letter. The two recovered letters to NBC and the Post were
processed on high-speed mail-sorting machines at the Trenton and Morgan
facilities. The letters to the two Senators were similarly processed at
Trenton and at the Brentwood facility in Washington, D.C.
Processing and delivering the letters contaminated or cross-
contaminated numerous facilities, including the Hart Senate Office
Building and 23 postal facilities, and resulted in the deaths of five
people, including two postal employees. Investigators have not yet
identified the person or persons responsible for these mailings.
Meanwhile, the Postal Service has reported about 20,000 incidents
involving suspicious packages or powder spills since the fall of 2001.
(Fig. 1 shows the date of confirmed or suspected illness, type, and
location of the anthrax cases that resulted from the fall 2001
mailings.):
Figure 1: Date in 2001, Type, and Location of Anthrax Cases:
[See PDF for image]
Note: The date reflects when CDC either (1) confirmed a case of anthrax
or (2) suspected a case of anthrax that could not be confirmed.
[A] This case involved a postal employee.
[B] This person died from inhalation anthrax.
[C] This person worked at or was associated with the Trenton facility
in New Jersey.
[D] This person worked at the Brentwood facility in Washington, D.C.
[End of figure]
As shown in figure 1, CDC confirmed the first case of anthrax on
October 4, 2001, in an employee of American Media Incorporated in Boca
Raton, Florida. He died the following day from inhalation anthrax. Ten
days after his death, CDC confirmed that a coworker--a mailroom
employee at the company--also had inhalation anthrax. The coworker
subsequently recovered. Even though the source of contamination was
never found, investigators thought that the two employees contracted
the disease through their proximity to an opened letter or letters
containing anthrax spores.[Footnote 21] If there was such a letter (or
letters), it would likely have been processed on high-speed mail-
sorting machines at the West Palm Beach, Florida, facility. Between
October 12 and October 28, 2001, six media employees and the child of
an ABC employee who had visited ABC developed cutaneous anthrax in New
York City--the second location with anthrax cases. Investigators
thought that these cases resulted from either handling envelopes
containing anthrax spores or being exposed to contaminated work sites.
On October 30, an eighth case of anthrax was confirmed in New York--the
only inhalation case there.[Footnote 22] The initial cases at the third
location with anthrax cases--New Jersey--involved, for the first time,
postal employees, two of whom were confirmed with cutaneous anthrax on
October 18 and 19, 2001.[Footnote 23] Investigators thought that the
employees had contracted the disease by handling the mail, rather than
by opening or being exposed to opened letters containing anthrax
spores. (See app. III for a timeline of key events.):
The first postal employee confirmed with inhalation anthrax worked at
the Brentwood facility in Washington D.C.--the fourth location with
anthrax cases. The confirmation of a case of inhalation anthrax
revealed that processing unopened mail could release enough anthrax
spores to cause inhalation anthrax, depending on the health of the
person exposed and the aerosolization capacity of the anthrax spores.
Subsequent inhalation cases, including the case involving the
Wallingford, Connecticut postal facility--the fifth location with an
anthrax case--underscored this finding. (Table 2 summarizes, for each
location, the number of confirmed or suspected cases of cutaneous and
inhalation anthrax among postal employees and others.):
Table 2: Distribution of Anthrax Cases, Fall 2001:
Facility location: Florida;
Number of confirmed or suspected cases: 2;
Type of anthrax and affected population: Cutaneous: Postal employees:
0;
Type of anthrax and affected population: Cutaneous: Others: 0;
Type of anthrax and affected population: Inhalation: Postal employees:
0;
Type of anthrax and affected population: Inhalation: Others: 2.
Facility location: New York;
Number of confirmed or suspected cases: 8;
Type of anthrax and affected population: Cutaneous: Postal employees:
0;
Type of anthrax and affected population: Cutaneous: Others: 7;
Type of anthrax and affected population: Inhalation: Postal employees:
0;
Type of anthrax and affected population: Inhalation: Others: 1.
Facility location: New Jersey;
Number of confirmed or suspected cases: 6;
Type of anthrax and affected population: Cutaneous: Postal employees:
3;
Type of anthrax and affected population: Cutaneous: Others: 1;
Type of anthrax and affected population: Inhalation: Postal employees:
2;
Type of anthrax and affected population: Inhalation: Others: 0.
Facility location: Washington, D.C;
Number of confirmed or suspected cases: 5;
Type of anthrax and affected population: Cutaneous: Postal employees:
0;
Type of anthrax and affected population: Cutaneous: Others: 0;
Type of anthrax and affected population: Inhalation: Postal employees:
4;
Type of anthrax and affected population: Inhalation: Others: 1.
Facility location: Connecticut;
Number of confirmed or suspected cases: 1;
Type of anthrax and affected population: Cutaneous: Postal employees:
0;
Type of anthrax and affected population: Cutaneous: Others: 0;
Type of anthrax and affected population: Inhalation: Postal employees:
0;
Type of anthrax and affected population: Inhalation: Others: 1.
Facility location: Total;
Number of confirmed or suspected cases: 22;
Type of anthrax and affected population: Cutaneous: Postal employees:
3;
Type of anthrax and affected population: Cutaneous: Others: 8;
Type of anthrax and affected population: Inhalation: Postal employees:
6;
Type of anthrax and affected population: Inhalation: Others: 5.
Source: GAO analysis of CDC information.
[End of table]
Roles and Responsibilities of Responders:
Responding to health emergencies, including bioterrorist attacks, is
generally a local responsibility, but localities can--and did--request
CDC's assistance in the fall of 2001. State and local health
departments and CDC--which has responsibility for the nationwide
surveillance of specific diseases, including anthrax--provided public
health advice and assistance to the Postal Service. CDC also performed
tests needed to confirm the cases of anthrax and conducted
epidemiological investigations to determine, among other things, how
the disease had occurred at the affected locations.[Footnote 24]
Numerous other federal agencies were responsible for investigating and
responding to the anthrax mailings. The FBI was, and still is,
responsible for the criminal investigation. The Postal Service's
Inspection Service continues to assist the FBI in the investigation.
Other agencies, including the National Institute for Occupational
Safety and Health and the Agency for Toxic Substances and Disease
Registry, also within the Department of Health and Human Services,
helped the Postal Service conduct environmental tests of its facilities
and advised the agency about the facilities' decontamination.[Footnote
25] The agencies collected samples from multiple locations throughout
the facilities, analyzed the samples, and used the results of their
analyses to guide decontamination activities in the facilities. The
U.S. Army Medical Research Institute of Infectious Diseases--which
conducts basic and applied research in the diagnosis, treatment, and
prevention of hazardous infectious diseases for the military--analyzed
environmental samples from some postal facilities. In addition, it
analyzed the substances in the anthrax-contaminated letters recovered
in New York and Washington, D.C., for the FBI. OSHA, which has
responsibility for employee health and safety issues, provided
technical assistance and guidance to the Postal Service on the
decontamination of postal facilities. At Wallingford, OSHA also
investigated the Postal Service's disclosure of test results at the
facility after a union leader filed a complaint with OSHA alleging that
the Postal Service had not complied with OSHA's requirements for
disclosing such results.
On October 8, 2001, the President created the Office of Homeland
Security to develop and coordinate a comprehensive national strategy
for dealing with domestic terrorist threats or attacks. Because the
office was just gearing up, it had limited involvement in the response
to the 2001 anthrax incidents. The Homeland Security Act of 2002
created a cabinet-level agency, the Department of Homeland Security.
The department is composed of 22 previously separate agencies and is
responsible for coordinating the efforts of federal agencies that
respond to acts of terrorism in the United States, including any future
anthrax incidents.
Postal Service Primarily Considered Health Risks to Employees in
Deciding to Close Facilities:
In deciding whether to close the five facilities in our review, the
Postal Service first considered the health risks to its employees and
then considered its mission to process and deliver the mail. As long as
public health agencies advised the Postal Service that health risks to
its employees were minimal, it kept the facilities open. However, the
Postal Service closed the facilities hours after CDC confirmed that
employees at Trenton and Brentwood had contracted anthrax. The three
other facilities remained open because public health officials had
advised the Postal Service that employees at those facilities were at
minimal risk. During the anthrax incidents, the Postal Service took
steps to protect its employees, including providing gloves and
disposable masks and reminding employees to wash their hands with soap
and water if they encountered a suspicious letter or package. More
recently, the Postal Service began testing and installing detection
systems at some of its processing facilities. Nevertheless, some postal
employees maintain that the Postal Service should have taken earlier
action to protect them. Agencies lacked critical information, such as
the potential for anthrax spores to leak from taped, sealed envelopes.
According to CDC and the Postal Service, they would have made different
decisions if they had understood the health risks to postal employees
earlier.
The Postal Service Considered Health Risks to Employees Ahead of Other
Factors:
Postal managers, public health officials, and union representatives
reported that the Postal Service considered several factors in deciding
whether to close the five postal facilities in our review, but the
health of its employees was its first concern. Unfortunately, however,
CDC and local public health organizations--which relied on their
knowledge and experience at that time--and the Postal Service, which
relied on the advice it received from public health officials,
incorrectly perceived the health risk to be minimal for several
reasons. First, because postal employees did not contract anthrax
during the earlier incidents in Florida and New York, CDC determined--
consistent with its investigations of outbreaks involving naturally
occurring infectious diseases--that postal employees were not at risk
because the same conditions would likely apply to subsequent clusters
of cases and letters.[Footnote 26] Second, the recovered envelopes--
those sent to media representatives in New York and to the Senators--
were taped and unopened when they arrived at their destinations,
suggesting that the addressees, rather than postal employees, were the
targets of the attacks and the persons whose health could be at risk.
Third, the available scientific information indicated that (1) anthrax
spores in nature typically aggregate to form particles that do not
readily aerosolize and (2) exposure to thousands of spores would be
needed to cause inhalation anthrax.[Footnote 27] This information led
CDC and others to conclude that the anthrax particles in the
contaminated letters would generally not leak through taped, unopened
envelopes in sufficient quantities to cause inhalation anthrax. While
public health officials recognized that handling unopened, contaminated
letters might result in exposure to some spores that could possibly
cause cutaneous anthrax, they believed that wearing gloves would
protect postal employees from this readily treatable condition and did
not think that postal facilities should be closed to avoid it.
Accordingly, CDC advised the Postal Service that the health risks to
postal employees from the contaminated letters were minimal and that
there was no need to close facilities that had processed the
contaminated letters. Absent evidence of illness among their employees
and given the views of public health officials, postal managers said
they focused on other factors, including (1) the psychological
importance of keeping the mail moving in the aftermath of the September
11, 2001, attacks and (2) the widespread economic consequences of
shutting down portions of the mail system. According to postal
managers, it would have been irresponsible to close postal facilities
without any recommendation to do so by public health or law enforcement
authorities, such as the FBI.
Neither Existing Closure Guidance Nor Later Instructions Were
Applicable to the Circumstances Surrounding the Fall 2001 Anthrax
Mailings:
The Postal Service had guidance for responding to anthrax and other
hazardous incidents, but this guidance did not address the events that
the Postal Service faced in the fall of 2001. The existing guidance--
"Emergency Response to Mail Allegedly Containing Anthrax"--was issued
in October 1999 in response to a growing number of suspicious
incidents, including spills involving white powder. The guidance
specified emergency response procedures and management actions for
dealing with suspicious mail (letters, packages, and other pieces of
mail) found in a U.S. postal facility. The guidance required postal
managers to minimize the potential for employees to be exposed by
quickly isolating any suspicious mail and promptly evacuating an
affected facility.[Footnote 28] However, the guidance addressed
discovered incidents--a suspicious piece of mail or a powder spill--not
undetected incidents such as those that occurred at the five facilities
in our review. Each of these facilities was apparently contaminated as
(1) envelopes containing anthrax or (2) cross-contaminated envelopes
passed through high-speed mail-sorting machines in the
facilities.[Footnote 29] Because neither a suspicious piece of mail nor
any leakage from a piece of mail was observed, there was a time lag
between the exposure and the discovery of contamination. On October 19,
2001, as the anthrax events were unfolding, the Postal Service issued
additional instructions for dealing with suspicious powder spills or
the discovery of a suspicious piece of mail. However, these
instructions--based on CDC advisories and termed "decision trees"--were
intended to deal with the discovery of a suspicious package or piece of
mail at a facility and, as subsequently became apparent, also did not
address the circumstances that occurred in the fall of 2001 since no
suspicious mail was discovered.
Postal Service Closed Facilities after CDC Confirmed Illness:
Once CDC confirmed that postal employees had contracted anthrax, the
Postal Service closed Trenton and Brentwood. It closed Trenton on
October 18, 2001, within hours after CDC confirmed that a letter
carrier--the first postal employee affected--had cutaneous anthrax.
Initially, CDC did not recommend that the entire Trenton facility be
closed because, at the time, it viewed facility closures as unnecessary
for cases of cutaneous anthrax, since this form of the disease is
readily treatable with antibacterial medication. Nevertheless, public
health officials from the New Jersey Department of Health and Senior
Services recommended that Trenton be closed to facilitate environmental
testing of the facility.[Footnote 30] According to CDC, it concurred
with this decision. The mail-processing area on the first floor of
Brentwood was closed on October 21, 2001, after CDC confirmed that an
employee there had inhalation anthrax. This is the same day that the
first of two postal employees died.[Footnote 31] The second floor of
the facility, which housed administrative offices, was subsequently
closed on October 22, 2001. Public health authorities began dispensing
antibacterial drugs to the two facilities' postal employees soon after
the closures.
The Postal Service kept West Palm Beach, Morgan, and Wallingford open
based on the advice of public health officials who indicated that
postal employees were at minimal risk.[Footnote 32] While CDC and local
public health agencies did not believe that the employees were at risk,
they nevertheless offered antibacterial drugs to employees at the three
facilities. At these facilities, the contaminated areas were isolated
and decontaminated while operations continued elsewhere in the
facilities.
The Postal Service Took Steps to Protect Its Employees, Including
Revising Its Guidelines on Facility Closures:
Nationwide, the Postal Service took several actions to protect its
employees from anthrax. For example, during the response, it provided
employees with protective equipment, such as gloves and disposable
masks, and information on handling suspicious mail. Consistent with
CDC's advice, the Postal Service also reminded employees to wash their
hands with soap and water if they encountered a suspicious letter or
package. In addition, the Postal Service required postal managers to
update their facilities' emergency action plans and on October 16,
2001, restricted the use of high-pressure compressed air to clean mail-
sorting equipment. For routine cleaning, employees were advised to
vacuum the equipment first and, if more effective methods were needed,
to use compressed air, but to limit the amount of pressure they used.
On October 26, 2001, the Postal Service banned the use of compressed
air altogether. The initial restriction and subsequent ban were
intended as a precaution to help ensure that dirt, paper dust, and any
existing spores would not be blown around a postal facility. According
to postal managers, these actions seemed sufficient in view of the
health risk information available to them at the time.
After closing Trenton on October 18, the Postal Service took additional
steps to protect Brentwood employees. For example, although the Postal
Service--following CDC's advice--kept Brentwood open until CDC
confirmed a case of inhalation anthrax, postal officials said that they
consulted public health officials about the possible health risks to
Brentwood employees. These consultations occurred after the Postal
Service learned that the letter to Senator Daschle contained anthrax
and had been processed through the U.S. mail--rather than delivered
through another means, such as a courier--which meant that it would
have been processed at Brentwood. In addition, on October 17, 2001, the
Postal Service arranged for a series of environmental tests at
Brentwood after it became aware that the Senate mailroom had tested
positive for anthrax. The Postal Service arranged for the tests even
though CDC determined from its epidemiological investigations that
testing was not needed. The first tests--called "quick tests"--occurred
on October 18, the same day that Trenton was closed. A local hazardous
materials response team conducted these two quick tests, and the
results, which were available later that day, were negative.[Footnote
33] According to the contractor's documentation, the positive results
from other tests--also taken on October 18--were not available until
October 22--the day after a Brentwood employee was confirmed with
inhalation anthrax and the facility was closed.[Footnote 34] In
addition, the Postal Service reported that it requested both nasal
swabs and medication for Brentwood employees in the days before the
facility was closed.[Footnote 35] However, according to postal
managers, the requests were not initially successful because public
health officials informed them that neither was necessary.[Footnote 36]
While noting that Postal Service officials could have taken other
actions to respond to the anthrax incidents, postal union leaders
nevertheless praised the Postal Service for its efforts to provide a
safe work environment and to prevent future occurrences, as well as to
involve them in the response and to keep employees informed. For
example, in testimony delivered to the House Committee on Government
Reform on October 30, 2001, two union leaders stressed that the Postal
Service had acted in good faith and that its decisions, including those
about Brentwood, were guided by the advice and recommendations it
received from the medical community.
Although the Postal Service sought the advice of public health agencies
and took more precautions than had been recommended, some employees
maintained that it did not act quickly enough to protect them. The
employees cited a number of factors that, in their view, should have
caused the Postal Service and others to conclude sooner that postal
employees could be at risk. First, according to these employees, the
fact that the anthrax was contained in an ordinary envelope--not packed
in multiple layers to prevent leakage and damage--should, by itself,
have caused authorities to conclude that spores could have escaped from
the envelopes.[Footnote 37] Second, apart from whether the packaging
was adequate, employees noted that mail-processing machines function at
high speeds and that the machines' mechanisms repeatedly squeeze mail
as it moves through the mail system. This process creates a great deal
of dirt and paper dust, demonstrating, according to the employees, that
mail can leak--a possibility that they said the Postal Service should
have recognized earlier. Compounding this risk, they said, was the
long-standing use of compressed air to clean postal processing
machines. The Postal Service terminated the use of compressed air on
October 26, 2001, but until then, the employees say, its use re-
aerosolized spores that had accumulated within mail-processing
machines.[Footnote 38] Finally, some employees expressed concern about
what they perceived as a delay in closing postal facilities. They
compared the decision to close congressional offices soon after anthrax
was identified in the letter to Senator Daschle on October 15 with the
Postal Service's decision to wait until cases of anthrax were
confirmed, leading some employees to conclude that their health was of
less concern than that of congressional employees.[Footnote 39] This
perception was particularly an issue at Brentwood, where two employees
died and some postal employees attributed the differences in the
responses to unequal treatment.
In November 2001, the Postal Service issued "interim guidance" for the
sampling, analysis, decontamination, and disposal of anthrax in postal
facilities that specified, among other things, factors to be considered
in making future closure decisions.[Footnote 40] Such guidance did not
exist before the fall 2001 anthrax incidents and, unlike the 1999
guidance, it specifically addressed unobserved exposures. According to
the guidance, postal facilities would be closed (1) "if a confirmed
case of inhalation anthrax is identified and a probable site of
exposure is detected" or (2) when evidence suggests an aerosolization
of anthrax in the facility (as evidenced by a positive sample from the
heating and ventilation system).[Footnote 41] This guidance was
consistent with guidance that CDC issued on November 9, 2001.[Footnote
42]
Agencies Lacked Critical Information Needed to Accurately Assess Health
Risk to Postal Employees:
Agencies lacked critical information needed to accurately assess the
health risk to postal employees. For example, officials from the Postal
Service, CDC, and other public health agencies acknowledged that, early
on, they had little knowledge of (1) the characteristics and properties
of refined anthrax; (2) the potential for anthrax spores to leak from
taped, sealed envelopes; or (3) the effects of these factors on
individuals' health. Public health officials, for example, told us that
until the first cases of anthrax were confirmed in Trenton and
Brentwood postal employees, there was no evidence that anyone handling
unopened mail would be at risk of contracting inhalation anthrax.
Analyses of the substance in the recovered envelopes contributed
additional information to their understanding. For example, on October
19, the U.S. Army Medical Research Institute of Infectious Diseases
relayed its observations to the FBI that the anthrax particles in the
letter to Senator Daschle were as small as 1 micron in
diameter.[Footnote 43] The Army Institute delivered a written report of
the results of its analyses to the FBI on October 22--the day after
Brentwood's closure.[Footnote 44] At about the same time, the FBI
analyzed the pore size of envelopes used for the mailings and
determined that the envelopes were extremely porous.[Footnote 45] The
results--available on October 23, 2001--revealed that the pores of the
envelopes were larger than some of the anthrax particles, making it
possible for the anthrax to escape through the envelopes.
Over time, other important differences between the substances in the
recovered letters became apparent. For example, on October 31, 2001,
CDC testified before the Senate Committee on Governmental Affairs that
it initially assumed that the characteristics of the anthrax in all of
the letters were the same. However, according to descriptions that CDC
received after the letters were recovered,[Footnote 46] the substance
in the letter to NBC was brown and granular, whereas the substance in
the letter to the New York Post was sandy.
Furthermore, according to a report issued in February 2003 about the
decontamination of the Morgan facility, the substances in both the NBC
and the New York Post letters contained compounds that did not appear
in the highly milled and potent white powder that CDC was told was
found in the letters to Senators Daschle and Leahy.[Footnote 47]
According to the Postmaster General's October 30, 2001, testimony
before the House Committee on Government Reform and other officials we
talked to, it was not until more than a week after the Daschle letter
was opened and days after Brentwood closed that these new pieces of
information came together and officials realized that the anthrax
spores in the letter to Senator Daschle were so highly refined that
they could penetrate paper.[Footnote 48] Consequently, when decisions
were being made about the risk to employees at Brentwood and Trenton,
public health and Postal Service officials said they did not yet know
that the substance in the letter to Senator Daschle was more easily
aerosolized and, therefore, potentially more dangerous than the
substances in the letters to media representatives in New York.
According to CDC, it likely would have made different decisions in some
facilities and circumstances had it known more about the
characteristics of the highly refined substance in the letter to
Senator Daschle and better understood (1) the significance of the
information that it was provided or (2) how infections arising from
bioterrorism incidents differ from outbreaks of naturally occurring
disease. CDC explained that in outbreaks involving naturally occurring
disease, early clues generally provide reliable information on the mode
and source of exposure, whereas--as learned in the fall of 2001--the
characteristics of the initial cases for bioterrorism-related disease
may be misleading since the perpetrator can vary the mode of
transmission and source of exposure.[Footnote 49] In testimony before a
subcommittee of the House Government Reform Committee in July 2002,
CDC's Associate Director for Science, National Institute for
Occupational Safety and Health, admitted that CDC "clearly did not know
what we did not know last October [2001] and that is the cardinal sin
that resulted in deaths."
Postal managers also told us that they would have made different
decisions if they had understood that CDC's health risk information had
limitations and that their employees could be at risk. According to the
former plant manager at Brentwood, he and others did everything they
could to ensure that postal employees were safe. For example, the
Deputy Director of the FBI, the Postmaster General, and a number of
other high-ranking postal managers conducted a press conference at the
facility to assure employees and the public that all appropriate steps
were being taken to protect them. The former plant manager noted that
none of the officials wore protective clothing or safety equipment.
Likewise, the former plant manager indicated that, on October 20--one
day before the first case of inhalation anthrax was confirmed--he
toured the facility with a CDC doctor, who also wore no protective
clothing or equipment. According to the former plant manager, the fact
that the doctor did not wear protective clothing or equipment reassured
him that the facility was safe. He emphasized that he would not have
been in the building and would not have allowed other postal employees
in the building if he had been aware that the facility was
contaminated.
Communication Problems Raised Employees' Concerns:
The Postal Service communicated information to affected postal
employees about the health risks posed by, and the extent of, anthrax
contamination at the five facilities in our review; but problems with
accuracy, clarity, and timeliness led employees to question the
information they received. The early health risk information provided
to the Postal Service by public health officials understated the
potential health risk to postal employees and information on the
medical response to anthrax contamination was unclear to employees
because it kept changing as knowledge evolved. Problems with accuracy
and clarity were exacerbated by postal employees' perceptions of
unequal treatment and long-standing distrust of management. Although
the Postal Service reported qualitative (positive or negative) results
of environmental tests at its facilities within 2 days, it delayed the
release of quantitative data (spore counts) for one facility,
Wallingford, even though OSHA requires such information to be provided
if it is requested. The Postal Service has taken steps aimed at
communicating more effectively.
Communications to Postal Employees Understated Health Risks:
During the fall of 2001, before postal employees were confirmed with
anthrax, the Postal Service transmitted extensive information from CDC
about the health risks of anthrax to postal employees.[Footnote 50] CDC
derived this information from the existing scientific literature,
experts, and its own early epidemiological investigations of the
anthrax incidents in Florida and New York. The early health risk
information, together with information that the envelopes were unopened
and taped when they passed through the U.S. mail system, led CDC to
conclude that the potential for leakage and aerosolization was too
small to pose a risk of inhalation anthrax to postal employees. If
postal employees contracted the disease, CDC believed they would
contract cutaneous anthrax, the readily treatable form of the disease.
The Postal Service disseminated information about this health risk to
postal employees, including information needed to watch for signs of
cutaneous anthrax and related information pertaining to the use of
gloves and other protective equipment intended to prevent this form of
the disease.[Footnote 51] The Postal Service also provided an October
12, 2001, CDC health advisory to postal employees that stated that to
cause cutaneous anthrax, the organism must be rubbed into abraded skin.
Further, the advisory indicated that anthrax spores would be very
difficult to refine into particles that would be small enough to
aerosolize.
Relying on available information, the state epidemiologist for the New
Jersey Department of Health and Senior Services told employees at
Trenton on October 15 that the likelihood of contracting anthrax
through an unopened envelope was "infinitesimal." Likewise, in an
October 18 press conference at the Brentwood facility, held in part to
announce a large financial reward for the arrest and conviction of the
individual or individuals responsible for the anthrax mailings, the
Postmaster General--accompanied by an FBI Deputy Director and the Chief
Postal Inspector--assured postal employees and others that they were
not at risk of contracting inhalation anthrax. Just 3 days later, when
the first Brentwood employee was confirmed with inhalation anthrax, CDC
and the Postal Service realized that the information they supplied to
postal employees had underestimated the risks to their health.
Medical Information Was Difficult to Communicate Accurately and
Clearly, and Efforts Were Complicated by Perceptions of Unequal
Treatment and Long-Standing Postal Labor-Management Relations Issues:
Public health agencies and the Postal Service reported that they had
difficulty communicating information about nasal swabs, antibacterial
drugs, and the anthrax vaccine accurately and clearly to postal
employees. In trying to communicate information about nasal swabs, for
example, they had to contend first with the effects of an error and
later with employees' perceptions of unequal treatment. During the fall
of 2001, nasal swabs were used to determine the location and extent of
contamination at a facility, not to diagnose illness. However, a Postal
Service bulletin issued on October 11, 2001, incorrectly suggested that
nasal swabs were useful in diagnosing anthrax.[Footnote 52] The media
also incorrectly described nasal swabs as a "test" for anthrax. The
Postal Service corrected the bulletin, but the media continued to refer
to nasal swabs as a test for the illness, and many postal employees
continued to believe the inaccurate information. When Capitol Hill
employees began receiving nasal swabs to test for exposure to
aerosolized anthrax spores after the letter to Senator Daschle was
opened on October 15, some Trenton and Brentwood employees believed
that they too should receive nasal swabs once it was determined that
the letter was processed in their facilities. However, public health
authorities were reluctant to administer the swabs to postal employees,
given their belief that too much time would have elapsed to detect
anthrax on a swab.[Footnote 53] Some postal employees perceived this
reluctance as evidence of unequal treatment. Public health officials
told us that addressing employees' perceptions of unequal treatment was
particularly challenging. As a result, when requested, the public
health officials said they often administered nasal swabs simply to
allay the employees' concerns.
Public health agencies also reported that they had difficulty
explaining the reasons for changes in (1) the medication recommended
for individuals who might have been exposed to anthrax and (2) the
length of the recommended treatment. Initially, CDC had recommended
ciprofloxacin for a variety of reasons,[Footnote 54] but later it
recommended doxycycline. Postal employees believed that they were
receiving an inferior drug because ciprofloxacin--which had been
initially provided to Capitol Hill staff--had been characterized as the
drug of choice in media reports. Similarly, in December 2001, when
postal employees and others were finishing the 60-day drug regimen
recommended in CDC's initial guidance, postal employees questioned
CDC's advice about the need to consider taking the drugs for an
additional 40 days. CDC officials acknowledged that CDC did not
effectively communicate uncertainties related to the appropriate length
of prophylaxis, even though there was significant disagreement on the
issue within CDC at the time. Since the incidents, CDC officials have
acknowledged the necessity of expressing uncertainty in terms the
public can understand and appending appropriate caveats to the agency's
statements. In addition, CDC has changed its processes to release
information more quickly, bring in other professionals to aid in
disseminating information, and expand its communication capacity, a
step that includes the development of an emergency plan to communicate
more effectively.
Finally, CDC officials reported difficulties in explaining information
about the administration of the anthrax vaccine to interested postal
employees. The Food and Drug Administration considers the vaccine safe
but has approved its use only for individuals who have not been exposed
to anthrax--not for those who may have been exposed. Consequently, CDC
had to administer the vaccine using extensive protocols that the Food
and Drug Administration requires for an "investigational new
drug."[Footnote 55] These protocols, which are standard for new drugs,
required postal employees to complete more paperwork and undergo more
monitoring than for approved drugs. According to some postal employees,
the protocols made them feel like "guinea pigs." CDC officials
acknowledged that CDC did not explain the vaccine program clearly and
concluded, in hindsight, that communication problems probably
contributed to the misperceptions of postal employees and others
potentially exposed to the disease.
As we reported in October 2003,[Footnote 56] differences between the
responses to anthrax contamination on Capitol Hill and Brentwood
reflected differences in the circumstances at the two locations (a
powder identified in a letter and positively tested as anthrax on
Capitol Hill versus no observable evidence of contamination at postal
facilities) and in the decision makers (the Attending Physician of the
U.S. Capitol versus the Postal Service in consultation with CDC).
However, it appears that these differences were less visible to postal
employees and others than the differences between the actions taken on
Capitol Hill--where the Hart Senate Office Building was closed within a
day and nasal swabs and antibacterial medications were quickly
administered to nearby employees and first responders--and at postal
facilities--where operations continued and medical intervention was
less immediate because contamination was not observed at the postal
facilities. Some postal employees perceived these differences as
evidence of unequal treatment.
Long-standing labor relations issues also complicated efforts to
communicate with postal employees. For example, while consistent with a
CDC alert at the time, some Brentwood employees told us that they
viewed instructions by Postal Service managers to pick up suspicious
letters and packages and isolate them in sealed containers as evidence
that the Postal Service was not concerned about their safety.[Footnote
57] According to CDC, local public health officials, union
representatives, and postal officials, postal employees were often
suspicious of postal management's motives and routinely scrutinized
information they received for evidence of any ulterior motives. In
fact, the Director of the Palm Beach County Health Department told us
that postal employees in Florida expressed a greater degree of anger
and mistrust toward management than she had ever observed. Such
concerns appear consistent with the results of our past work, which
has identified persistent workplace problems exacerbated by decades of
adversarial labor-management problems. These problems were so serious,
we reported in 2001, that long-standing and adversarial labor-
management relations hampered efforts to address its management
challenges.[Footnote 58] The President's Commission on the United
States Postal Service also identified a need to address this long-
standing issue.[Footnote 59]
Postal Service Did Not Provide Timely Quantitative Information on
Contamination at One Facility When Requested:
The Postal Service provided employees with the qualitative results
(i.e., negative or positive) of environmental tests conducted at the
five facilities in our review within 2 days of receiving the results,
but it did not promptly disclose available quantitative results (spore
counts) for the Wallingford facility when requested. OSHA requires
employers to disclose available test results in response to an
employee's request.[Footnote 60] Initially, the Postal Service obtained
only qualitative results, but as testing methods evolved, it obtained
quantitative results for three of the five facilities--Wallingford,
which remained open, and Brentwood and Trenton, both of which
closed.[Footnote 61]
As we reported in April 2003, the Postal Service obtained quantitative
test results for Wallingford on December 2, 2001, but it did not
disclose these results until September 4, 2002.[Footnote 62] Although a
union leader had requested the results in January and February 2002,
the Postal Service did not initially provide them, it said, because,
among other reasons, it was uncertain what the results meant for
employees' safety and public health, it could not validate the results
as its guidelines require, and Connecticut's Chief Epidemiologist had
assured postal managers that the results did not indicate any
additional health risk to employees at the facility.[Footnote 63] The
Postal Service disclosed the quantitative results after the union
leader filed a formal complaint with OSHA and OSHA investigated the
complaint. The complaint alleged that the Postal Service's failure to
"properly and timely disclose" the level of contamination in the
facility left employees without adequate information for making
informed decisions about such issues as whether to continue taking
antibacterial drugs and working in the facility.[Footnote 64] Although
OSHA did not take regulatory action against the Postal
Service,[Footnote 65] it stressed the importance of timely
communication of test results and stated in a letter to the Postal
Service that a "failure to effectively communicate issues" affecting
employees' health and safety "can lead to fear and mistrust."[Footnote
66]
According to documentation from CDC, the quantitative results for
Brentwood, which were based on samples taken by CDC investigators and
Postal Service contractors in October 2001, were made available to the
Postal Service and national union representatives on November 1, 2001,
and CDC published the results on December 21, 2001.[Footnote 67]
According to the document, 27 of the 39 vacuum samples--69 percent--
tested positive for anthrax, with concentrations up to 9.7 million
colony-forming units per gram of material collected. The Postal Service
notified former Brentwood employees about the quantitative results on
January 25, 2002, and referred them to CDC's Web site to obtain the
actual results. CDC reported the quantitative results for tests taken
in Trenton in February 2002 to the Postal Service and to
representatives of the national postal unions on May 31, 2002.[Footnote
68] This analysis indicated that 247 of the 362 samples--68 percent--
were positive for anthrax, with concentrations up to 800 million
colony-forming units.[Footnote 69]
The Postal Service Took Steps Aimed at Communicating More Effectively:
Recognizing the need to improve its communication both internally and
externally, the Postal Service took a number of steps aimed at
communicating more effectively during the fall of 2001. First, on
October 16, 2001, it established a National Postal Operations Center to
coordinate information within the postal system. It also created a Mail
Security Task Force composed of representatives from management
associations and employee unions. Union leaders applauded the efforts
of this task force, which met daily as the crisis unfolded, to involve
them in decision making. Finally, to improve its communications with
other agencies, on October 31, 2001, the Postal Service established a
Unified Incident Command Center with representatives from the agencies
that respond to contamination in postal facilities. According to the
Chief Operating Officer, the Postal Service had not previously needed
such an infrastructure because, before September 11, its weather-
related and other emergencies were relatively short-lived and could be
dealt with locally.
The Postal Service also worked with the National Response Team--a group
of 16 federal agencies responsible for planning, preparing, and
responding to the release of hazardous substances--to revise existing
guidelines for responding to anthrax. Consistent with recommendations
in our April 7, 2003, report on the response to anthrax at the
Wallingford facility, the most recent version of the
guidelines,[Footnote 70] dated November 3, 2003, suggests that agencies
(1) disclose more--rather than less--information, particularly when the
release of undisclosed information could damage an agency's
credibility; (2) consider the needs of different audiences (e.g.,
employees, reporters, local politicians) for different types of
information; (3) anticipate what information people need and in what
form; and (4) admit when you do not know the information. As we
recommended, the Postal Service also revised its guidance to require
that facility managers communicate future test results--including
quantitative results--to employees and others as quickly as possible,
along with information explaining any limitations or uncertainties
associated with the results.[Footnote 71]
While the Postal Service agreed to explain any limitations or
uncertainties associated with future test results, it did not
accurately characterize the extent of residual risk at Brentwood after
the facility was decontaminated. As we previously testified, an October
2003 newsletter to former Brentwood employees incorrectly stated that
the facility was "100 percent free of anthrax contamination" and that
there was "no remaining health risk" associated with returning to work
there. Although the facility has since been certified as safe, it is
scientifically impossible to eliminate all risk or to guarantee that
working at a previously contaminated facility is absolutely risk free.
Postal managers agreed with this assessment and indicated that a
misunderstanding within the Postal Service resulted in the distribution
of incorrect information to employees before the document had been
fully reviewed. The Postal Service mailed corrected information to
Brentwood employees in December 2003.
Several Lessons Emerged from the Response to Anthrax Contamination:
The response to anthrax contamination afforded multiple lessons, two of
which are key. First, it is important for agencies to err on the side
of caution when dealing with uncertain and potentially life-threatening
situations--meaning that agencies need to choose a course of action
that poses the least risk of harm to individuals. Because public health
agencies underestimated the health risks involved in the anthrax
attacks, actions to protect postal employees were delayed. Public
health agencies and the Postal Service have since adopted a more
proactive approach and the Postal Service has twice revised its
guidance. However, the most recently revised guidance--issued in
December 2003--needs improvement in several areas. The second key
lesson is that sharing information in a timely manner is critical to an
effective response. While collocating liaisons from CDC and the Postal
Inspection Service with FBI headquarters officials facilitated timely
information sharing, agencies reported that information was not always
shared within and among public health agencies and the Postal Service.
Several factors may have hindered the prompt exchange of information,
including unclear responsibilities for decision making. Two additional
lessons, on the need for reliable methods to test for anthrax in the
environment and on the need for an emergency medical plan, also
emerged.
Erring on the Side of Caution Is Important When Human Life May Be at
Risk:
The uncertainty of health risk information--demonstrated by the gap
between what public health agencies knew about anthrax and what they
learned over time--points to a need for agencies to err on the side of
caution when considering actions to protect people in uncertain and
potentially life-threatening situations. For example, the Commander of
the U.S. Army Medical Research Institute of Infectious Diseases noted
in testimony before a subcommittee of the House Committee on Government
Reform in May 2003, that there is "still much to be learned about the
effects of this agent [anthrax] under conditions different from those
encountered during natural outbreaks." In particular, he said, the
health effects of aerosolized anthrax spores on human populations are
poorly understood, and there is no scientific consensus on the lethal
dose for humans. Thus, any level of contamination could potentially
harm some individuals. Consistent with what he described as the Army
Institute's long-standing approach, the Commander advised agencies to
initially err on the side of caution "in the absence of surety" while
taking full advantage of all available expertise to formulate a future
long-term response. In addition, due to such factors as limitations in
testing methods and the uncertainty of the anthrax dose necessary to
cause infection, representatives from the Environmental Protection
Agency and the U.S. Army's Dugway Proving Ground have also indicated
the advisability of taking a cautious approach when dealing with
anthrax.[Footnote 72]
As discussed, the events of October 2001 soon demonstrated that the
agencies' inferences about the anthrax health risks to postal employees
were wrong. For example, 3 days after the Postmaster General, in
consultation with public health officials, assured postal employees
that they were not at risk of contracting inhalation anthrax, CDC
confirmed the first case of inhalation anthrax in a postal employee and
within 5 days, CDC confirmed three more cases. These cases belied the
views of public health agencies that postal employees were not at risk
for contracting inhalation anthrax. Ultimately, even the participants
in the press conference, who did not work at Brentwood, were advised to
take antibacterial drugs because they might have been exposed to
contamination at the facility. According to the former director of the
D.C. Department of Public Health, once a postal employee developed
inhalation anthrax, it became clear that CDC's recommendations, while
sound in terms of prior knowledge and science, "had left the Brentwood
workers unprotected."
The Palm Beach County Health Department initiated its epidemiological
investigation on October 3, 2001, about 36 hours before it received
confirmation that the first of two employees from American Media
Incorporated had inhalation anthrax. Initially, the epidemiological
investigation focused on, among other locations, office space within
American Media Incorporated. As the investigation proceeded,
investigators realized that the contamination might have come from a
letter delivered by the Postal Service. On the basis of this
possibility, the department began offering antibacterial medication to
selected postal employees--those most likely to have handled mail to
the media company--on October 12, the same day that environmental
testing began at selected postal facilities and 3 days before anthrax
contamination was confirmed at any of the facilities.[Footnote 73] The
director of the Palm Beach County Health Department acknowledged that
the department's sensitivity to risk had been heightened by the first
case of inhalation anthrax at American Media Incorporated. The director
emphasized the importance of intervening early when a delay in
responding could threaten lives. In her view, the only risk in
responding immediately is the possibility of being criticized for
wasting public money. According to public health officials in Florida,
the single most important lesson they learned from their experience
with anthrax was the importance of taking precautions in the face of
potentially life-threatening situations.
An April 2002 report prepared for the Department of Defense[Footnote
74]noted that because neither the local health officials nor the
private physicians involved in the Florida response waited for final
CDC confirmation of anthrax disease before acting, the medical
community in Florida had a 36-hour head start on containing the crisis.
The report also identified other proactive steps that Florida public
health officials took to alert the medical community and the public to
the risks of anthrax. For example, public health officials notified all
hospitals of the anthrax threat, attempted to fax an informational
letter to every licensed doctor in Florida, established a toll-free
telephone number for people who might have been exposed, and set up an
informational Web site staffed with doctors who were available to
answer direct questions.[Footnote 75] According to the report, these
steps heightened public awareness, increased medical surveillance
throughout the system, and aided in discovering the second case of
inhalation anthrax in Florida.
Since the anthrax incidents, public health agencies and the Postal
Service have moved to a more proactive approach. On November 9, 2001,
CDC revised its guidance, indicating that closing a facility may be
warranted, among other conditions, (1) after a case of inhalation
anthrax is detected and a probable site of exposure is identified, (2)
when there is a known aerosolization of anthrax in the facility, or (3)
where evidence strongly suggests that an aerosolization of anthrax has
occurred. Furthermore, while CDC's November 2001 guidance recommends
minimizing the risk of inhalation anthrax and reducing opportunities
for the spread of contamination, the guidance states that facility
closures are not warranted based solely on the identification of
cutaneous anthrax cases or anthrax in samples from environmental
surfaces.
In May 2004, we discussed CDC's November 9, 2001, guidance for
responding to cases of cutaneous anthrax and positive environmental
samples with several CDC officials, including the Acting Associate
Director for Policy, Planning, and Evaluation, Office of Terrorism
Preparedness and Emergency Response. The officials noted that CDC
learned a great deal about the potential for aerosolization during the
fall of 2001 but that its knowledge and current approach are not yet
fully reflected in its guidance. While emphasizing that the decisions
reached in any response are highly dependent on the circumstances at
each site, the officials said that if a case of cutaneous anthrax or
positive environmental samples were identified at a postal facility,
CDC would immediately assemble a multidisciplinary team of experts to
assess the situation. The team would, among other things, determine the
extent of contamination, the likelihood of aerosolization, and the
potential health risks to postal employees. In addition, CDC informed
us that it may require closure or, depending upon the circumstances,
recommend that other federal or state agencies close the facility. In
fact, according to one of the officials, CDC would now likely recommend
that a facility be closed unless CDC was otherwise convinced that the
facility should remain open. Later this year, CDC expects to publish
updated guidance on its current approach, including recommendations for
planning for and responding to a case of cutaneous anthrax or positive
environmental samples in postal facilities.
The Postal Service has taken several proactive steps, including
changing its cleaning procedures, increasing its use of technology, and
revising its guidance. As discussed, it restricted its use of
compressed air to clean ("blow-out") its mail-processing machines on
October 16, 2001, and eliminated the use of this procedure altogether
on October 26, 2001. According to its existing guidance, Postal Service
employees are now to vacuum the mail-processing machines and, instead
of dry sweeping the floors, are to use wet or treated mops to clean
floors.
The Postal Service has also been shipping certain types of mail
destined for federal agencies in Washington, D.C., to a facility in New
Jersey, where the mail is irradiated to kill any organisms, such as
anthrax. In addition, the Postal Service has pilot-tested a new
detection system at 15 facilities and plans to install the system at
283 of its processing facilities by July 2006. This system collects and
preliminarily analyzes samples from the environment and triggers an
alarm if anthrax is detected.[Footnote 76] The Postal Service's
guidelines for implementing the new detection system call for taking
immediate emergency actions, including evacuation, as soon as the
system is triggered. Furthermore, according to these guidelines,
[Footnote 77] a facility will reopen only if a follow-up analysis of
the sample is negative for anthrax--a process that can take several
days.[Footnote 78]
If the detection system is triggered at a facility with the technology,
the Postal Service also plans to follow CDC's April 2004 guidance to
employers and others using autonomous systems to detect
anthrax,[Footnote 79] which not only recommends immediate evacuation,
but also prescribes antibacterial treatment for employees "as soon as
possible" after a qualified laboratory has initially confirmed a
positive result. According to the guidance, such treatment should
continue until the sample is cultured, which will likely take 3 to 5
days. If positive results are ultimately confirmed, CDC recommends a
60-day course of antibacterial drugs in combination with inoculation
with the anthrax vaccine. Because the Postal Service issued guidance to
reflect CDC's recommended medical interventions on June 30,
2004,[Footnote 80] we eliminated a proposed recommendation in our draft
report that it do so. According to the Postal Service's Manager, Safety
Performance Management, the Postal Service has already implemented the
CDC guidance through training, standard operating procedures, and
emergency management plans at sites with the detection systems.
The Postal Service revised its Interim Guidelines in December 2003 to
reflect the need for more proactive measures when responding to
anthrax.
The guidelines are generally applicable to all postal
facilities.[Footnote 81] For the first time, the guidance describes a
"suspected release" of anthrax spores as an emergency and specifies
that if the suspicion is "strong," the building will be evacuated and
secured. Furthermore, in accordance with CDC's April 2004
recommendations, the guidance specifies antibacterial prophylaxis for
postal employees and others along the transit path of an envelope
containing anthrax that may have been aerosolized. The revised
guidance--which conforms to the guidelines developed by the National
Response Team--also emphasizes the Postal Service's commitment to
continuously improve its responses and processes related to anthrax and
other biohazards. This commitment includes updating its guidance as
more information is gleaned, lessons are learned, and technologies
advance.
While the December 2003 guidance reflects some of the lessons learned
since the fall of 2001, it does not define or provide examples of some
key terms, including what would constitute either a "suspected release"
or a "strong suspicion" of anthrax that would warrant evacuation from a
facility. In addition, the December 2003 guidance references outdated
guidance and could therefore cause confusion during an emergency
response. Specifically, the guidance refers readers to the Postal
Service's October 1999 guidance on responding to mail allegedly
containing anthrax for a description of,[Footnote 82] among other
topics, management roles and responsibilities and lines of
responsibility for the response. Directing readers to this outdated
information could cause confusion in the future because the 1999
guidance is no longer in effect.[Footnote 83] The December 2003
guidance also does not fully address all of the circumstances that the
Postal Service faced in 2001 or could likely face in the future. For
example, although the guidance calls for closure if sampling results
indicate that anthrax has been aerosolized and transported throughout a
facility, the Postal Service would not have any sampling results for
facilities without detection systems unless (1) it routinely collected
and tested samples from all of its facilities or (2) an observable
event--such as the discovery of a suspicious letter or package--or a
"strong suspicion" had triggered a decision to sample. The guidance
also specifies closure if a diagnosis of inhalation anthrax is
confirmed in a postal employee, but confirmation takes time, and the
guidance does not indicate what measures would be taken in the interim.
Although the Postal Service's December 2003 guidance does not fully
address all of the circumstances the agency faced in 2001, the Postal
Service has since taken additional precautions in responding to
threats. However, it has not yet finalized its guidance to reflect
these precautions. According to the Manager, Safety Performance
Management, the Postal Service has learned not to wait for others
before taking action; now, if it learned that it had delivered an
envelope containing anthrax, it would immediately determine the path of
the recovered envelope through the mail system and immediately close
the facilities that had processed it. Consistent with this proactive
approach, on November 6, 2003, the Postal Service shut down 11 postal
facilities in and around Washington, D.C., after a preliminary test--
not a confirmed result--from a routine air sample taken by a U.S. Navy
contractor on November 5 indicated that a Navy mail-processing facility
might be contaminated with anthrax. The Postal Service tracked the flow
of mail through the facility and closed 11 postal facilities, most of
which picked up mail from the Navy facility. The subsequent
confirmatory tests were negative, and the postal facilities reopened on
November 7 and 8. In addition, on February 2, 2004, the Postal Service
shut down its "V Street" facility, which now processes mail for Capitol
Hill and other federal offices in Washington, D.C, soon after
preliminary tests indicated that a powder found on a mail machine in
the Senate mailroom was ricin, a deadly toxin.[Footnote 84] No letter
was ever found in this incident, and no ricin was detected at the V
Street facility. Nevertheless, the Postal Service monitored the health
of the facility's employees and the facility remained closed for 2 days
while 132 environmental samples were taken and analyzed. All of the
samples were negative, and the facility reopened on February 4, 2004.
According to Postal Service managers, the Postal Service is in the
process of updating its guidance and intends to replace the December
2003 interim guidelines for anthrax with a more comprehensive "all
hazards" emergency response plan for addressing future natural and man-
made emergencies. According to the Manager, Safety Performance
Management, the plan will be completed by the fall of 2004 and will
address the additional precautions that the Postal Service has taken
since the fall of 2001, such as its November 2003 closure of postal
facilities after receiving preliminary test results indicating the
possibility of anthrax.
Although the Postal Service has taken a more proactive approach to
protect its employees since the anthrax attacks, it is also responsible
for carrying out its mission to process and deliver the mail. False
positive test results, such as the one obtained for the Navy mail-
processing facility, are but one of the obstacles to efficient
operations. Incidents involving suspicious packages or powder spills
can also interrupt operations, cause fear, and divert resources, not
only for the Postal Service but also for law enforcement and public
health agencies at all levels of government. During the anthrax
attacks, the frequency of suspicious powder incidents increased
dramatically. According to the head of the Postal Inspection Service,
over 7,000 anthrax hoaxes, threats, and suspicious letters and
packages--an average of almost 600 per day--were reported to his agency
in the weeks following the first anthrax attack, and nearly 300 postal
facilities had to be evacuated because of these incidents. On October
30, 2001, the head of the FBI's Counterterrorism Division testified
before the House Committee on Government Reform that the FBI and state
and local authorities were overwhelmed by hoaxes in the wake of the
anthrax incident, handling more than 2,000 in the first 2 weeks of
October 2001, compared with about 250 a year previously. He cited both
the "indeterminable" resources required to address them and "the terror
they bring to the victims." Additionally, according to CDC officials,
large numbers of medical, public health, law enforcement, and emergency
response personnel throughout the country and the world dealt with
numerous hoaxes perpetrated in the weeks after the incidents. According
to officials, while the frequency of incidents involving suspicious
packages or powder spills has declined since 2001, they nevertheless
remain a challenge to the Postal Service and other agencies.
Timely Sharing of Information Is Critical to an Effective Response:
A second key lesson learned during the anthrax response was the need
for prompt information sharing. While efforts were made to facilitate
effective, timely communication, information was not always shared
within and among agencies. Several factors may have contributed to the
problems with information sharing.
Collocating Liaisons at FBI Headquarters Facilitated Timely Information
Sharing:
Historically, according to an April 2002 report prepared for the
Department of Defense,[Footnote 85]the FBI has "been reluctant to share
information it has collected in pursuit of a criminal investigation,"
and the goals of law enforcement and of public health sometimes
conflict. During the anthrax response, the FBI tried to mitigate these
differences by collocating liaisons from CDC and the Postal Inspection
Service with FBI headquarters officials. As the Section Chief of the
FBI's Counterterrorism Division testified on October 30, 2001, before
the House Committee on Government Reform, the CDC liaison was
"literally living in my space at FBI headquarters" and the Postal
Inspection Service liaison was "also working in our space, in on every
briefing, . . . so that he can coordinate postal efforts with the FBI
efforts." As a result, he said, "there's no information that we have or
the Postal Service has that doesn't cross back and forth, so that we're
all totally informed of all aspects of the investigation."
The CDC and Postal Inspection Service liaisons we interviewed confirmed
that they generally received timely information from the FBI. For
example, the CDC liaison testified that he participated in an
interagency teleconference on October 15, when the FBI first received
information from the U.S. Army Medical Research Institute of Infectious
Diseases describing the anthrax contamination in the letter to Senator
Daschle. It was during this teleconference that a scientist for the
Army Institute referred to the anthrax spores in the letter as
"weaponized"--a term that was subsequently modified.[Footnote 86] The
CDC liaison further testified that he hosted a conference call to relay
the information to other CDC personnel in the early hours of October
16. The liaison for the Postal Inspection Service did not begin work at
the FBI until October 17, 2001; consequently, he did not participate in
the interagency teleconference on October 15. Nevertheless, the liaison
told us that, to the best of his knowledge, the FBI shared all of the
information it had, including the test results of the Daschle letter.
He described his agency's relationship with the FBI as cooperative,
saying that if the Inspection Service asked for something, the FBI did
its best to provide what was needed; and if the FBI asked for
something, the Inspection Service likewise did its best to supply it.
While collocating liaisons from other agencies at FBI headquarters
facilitated information sharing, it appears that there are still
opportunities for improvement. For example, although CDC asked the FBI
for information on the size of the spores in the Daschle letter and
their potential to aerosolize on October 19, 2001, a discrepancy exists
between CDC and the FBI about when the information was provided. We
could not resolve the discrepancy. The CDC liaison told us that he
received the information from the FBI on October 24, 2001--a day after
the Secretary of Health and Human Services was briefed on the results.
In contrast, FBI officials said that the information was provided to
CDC's liaison on October 22--the same day that the U.S. Army Medical
Research Institute of Infectious Diseases delivered its report to the
FBI.[Footnote 87] Similarly, the liaison for the Postal Inspection
Service and the Postal Service's former Senior Vice President for
Government Relations and Public Policy told us that they were unaware
of the Army Institute's results, including the results of its spore
size analysis, until days after Brentwood's closure.[Footnote 88]
According to the testimony of the Commanding General of the U.S.
Medical Research and Materiel Command before the Senate Committee on
Governmental Affairs on October 31, 2001,[Footnote 89] the Army
Institute's analyses revealed particles ranging from single spores to
aggregates of spores up to 100 microns or more in diameter.
Furthermore, the spores had a "propensity to pulverize."
Problems with Sharing Information Were Reported within and among
Agencies:
Local public health officials identified problems with the timely
sharing of information both within CDC and among state public health
agencies. For example, the epidemiologist for New Jersey told us that
based on his interactions with the CDC team that assisted in New
Jersey, the information CDC learned from the response in Florida did
not appear to have been shared. The epidemiologist also said that he
did not acquire some information about the Florida response that could
have influenced his decision making until a year after the anthrax
incidents. Specifically, he learned from an October 2002 CDC
publication[Footnote 90] that public health authorities in Florida had
provided antibacterial drugs for some postal employees on October 12,
2001--the same day testing was initiated at selected postal facilities
in Florida[Footnote 91]--and that the Postal Service had some
preliminary positive test results on October 13, 2001. The
epidemiologist said that if this information had been shared at the
time, New Jersey officials would very likely have begun testing the
Trenton facility immediately and might have urged closing the facility
and offering antibacterial medication to the employees deemed most
likely to have been affected. The former director of the D.C.
Department of Health also reported problems with information sharing.
Specifically, he said that information about the characteristics of
anthrax in the Daschle letter was not shared with departmental
personnel and other local officials, including the D.C. mayor. As a
result, he said he first read about the anthrax being "weaponized" in
the newspaper.
Within the Postal Service, managers found that some postal employees
had not shared current and accurate information on how they could be
contacted in an emergency. As a result, the managers said, they were
greatly hampered in their efforts to relay important information to
Trenton and Brentwood employees who were not at work when the
facilities closed, including information on how to receive medical
treatment and where to report to work. Postal managers said they had to
rely on contact information supplied by union representatives, use
postal inspectors and local law enforcement authorities to search for
employees and, when unsuccessful, wait for employees to report for
duty after they learned about the facility closures through the media.
Several Factors May Have Hindered Timely Information Sharing:
The problems with timely information sharing may have occurred for a
variety of reasons. First, according to the Postal Service's Chief
Operating Officer and other senior postal managers, information on who
was responsible for managing the response within federal agencies was
not always clear. Individuals involved in early discussions, the
managers learned, were not always authorized to make decisions. As a
result, decisions were sometimes delayed while decision makers
familiarized themselves with the issues. A U.S. Army Medical Research
Institute of Infectious Diseases official also observed that within
CDC, and between CDC and affected locations, information was not shared
well because, at the time, CDC did not have a command center. Changes
in CDC staffing further complicated information sharing, according to
Postal Service managers, who cited difficulties in educating CDC
officials who lacked knowledge of postal operations.
Within the Postal Service, problems with sharing information appear to
be linked to poor relations between labor and management. For example,
union representatives and postal managers told us that postal employees
often do not provide current and accurate contact information because
they do not trust postal management.
As recollections have faded over time and changes in agency personnel
have occurred, it has become increasingly difficult to reconstruct
events and determine what information was available to whom at what
time. Documentation of who participated in key meetings, what
information was communicated, and what decisions were reached is often
unavailable or difficult to identify and obtain. In our earlier work on
the anthrax contamination at Wallingford, for example, we could not
determine when the Postal Service first learned of the quantitative
test results for the facility because there was no definitive
documentation. Similarly, during this review, we could not always
reconcile seemingly conflicting recollections of what information was
shared, with whom, and when, because participants often did not
document their activities or decisions. Even during the response,
postal managers said, it was very difficult to reconcile conflicting
information from different parties. Nearly 3 years later, it is even
more difficult.
Agencies Have Taken Steps to Improve Information Sharing and
Documentation:
Organizational changes made since the anthrax incidents may facilitate
information sharing at the federal level. While the Office of Homeland
Security existed in the fall of 2001, it had just been created and
played a limited role in the anthrax response. Now that there is a
cabinet-level Department of Homeland Security, responsible for
coordinating the homeland security activities of multiple federal
agencies, opportunities exist for establishing clear lines of authority
and designating positions with responsibility for making decisions in
the event of a future bioterrorist attack. According to the Postal
Service's Chief Operating Officer and other senior postal managers,
coordination at the federal level has been greatly improved with the
creation of the Department of Homeland Security. Postal managers noted
that when ricin was discovered in a South Carolina postal facility in
October 2003, personnel from the new department immediately took the
lead, sought advice from all the relevant agencies, and reached a quick
consensus on how to proceed. However, when a ricin-contaminated letter
addressed to the White House was intercepted at an off-site nonpostal
mail-sorting facility in November 2003, the Secret Service waited 2
days after the substance was positively identified to notify the FBI,
the Postal Service, and other agencies about the discovery. According
to postal managers, the following day, the Department of Homeland
Security oversaw a series of conference calls to discuss the situation.
A Postal Service manager said that the Postal Service would have liked
to have known about the ricin letter earlier so that the Postal Service
could have monitored the health of the employees, even though there is
no drug or antidote for ricin poisoning.
The Postal Service has also improved its ability to share information.
During the anthrax response, the Postal Service learned more about the
roles and responsibilities of key federal agencies and personnel.
Postal managers said they now interact regularly with federal agencies,
including OSHA and the Environmental Protection Agency. In addition,
postal managers meet periodically with representatives of the 16
federal agencies that make up the National Response Team. Such regular
interaction has established a basis for better coordination with
federal agencies than the Postal Service had prior to the anthrax
incidents.
Internally, the Postal Service has centralized responsibility for any
future response. According to postal managers, the agency has created a
new position, the Vice President for Emergency Preparedness, to
identify a single decision maker and to ensure that one individual will
be involved in all phases of planning for and responding to any future
emergency. Additionally, according to officials from the Postal
Inspection Service, the Postal Service has established a 24-hour watch
desk so that when an incident occurs, a call goes directly to the desk
and the Inspection Service can transmit information nationwide. The
agency can then see, track, and analyze patterns as they develop, they
said, whereas in the past such information was not available until
after a report on the incident had been prepared. They noted that
having earlier information on the response also allows the Inspection
Service to meet sooner with the Department of Homeland Security to
discuss the issues.
Finally, the Postal Service has established procedures for obtaining
up-to-date information for contacting employees. For example, when the
Brentwood facility reopened, the Postal Service required employees to
provide current information before their identification badges were
issued. In addition, the Postal Service said the plant orientation
brochure and orientation briefing would address the importance of
keeping the information up to date. The Postal Service added that it
would post periodic reminders and locate a kiosk within the workspace
to make it easier for employees to update their contact information.
Efforts have also been made to improve documentation during the
response to a bioterrorist attack. In our April 2003 report on the
events at Wallingford, we recommended that the Postal Service and the
Environmental Protection Agency--as lead agency of the National
Response Team--revise their guidance to require and maintain
documentation of the basis for decisions made, including the health-
related advice that they receive and the specific content of their
communications to employees and others. This information is needed to
establish a clear record of actions taken and to help reconcile
differences in the recollections of participants. Both organizations
have implemented this recommendation. Guidance developed by the
National Response Team, for example, recommends that agencies "develop
and maintain good records documenting advice received from public
health officials and others about the communication of health-related
information of workers and the general public."
Two Other Lessons Also Emerged:
In addition to the two key lessons that the Postal Service and other
agencies learned about the importance of responding proactively in the
face of uncertain health risks and of sharing information in a timely
manner with all affected parties during an emergency, we identified two
additional lessons during our review: the need for reliable methods to
test for anthrax in the environment and the need for a plan to provide
emergency medical services to employees.
Reliable Methods Are Needed to Test for Anthrax in the Environment:
The lesson on needing reliable methods to test for anthrax
contamination in the environment emerged when two initial quick tests
at Brentwood--performed by a local hazardous materials response team on
October 18, 2001--produced negative results that misled the Postal
Service and public health agencies. As a result, the facility remained
open and CDC did not recommend antibacterial drugs for employees until
after it confirmed a case of inhalation anthrax in a Brentwood employee
on October 21. In total, four Brentwood employees contracted inhalation
anthrax, two of whom died, and later tests showed that the facility was
heavily contaminated. At Wallingford, four rounds of tests were also
conducted before anthrax was identified in the facility.
During an anthrax investigation, taking environmental samples is
critical to identify the likely source of infection and the extent of
environmental contamination and to support decisions about the need for
antibacterial medication or decontamination and determine when
employees and others can reenter a facility. However, at the time of
the 2001 investigations, there were no validated methods of sampling
the environment to test for anthrax.
The quick tests that were used at Brentwood are designed to detect
living organisms, but are not specific to anthrax and are known to
produce a high rate of false positive results. A false positive occurs
when organisms are detected in a sample, but follow-up laboratory
testing proves that they are not anthrax. Laboratory testing
traditionally involves culturing bacterial spores taken from the sample
so that they can grow into cells whose identity can be confirmed
through a variety of additional tests. According to CDC, obtaining
confirmation can take 3 to 5 days.
Quick tests may also produce false negative results if the environment
is contaminated but the sample does not contain a sufficient number of
spores for the test to detect any living organisms. While positive
results may have provided early warning of contamination at Brentwood,
even though more time would have been needed to identify the
contaminant as anthrax, the negative results appear to have promoted a
false sense of security. Results from other tests, conducted the same
day, took much longer to obtain but revealed that the facility was
contaminated.[Footnote 92]
The environmental testing at Wallingford, conducted in November and
December 2001, helped to demonstrate the relative sensitivity of
different sampling methods.[Footnote 93] Various methods were used
there, including dry and wet swabs, wet wipes, and a high efficiency
particulate air (HEPA) vacuum.[Footnote 94] For the first two rounds of
tests, contractors hired by the Postal Service used dry swabs, and for
the third round, a CDC investigation team used wet swabs. CDC found no
contamination in the samples collected by these methods. For the fourth
round, the CDC investigative team used a combination of these methods,
and found contamination in the samples collected from mail-sorting
machines. On the basis of research on and experience from sampling
efforts in the fall of 2001, CDC eventually recommended the use of wet
wipes and vacuums for future investigations of large facilities.
In 2001, CDC reported that it lacked data on the relative effectiveness
of the methods used to collect samples from surfaces typically found in
an indoor environment. Since then, various studies have addressed this
issue. In a report published in 2002,[Footnote 95] for example, side-
by-side samples were collected from surfaces at Brentwood before it was
decontaminated, using swabs, wipes, and a HEPA vacuum. Wet wipes and
the vacuum were found to be more effective than surface swabs,
particularly dry swabs. While various sampling and analytical methods
have been evaluated for the detection of anthrax, none of those that
were used in postal facilities during the fall of 2001 had been
scientifically validated. GAO is currently completing a review of,
among other matters, (1) the activities performed by federal agencies
in the fall of 2001 to detect anthrax contamination in postal
facilities, (2) the results of these activities, and (3) the process of
validation and its significance. The results of this review, including
recommendations for improving sampling methods, are expected before the
end of 2004.
Policies and Procedures for Obtaining Emergency Medical Services:
The lesson about the need for an emergency medical plan detailing,
among other matters, where postal employees would go for medical
services and who would pay arose when the lack of such a plan resulted
in some confusion in New Jersey. Medical treatment was not immediately
provided to postal employees after Trenton closed on October
18.[Footnote 96] The following day, New Jersey public health officials
recommended that postal employees consult with their personal
physicians about getting antibacterial medication.[Footnote 97] They
made this recommendation late on a Friday afternoon, when there was
little opportunity for postal employees to contact their personal
physicians. The local mayor disagreed with the recommendation and
arranged instead for a local hospital, which had an existing contract
to provide treatment for job-related injuries to postal employees, to
begin treating postal employees immediately. However, specific
arrangements for paying for the anthrax-related treatment were not made
at that time; consequently, it was unclear who was financially
responsible for the treatment--the Postal Service, the Office of
Homeland Security using funds for emergencies, or the state. Payment of
the bill, which was submitted to the Postal Service in March 2002, was
delayed for about 3 months for a number of reasons. Specifically, the
Postal Service's existing agreement with the hospital for providing
services to postal employees did not cover all of the types of services
needed to deal with anthrax exposure; the Postal Service did not
specifically authorize the services in advance, as required; and
initially, the hospital did not provide any supporting documentation
with its bill. Nevertheless, after resolving these issues, the Postal
Service reached agreement with the hospital on the amount to be
reimbursed and, in June 2002, paid the hospital $618,000.
Subsequently, the Postal Service worked with the New Jersey Department
of Health and Senior Services to develop response guidelines to deal
with possible future anthrax exposure events. The guidelines, which
were still in draft as of mid-June 2004, included arrangements for
getting emergency medical services for postal employees but did not
address policies and procedures for payments. In commenting on a draft
of this report, the Postal Service noted that it is working with the
Department of Homeland Security and other entities responsible for
dealing with terrorist activity to formulate policies and procedures
for dealing with terrorist events, including how to pay providers of
emergency medical services. While we agree that the Postal Service's
policies and procedures eventually should be consistent with those
adopted by others, it is not clear when the broader policies and
procedures will be available. Thus, consistent with our recommendation,
we continue to believe that the Postal Service should establish a time
frame by which it will develop interim policies and procedures for
paying emergency service providers.
Conclusions:
Since the anthrax incidents, the Postal Service has twice revised its
Interim Guidelines to incorporate the lessons it has learned from the
response to anthrax in its facilities. While the revised guidance
addresses many of the circumstances that the Postal Service faced in
2001 and could face in the future, the specific concerns that we
identified--including the use of undefined terms, such as "suspected
release" and "strong suspicion," and the references to outdated
guidance--could be confusing for decision makers. Without definitions
of such terms, for example, it would not be clear what events should
trigger an evacuation or closure or what evidence should indicate a
need for medical intervention, particularly for facilities without
anthrax detection devices. Furthermore, the revised guidance does not
reflect precautions that the Postal Service has taken since 2001, such
as closing facilities after receiving preliminary test results
indicating possible contamination with anthrax and ricin. The Postal
Service acknowledges limitations in its existing guidance and has
committed to updating its guidance as more information is gleaned and
more lessons are learned.
Like the Postal Service, CDC has not yet published its updated guidance
to reflect its current knowledge about anthrax or its current approach
for responding to evidence of anthrax contamination. Consequently, for
cases of cutaneous anthrax or positive environmental samples, CDC's
published guidance does not call for a facility to be closed, even
though CDC informed us that it may now require or recommend other
agencies to close facilities in these circumstances. Given the many
uncertainties revealed during the anthrax incidents--including (1) the
possibility that cases of cutaneous anthrax may indicate a risk of
inhalation anthrax and (2) the potential for very low levels of
environmental exposure to cause inhalation anthrax in some persons,
especially those with preexisting health conditions--we believe it is
important for CDC to publish its revised guidance to reflect its
current approach. Because CDC is currently revising its guidance to
reflect the cautious approach it described and plans to have this
guidance completed by the end of 2004, we are not making a specific
recommendation that it do so at this time.
The Postal Service and New Jersey have drafted an agreement for
providing emergency medical services to postal employees in New Jersey
but have not yet developed policies and procedures for paying for these
services. The Postal Service is also working with the Department of
Homeland Security and others responsible for dealing with terrorist
events, among other things, to formulate governmentwide policies and
procedures for paying for emergency medical services. However, it is
not known when these policies and procedures will be available. As a
result, if another emergency arises in the interim, confusion could
again cause delays in payments to providers and/or disputes over
payments. Given that nearly 3 years have elapsed since the Trenton
postal employees were exposed to anthrax and reimbursement issues
arose, we believe that, at a minimum, the Postal Service should set and
meet a definitive time frame for developing interim policies and
procedures for paying for emergency services. These policies and
procedures should address the documentation needed by the Postal
Service to support bills submitted to it and any other steps the Postal
Service believes are necessary to provide for sound financial
management.
Recommendations for Executive Action:
To help ensure that the Postal Service has accurate, clear,
comprehensive, and up-to-date guidance for responding to an emergency,
we recommend that the Postmaster General, working with other agency
officials as appropriate, implement the following two recommendations.
First, the Postal Service should revise its December 2003 Interim
Guidelines to:
* define key terms, such as "suspected release" and "strong suspicion"
of contamination;
* ensure that any references to earlier guidance are still applicable;
and:
* clarify the actions that the Postal Service would take under various
scenarios, such as when (1) the Postal Service receives preliminary
evidence of anthrax contamination or (2) a postal employee is diagnosed
with either inhalation or cutaneous anthrax.
Second, to help ensure (1) the availability of timely and appropriate
emergency medical treatment and (2) that medical providers receive
timely payment for emergency medical services provided to postal
employees exposed to anthrax or other threatening substances, the
Postal Service should establish and meet a definitive time frame for
developing interim policies and procedures on paying for such services.
Agency Comments and Our Evaluation:
We requested comments on a draft of this report from the Postal
Service, CDC, the FBI, the U.S. Army Medical Research Institute of
Infectious Diseases, and representatives of three postal unions (the
American Postal Workers Union, the National Postal Mailhandlers Union,
and the National Association of Letter Carriers). Most of these
organizations provided technical comments, which we incorporated as
appropriate.[Footnote 98] The Postal Service's written response to our
draft report agreed with the thrust of our recommendations. CDC
provided detailed written comments to clarify portions of our draft
report. The agencies' comments are summarized below.
The Postal Service acknowledged that it would have made different
decisions had the present state of medical and scientific knowledge
been available in 2001. However, the Postal Service said it was pleased
that we recognized that the health and safety of its employees and
customers were its first priority and that its decisions were based on
the advice and guidance it received from the scientific and medical
community. Regarding our draft recommendations, the Postal Service said
that it either (1) had revised or (2) would revise and clarify its
guidance. For example, the Postal Service noted that it had recently
published a new management instruction that establishes the procedures
to be followed if a biohazard detection system generates a positive
test alert, including the procedures set forth in CDC's April 2004
guidance for evacuating a facility and administering postexposure
antibacterial drugs. We deleted our proposed recommendation in this
area to reflect the Postal Service's action. The Postal Service also
said that it would work with the Department of Homeland Security and
other relevant entities to develop appropriate policies and procedures
for paying for emergency medical service; however, it is unclear when
these policies and procedures will be available. Finally, although the
Postal Service said that we concluded that its decisions in 2001 were
appropriate under the circumstances, we did not draw conclusions on
this issue. As stated in our report, our first objective was to
describe the factors considered in deciding whether to close the five
postal facilities and the actions taken to protect postal employees--
not to assess the appropriateness of the Postal Service's actions and
decisions. The Postal Service's comment letter is reproduced in
appendix IV.
In its general comments, CDC agreed that communication challenges
occurred during the anthrax incidents, but maintained that the draft
report did not adequately emphasize (1) the nation's limited experience
with anthrax or (2) the lack of assigned federal leadership
responsibility for coordinating a response to it. CDC also objected to
our use of the term "assumptions" in our draft report to describe how
it arrived at its public health recommendations. CDC emphasized that
its decisions and recommendations were based on available science--not
assumptions about health risk. Specifically, CDC indicated that its
decisions "were based on inferences from previous experience and [its]
epidemiological observations in Florida and New York, where no disease
occurred among postal workers." While we believe our draft report
clearly described the limitations of available knowledge and experience
in the fall of 2001 and how these limitations led to the development of
incorrect inferences and working assumptions about health risk to
postal employees, we revised the report to further clarify these and
other points. CDC's general comments are reproduced in appendix V. We
addressed CDC's technical comments, as appropriate, in the body of the
report.
We are sending copies of this report to the Postmaster General; the
Chairman of the Senate Committee on Governmental Affairs; the Chairman
and Ranking Minority Member of the House Committee on Government
Reform; the CDC; OSHA; the U.S. Army Medical Research Institute of
Infectious Diseases, and the FBI, as well as to postal unions, local
public health departments, and other interested parties. We will
provide copies to others on request. In addition, the report will be
available at no charge on the GAO Web site at
[Hyperlink, http://www.gao.gov].
If you have any questions about this report, please contact me on (202)
512-2834 or at [Hyperlink, goldsteinm@gao.gov]. Key contributors to
this assignment were Don Allison, Jeannie Bryant, Derrick Collins,
Elizabeth Eisenstadt, Bert Japikse, José Matos, Kathleen Turner, and
Bernard Ungar.
Signed by:
Mark L. Goldstein:
Director, Physical Infrastructure Issues:
[End of section]
Appendixes:
Appendix I: Comparison of Medical Services and Reassignment Benefits
Provided to Postal Employees at Selected Facilities:
Employees at the five facilities in our review received similar medical
services, but the timing of the services varied depending on events at
each location. Likewise, employees at the two facilities that were
closed--Trenton and Brentwood--received similar reassignment benefits;
however, the duration of the benefits differed. Available information
on reassignment benefits received at facilities that the Postal Service
said were closed for other emergencies was neither complete nor
comparable, hampering efforts to compare benefits across facilities.
This information is incomplete because the Postal Service does not
centrally maintain information on its facility closures. Furthermore,
of the 22 closures for other emergencies that the Postal Service
identified during the 5-year period between January 1, 1998, and
December 31, 2002, none lasted nearly as long as the closures of
Trenton and Brentwood.
Similar Medical Services Were Provided to Employees at the Five
Facilities, but the Timing of the Services Varied:
Public health authorities provided similar medical services to
employees at the five facilities in our review, including educational
briefings on anthrax, literature to help employees make informed health
decisions, medical screening, and antibacterial drugs; however, the
timing of the services varied with the circumstances at each location.
For example, in Florida, the local public health officials offered
antibacterial drugs to employees at the West Palm Beach facility as
soon as testing began at the facility and before any positive results
were known. As discussed in the body of this report, the officials took
this action because they believed it was important to respond
proactively to the suspicion of contamination. In contrast, at the
other facilities in our review, antibiotic prophylaxis was provided
after the facility tested positive or after the Centers for Disease
Control and Prevention (CDC) confirmed that a postal employee or
customer had contracted anthrax. Table 3 identifies key events and
indicates when medical screening began and antibacterial medication was
offered to employees at the five facilities.
Table 3: Key Events and Selected Medical Services Provided to Employees
at the Five Postal Facilities:
Postal facility: Trenton;
Primary medical service provider: Local hospital;
Date of key events and selected medical services provided:
10/18/01: CDC confirmed that a postal employee had cutaneous anthrax.
The facility was closed;
10/19/01: Medical screening and distribution of antibacterial drugs
were initiated.
Postal facility: Brentwood;
Primary medical service provider: D.C. Department of Health;
Date of key events and selected medical services provided:
AM 10/21/01: CDC confirmed that a postal employee had inhalation
anthrax. The mail-processing area of the facility was closed;
PM 10/21/01: Medical screening and distribution of antibacterial drugs
were initiated.
Postal facility: Morgan;
Primary medical service provider: CDC;
Date of key events and selected medical services provided:
10/24/01: Medical screening and distribution of antibacterial drugs
were initiated.
Postal facility: West Palm Beach;
Primary medical service provider: Palm Beach County Health Department;
Date of key events and selected medical services provided:
10/27/01: Initiation of environmental tests at the facility;
10/27/01: Antibacterial drugs were offered to postal employees at the
facility;
10/29/01: The facility tested positive for anthrax.
Postal facility: Wallingford;
Primary medical service provider: Connecticut Department of Public
Health;
Date of key events and selected medical services provided:
11/21/01: CDC confirmed that an elderly woman (a postal customer in
Connecticut) had inhalation anthrax;
11/21/01: Medical screening and distribution of antibacterial drugs
were initiated.
Sources: GAO presentation of Postal Service, CDC, and state health
department information.
[End of table]
Employees at the Two Closed Facilities Received Various Reassignment
Benefits That Lasted for Different Periods of Time:
Employees at the Trenton and Brentwood facilities received various
benefits related to their reassignment to other facilities; however,
the duration of the benefits differed at the two facilities.[Footnote
99] The reassignment benefits to Trenton and Brentwood employees
included administrative leave, free bus transportation and payment for
time spent on the bus, and reimbursement for any additional commuting
expenses.[Footnote 100] The Postal Service provided the administrative
leave first--from 1 to 3 days of time off--while it made alternative
work arrangements for the employees. In addition, the Postal Service
allowed employees to use administrative leave for any work time spent
obtaining medical treatment.
Second, the Postal Service provided Trenton and Brentwood employees
with free bus transportation to their new work locations and
compensated them for their time spent commuting on the bus. However,
the length of time that the transportation was offered and the period
of compensation for the commute differed at the two locations. At
Trenton--where most employees were initially reassigned to one of two
facilities[Footnote 101]--interested employees were bused from the
parking lot of the Trenton facility to the alternative facilities
beginning on Monday, October 22, 2001, and continuing until a new
interim facility was opened in November 2002. The round-trip commute
took about 2 hours per day and, for about the first month, the
employees were paid for the time they spent commuting on the bus.
However, as of November 19, 2001, the Postal Service stopped paying
employees for their commuting time on the bus, indicating that it was
inconsistent with postal policy because the alternative locations were
within the local commuting area.[Footnote 102] Although the Postal
Service stopped paying for the time spent commuting on the bus, free
bus transportation was provided until November 2002, when an interim
facility was established. Similarly, the Postal Service assigned
Brentwood employees to several facilities around Washington, D.C., and
bused interested employees, free of charge, from the parking lot of the
facility to one of the new work locations in Maryland beginning on
Monday, October 22, 2001. At Brentwood, as at Trenton, the employees
were initially paid for their commuting time, but Brentwood employees
received this benefit for about 3 months--2 months longer than the
Trenton employees. According to a former manager of the Brentwood
facility, the time spent commuting was reimbursed for a longer period
at Brentwood out of consideration for the trauma arising from the
deaths of employees there. The Postal Service terminated the benefit to
Brentwood employees in January 2002, indicating that the payments were
costly and inconsistent with postal policy. However, it continued to
provide bus service to an alternate work location in Maryland until
January 2003.
At both locations, the Postal Service reimbursed employees for any
additional commuting expenses they incurred while traveling
independently to their new work locations, such as extra mileage driven
in their vehicles or additional fares paid for public transportation.
At Trenton, employees were reimbursed about $1.5 million in fiscal year
2002 and about $1.4 million in fiscal year 2003 for their additional
commuting costs. Brentwood employees were reimbursed more than $540,000
in fiscal year 2002 and more than $1.1 million in fiscal year 2003,
according to the Postal Service.[Footnote 103]
Information on Benefits Paid to Employees at Facilities Closed for
Other Emergencies Is Neither Complete nor Comparable, Hampering
Comparisons across Facilities:
Available information on reassignment benefits received at facilities
closed for other emergencies was neither complete nor comparable,
hampering efforts to compare benefits across facilities. First, the
Postal Service does not centrally maintain information on its facility
closures. Thus, it was able to provide only general information on a
portion of its facilities--the 22 facilities with 10 or more employees
that, it says, were closed for more than 3 days between January 1,
1998, and December 31, 2002. Moreover, the circumstances associated
with these closures (e.g., facility size, number of employees, length
of closure) are not comparable to the closures of the Trenton and
Brentwood facilities.[Footnote 104] For example, as shown in table 4,
only 1 of the 22 closed facilities--the Houston Processing and
Distribution Center--is comparable in size and function to the Trenton
and Brentwood facilities. However, unlike Trenton and Brentwood, the
Houston facility was closed for less than a month because of damage
from tropical storm Allison in June 2001. The facility's operations and
1,560 employees were moved temporarily to another facility.
Of the remaining 21 facilities, 12 closed for damage from natural
disasters (fires, floods, or other weather-related reasons), 5 closed
for safety reasons (such as renovation), and 4 closed for damage from
the September 11, 2001, terrorist attacks on the World Trade Center.
The number of employees at these facilities ranged from 10 to 338--far
fewer than the numbers of employees at Trenton and Brentwood.
Operations for 14 of the 21 facilities were temporarily transferred to
other facilities, and the facilities have since reopened; 3 of the 21
facilities were closed for such a short time that the Postal Service
granted the employees administrative leave and did not have to transfer
operations to other facilities. Operations at 3 of the 4 facilities
that were closed for damage from the terrorist attacks were moved
temporarily to new facilities close to the original facilities. The
fourth facility, the Church Street station in New York City, remained
closed as of June 30, 2004. Table 4 provides information about the
postal facilities closed for other emergencies during the 5 years
between January 1, 1998, and December 31, 2002.
Table 4: Postal Facilities Closed for Other Emergencies, January 1,
1998, through December 31, 2002:
Facility location: Brooklyn, N.Y., New Lots Station;
Reason for closure: S;
Number of employees: 66[B];
Approximate date: Closed: 3/1998;
Approximate date: Reopened: 4/1998.
Facility location: Phoenix, Ariz., McDowell Station;
Reason for closure: S;
Number of employees: 65[B];
Approximate date: Closed: 5/1998;
Approximate date: Reopened: 8/1998.
Facility location: Loudonville, Ohio, Main Post Office;
Reason for closure: N;
Number of employees: 10[B];
Approximate date: Closed: 1/1999;
Approximate date: Reopened: 4/1999.
Facility location: Bound Brook, N.J., Main Post Office;
Reason for closure: N;
Number of employees: 30[B];
Approximate date: Closed: 9/1999;
Approximate date: Reopened: 5/2000.
Facility location: Los Alamos, N. Mex., Main Post Office;
Reason for closure: N;
Number of employees: 44[A];
Approximate date: Closed: 5/2000;
Approximate date: Reopened: 5/2000.
Facility location: Davenport, Iowa, Main Post Office;
Reason for closure: N;
Number of employees: 101[B];
Approximate date: Closed: 4/2001;
Approximate date: Reopened: 5/2001.
Facility location: Houston, Tex., Computerized Forwarding System;
Reason for closure: N;
Number of employees: 65[B];
Approximate date: Closed: 6/2001;
Approximate date: Reopened: 6/2001.
Facility location: Houston, Tex., Processing and Distribution Center;
Reason for closure: N;
Number of employees: 1,560[B];
Approximate date: Closed: 6/2001;
Approximate date: Reopened: 6/2001.
Facility location: New York City, 3 stations;
Reason for closure: (3) WTC;
Number of employees: 338[B];
Approximate date: Closed: 9/ 2001;
Approximate date: Reopened: 9/2001.
Facility location: La Plata, Md., Main Post Office;
Reason for closure: N;
Number of employees: 11[B];
Approximate date: Closed: 4/ 2002;
Approximate date: Reopened: 4/2002.
Facility location: Archbald, Pa., Main Post Office;
Reason for closure: N;
Number of employees: 14[B];
Approximate date: Closed: 4/ 2002;
Approximate date: Reopened: 6/2002.
Facility location: Roseau, Minn., Main Post Office;
Reason for closure: N;
Number of employees: 11[B];
Approximate date: Closed: 6/ 2002;
Approximate date: Reopened: 7/2002.
Facility location: Brooklyn, N.Y., Brevoort Station;
Reason for closure: S;
Number of employees: 58[B];
Approximate date: Closed: 8/2002;
Approximate date: Reopened: 8/2002.
Facility location: Abbeville, La., Main Post Office;
Reason for closure: N;
Number of employees: 31[A];
Approximate date: Closed: 11/2002;
Approximate date: Reopened: 11/2002.
Facility location: Kaplan, La., Main Post Office;
Reason for closure: N;
Number of employees: 15[A];
Approximate date: Closed: 11/ 2002;
Approximate date: Reopened: 11/2002.
Facility location: Cold Spring, N.Y., Main Post Office;
Reason for closure: N;
Number of employees: 12[B];
Approximate date: Closed: 2/2002;
Approximate date: Reopened: 1/2003.
Facility location: Dallas, Tex., Downtown Station;
Reason for closure: S;
Number of employees: 124[B];
Approximate date: Closed: 4/ 2001;
Approximate date: Reopened: 6/2003.
Facility location: Balch Springs, Tex., Station;
Reason for closure: S;
Number of employees: 16[B];
Approximate date: Closed: 11/2000;
Approximate date: Reopened: 6/2003.
Facility location: New York City, Church St. Station;
Reason for closure: WTC;
Number of employees: 202[B];
Approximate date: Closed: 9/2001;
Approximate date: Reopened: Not reopened[C].
Facility location: Tampa, Fla., Ybor City Station;
Reason for closure: N;
Number of employees: 60[B];
Approximate date: Closed: 5/ 2001;
Approximate date: Reopened: Not reopened[C].
Total facilities closed: 22.
Facilities not reopened: 2.
Source: GAO presentation of Postal Service data as of June 30, 2004.
Note: Reasons for closure:
S = building safety.
N = natural disaster or other emergency.
WTC = closed as a result of the attacks on the World Trade Center.
[A] The Postal Service reported that it granted employees
administrative leave.
[B] According to the Postal Service, employees were assigned to other
facilities during the closure.
[C] The functions of this facility were transferred.
[End of table]
[End of section]
Appendix II: Objectives, Scope, and Methodology:
As requested, we reviewed the response to anthrax contamination at five
postal processing and distribution centers--the Trenton Processing and
Distribution Center in Hamilton, New Jersey; the Brentwood Processing
and Distribution Center in Washington, D.C; the Southern Connecticut
Processing and Distribution Center in Wallingford, Connecticut; the
West Palm Beach Processing and Distribution Center in West Palm Beach,
Florida; and the Morgan Processing and Distribution Center in New York
City.[Footnote 105]
Specifically, our objectives were to describe (1) the factors
considered in deciding whether to close the five processing and
distribution centers; (2) the information communicated to affected
postal employees about the health risks posed by, and the extent of,
contamination in these facilities; and (3) how lessons learned from the
response to the contamination could be used in future situations.
Additionally, as requested, we determined what, if any, medical
services and reassignment benefits were provided to employees at the
five processing and distribution centers and how these benefits
compared to those provided to employees at facilities closed for other
emergencies during the 5-year period ending December 31, 2002.
To address our overall reporting objectives, we interviewed federal and
local officials involved in investigating and responding to anthrax
contamination at the five postal processing and distribution centers in
our review. We discussed, among other matters, the roles,
responsibilities, activities, and lessons of the U.S. Postal Service;
the Federal Bureau of Investigation (FBI); CDC and its National
Institute for Occupational Safety and Health within the Department of
Health and Human Services; the Environmental Protection Agency; the
Occupational Safety and Health Administration within the Department of
Labor; and the U.S. Army Medical Research Institute of Infectious
Diseases within the Department of Defense. We also interviewed
officials from the New Jersey Department of Health and Senior Services,
the D.C. Department of Health, the Florida Department of Health, the
Palm Beach County Department of Health in Florida, the New York City
Department of Health and Mental Hygiene, and the Connecticut Department
of Health. We also spoke to postal managers and union representatives
from each of the facilities, including representatives from the
American Postal Workers Union, the National Association of Letter
Carriers, and the National Postal Mail Handlers Union, and we met with
representatives of an employee group who had worked at the Brentwood
facility. Our work related to the Wallingford facility in Connecticut
was principally derived from previous work we conducted between
September 2002 and March 2003.[Footnote 106] We updated this
information, obtained additional supporting information, and
incorporated the information, as appropriate, in this report to address
our reporting objectives at the five facilities.
To understand the context in which the response to anthrax
contamination occurred, we reviewed and analyzed, among other things,
published literature; including technical reports on anthrax, studies
and analyses of the anthrax incidents, prior reports by GAO and the
Postal Service's Office of Inspector General, and newspaper articles
from the period October 1, 2001, through December 31, 2001, in
communities near the five postal facilities. To obtain information on
anthrax, the treatment of the disease, and the response to the 2001
contamination, we also reviewed reports prepared by CDC (including its
Mortality and Morbidity Weekly reports and its monthly Emerging
Infectious Diseases journals), as well other medical publications, such
as the Journal of the American Medical Association. We reviewed
testimony delivered before numerous congressional committees on the
response to the anthrax contamination in the fall of 2001; we also
reviewed videotapes of national and local television coverage of the
events as they were unfolding.
Specifically, to determine the factors considered in deciding whether
to close postal facilities, we interviewed headquarters' postal
officials as well as managers at each of the five facilities to
identify the person or persons responsible for deciding whether to
close the facility and to understand their roles in the decisions that
were made. We also interviewed local public health officials, including
state officials who participated in making closure decisions; reviewed
agency documentation related to the factors considered in deciding
whether to close facilities; and reviewed results of environmental
testing for anthrax at the facilities. We interviewed a former official
from the D.C. Department of Health who provided advice to the Postal
Service in the days prior to the closure of the Brentwood facility. To
understand the policies and guidance related to closure decisions, we
reviewed the Postal Service's anthrax-related guidance available at
that time, specifically its October 1999 Emergency Response to Mail
Allegedly Containing Anthrax; its October 19, 2001, guidance for
responding to anthrax; and its Interim Guidelines for Sampling,
Analysis, Decontamination, and Disposal of Anthrax for U.S. Postal
Facilities initially dated November 16, 2001. We also reviewed CDC's
guidance for closing facilities and the Postal Service's plans for
responding to other hazardous incidents in the fall of 2001, including
its plans for controlling exposure to blood-borne diseases, evacuating
facilities, and responding to releases of hazardous materials. Finally,
we reviewed available emergency response plans at the Trenton and
Brentwood facilities.
To obtain information on what was communicated to employees about
health risks posed by anthrax and the extent of contamination in
facilities, we interviewed a wide range of postal and public health
officials who provided information to employees during the crisis,
including the epidemiologists for New Jersey and Connecticut, the CDC
doctor who assisted in the response at Morgan, the occupational nurse
for the Postal Service who assisted in providing medical services at
the Robert Wood Johnson University Hospital in Hamilton, New Jersey,
and the public health doctors who provided care to postal employees, as
well as staff from the National Institute for Occupational Safety and
Health who participated in testing and analyzing facility samples. To
obtain employee views about the response to anthrax and what was
communicated to them, we interviewed union representatives from each of
the five facilities and met with representatives of an employee group
who had worked at the Brentwood facility. In addition, we reviewed
letters, flyers, and newsletters sent to employees, as well as
videotapes of news programs and meetings between the Postal Service and
affected parties, including employees. We also reviewed the
Occupational Safety and Health Administration's regulations for
disclosing test results to employees, as well as documentation of
briefings, health advisories, and various news bulletins provided to
employees. To determine what was communicated to employees about the
contamination at each facility, including the results of testing, we
interviewed officials from the Postal Service, CDC, local public health
authorities, the National Institute for Occupational Safety and Health,
the FBI, the U.S. Army Medical Research Institute of Infectious
Diseases, and the Occupational Safety and Health Administration. We
also obtained environmental tests results for the facilities and
reports and other documentation prepared by government and contractor
personnel. We did not independently assess or verify any of these data,
including the adequacy or reliability of the testing methods. Because
the Postal Service and others did not document all of the advice that
they received or provided, and did not, in all cases, document the
precise information communicated to employees during various talks at
the facilities, we sometimes relied on the recollections of Postal
Service, public health, and other officials to reconstruct the events
in this report. To the extent possible, we corroborated the information
with other sources.
To determine how lessons learned from the response to the contamination
could be used in future situations, we reviewed testimony and relevant
reports to identify actions taken to prepare for future bioterrorism
incidents, including those related to the creation of the new
Department of Homeland Security. We also interviewed involved parties,
including CDC and local public health authorities, about the lessons
that have been or should be learned from the response to anthrax. We
identified and documented actions taken, including actions taken to
respond to our April 7, 2003, report about the response to anthrax at
the Wallingford facility in Connecticut. For example, we reviewed
guidelines revised by the National Response Team for responding to
anthrax contamination. Finally we reviewed the Postal Service's
December 2003 updated guidance, entitled Interim Guidelines for
Sampling, Analysis, Decontamination, and Disposal of Anthrax for U.S.
Postal Facilities, for, among other things, the Postal Service's most
recent guidance on closing facilities and communicating test results to
workers. We also obtained and reviewed the Postal Service's guidance
for responding to anthrax at facilities with detection systems.
Fourth, to determine what, if any, medical services and reassignment
benefits were provided to employees, we interviewed officials from CDC,
local public health officials, and Postal Service managers who helped
coordinate the medical services at the five facilities in our review,
including managers from the D.C. Department of Health who assisted in
organizing the provision of medical services to Brentwood employees. We
also interviewed officials at the Robert Wood Johnson University
Hospital to obtain information about the medical services provided to
Trenton postal employees and to discuss issues related to the
hospital's payment for the services. In addition, we discussed these
issues with postal accounting staff at headquarters. We did not attempt
to determine whether appropriate medications and guidance were provided
to employees or whether appropriate medical protocols were followed at
the five locations. To determine what, if any, reassignment benefits
were paid to employees we interviewed Postal Service managers at the
five facilities, including the human resource managers and
representatives from the local unions. We also reviewed the Postal
Service's Employee and Labor Relations Manual and the national
collective bargaining agreements for three unions representing postal
employees and the Postal Service's memoranda terminating the
reassignment benefits at Trenton and Brentwood. We did not attempt to
determine whether appropriate benefits were provided to employees.
Finally, to compare benefits received at the five facilities with those
received by employees at facilities closed for emergencies, we
requested and reviewed summary information on benefits received at
facilities closed between January 1, 1998, and December 31, 2002, for
emergencies unrelated to anthrax. Because the Postal Service
specifically stated the limitations of the data, we did not attempt to
independently assess or verify any of these data.
We did not examine issues related to the other 18 postal facilities
that tested positive for anthrax or matters that are being
litigated.[Footnote 107] Likewise, we did not assess the response to
the anthrax contamination at the Hart Senate Office building in
Washington, D.C; however, a previous GAO report provided information
on this topic,[Footnote 108] which we incorporated as appropriate.
[End of section]
Appendix III: Time Line of Key Events, Fall 2001:
Date: Tuesday, 9/11/01;
Events:
* Terrorist attacks on the World Trade Center and the Pentagon heighten
concerns about possible bioterrorism.
Date: Monday, 9/18/01;
Events:
* Letters containing anthrax spores are mailed to the National
Broadcasting Company (NBC) and the New York Post from Trenton, N.J.
Date: Wednesday, 9/26/01-Monday, 10/01/01;
Events:
* Two NBC employees, a New York Post employee, and the baby of an
American Broadcasting Company (ABC) employee in New York City, and two
postal employees in N.J. seek medical treatment for skin conditions;
* In Fla., an American Media Incorporated employee is admitted to the
hospital with a respiratory condition.
Date: Tuesday, 10/02/01;
Events:
* In Fla., a second American Media Incorporated employee is admitted to
the hospital with a diagnosis of meningitis;
* CDC issues an alert about bioterrorism, which provides information
about preventive measures for anthrax.
Date: Thursday, 10/04/01;
Events:
* CDC and the Fla. Department of Health announce that an American Media
Incorporated employee has inhalation anthrax.
Date: Friday, 10/05/01;
Events:
* In Fla., an American Media Incorporated employee becomes the first
person to die from anthrax.
Date: Monday, 10/08/01;
Events:
* In Washington, D.C., the Postmaster General announces that the Postal
Inspection Service is working with other law enforcement agencies on
the incident in Fla.
Date: Tuesday, 10/09/01;
Events:
* Letters containing anthrax spores are mailed to Senator Daschle and
Senator Leahy from Trenton, N.J.
Date: Wednesday, 10/10/01;
Events:
* The Postal Service begins to educate employees nationwide on signs
of cutaneous anthrax exposure and procedures for handling mail to
avoid anthrax infection.
Date: Friday, 10/12/01;
Events:
* In N.Y., the New York City Department of Health announces that an NBC
employee has a confirmed case of cutaneous anthrax;
* The FBI recovers the letter sent to NBC and, later that day, a public
health laboratory in New York City confirms that the letter contained
anthrax. However, there was insufficient sample remaining to determine
the size of the anthrax particles;
* The Postal Service says that it will offer gloves and disposable
masks to all employees who handle mail;
* Senator Daschle's letter passes through the Brentwood processing and
distribution center;
* The Boca Raton post office in Fla., which handled mail for American
Media Incorporated, is tested for anthrax, and the Palm Beach County
Department of Health administers nasal swabs and offers a 15-day supply
of ciprofloxacin to postal employees considered most likely to have
handled the mail to American Media Incorporated.
Date: Monday, 10/15/01;
Events:
* On Capitol Hill, an employee opens an envelope that is addressed to
Senator Daschle containing anthrax. Staffs in that office, an adjacent
office, and first responders are given nasal swabs and a 3-day supply
of antibacterial drugs;
* In N.J., the State Department of Health and Senior Services assures
Trenton employees that they have a low risk of contracting anthrax;
* In Fla., the presence of anthrax spores is confirmed at the Boca
Raton post office;
* In Fla., CDC confirms that a second American Media Incorporated
employee has inhalation anthrax;
* U.S. Army Medical Research Institute of Infectious Diseases
personnel communicate the initial results of the agency's analyses of
the substance in the letter to Senator Daschle to the FBI and the CDC.
Date: Tuesday, 10/16/01-Wednesday, 10/17/01;
Events:
* In Washington, D.C., part of the Hart Senate Office Building is
closed in the morning, and the remainder of the building is closed in
the evening. Over the next 3 days, employees located in the Hart
building and other Capitol Hill employees who request them are given
nasal swabs and a 3-day supply of antibacterial drugs;
* U.S. Army Medical Research Institute of Infectious Diseases
personnel conduct additional analyses of the substance in the Daschle
letter and communicate their generalized findings to representatives
of the FBI, CDC, and selected other agencies. Representatives from the
Postal Service were not present.
Date: Thursday, 10/18/01;
Events:
* In Washington, D.C., a local hazardous materials response team
conducts two "quick tests" at Brentwood. The tests are negative for
anthrax. A contractor begins taking additional samples for laboratory
testing in the evening;
* In Washington, D.C., the Postmaster General holds a press conference
at Brentwood, in part to reassure postal employees that they are at
low risk for contracting anthrax;
* In N.J., CDC confirms cutaneous anthrax in a N.J. postal employee,
and a second suspected case is identified. The Trenton facility is
closed for environmental testing, and employees are sent home;
* In N.Y., the New York City Department of Health announces another
case of cutaneous anthrax in a Columbia Broadcasting System employee;
* In Fla., the Postal Service arranges with the Environmental
Protection Agency to clean two post offices contaminated with anthrax
spores;
* CDC distributes a press release announcing that the Food and Drug
Administration has approved doxycycline for postexposure prophylaxis
for anthrax, and begins recommending its use instead of ciprofloxacin;
* In Washington, D.C., a Brentwood postal employee seeks medical
attention;
* U.S. Army Medical Research Institute of Infectious Diseases
personnel continue their analyses of the anthrax in the letter sent to
Senator Daschle.
Date: Friday, 10/19/01;
Events:
* In N.J., the Department of Health and Senior Services refers postal
employees to their private physicians for medical treatment. The mayor
makes alternative arrangements and employees begin seeking treatment at
a local hospital. CDC confirms that another N.J. postal employee has
cutaneous anthrax;
* In Washington, D.C., a hospital notifies CDC that it has admitted a
Brentwood employee with a possible case of inhalation anthrax;
* U.S. Army Medical Research Institute of Infectious Diseases personnel
brief FBI personnel on, among other things, their observations about
the size of the anthrax particles in Senator Daschle's letter. Staff
from CDC and the Postal Service were not present;
* The FBI recovers the contaminated letter to the New York Post. The
letter was recovered unopened from mail that had been set aside as
suspicious by the media company.
Date: Saturday, 10/20/01;
Events:
* In Washington, D.C., another Brentwood employee is admitted to a
hospital with a respiratory condition;
* CDC arrives at the Brentwood facility to meet with Postal Service
managers and monitor the employee admitted to the hospital on 10/19.
According to Postal Service officials, CDC informed them that there
was no reason to close Brentwood unless and until an employee is
confirmed to have inhalation anthrax;
* Analyses by the U.S. Army Medical Research Institute of Infectious
Diseases determine that the letter to the New York Post, recovered on
10/19, contains anthrax. According to the FBI, the sample was not
suitable for testing the size of the anthrax particles.
Date: Sunday, 10/21/01;
Events:
* In Washington, D.C., the Brentwood employee who was admitted to the
hospital on 10/19/01 is confirmed to have inhalation anthrax. The mail-
processing area on the first floor of Brentwood is closed and
evaluation and prophylaxis of Brentwood employees begins;
* In Washington, D.C., the Brentwood employee who initially sought
medical attention on 10/18/01 is admitted to a hospital with a possible
case of inhalation anthrax and becomes the first postal employee (and
second person) to die;
* In Washington, D.C., another Brentwood employee seeks medical
attention at a hospital. His chest X-ray is initially determined to be
normal, and he is discharged.
Date: Monday, 10/22/01;
Events:
* In Washington, D.C., the Brentwood postal employee who sought
medical attention on 10/21/01 and was discharged is readmitted to the
hospital. This time, he is diagnosed with inhalation anthrax and
subsequently dies, becoming the second postal employee (and third
person) to die from anthrax;
* In Washington, D.C., distribution of antibacterial drugs is expanded
to include all employees and visitors to nonpublic areas at the
Brentwood facility;
* The Postal Service learns that environmental tests of Brentwood are
positive for anthrax;
* U.S. Army Medical Research Institute of Infectious Diseases
personnel hand-delivered a report, dated 10/21/01, describing the
results of their various analyses of the substance in Senator
Daschle's letter to the FBI. The report had been previously faxed to
the FBI on 10/21/01;
* According to FBI officials, the CDC liaison is briefed on the
results of the 10/21/01 report prepared by the U.S. Army Medical
Research Institute of Infectious Diseases on its analyses of Senator
Daschle's letter, but CDC's liaison said he was not briefed until
later.
Date: Wednesday, 10/23/01;
Events:
* In N.Y., environmental test results from the Morgan facility, which
processed the anthrax- contaminated letters delivered to media
personnel in N.Y., are positive for anthrax;
* In Washington, D.C., the Secretary of Health and Human Services is
briefed on the results of the U.S. Army Medical Research Institute of
Infectious Diseases' analyses;
* The Postal Service participates in discussions with U.S. Army
Medical Research Institute of Infectious Diseases about test results
from Senator Daschle's letter;
* The FBI learns that an envelope similar to the ones used in the
anthrax mailings had pores up to 50 microns in size.
Date: Thursday, 10/24/01;
Events:
* According to the CDC liaison, he was informed about the results of
U.S. Army Medical Research Institute of Infectious Diseases' 10/21/01
analyses of Senator Daschle's letter.
Date: Sunday, 10/28/01;
Events:
* In N.J., CDC confirms that a Trenton postal employee has inhalation
anthrax.
Date: Monday, 10/29/01;
Events:
* In N.Y., preliminary tests indicate that a N.Y. resident who was
admitted to the hospital on 10/28 has inhalation anthrax;
* In N.J., laboratory testing confirms cutaneous anthrax in a woman
who received mail from the Trenton facility, but had not visited the
facility. The woman originally sought medical attention on 10/18/01
and was admitted to the hospital on 10/22/01 for a skin condition;
* In N.J., laboratory testing confirms a second case of inhalation
anthrax in a Trenton postal employee who initially sought medical
attention on 10/16/01 and was admitted to the hospital on 10/ 18/01
with a respiratory condition.
Date: Wednesday, 10/31/01;
Events:
* In N.Y., the person hospitalized on 10/29/01 becomes the fourth
person to die from inhalation anthrax.
Date: Friday, 11/2/01;
Events:
* In N.Y., public health officials announce another case of cutaneous
anthrax, in a New York Post employee.
Date: Friday, 11/16/01;
Events:
* In Washington, D.C., a letter addressed to Senator Leahy is
recovered in mail that was impounded before delivery to Capitol Hill
by the FBI on 10/17/01. The letter, which was also mailed in Trenton,
N.J., and processed through both the Trenton and Brentwood postal
facilities, was subsequently found to contain anthrax. A total of four
letters containing anthrax have now been recovered, all mailed from
Trenton, N.J.
Date: Wednesday, 11/21/01;
Events:
* In Connecticut, an elderly woman who was admitted to the hospital
for dehydration on 11/16/01 becomes the fifth person to die from
inhalation anthrax;
* The Connecticut Department of Public Health, in consultation with
CDC, begins prophylaxis for postal employees working at the
Wallingford postal facility, which processed mail to the fifth
victim's home.
Date: Friday, 12/27/01;
Events:
* CDC offers the anthrax vaccine to postal employees.
Source: GAO based on information provided by the U.S. Postal Service,
the CDC, the Connecticut Department of Public Health, the D.C.
Department of Health, the FBI, the Florida Department of Health, the
New Jersey Department of Health and Senior Services, and the New York
City Department of Health and Mental Hygiene.
[End of table]
[End of section]
Appendix IV: Comments from the U.S. Postal Service:
UNITED STATES POSTAL SERVICE:
HENRY A. PANKEY:
VICE PRESIDENT, EMERGENCY PREPAREDNESS:
July 2, 2004:
Mr. Mark L. Goldstein:
Director, Physical Infrastructure Issues:
United States General Accounting Office:
Washington, DC 20548-0001:
Dear Mr. Goldstein:
Thank you for providing the Postal Service with the opportunity to
review and comment on the draft report, U.S. Postal Service: Better
Guidance Needed to Ensure An Appropriate Response to Anthrax
Contamination.
We are pleased that the GAO correctly recognizes that the health and
safety of our employees and customers was at all times our first
priority during the anthrax crisis of 2001. We also agree with your
conclusion that the decisions made by the Postal Service, which as you
state were based upon and consistent with the advice and guidance that
we received from the scientific community and public health agencies,
were appropriate under the circumstances. In that regard, we note that
the medical and scientific knowledge relating to anthrax has evolved
considerably since the unprecedented anthrax attacks, and we
acknowledge that we would have made some different decisions had the
present state of medical and scientific knowledge been available to us
in October of 2001.
Regarding Recommendations 1 and 2, that we revise and clarify the
Interim Guidelines and other related emergency response guidance, we
will make or are in the process of making the appropriate revisions.
For example, we will shortly publish a Management Instruction (MI) that
sets out the procedures to be followed if a Biohazard Detection System
generates a positive test and subsequent alert. The policy covers
facility evacuation, personal decontamination and the administration of
post-exposure antibiotics. This MI is consistent with the April 2004
guidance from the Centers for Disease Control and Prevention concerning
the medical interventions appropriate during the response to a
detection system alert for anthrax exposure in a facility. When
published, this MI will fully respond to Recommendation 2.
For Recommendation 3, that we set a time frame for developing
procedures to ensure that medical providers receive timely payment for
services they may be requested to provide in the event of a similar
medical emergency, the entities responsible for dealing with terrorist
activity are continuing to formulate policy concerning how to deal with
terrorist events, including how to pay or reimburse medical providers
that provide emergency medical services during a terrorist incident. We
will continue to work with the Department of Homeland Security and
other relevant entities to develop appropriate policies and procedures
in this regard.
We have worked in good faith to provide full and complete communication
to our employees and their union representatives on all aspects of the
testing and decontamination process at the Curseen/Morris and Trenton
Processing and Distribution Centers.
If you or your staff would like to discuss any of these comments
further, I am available at your convenience.
Sincerely,
Signed by:
Henry A. Pankey:
[End of section]
Appendix V: Comments from the Centers for Disease Control and
Prevention:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Public Health Service:
Centers for Disease Control and Prevention (CDC):
Atlanta GA 30333:
JUL 1 2004:
Mr. Mark Goldstein:
Director, Physical Infrastructure Issues:
United States General Accounting Office:
Washington, D.C. 20548:
Dear Mr. Goldstein:
Enclosed are the Centers for Disease Control and Prevention's (CDC)
comments regarding the U.S. General Accounting Office's (GAO) draft
report entitled "US. Postal Service: Better Guidance Needed to Ensure
an Appropriate Response to Anthrax Contamination" (GAO-04-239).
Due to GAO's unusual requirements for the review of this draft report,
the enclosed comments represent CDC's tentative position and are
subject to re-evaluation when the final version of the report is
received.
CDC appreciates the opportunity to comment on the draft report prior to
its publication.
Sincerely,
Signed by:
Julie Louise Gerberding, MD, MPH:
Director:
Enclosure:
Comments of the Centers for Disease Control and Prevention, Department
of Health and Human Services, on the U.S. General Accounting Office's
Draft Report "U.S. Postal Service: Better Guidance Needed to Ensure an
Appropriate Response to Anthrax Contamination" (GAO-04-239):
CDC appreciates the opportunity to review the draft report. However,
given GAO's unusual rules for review of this draft, the document could
not be circulated to all CDC staff who participated in the 2001 anthrax
investigations or to all approving and clearance officials. Therefore,
CDC would like to acknowledge that the following comments were made,
under the circumstances, to the best of the agency's ability and some
areas of the draft report may not have been sufficiently reviewed or
cleared.
General Comments:
While CDC acknowledged the communication challenges which occurred
during the anthrax attacks, the GAO report should highlight the
following points more prominently throughout:
* No one had dealt with an anthrax event of this nature and magnitude
previously, and the last serious outbreak occurred in the 1970s leaving
agencies with very little to rely on in terms of protocol for handling
these types of issues.
* The lines of authority for managing this type of crisis were very
confusing and there was a lack of assigned responsibility government-
wide for taking the lead role in coordinating a response to these
attacks, a situation which has been rectified with the creation of the
Department of Homeland Security (DHS) and the exertion of DHS authority
for these issues. While this is acknowledged in the report, it is done
quite late in the text, and CDC believes that acknowledging this fact
earlier would provide a more accurate picture of the leadership
challenges facing all the agencies involved in the 2001 anthrax
response.
In addition, the report repeatedly states that CDC made "assumptions"
concerning the health risks associated with anthrax exposure at the
postal facilities. CDC believes that this leaves an inaccurate picture
of occurrences at the time of the anthrax attacks. A more
scientifically accurate description is provided in the report on page
36, lines 915-916, where it is stated that "CDC recommendations, while
sound in terms of prior knowledge and science, had left the Brentwood
workers unprotected." This description more accurately reflects the
process by which CDC makes recommendations, (i.e., recommendations are
not based on assumptions but rather are based on the best available
science). CDC believes it is critical that the report be revised to
address this issue in order to avoid misperceptions concerning CDC's
decision-making processes which are always science-based.
This issue has been discussed in previous publications by CDC authors.
For example, Perkins, Popovic and Yeskey (2002) include this statement:
The decision-making involved in closing the U.S. Postal Service's
Brentwood Processing and Distribution Facility, Washington, D.C., has
been criticized. The risk to Brentwood facility employees by
contaminated envelopes in transit was not recognized in time to
prevent illness in four employees, two of whom died. Decisions
concerning the Brentwood facility were based on inferences from
previous experience and epidemiologic observations in Florida and New
York, where no disease occurred among postal workers. A possible
explanation for the differential risk is that the B. anthracis spore
preparation in the October 9 envelopes had a higher potential for
aerosolization than the preparation in the September 18 envelopes or
that the two mailings were made under or exposed to different
environmental conditions (e.g., amount of moisture) that created a
different potential for aerosolization. A different aerosolization
potential is supported by the epidemic curve in the manuscript by
Jernigan et al., which shows a higher proportion of inhalational
(versus cutaneous) anthrax cases associated with the October 9 mailing.
In naturally occurring disease, once risk is understood, it generally
remains constant; however, in intentional contamination, risk may be
altered by the perpetrator(s).
[End of section]
FOOTNOTES
[1] Technically, the term "anthrax" refers to the disease caused by the
bacterium Bacillus anthracis, not to the bacterium or its spores.
However, for ease of reading and consistency with the terminology
commonly used in the media and by the general public, this report
generally uses the term to refer to both the disease and the bacterium.
[2] Another case of cutaneous anthrax was confirmed in March 2002 in a
laboratory worker who contracted the disease by processing
environmental samples in support of the investigations.
[3] The nine affected postal employees were all associated with one of
the two facilities. Four of the employees worked at Brentwood, four
worked at Trenton, and one worked at a post office that received mail
from Trenton.
[4] For clarity, we refer to the five facilities as the Trenton,
Brentwood, West Palm Beach, Morgan, and Wallingford postal facilities.
[5] The Brentwood facility has been renamed the Joseph Curseen Jr. and
Thomas Morris Jr. Processing and Distribution Center in memory of the
two Brentwood employees who died of inhalation anthrax.
[6] Issues related to contamination at the other 18 facilities that
tested positive for anthrax were beyond the scope of this review.
[7] GAO, U.S. Postal Service: Better Guidance Is Needed to Improve
Communication Should Anthrax Contamination Occur in the Future, GAO-03-
316 (Washington, D.C.: Apr. 7, 2003).
[8] GAO, U.S. Postal Service: Clear Communication with Employees Needed
before Reopening the Brentwood Facility, GAO-04-205T (Washington, D.C.:
Oct. 23, 2003).
[9] Each of the five facilities was apparently contaminated as (1)
envelopes containing anthrax or (2) cross-contaminated envelopes passed
through high-speed mail-sorting machines in the facilities. Two other
processing and distribution centers, one in Raleigh, North Carolina,
and the other in Bellmawr, New Jersey, also tested positive for
anthrax, but they are not believed to have processed contaminated mail.
[10] Our work related to the Wallingford facility in Connecticut was
principally derived from previous work we conducted between September
2002 and March 2003. We updated this information, obtained additional
supporting information, and incorporated the information, as
appropriate, to address our reporting objectives at the five
facilities.
[11] See, e.g., Briscoe v. Potter, No. 1:03cv2084 (DC DC filed Sept.
15, 2003); Hubbard v. Potter, No. 1:03cv1062 (DC DC filed Feb. 13,
2004); Trenton Metropolitan Area Local v. the United States Postal
Service, No. 04-1628(6EB) (DC NJ filed Apr. 6, 2004).
[12] See GAO, Bioterrorism: Public Health Response to Anthrax Incidents
of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003).
[13] Cutaneous means "of, relating to, or affecting the skin."
Cutaneous anthrax is characterized by skin lesions.
[14] The third form of anthrax, gastrointestinal, results from
ingesting undercooked contaminated meat.
[15] In 1976 a self-employed weaver in California contracted the
disease from exposure to contaminated imported yarn containing goat
hair. Between 1950 and August 2001, CDC investigated nine cases of
inhalation anthrax, six of which occurred in 1957. Five of the 1957
cases were caused by exposure to contaminated goat hair at a textile
mill in New Hampshire. Between 1944 and 1994, 224 cases of cutaneous
anthrax were identified. See "Anthrax as a Biological Weapon, 2002:
Updated Recommendations," Journal of the American Medical Association,
287 (2002): 2236-2252.
[16] The process of refining a substance purifies it. The more
refinement that occurs, the more highly purified a substance becomes.
[17] According to information available on CDC's Web site as of June
14, 2004, early treatment with antibacterial drugs cures most cases of
cutaneous anthrax. Even if untreated, CDC reported that "80 percent of
the people who become infected with cutaneous anthrax do not die."
[18] CDC classified 4 of the 22 anthrax cases as suspected. All 4 were
cases of cutaneous anthrax.
[19] Centers for Disease Control and Prevention, Department of Health
and Human Services, Emerging Infectious Diseases, vol. 8, No. 10
(October 2002): 1020.
[20] Individuals at these locations developed the disease, indicating
that contaminated letters may also have been delivered there. Employees
of American Media Incorporated in Florida developed inhalation anthrax,
whereas individuals in New York initially developed only the cutaneous
form of the disease.
[21] Given that a contaminated envelope or package was not recovered,
investigators could not initially establish how the anthrax had been
delivered to American Media Incorporated--by U.S. mail or by some other
means, such as a courier delivery. According to CDC, investigators
began to explore the possibility that the Postal Service may have
delivered a letter containing anthrax as early as October 10, 2001.
However, according to the Postal Service, it was not until October 12-
-when it learned that it had delivered the letter recovered at NBC--
that the link to the U.S. mail system was clearly established.
[22] Unlike the other cases in New York, this individual was a hospital
employee while the other seven were media employees or their children.
Investigators believe that she was probably exposed to mail that had
been cross-contaminated by its proximity to one of the letters
containing anthrax spores.
[23] On October 18, 2001, CDC classified another New Jersey postal
employee as having a "suspected" case of cutaneous anthrax.
[24] Epidemiological investigations involve interviews with family
members, associates, coworkers, and other possible contacts for the
purpose of eliminating some possibilities and focusing on others. For
example, according to a handbook prepared by the FBI, if interviews
with coworkers prove to be negative and no one else at work is
affected, then public health investigators may be able to rule out the
workplace as the source for the disease. Similarly, if interviews
suggest the individual's associates have signs of the disease and that
they shared a common experience, such as attending the same event,
investigators may be able to focus their investigation on the common
experience. The FBI prepared the Criminal and Epidemiological
Investigation Handbook (2003) in consultation with public health
officials and the U.S. Army Soldier and Biological Chemical Command.
[25] The Environmental Protection Agency was also involved in
discussions about and activities related to the decontamination of
postal facilities, including the Brentwood facility.
[26] According to CDC, once risk is understood in cases involving a
naturally occurring disease, it generally remains constant. Thus, early
cases often provide clues to the mode and source of exposure. For
bioterrorism-related diseases, however, the characteristics of the
initial cases can be misleading because, as CDC and others learned in
the fall of 2001, the perpetrator may vary the mode of transmission and
source of exposure.
[27] Various estimates of the amount of spores needed to cause
inhalation anthrax existed in the fall of 2001. For example, according
to a letter to members of the American Postal Workers Union in December
2001, early on, the medical community had suggested that 8,000 to
10,000 spores would be needed to cause the disease. Other estimates
ranged from 8,000 to 22,000 and 2,500 to 55,000. In its technical
comments on our draft report, CDC informed us that--based on research
of primates--exposure to 8,000 to 50,000 aerosolized spores is
sufficient to kill 50 percent of the animals exposed. However, CDC
noted that the infectious dose in humans by any route is not known and
the influence of the bacterial strain or host factors on the infectious
dose is not completely understood.
[28] According to the Postal Service, there are numerous possible
indicators of a suspicious piece of mail, including stained mail or
mail that emits an odor. Mail with a threatening message or containing
loose sifting material may also cause suspicion, as may mail with
excessive postage or weight, a handwritten or poorly typed address, no
return address, and a lopsided or uneven envelope.
[29] Envelopes can be cross-contaminated when processed close to a
letter containing anthrax.
[30] On October 28 and 29--about a week and a half later--CDC confirmed
cases of inhalation anthrax in two Trenton employees, and Trenton
remained closed.
[31] The two deceased employees sought medical attention but were not
diagnosed with the disease before they died.
[32] By the time environmental testing revealed contamination, the
typical incubation period for inhalation anthrax (less than 2 weeks)
had already passed. The West Palm Beach and Morgan facilities are
believed to have been contaminated by letters sent in mid-September
2001. Thus, when contamination was identified in the facilities on
October 29 and October 23, respectively, the most likely period of
incubation had already passed. Wallingford was believed to have been
contaminated in mid-October; however, the contamination was not
identified until December 2, about 6 weeks later.
[33] The tests were taken using hand-held assays that instantaneously
analyze samples for anthrax. According to CDC, these tests are not
reliable for detecting anthrax.
[34] In contrast to the quick tests, these samples were cultured and
analyzed in a laboratory setting.
[35] Nasal swabs are samples taken from an individual's nasal passages,
preferably soon after a possible exposure to contamination. During the
fall of 2001, the samples were sometimes taken to determine the
location and extent of contamination at a facility or site. However,
nasal swabs are not useful in diagnosing the disease in an individual
or in evaluating an individual's risk of disease, in part, because a
negative result does not mean a person will not contract the disease.
In addition, a positive result does not mean that a person has
contracted the disease because, among other reasons, spores can wash
out of the person's nasal passages before being inhaled.
[36] In its technical comments on a draft of our report, CDC noted that
nasal swab samples were collected on October 21 - 22, 2001--after the
facility closed. Public health officials collected the samples as they
distributed antibacterial drugs to employees of and visitors to the
Brentwood facility. According to CDC, 3,110 nasal swabs were collected,
all of which were negative for anthrax.
[37] By statute, infectious materials such as anthrax spores that are
"disease germs or scabs, [or] other natural or artificial articles,
compositions, or material which may kill or injure another" cannot be
mailed. Such materials are termed "nonmailable matter." Knowingly
mailing such material is a criminal offense and doing so with the
intent to kill or injure is a felony. When an etiologic material
(infectious substance) is not "outwardly or of [its] own force
dangerous or injurious to life, health, or property," the Postal
Service may allow it to be mailed subject to appropriate rules and
regulations governing its preparation and packing. As a result, the
Postal Service allows the mailing of small quantities of appropriately
packaged infectious material, but only if it is intended for medical or
veterinary use, research, or laboratory certification related to public
health. In those instances, the infectious material must be contained
within a securely sealed, pressure resistant, watertight primary
receptacle surrounded with an absorbent and cushioning material. This
in turn is enclosed in a securely sealed, watertight, and durable
secondary packaging which must be enclosed in an outer packaging
constructed of fiberboard or other equivalent material.
[38] As discussed earlier, the Postal Service placed limitations on the
use of compressed air on October 16, 2001, and terminated its use on
October 26, 2001.
[39] Differences between the responses to anthrax contamination on
Capitol Hill and at postal facilities reflected differences in the
circumstances at the locations (a powder identified in a letter and
positively tested as anthrax on Capitol Hill versus no observable
evidence of contamination at postal facilities). This topic is
discussed in more detail later in this report.
[40] Interim Guidelines for Sampling, Analysis, Decontamination, and
Disposal of Anthrax for U.S. Postal Service Facilities, November 16,
2001.
[41] In addition, the guidelines state that closure may occur if
recommended by a state or local health department, the FBI, or the
Postal Inspection Service.
[42] CDC's November 9, 2001, guidelines state that closing a facility
may be indicated (1) after a case of inhalation anthrax is detected and
a probable site of exposure is identified; (2) when there is a known
aerosolization of anthrax in the facility; (3) where evidence strongly
suggests an aerosolization of anthrax has occurred; or (4) as
determined by law enforcement authorities in a criminal investigation.
[43] A micron equals 1 millionth of a meter, or 1 thousandth of a
millimeter. The period at the end of a sentence is approximately 500
microns in diameter.
[44] The report was also faxed to the FBI on Sunday, October 21, 2001.
[45] Each of the recovered envelopes was a franked (prepaid) Postal
Service "blue eagle" envelope available from Postal Service vending
machines.
[46] The FBI recovered the contaminated letter to NBC and the New York
Post on October 12 and October 19, respectively.
[47] According to testimony by an FBI official before the House
Committee on Government Reform on October 30, 2001, the various anthrax
samples were "indistinguishable from one another on a DNA analysis."
The differences in the substance, according to a CDC publication, could
be attributable to (1) differences in the spore preparation or (2)
exposure to different environmental conditions (e.g., moisture) that
created a different potential for aerosolization.
[48] The Army Institute did not analyze the size of the particles in
the letter to NBC because of insufficient material. Similarly,
according to the FBI, the letter to the New York Post, which was
initially analyzed on October 20, 2001, "was not suitable" for particle
size testing.
[49] For additional information, see Jernigan et al., "Investigation of
Bioterrorism-Related Anthrax, United States, 2001: Epidemiologic
Findings," Emerging Infectious Diseases, vol. 8, No. 10 (October 2002).
[50] The Postal Service used a wide variety of methods to communicate
information to employees, including briefings, newsletters, fact
sheets, videos played on closed-circuit televisions in its facilities,
and a toll-free information line. CDC and local public health officials
attended some of the employee briefings. In addition, the Postal
Service said it regularly updated its Web site and, after the
facilities closed, it mailed information to its employees' homes.
[51] On numerous occasions, the Postal Service also provided employees
with instructions on what to do if they observed a powder spill or
found a suspicious package.
[52] In its technical comments on our draft report, CDC noted that,
under the best conditions, nasal swabs serve primarily to identify
persons who have been exposed to anthrax. According to CDC, this
information along with other information about an employee's job, work
location, and tasks may be used to support hypotheses about potential
pathways of exposure. Nevertheless, CDC noted that the reliability of
nasal swabs for this purpose is unknown.
[53] As discussed, such samples should be taken soon after exposure,
before the spores are inhaled or washed out of a person's nasal
passages.
[54] CDC initially recommended ciprofloxacin for several reasons.
First, absent information about the strain's susceptibility to various
drugs, CDC considered ciprofloxacin most likely to be effective against
any naturally occurring strain of anthrax. Also, as the newest
antibacterial available, CDC considered it less likely that someone
would have had time to engineer a resistant strain of anthrax. Finally,
the Food and Drug Administration had already approved ciprofloxacin for
the postexposure prophylaxis for inhalation anthrax. After CDC
determined that the anthrax was equally susceptible to doxycycline and
other drugs and the Food and Drug Administration announced that
doxycycline was approved for inhalation anthrax, CDC began recommending
that individuals use doxycycline instead. At the time, the switch to
doxycycline was considered desirable for a variety of reasons,
including its (1) lower risk for side effects, (2) lower cost, and (3)
greater availability. In its technical comments on a draft of this
report, CDC noted that research conducted in the fall of 2001 suggests
that doxycycline and ciprofloxacin generally have equal rates of side
effects.
[55] Requirements for investigational new drugs apply to new,
unapproved drugs as well as to drugs--such as the anthrax vaccine--that
have been approved by the Food and Drug Administration for a different
use or purpose.
[56] GAO-04-205T.
[57] This instruction was consistent with guidance the Postal Service
issued on October 10, 2001, and a health advisory from the CDC. The
Postal Service revised its guidance on October 12, 2001. Instead of
handling suspicious letters and packages, employees were told to
isolate them and contact their supervisor.
[58] GAO, Major Management Challenges and Program Risks: U.S. Postal
Service, GAO-01-262 (Washington, D.C.: January 2001).
[59] Report of the President's Commission on the United States Postal
Service, Embracing the Future: Making the Tough Choices to Preserve
Universal Mail Service, July 31, 2003.
[60] See 29 C.F.R. § 1910.1020 (e)(1)(i).
[61] The results were quantified to assist agencies in decontaminating
the facilities.
[62] The results indicated that four mail-sorting machines were
contaminated, including one that was highly contaminated. Analysis of a
sample taken from the highly contaminated machine identified about 3
million colony-forming units (i.e., living cells) of anthrax.
[63] The Chief Epidemiologist informed postal managers that there was
no additional risk to employees for a variety of reasons--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 antibacterial drugs; and, in
the view of public health officials, the incubation period for the
disease had already passed without illness.
[64] The union leader and other union representatives at Wallingford
subsequently explained to us that, according to their discussions with
employees at the facility, many of the employees either (1) did not
take their antibacterial medication or (2) stopped taking their
medicine prematurely based on the Postal Service's use of the terms
"trace" and "concentration" to characterize the extent of contamination
in the facility.
[65] According to an OSHA Regional Administrator involved in the
decision not to take regulatory action, OSHA'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 Wallingford facility; and (3) existence of an ongoing criminal
investigation into the source of the anthrax spores that involved
several federal agencies.
[66] In its technical comments on a draft of this report, CDC noted
that there are several issues related to the December 2, 2001, test
results at Wallingford. These issues are discussed in more detail in
our prior report. See GAO-03-316.
[67] U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, Morbidity and Mortality Weekly Report,
"Evaluation of Bacillus anthracis Contamination Inside the Brentwood
Mail Processing and Distribution Center--District of Columbia, October
2001." (Atlanta, GA: Dec. 21, 2001).
[68] CDC provided the qualitative test results to the Postal Service
and its unions on March 4, 2002. These samples were reanalyzed and
quantified and CDC reported the results to the Postal Service and its
unions on May 31.
[69] The sample with a concentration of 800 million colony-forming
units of anthrax was a composite wipe--a combination sample taken from
four stacker bins on one of the facility's contaminated mail-processing
machines. Thus, according to CDC, the concentration would be more
accurately reported as "800 million CFUs (colony-forming units) per 4
bin composite wipe."
[70] Technical Assistance for Anthrax Response, Interim-Final Draft
Phase I Update, November 3, 2003.
[71] Interim Guidelines for Sampling, Analysis, Decontamination, and
Disposal of Anthrax for U.S. Postal Service Facilities, December 2003.
[72] The mission of the Dugway Proving Ground is to test U.S. and
Allied biological and chemical defense systems; perform nuclear,
biological, and chemical survivable testing of defense material;
provide support to chemical and biological weapons conventions; and
operate and maintain an installation to support its testing mission.
[73] At the other facilities in our review, antibacterial prophylaxis
was provided after the facility tested positive or after CDC confirmed
that a postal employee or customer had contracted anthrax.
[74] Center for Strategic and International Studies and the Defense
Threat Reduction Agency, Lessons from the Anthrax Attacks: Implications
for U.S. Bioterrorism Preparedness, April 2002.
[75] In its technical comments on a draft of this report, CDC noted
that many parts of the country, including Washington, D.C., New Jersey,
and New York also took similar actions.
[76] The technology is designed, ultimately, to detect multiple
biological and chemical contaminants, but the Postal Service is
currently using the system only to test for anthrax.
[77] Biohazard Detection System Pre-production Concept of Operations,
July 18, 2003.
[78] This follow-up analysis involves culturing the sample that
triggered the alarm. Spores collected by the detection system are
cultured so that the resulting bacteria can be positively confirmed.
[79] U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, Morbidity and Mortality Weekly
Report,"Responding to Detection of Aerosolized Bacillus anthracis by
Autonomous Detection Systems in the Workplace," (Atlanta, GA: Apr. 30,
2004).
[80] Biohazard Detection System Alert-Positive Test: Evacuation,
personal decontamination, and postexposure prophylaxis, June 30, 2004.
[81] As discussed, additional guidance exists for facilities with
anthrax detection systems.
[82] Emergency Response to Mail Allegedly Containing Anthrax, October
4, 1999, Management Instruction EL-860-1999-3.
[83] In response to our inquiries, on June 24, 2004, the Postal Service
published a bulletin indicating that roles and lines of responsibility
identified in sections 4 to 7 of the December 2003 guidance are
obsolete. The December 2003 guidance, however, has not yet been updated
to eliminate the obsolete information.
[84] Ricin is a poison that can be made from the waste (mash) left over
from processing castor beans. Ricin can be made in the form of a
powder, a mist, or a pellet or it can be dissolved in water or weak
acid.
[85] Center for Strategic and International Studies and the Defense
Threat Reduction Agency, Lessons from the Anthrax Attacks: Implications
for U.S. Bioterrorism Preparedness, April 2002.
[86] On October 16, the U.S. Army Medical Research Institute of
Infectious Diseases revised its description, indicating in another
teleconference that the spores were "professionally done" and
"energetic." According to an official from the Army Institute, these
terms were considered more appropriate, since personnel at the Army
Institute, he said, were not familiar with weaponized materials.
[87] The Army Institute also faxed a report of the results of its
analyses to the FBI on Sunday, October 21, 2001.
[88] Questions remain about why this information was not or may not
have been communicated to CDC and the Postal Service earlier. An
official from the U.S. Army Medical Research Institute of Infectious
Diseases told us that under the terms of its agreement with the FBI,
officials from the Army Institute could not discuss their test results
without FBI approval. Thus, according to the Postal Service's former
Senior Vice President for Government Relations and Public Policy, an
official from the Army Institute subsequently called to apologize for
the delay.
[89] The Army Institute is part of the U.S. Army Medical Research and
Materiel Command.
[90] Centers for Disease Control and Prevention, Department of Health
and Human Services, Emerging Infectious Diseases, vol. 8, No. 10
(October 2002): 1033.
[91] While an established link to U.S. mail did not initially exist in
Florida, investigators were beginning to explore that possibility.
[92] It is unclear whether the two quick tests produced false negatives
because, with only two samples available, investigators may have
inadvertently sampled uncontaminated areas.
[93] For additional information about the sensitivity and effectiveness
of various sampling methods, see E.H. Teshale, J. Painter, G.A. Burr,
P. Mead, S.V. Wright, L.F. Cseh et al., "Environmental Sampling for
Spores of Bacillus anthracis," Emerging Infectious Diseases, vol. 8,
No. 10 (October 2002): 1083.
[94] Swabs--either wet or dry--have small surface areas (similar to Q-
tipsŪcotton swabs) and are typically used to collect samples from
small, nonporous surface areas that do not have a large accumulation of
dust. Wet wipes--sterile gauze pads--are typically used to collect
samples from larger, nonporous surface areas. A HEPA vacuum is a
suction device with a nozzle that has a filter attached to it for
collecting dust samples from a surface or from the air.
[95] W.T. Sanderson, M.J. Hein, L. Taylor, B.D. Curwin, G.M. Kinnes,
T.A. Seitz, et al., "Surface Sampling Methods for Bacillus anthracis
Spore Contamination," Emerging Infectious Diseases, vol. 8, No. 10
(October 2002): 1145.
[96] Public health officials told us the facility was closed for
testing to determine the extent of the contamination and that they
initially did not believe that immediate antibacterial treatment was
appropriate because a case of cutaneous, rather than inhalation,
anthrax had been identified.
[97] According to the New Jersey epidemiologist, the recommendation was
based on several factors: (1) the relatively high mean age of the
postal employees suggested that added medications should be supervised
by their personal physicians, (2) the lack of state and local public
health resources to provide direct medical services to the employees,
and (3) the lack of clear state authority to designate a specific
nongovernmental facility to provide these services.
[98] We also provided local public health officials with relevant
excerpts of our draft report. However, none of the officials provided
comments.
[99] The Postal Service allowed employees at the three other facilities
to take leave or to work temporarily at other locations while their
facilities were being tested and decontaminated. However, few employees
took advantage of these opportunities. At Wallingford, for example,
only 3 of the over 1,100 employees asked to work elsewhere during the
facility's testing, while 180 employees took leave during the
facility's decontamination. At Morgan, the Postal Service allowed
employees to work on other floors of the facility or at the postal
facility across the street from Morgan during the facility's testing
and decontamination, but few people asked to do so. Similarly, at West
Palm Beach, although some employees took leave during the facility's
decontamination, none requested to be reassigned to other postal
facilities, according to the facility manager.
[100] The benefits provided to employees following a postal facility's
closure are specified in the Postal Service's Employee and Labor
Relations Manual and in its collective bargaining agreements with
unions.
[101] Not all Trenton employees were eligible for reassignment
benefits. For example, carrier operations, which include sorting the
mail, preparing it for letter carriers to deliver, and retail
operations, continued in the parking lot of the facility, and therefore
reassignment benefits were not paid to the employees performing these
functions. Carrier operations continued in the Trenton parking lot for
a few months, until they were relocated to a new building within a few
miles of the Trenton facility.
[102] Trenton employees filed grievances over the decision not to
compensate them for their commuting time. The grievances were not
resolved and Trenton employees filed a lawsuit to force the Postal
Service into arbitration on this issue. See Trenton Metropolitan Area
Local v. the United States Postal Service, No. 04-1628(6EB) (DC NJ
filed April 6, 2004).
[103] Although Trenton had fewer employees than Brentwood, it incurred
higher costs because of greater distances traveled. In many cases,
Trenton employees traveled more than 20 miles per round trip to
alternate facilities and in some cases in excess of 60 miles. The
Postal Service reported that its costs increased at Brentwood between
fiscal years 2002 and 2003, in part because of a procedural change that
allowed Brentwood employees to begin claiming reimbursement for the use
of their private vehicles for transportation to work.
[104] When Trenton and Brentwood closed in October 2001, they had about
960 and 2,490 employees, respectively. Trenton is not expected to
reopen until February 2005, which would be more than 3 years after its
closure. Brentwood reopened and was fully operational on December 22,
2003--about 26 months after it closed.
[105] Each of the five facilities was apparently contaminated as (1)
envelopes containing anthrax or (2) cross-contaminated envelopes passed
through high-speed mail-sorting machines in the facilities. Two other
processing and distribution centers, one in Raleigh, North Carolina,
and the other in Bellmawr, New Jersey, also tested positive for
anthrax, but they are not believed to have processed contaminated mail.
[106] GAO-03-316.
[107] See, for example, Briscoe v. Potter, No. 1:03cv2084 (DC DC. filed
Sept. 15, 2003); Hubbard v. Potter, No. 1:03cv1062 (DC DC filed Feb.
13, 2004).
[108] GAO-04-152.
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Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548:
