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entitled 'U.S. Postal Service: Better Guidance Is Needed to Improve 
Communication Should Anthrax Contamination Occur in the Future' which 
was released on April 21, 2003.



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Report to the Ranking Minority Member Committee on Governmental Affairs 

U.S. Senate:



United States General Accounting Office:



GAO:



April 2003:



U.S. Postal Service:



Better Guidance Is Needed to Improve Communication Should Anthrax 

Contamination Occur in the Future:



GAO-03-316:



GAO Highlights:



Highlights of GAO-03-316, a report to the Ranking Minority Member, 

Committee on Governmental Affairs, U.S. Senate 



Why GAO Did This Study:



In 2001, letters contaminated with anthrax resulted in  23 cases of the 

disease, 5 deaths, and the contamination of numerous U.S. Postal 

Service facilities, including the Southern Connecticut Processing and 

Distribution Center in Wallingford, Connecticut (the Wallingford 

facility). GAO was asked to address, among other matters, whether (1) 

the Postal Service followed applicable guidelines and requirements for 

informing employees at the facility about the contamination and (2) 

lessons can be learned from the response to the facilitys 

contamination.  



What GAO Found:



The Wallingford facility first tested positive for anthrax in early 

December 2001. The contamination was found in samples collected from 

four mail-sorting machines in November.  Analyses of the samples 

produced quantified results, including about 3 million anthrax 

colonies, or living anthrax cells, in one of the samples. While this 

was far more than the amount needed to cause death, none of the 

employees at the facility became sick from the anthrax contamination.



The Postal Services decision not to inform workers about the number of 

anthrax colonies identified in December 2001 appears consistent with 

its guidelines because, according to the Service, it could not validate 

the results, as required. However, its subsequent decision not to 

release the results after an employee union requested all the 

facilitys test results in January and February 2002, was not 

consistent with OSHAs requirement for disclosing test results that are 

requested. An OSHA investigation resulted in the Services release of 

the quantitative test results in September 2002about 9 months after 

the results were first known. Although OSHA did not issue a regulatory 

citation, it expressed concern about communication deficiencies.    



In retrospect, the Services decision not to release the quantitative 

test results in December 2001 was understandable given the challenging 

circumstances that existed at the time, the advice it received from 

public health officials, an ongoing criminal investigation, and 

uncertainties about the sampling methods used. However, numerous 

lessons can be learned from the experience, such as the need for more 

complete and timely information to workers to maintain trust and 

credibility and to help ensure that workers have essential information 

for making informed health decisions. Federal guidelines developed in 

2002 by GSA and the National Response Team suggest that morerather 

than lessinformation should be disclosed. However, neither the 

Services guidelines nor the more recent federal guidelines fully 

address the communication-related issues that developed in Wallingford. 

For example, none of the guidelines specifically require the full 

disclosure of quantified test results. Likewise, OSHAs regulations do 

not require employers to disclose test results to workers unless 

requested, which assumes that workers are aware of the test results and 

know about this requirement.



What GAO Recommends:





To help prevent a reoccurrence of communication problems, GAO 

recommends that the Postal Service, OSHA, GSA, and the National 

Response Teama group chaired by the Administrator of EPA and 

comprising 16 federal agencies with responsibilities for planning, 

preparing, and responding to activities related to the release of 

hazardous substanceswork together to revise their existing guidelines 

or regulations to, among other things, require prompt communication of 

available test results, including quantitative results, to workers and 

others, as applicable.  The Service, EPA, and GSA generally agreed with 

our recommendations, indicating that they would work together to revise 

their guidelines. OSHA did not comment on our recommendations.



www.gao.gov/cgi-bin/getrpt?GAO-03-316



To view the full report, including the scope

and methodology, click on the link above.

For more information, contact Bernard L. Ungar, (202) 512-2834, 

ungarb@gao.gov. 



[End of section]



Contents:



Letter:



Results in Brief:



Background:



Anthrax Contamination Was First Identified at Wallingford in December 

2001 after an Extensive Multiagency Investigation:



Quantitative Test Results Were Provided to Workers in April 2002--but 

Not in December 2001:



Disclosure of Anthrax Test Results:



Lessons Learned at the Wallingford Facility Suggest the Need for More 

Complete and Timely Information to Workers:



Conclusions:



Recommendations for Executive Action:



Agency Comments and Our Evaluation:



Appendix I: Objectives, Scope, and Methodology:



Appendix II: Summary of Anthrax Testing at the Wallingford 

Facility between November 2001 and April 2002:



Appendix III: Comments from the Environmental Protection Agency:



Appendix IV: Comments from the U.S. Postal Service:



Appendix V: Comments from the American Postal Workers Union:



Table:



Table 1: Summary of Sampling for Anthrax Contamination between November 

2001 and April 2002 and the Associated Test Results:



Abbreviations:



CDC: Centers for Disease Control and Prevention

EPA: Environmental Protection Agency

FBI: Federal Bureau of Investigation

GSA: General Services Administration

HEPA: High Efficiency Particulate Air 

HHS: Department of Health and Human Services

OSHA: Occupational Safety and Health Administration:



This is a work of the U.S. Government and is not subject to copyright 

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in its entirety without further permission from GAO. It may contain 

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copyright holder may be necessary should you wish to reproduce 

copyrighted materials separately from GAOs product.



[End of section]



United States General Accounting Office:



Washington, DC 20548:



April 7, 2003



The Honorable Joseph I. Lieberman

Ranking Minority Member

Committee on Governmental Affairs

United States Senate:



Dear Senator Lieberman:



In September and October 2001, letters containing anthrax spores were 

mailed to news media personnel and congressional officials, leading to 

the first bioterrorism-related cases of anthrax in the United 

States.[Footnote 1] The contaminated letters caused 23 illnesses and 

resulted in 5 deaths from inhalation anthrax and the contamination of 

numerous postal facilities. The U.S. Postal Service initially responded 

to this crisis by collecting and testing samples from over 280 of its 

facilities, including the Southern Connecticut Processing and 

Distribution Center in Wallingford, Connecticut (the Wallingford 

facility). The facility was first tested on November 11, 2001, and no 

contamination was found.



In late November 2001, the death of a Connecticut woman--1 of the 5 

people who died--spurred an extensive investigation by a multiagency 

team to determine, among other things, how she had been exposed to 

anthrax. Believing that the woman may have died from exposure to mail 

that had been contaminated as it passed through the Wallingford 

facility, federal and state investigators conducted more extensive 

testing of the facility. Facility workers received antibiotics on 

November 21, 2001--the day that the elderly woman died. The antibiotics 

were provided as a precautionary measure, since the Postal Services 

earlier testing of the facility had not identified any contamination. 

At about the same time, the Postal Service also initiated a medical 

surveillance program to monitor the health of the facilitys employees. 

The investigative team sampled the facility on numerous occasions 

between November and December 2001 and, in early December, identified 

anthrax on four mail-sorting machines. Anthrax also was identified in 

areas above the mail-sorting machines in April 2002.[Footnote 2] On 

both occasions, the affected areas were decontaminated, while mail 

processing continued in other areas of the facility.



Perhaps because the facilitys workers had been provided with 

antibiotics, none of the employees at the Wallingford facility became 

sick from anthrax. However, you requested that we review the Postal 

Services disclosure of anthrax test results to the facilitys workers. 

As agreed, in this report, we address (1) how and when contamination 

was identified at the Wallingford facility, (2) what and when 

information was communicated to facility workers, (3) whether the 

Postal Service followed applicable guidelines and requirements for 

informing facility workers about the contamination, and (4) whether 

lessons can be learned from the response to contamination at the 

facility. As agreed, our future work will compare the treatment of 

postal workers at the Wallingford facility with the treatment of 

employees at other postal facilities contaminated with anthrax in the 

fall of 2001.



To address our reporting objectives, we interviewed federal and state 

officials involved in investigating and responding to anthrax 

contamination at the Wallingford facility, including officials from the 

Postal Services headquarters office, its Connecticut district, and the 

Wallingford facility; the Connecticut Department of Public Health; and 

numerous federal agencies. We also interviewed representatives of 

employees at the facility, including the national American Postal 

Workers Union and its Greater Connecticut Area Local Union. We 

discussed, among other matters, the officials roles and involvement in 

responding to the crisis and lessons that can be learned from the 

response. We obtained and reviewed documentation related to the 

sampling and testing of the facility, including laboratory test 

results; information about when and how test results and associated 

health risks were communicated to facility workers; the Postal 

Services guidelines for releasing and communicating test results; the 

Occupational Safety and Health Administrations (OSHA) regulatory 

requirements for disclosing test results to workers; more recent 

federal guidelines developed in 2002 by the General Services 

Administration (GSA) and the National Response Team--a group chaired by 

the Administrator of the Environmental Protection Agency (EPA) and 

comprising 16 federal agencies with responsibility for planning, 

preparing, and responding to activities related to the release of 

hazardous substance; and other documents related to the facilitys 

contamination. Additional information on our scope and methodology 

appears in appendix I.

:



Results in Brief:



Following a series of negative test results in November 2001, the 

Wallingford facility first tested positive for anthrax in early 

December. The positive results were found in samples collected from 

four mail-sorting machines on November 28, 2001. Subsequent analyses of 

the samples identified two quantitative results, including about 3 

million colony-forming units of anthrax in a sample collected from one 

of the mail-sorting machines.[Footnote 3] This finding was far more 

than the 8,000 to 10,000 spores considered harmful, at that time, if 

inhaled in a fine powder form. Although district postal managers said 

they received written confirmation of the test results from the Chief 

Epidemiologist for the Connecticut Department of Public Health (Chief 

Epidemiologist) on December 10, 2001, available documentation indicates 

that Postal Service headquarters may have received the results 2 days 

earlier. In April 2002, after the mail-sorting machines had been 

decontaminated and returned to operation, anthrax was found in samples 

collected from areas above the machines. Following both the December 

2001 and April 2002 test results, the contaminated areas were isolated 

and decontaminated and, thereafter, returned to operation.



On December 2, 2001--when anthrax contamination was first identified in 

the facility--Postal Service managers and a physician under contract 

with the Postal Service met with workers to inform them that trace 

amounts of anthrax had been found in samples collected on November 28. 

Knowing that the laboratory initially identified a small number (1 or 2 

colony-forming units) of anthrax spores, the Chief Epidemiologist--who 

helped lead the investigation--told district postal managers that it 

would be accurate to use the term trace to describe the extent of 

contamination. On December 2, postal managers also relayed the Chief 

Epidemiologists health-related recommendations to the facilitys 

employees. For example, although the Chief Epidemiologist viewed the 

health risk as minimal, workers were advised, as a precautionary 

measure, to continue taking the antibiotics they received on November 

21, 2001--the day that the Connecticut woman died from inhalation 

anthrax. On December 12, 2001--2 days after district postal managers 

said they received written confirmation of the presence of about 3 

million spores in a sample collected on November 28 and, possibly, 4 

days after headquarters postal managers received the results--postal 

managers once again relayed the Chief Epidemiologists views and 

health-related recommendations to employees at the facility. 

Specifically, district postal managers told us that they informed 

workers that, while trace amounts of anthrax existed on three mail-

sorting machines, a concentration of spores had been identified in a 

sample collected from a fourth machine. Although the extent of 

contamination was much greater than initially believed, following the 

assurances of the Chief Epidemiologist, postal managers said they 

informed workers that there was no additional risk to employees 

because all of the steps needed to protect them had already been taken. 

In April 2002, the Postal Service provided employees with the actual 

quantitative test results (1 to 18 colony-forming units) from the 

samples collected in April from areas above the previously contaminated 

mail-sorting machines.



Although the Postal Services communication of anthrax test results 

appears consistent with its guidelines, its decision not to provide the 

December 2001 quantified results (i.e., the number of colony-forming 

units found in the positive samples)--after being requested to do so by 

an employee union--did not satisfy OSHAs disclosure requirements. The 

Postal Service generally provided the facilitys test results to 

workers within 1 day of receiving the test results. Such timely 

disclosure is consistent with the Postal Services guidelines to notify 

workers as soon as possible. However, for a period of 2 days, 

district managers delayed informing the facilitys workers about the 

documented test results that the district postal managers received on 

December 10, 2001. According to the Postal Service, the additional time 

was needed to obtain advice from public health officials about the 

meaning of the results, particularly the result indicating the presence 

of about 3 million spores in a sample collected from one mail-sorting 

machine. According to Postal Service managers, the December 2001 

decision not to release the quantitative results--even after being 

requested to do so by a union leader--was also consistent with the 

Postal Services guidelines because, according to the managers, the 

Postal Service could not ensure that the sampling had been done in 

accordance with procedures specified in its guidelines, and, thus, it 

could not validate the results, as required by its guidelines. However, 

the Postal Services decision not to release the December 2001 

quantitative test results after a union leader requested all of the 

facilitys test results on January 29, 2002, and February 6, 2002, was 

not consistent with OSHAs regulations for disclosing test results that 

are requested by workers or their designated representatives. OSHAs 

regulations require employers to disclose test results within 15 

working days of the request or explain the delay and provide the 

requester with a time frame for releasing the results. OSHAs 

subsequent investigation into this matter resulted in the Postal 

Services release of the December 2001 quantitative test results in 

September 2002--more than 7 months after the union leader first 

requested the results and about 9 months after the test results were 

known by the Postal Service. OSHA did not cite the Postal Service for 

not disclosing the quantitative test results earlier; however, in an 

October 7, 2002, letter to the Postal Service, OSHA noted that a 

failure to effectively communicate issues which can have an effect on 

a workers health and safety, can lead to fear and mistrust.:



While the Postal Services decision not to release the quantitative 

test results in December 2001 is understandable given all of the 

circumstances that existed at the time, the lessons learned from this 

experience suggest the need for more complete and timely information to 

workers to maintain trust and credibility. Officials from OSHA and 

members of the investigative team did not specifically fault the Postal 

Service for not releasing the quantified results when they were first 

known in December 2001. However, they said full and timely disclosure 

of test results is the best method for communicating with employees and 

others. Two federal guidelines developed in 2002 by GSA and the 

National Response Team suggest that more--rather than less--information 

should be disclosed. For example, GSAs guidelines emphasize the need 

for timely, clear, consistent, and factual information, including any 

limitations associated with the information, so that people can make 

informed decisions. The other set of guidelines, developed by the 

National Response Team, warns agencies not to withhold information 

because it could affect the agencys credibility. However, neither the 

Postal Services guidance nor the more recent federal guidelines fully 

address the anthrax communication-related issues that developed at the 

Wallingford facility. For example, none of the guidelines specifically 

require the full disclosure of all test results, including quantitative 

test results. Likewise, OSHAs regulations for communicating test 

results to workers do not address the need for full, immediate, and 

proactive disclosure. We are making several recommendations to minimize 

the likelihood that the communication-related problems at the 

Wallingford facility will reoccur elsewhere.



The Postal Service, EPA, and GSA generally agreed with our findings and 

recommendations and indicated that they would work together to revise 

their respective guidelines. The union also agreed with our 

recommendations to better coordinate communication between federal 

agencies when events occur. However, the union said that our report did 

not adequately reflect the unions perspective of the facts and that a 

number of our conclusions were not supported by the facts. We disagree. 

We believe that our conclusions are fully supported by the evidence 

presented in this report and that the report presents a fair, 

objective, and balanced depiction of the facts as best we could 

determine them.



Background:



Anthrax is an acute infectious disease caused by the spore-forming 

bacterium called Bacillus anthracis. Anthrax is found in the soil in 

many parts of the world and forms spores (like seeds) that can remain 

dormant in the environment for many years. Anthrax can infect humans; 

however, the disease occurs most commonly in herbivores.[Footnote 4]



Human anthrax infections are rare in the United States and have 

normally resulted from occupational exposure to infected animals or 

contaminated animal products, such as wool, hides, or hair. Infection 

can occur in three forms: (1) cutaneous, usually through a cut or an 

abrasion; [Footnote 5] (2) gastrointestinal, by ingesting undercooked 

contaminated meat; and (3) inhalation, by breathing aerosolized anthrax 

spores into the lungs. Aerosolization occurs when anthrax spores become 

airborne, thus enabling a person to inhale the spores into the lungs. 

Symptoms depend on how the disease is contracted and, on the basis of 

experiences in the fall of 2001, are now thought by medical experts to 

typically appear within 4 to 6 days of exposure, although individuals 

have contracted the disease as long as 43 days after exposure. The 

disease can be treated with a variety of antibiotics and is not 

contagious.



Persons who come in contact with anthrax spores are described as having 

been exposed. Depending on the extent of contamination and its form, 

a person can be exposed without developing the disease. Anthrax spores 

are dormant cells that can germinate and, if viable, replicate under 

suitable environmental conditions, such as in the human body. A person 

can die if the anthrax spores grow and the bacteria multiply and spread 

throughout the body. There is a range of laboratory tests for detecting 

anthrax in a persons body and in the environment. Laboratories report 

anthrax test results either qualitatively (e.g., as positive or 

negative) or quantitatively (e.g., as a specific number of colony-

forming units per gram or square inch of material sampled or in 

milligrams per microliter).



Before the fall of 2001, outbreaks of inhalation anthrax in the United 

States had been linked mainly to occupational exposure. However, 

according to the Centers for Disease Control and Prevention (CDC), 

there was a release of anthrax in 1979 from a military bioweapons 

facility in Sverdlovsk in the Former Soviet Union. The release of 

anthrax, which had been prepared in a powder form, reportedly caused 

the death of 66 people and demonstrated the lethal potential of 

aerosolized anthrax as a weapon.[Footnote 6]



Because so few instances of inhalation anthrax have occurred, 

scientific understanding about the number of spores needed to cause the 

disease is still evolving. According to the contract physician 

responsible for providing medical advice to postal employees at the 

Wallingford facility in the fall of 2001, her literature search 

revealed that a person would need to inhale 8,000 to 10,000 spores to 

contract the disease.[Footnote 7] However, given that anthrax spores 

were never discovered in the Connecticut womans home or places that 

she frequented,[Footnote 8] experts we consulted now believe that the 

number of spores needed to cause inhalation anthrax could be very 

small, depending on a persons health status and the aerosolization 

capacity of the anthrax spores.



The Postal Services infrastructure includes, in part, its headquarters 

office in Washington, D.C.; 8 area offices; the Capital Metro 

Operations office; approximately 350 mail processing and distribution 

centers, including the Wallingford facility; and about 38,000 post 

offices, stations, and branches. The area offices are further divided 

into 85 postal districts throughout the United States, including the 

Connecticut district in Hartford, which oversees operations at the 

Wallingford facility. The Wallingford facility is operated by a 

facility manager and is under the jurisdiction of the District Manager 

in Hartford.



On or about October 9, 2001, at least two letters containing anthrax 

spores entered the U.S. mail stream--one was addressed to Senator 

Thomas Daschle, the other to Senator Patrick Leahy. Before being sent 

to the Brentwood facility in Washington, D.C.--the facility that 

processed mail to the Senators--the letters were processed on high-

speed mail-sorting machines at a postal facility in Hamilton, New 

Jersey. The Hamilton facility--also known as the Trenton postal 

facility--processed mail that was to be transported to Wallingford for 

further processing.[Footnote 9]



The Wallingford facility covers about 350,000 square feet and has over 

1,100 employees. The facility handles nearly 3 million pieces of mail 

per day and operates 24 hours a day with employees who work one of 

three 8-hour shifts. Two unions--the Greater Connecticut Area Local 

American Postal Workers Union, in New Haven, Connecticut, and the Mail 

Handlers Union in Boston, Massachusetts--represent workers at the 

facility.



In October 2001, the Postal Service established a Unified Incident 

Command Center (the Command Center) in Washington, D.C., to, among 

other things, manage the Postal Services response to anthrax 

contamination in its facilities. The Command Center was staffed by 

Postal Service employees and supported by several agencies, including 

EPA; CDC; the U.S. Army Corps of Engineers; the U.S. Postal Inspection 

Service; OSHA; and the Federal Bureau of Investigation (FBI).



On November 20, 2001, a team of representatives from state and federal 

government agencies with responsibilities for law enforcement (the 

Connecticut State Police and the FBI); environmental safety (the 

Connecticut Department of Environmental Protection); public health (the 

Connecticut Department of Public Health, local health departments, and 

CDC); and the Postal Service was formed to investigate and formulate 

the public health response to the case of the elderly woman who 

contracted and subsequently died from inhalation anthrax. The Chief 

Epidemiologist for the Connecticut Department of Public Health (Chief 

Epidemiologist),[Footnote 10] an on-site CDC team leader, and a CDC 

team leader in Atlanta, jointly led the on-site investigation team. The 

team communicated with one another largely through twice-daily 

confidential telephone conference calls during which information was 

shared, possible actions were discussed, and decisions were made. Once 

contamination was identified in the Wallingford facility, a facility-

specific response team was formed consisting of the National Institute 

for Occupational Safety and Health, the Agency for Toxic Substances and 

Disease Registry, and CDC--all within the Department of Health and 

Human Services (HHS); the Corps of Engineers; the Postal Service; EPA; 

and the Connecticut Department of Public Health. The team was led by 

the Postal Services Command Center. OSHA--an agency within the 

Department of Labor that enforces safety and health standards in the 

workplace--was not part of the response team.



The Postal Service requested and the investigative team agreed that the 

Postal Service would be the sole party responsible for communicating 

test results and other information to the workers at the facility. In 

this regard, the physician under contract with the Postal Service 

informed the facilitys workers that, according to her research, 

inhalation of 8,000 to 10,000 spores would likely be needed to cause 

inhalation anthrax.



Anthrax Contamination Was First Identified at Wallingford in December 

2001 after an Extensive Multiagency Investigation:



The Wallingford facility was tested on numerous occasions between 

November 2001 and April 2002 (see table 1). The first sampling was 

performed by a Postal Service contractor on November 11, 2001, as part 

of the Postal Services effort to identify facilities that may have 

been contaminated with anthrax. The contractor collected 53 samples 

using dry swabs.[Footnote 11] The laboratory found no contamination and 

provided the negative results to Postal Service managers on November 

14. A second Postal Service contractor sampled the facility on November 

21, 2001--the day the Connecticut woman died. The 64 samples, collected 

using dry swabs, tested negative, and the results were verbally 

provided to Postal Service officials on November 23. (App. II 

summarizes additional information about sampling at the facility, 

including the dates of the samples, the agencies involved in the 

sampling, the date and content of information provided to workers. This 

appendix also provides information about decontamination activities at 

the facility.):



Table 1: Table 1: Summary of Sampling for Anthrax Contamination between 

November 2001 and April 2002 and the Associated Test Results:



Sampling date: 11/11/01; Type (Number of samples): Dry swabs (53); 

Result: Negative; Agency that collected the samples[[A]]: Postal 

Service.



Sampling date: 11/21/01; Type (Number of samples): Dry swabs (64); 

Result: Negative; Agency that collected the samples[[A]]: Postal 

Service.



Sampling date: 11/25/01; Type (Number of samples): Wet swabs (60); 

Result: Negative; Agency that collected the samples[[A]]: CDC.



Sampling date: 11/28/01; Type (Number of samples): Wet wipes and HEPA 

vacuums (212); Result: Positive; Agency that collected the 

samples[[A]]: CDC.



Sampling date: 12/02/01; Type (Number of samples): Wet wipes (200); 

Result: Positive; Agency that collected the samples[[A]]: CDC.



Sampling date: 4/21/02; Type (Number of samples): HEPA vacuums (101); 

Result: Positive; Agency that collected the samples[[A]]: Postal 

Service.



Sources: GAO (summary) and Postal Service and CDC (data).



Legend:



CDC - Centers for Disease Control and Prevention

HEPA - High Efficiency Particulate Air:



[A] The Postal Service used a contractor; CDC was assisted by the 

Agency for Toxic Substances and Disease Registry.



[End of table]



Following confirmation on November 20, 2001, that the elderly 

Connecticut woman had contracted inhalation anthrax, the multiagency 

state and federal investigative team targeted mail as one possible 

source of her exposure. Having found no contamination at the 

Wallingford facility or at the womans home and other places she 

frequented in the 2 months preceding her death, CDC and the Agency for 

Toxic Substances and Disease Registry resampled the facility on 

November 25, 2001, using wet swabs--not dry swabs. These 60 samples 

also tested negative. The laboratory informed the Chief Epidemiologist 

of the results, and he, in turn, called district postal managers to 

relay the results.



Determined to ascertain the role that mail may have played in the 

womans exposure to anthrax, on November 28, 2001, CDC and the Agency 

for Toxic Substances and Disease Registry, with the full support of the 

Postal Service, performed what officials termed a targeted and 

extensive sampling of the facility. The team collected 212 samples, 

the majority of which were from machines that could have been used to 

process mail to the deceased womans home. The team also used different 

collection methods than had been used earlier--that is, the team 

collected samples using two methods: wet wipes and HEPA vacuums rather 

than dry swabs or wet swabs alone.[Footnote 12] The use of these 

sampling methods resulted in the identification of anthrax on 4 of the 

facilitys 13 mail-sorting machines.



The Chief Epidemiologist first knew the results of the November 28, 

2001, sampling effort on December 2, when samples collected from three 

of the mail-sorting machines tested positive for anthrax. Shortly 

thereafter, a fourth machine--which also had been sampled on November 

28, 2001--also tested positive for anthrax.[Footnote 13] The laboratory 

analyzed the November 28, 2001, samples and provided two quantified 

results. The results indicated that although all four of the machines 

were contaminated, one of the machines was heavily contaminated. 

Specifically, on the basis of the laboratorys quantified results, the 

Chief Epidemiologist identified 2.9 million colony-forming units of 

anthrax--about 3 million spores--in a sample of 0.55 grams of material 

(dust) collected from the heavily contaminated machine.[Footnote 14] A 

second sample identified 370 colony-forming units per gram of material 

collected from another mail-sorting machine. The two samples were 

collected using HEPA vacuums.[Footnote 15]



The laboratory e-mailed the quantitative results to CDC officials and 

the Chief Epidemiologist on December 6. After subsequent discussions 

with the laboratory concerning the results as well as related 

discussions over the next few days with members of the investigative 

and response teams, the Chief Epidemiologist faxed the results on 

December 9 to the Postal Services district Human Resource Manager, 

who, according to the manager, received them on December 10. Precisely 

when Postal Service headquarters and district managers first became 

aware of the quantified test results is unclear. According to CDC 

officials and the Chief Epidemiologist, they began discussing the 

quantitative results with team members, which they believe included a 

district postal manager, on December 6, 2001. However, district postal 

managers said that they were not involved in discussions about the 

quantitative results until December 9. District postal managers 

confirmed that the Chief Epidemiologist faxed the quantitative results 

to the district on December 9 (a Sunday) and that district postal 

managers received the fax on December 10. However, a chronology of the 

events prepared in January 2002 by Postal Service employees and shared 

with CDC indicates that postal managers at headquarters may have 

received the documented results on or about December 8, 2001. We 

discussed the chronology with postal headquarters managers in March 

2003 and they told us that, according to their recollections, there 

were errors in the chronology that were not corrected. They also said 

that they do not otherwise recall precisely when they received the 

documented quantitative results. Absent definitive documentation of 

when Postal Service headquarters received the test results and 

documentation of the discussions between public health and postal 

managers, we were unable to determine when Postal Service headquarters 

managers first learned of the quantitative test results.



On December 9, 2001, the Chief Epidemiologist also relayed the results 

of other samples collected at the facility. The samples were collected 

on December 2--hours before the four contaminated mail-sorting machines 

were to be enclosed and decontaminated--by CDC and the Agency for Toxic 

Substances and Disease Registry. The 200 samples were collected using 

wet wipes to establish the extent of contamination on the machines. The 

results identified unspecified amounts of contamination (i.e., 

positives) on (1) 30 of 52 samples collected from the heavily 

contaminated machine, (2) 3 of 52 samples from a second machine, and 

(3) 1 of 48 samples from each of the two other mail-sorting machines.



A Postal Service contractor under the guidance of CDC and the Corps of 

Engineers decontaminated the four mail-sorting machines. To test the 

effectiveness of the decontamination, follow-up samples were collected 

between December 7 and December 18, 2001. The laboratory informed the 

Chief Epidemiologist of the negative results on December 20. The Chief 

Epidemiologist relayed the results to district postal managers who, 

shortly thereafter, returned the machines to operation. The facility 

remained open throughout the period in part because, according to 

public health officials, there was no evidence that the anthrax was 

airborne, workers had already received antibiotics, no one had 

contracted the disease, and action had already been taken to isolate 

the contaminated machines from workers on December 2, 2001--the day 

that anthrax contamination was first reported.[Footnote 16]



On April 21, 2002, a Postal Service contractor, in consultation with 

CDC, OSHA, EPA, and the Connecticut Department of Public Health, 

sampled areas above the previously contaminated machines using HEPA 

vacuums. The sampling was performed because of a Postal Service 

requirement for testing prior to the routine cleaning of elevated areas 

in facilities that had previously tested positive for anthrax. The 

effort was undertaken to protect workers from the possibility of 

exposure to spores that may have blown into these areas as a result of 

the Postal Services prior use of compressed air to clean its 

facilities. The laboratory relayed the results from the April 21 

sampling effort to district postal managers on April 24. The results 

revealed from 1 to 18 colony-forming units in 3 of 101 samples 

collected from the elevated areas.[Footnote 17] The contaminated areas 

were subsequently encapsulated and decontaminated. A Postal Service 

contractor collected follow-up samples to test the effectiveness of the 

decontamination between May 1 and June 3, 2002. The laboratory reported 

negative results in all of the samples directly to district postal 

managers on June 6 and, on June 7, the facility was returned to full 

operation.[Footnote 18]



Quantitative Test Results Were Provided to Workers in April 2002--but 

Not in December 2001:



The Postal Service typically provided nonquantitative (i.e., positive 

or negative) results from samples collected between November 2001 and 

April 2002 to employees on each of the facilitys three work shifts. 

The specific content of the information disclosed varied. The Postal 

Service began communicating the results of the first samples--which 

were collected on November 11, 2001--on November 15, the day after the 

Postal Service received the negative results. The Facility Manager 

informed supervisors and union officials of the results, and the 

supervisors, in turn, informed employees at the facility. According to 

a district manager, the test results also were posted on designated 

bulletin boards at the facility. The Postal Service began relaying the 

results of the November 21, 2001, sampling effort, which were also 

negative, to employees in a briefing on November 23, the day that 

district postal managers were notified of the results. On November 27, 

the day that district managers received the results from the third 

sampling done on November 25, 2001, the Facility Manager once again 

began briefing employees about the negative results.



According to district postal managers, they began informing employees 

about contamination at the facility on December 2, 2001, the same day 

they learned that the facility was contaminated. The positive results 

were identified from samples collected on November 28, 2001, and were 

relayed to district postal managers in a telephone call from the Chief 

Epidemiologist. The Chief Epidemiologist met with district postal 

facility managers, union representatives, and a physician under 

contract with the Postal Service on December 2, 2001, to discuss the 

results. District postal managers told us that no documentation of the 

meeting exists; however, according to several of the individuals 

present, the Chief Epidemiologist described the extent of contamination 

as trace amounts on three mail-sorting machines.[Footnote 19] 

According to the Chief Epidemiologist, although the laboratory 

initially reported only a positive finding, his subsequent discussions 

with laboratory personnel indicated that the samples contained one or 

two colony-forming units of anthrax. Thus, he said, he used the term 

to denote a small amount of contamination. Also, he said, trace 

seemed appropriate given the number of sampling efforts undertaken 

before any contamination was found in the facility.



According to officials present at the December 2, 2001, meeting, they 

pressed the Chief Epidemiologist about any possible risk to workers at 

the facility and were assured that for a variety of reasons, there was 

no additional health risk. First, as a precautionary measure, workers 

had been provided antibiotics on November 21, the day the Connecticut 

woman died from inhalation anthrax. Second, even if workers had not 

chosen to take the antibiotics, the results of the Postal Services 

medical surveillance program indicated that none of the facilitys 

workers had contracted the disease. Further, in the view of the Chief 

Epidemiologist and CDC officials, workers were not expected to contract 

the illness because the contamination was found weeks after what public 

health officials considered the likely incubation period for the 

disease.[Footnote 20] Third, the contaminated machines were being 

isolated and decontamination was scheduled to begin the next day. 

Fourth, there was no evidence that the anthrax was airborne because no 

spores had been found in the facilitys heating, ventilating, and air 

conditioning systems. Finally, related to this last issue, the Chief 

Epidemiologist told us that the likelihood of spores being blown within 

the facility (becoming airborne) had been greatly reduced by the Postal 

Services decision on October 23, 2001, to stop using compressed air to 

clean its facilities. Nevertheless, as a precautionary measure, the 

Chief Epidemiologist recommended that the Postal Service advise 

facility workers to continue taking antibiotics.



According to district postal managers, after their December 2, 2001, 

meeting with the Chief Epidemiologist; the physician and postal 

managers, including the Facility Manager, began briefing employees on 

each of the facilitys three shifts. The managers relayed the Chief 

Epidemiologists views that there was no additional health risk 

associated with the test results. According to the managers, they also 

informed workers about planned actions to remediate the 

contamination.[Footnote 21]



As previously discussed, district postal managers recall being notified 

of the quantitative test results on December 9, 2001, which is the date 

they told us that the Chief Epidemiologist first called them to relay 

the results of additional laboratory analyses that he and CDC had 

received on December 6, 2001. The results were from the two samples 

collected on November 28, 2001, including the sample involving 2.9 

million colony-forming units per 0.55 grams of sample material (dust) 

collected from one of the four contaminated mail-sorting machines. The 

Chief Epidemiologist told us that he discussed the results with 

laboratory personnel and, after these discussions, concluded that the 

results revealed the presence of about 3 million spores. According to 

district postal managers, the test results were discussed at length in 

teleconferences between them, the Chief Epidemiologist, and other 

members of the investigation team on December 9 and 10. District postal 

managers said that they were concerned about the test results and asked 

whether the facilitys employees were at risk. Although we were told 

that no documentation exists about the advice the Postal Service 

received at the time, according to district postal managers, the Chief 

Epidemiologist informed them that there was no additional risk to 

employees for the same reasons previously cited--the contaminated 

machines had already been isolated and were being decontaminated; the 

anthrax was not believed to be airborne; employees at the facility had 

already been offered antibiotics; and, in the view of public health 

officials, the incubation period for the disease had already passed 

without illness. Nevertheless, as a precautionary measure, the Chief 

Epidemiologist recommended that the Postal Service managers advise 

workers to continue taking their antibiotics. CDC concurred with the 

Chief Epidemiologists recommendation and assessment about the health 

risk.



According to participants in the teleconferences, they also discussed 

how to communicate the quantitative test results to workers at the 

facility. As a result of these conversations, we were told, the 

participants agreed that using the term trace--after the finding of 

about 3 million spores in a sample from one of the four mail-sorting 

machines--was no longer appropriate in describing the extent of 

contamination at the facility. As a result, district managers asked the 

Chief Epidemiologist how the results could be communicated to employees 

and others. According to district postal managers, the Chief 

Epidemiologist advised them that it would be accurate to characterize 

the contamination as a concentration of spores on one mail-sorting 

machine and trace amounts on three others. The Chief Epidemiologist 

agreed that he used the terms trace and concentration to describe 

contamination at the facility. However, he subsequently informed us 

that he did not provide a single description of the extent of 

contamination in the facility but, instead, told postal managers that 

this was one way to discuss the extent of contamination to facility 

workers. According to the Chief Epidemiologist, it was up to the Postal 

Service to determine how to communicate the test results. A district 

postal manager told us that he relayed information about the 

concentration of spores in the facility--one of the interpretations 

provided by the Chief Epidemiologist--to the Facility Manager, without 

any information about the actual quantitative results. The Chief 

Epidemiologist and district postal managers agree that they never 

discussed whether the Postal Service should disclose the quantified 

test results to employees.



According to the Chief Epidemiologist, at the invitation of district 

postal managers, he met with facility managers and union leaders on 

December 12 to discuss the test results and to answer questions about 

his health recommendations.[Footnote 22] The terms concentration of 

spores and heavily contaminated machine were used, he said, but no 

quantitative results were presented or discussed. Union representatives 

and Postal Service officials we spoke to do not recall this meeting. 

However, district postal managers issued a press release on December 12 

containing the terminology that the Chief Epidemiologist said he had 

used. Further, district postal managers told us that supervisors on 

each of the facilitys three work shifts began relaying the Chief 

Epidemiologists views and health-related recommendations directly to 

the facilitys employees on December 12. Union representatives told us 

that they did not recall any supervisory briefings on December 

12.[Footnote 23] Although no documentation of these briefings is 

available, postal headquarters officials said that the December 12 

press release would have been made widely available per the Services 

standard operating procedures and that a local Connecticut newspaper 

reported the information contained in the press release on December 13.



According to the district managers, during follow-up testing later that 

month, workers were routinely advised of the qualitative (e.g., 

negative/positive) test results when the Postal Service received them 

from the laboratory. Beginning on December 20, 2001, workers were 

briefed that all of the follow-up samples had tested negative for 

contamination. On December 21, the Postal Service issued a press 

release stating that the four mail-sorting machines had been completely 

decontaminated and returned to service.



In contrast to its actions in December 2001, the Postal Service fully 

released all test results related to its April 21, 2002, sampling of 

the facilitys elevated areas. An OSHA official involved in sampling 

the facilitys elevated areas--OSHA was not involved in December 2001-

-recommended immediate disclosure of all of the results. The results, 

which included the finding of from 1 to 18 colony-forming units in 

several samples, were provided to union representatives in a meeting on 

April 24, the same day that postal managers were notified of the 

results. Later that day, facility managers and the Chief Epidemiologist 

began briefing employees about the results, indicating that 3 of 101 

samples collected from 71 locations were contaminated.[Footnote 24] 

According to the President of the Greater Connecticut Area Local 

American Postal Workers Union, the quantitative results were also 

posted on bulletin boards in the facility. There is little 

documentation of these briefings or the advice that the Postal Service 

received from public health officials. However, we were told that 

postal managers relayed the views and recommendations of the 

Connecticut Department of Public Health officials, who had advised them 

that there was no immediate health risk to workers and, therefore, that 

the employees would not need to take antibiotics. This decision was 

based, in part, on the view that the contaminated areas had already 

been isolated and, in consultation with CDC, OSHA, and EPA, were to be 

decontaminated. The managers also assured workers that testing would be 

performed to ensure that no contamination was present before the areas 

were returned to operation.[Footnote 25] The elevated areas were 

resampled in a series of tests and, on June 6, 2002, the final 

laboratory report indicated that all samples were negative for anthrax. 

Postal Service managers met daily with union representatives to provide 

and discuss test results and the status of decontamination efforts. The 

Postal Service posted the final results on bulletin boards in the 

facility on June 7, informing employees that decontamination had been 

completed.



Disclosure of Anthrax Test Results:



Consistent with its guidelines, the Postal Service generally provided 

the facilitys test results to workers within 1 day of receiving the 

results. The one exception to this practice involved the December 2001 

quantitative test results. In this case, there was a delay of at least 

2 days between the date that the Postal Service received documentation 

of the quantified test results and the date that it notified its 

workers about the concentration of spores on one mail-sorting 

machine. It is not clear precisely when in December 2001 the Postal 

Service first received the documented test results. While the Postal 

Service informed workers of the results in a qualitative manner, it did 

not disclose the actual quantitative results to workers until September 

2002. The Postal Services decision not to release the quantitative 

test results in December 2001 appears to have been consistent with its 

guidelines because the sampling methods used could not be validated, as 

required. However, its decision not to release the December 2001 

quantitative test results in response to two requests by a local union 

leader in January 2002 and February 2002 was not consistent with OSHAs 

regulations for disclosing test results that are requested by workers 

or their designated representatives. OSHAs subsequent investigation 

into this matter resulted in the Postal Services release of the 

December 2001 quantitative test results in September 2002--more than 7 

months after the union leader first requested the results and about 9 

months after the results were first known by the Postal Service. OSHA 

did not cite the Postal Service for its decision not to disclose the 

results earlier; however, in a October 7, 2002, letter to the Postal 

Service, OSHA noted that a failure to effectively communicate issues 

which can have an effect on a workers health and safety, can lead to 

fear and mistrust.:



The Postal Services Release of the December 2001 Test Results Appears 

Consistent with Its Guidelines:



Following the anthrax contamination of several postal facilities, the 

Postal Service, in consultation with public health and other 

organizations that were members of the Postal Services Command Center, 

issued--in December 2001--policies and procedures for, among other 

things, releasing and communicating anthrax test results.[Footnote 26] 

The guidelines specify, among other things, how and when test results 

will be communicated to employees and the public. The guidelines state 

that results cannot be released until confirmed data are received from 

CDC or a state public health laboratory. Also, all confirmed data have 

to be validated before being sent to the Command Center.[Footnote 27] 

Once data are confirmed and validated, the guidelines state that the 

Manager of the Command Center is to release the data to affected 

district and facility managers, the affected state health 

department(s), and the CDC liaison at the Command Center. According to 

the guidelines, when a Facility Manager receives the results, he or she 

is to ensure that employees, union representatives, and other affected 

parties are notified as soon as possible. An earlier version of the 

guidelines, dated November 16, 2001, has identical requirements.



The Postal Service, with one exception, began disclosing the laboratory 

test results for samples collected from the facility within 1 day of 

receiving the qualitative results. Such prompt disclosure is consistent 

with the Postal Services guidelines, which require facility managers 

to notify workers of sample results as soon as possible if the 

results are confirmed and validated. The one exception to this practice 

appears to have occurred after the Postal Service received written 

confirmation of the results from the two quantified samples collected 

on November 28, 2001. According to district postal managers, they began 

relaying the results to facility workers on December 12, 2001--2 days 

after district postal managers said they first received written 

confirmation of the laboratorys quantified results from the Chief 

Epidemiologist. District postal managers provided several reasons for 

their 2-day delay in notifying workers of the results.[Footnote 28] 

First, they said they needed time to consult with public health 

officials from Connecticuts Department of Public Health and CDC about 

(1) the meaning and implications of the quantitative results and (2) 

how to describe the results and associated health risks to employees at 

the facility. Second, the managers said that they needed additional 

time to obtain advice from Postal Service headquarters and to draft a 

press release. Although the district did not receive the quantitative 

results until December 10, as previously discussed, a chronology of 

events prepared in January 2002 by Postal Service employees and shared 

with CDC indicates that postal managers at headquarters may have 

received the documented results on or about December 8, 2001--4 days 

before workers were informed of the test results.[Footnote 29] The 

length of the delay in informing workers cannot be specifically 

determined because postal headquarters managers do not recall when they 

first obtained the written test results.



According to Postal Service managers, the decision to withhold the 

actual quantified results from facility workers also was consistent 

with the guidelines because the Postal Service could not ensure that 

the contractors sampling procedures were consistent with the 

procedures and protocols specified in the guidelines. As a result, 

according to the Postal Service, it was unable to validate the results 

as required by its guidelines. More specifically, the Postal Service 

indicated that the results could not be validated, in part, because the 

team that collected the samples--individuals from the Agency for Toxic 

Substances and Disease Registry and CDC--did not always measure and 

record the extent of the surface area that they sampled.[Footnote 30] 

Also, the team used various sampling methods, and there was no way to 

correlate the results from the various methods used.[Footnote 31] The 

Postal Service also indicated that the laboratory that produced the 

results was not hired by or working directly for the Postal Service, as 

had been expected when the Postal Service developed its 

guidelines.[Footnote 32]



Aside from the requirements in its guidelines, district postal managers 

said two other factors influenced their decision not to disclose the 

quantified results in December 2001. First, district postal managers 

said that they were uncertain about whether they could release the 

results given the ongoing FBI criminal investigation related to the 

facilitys contamination.[Footnote 33] Although acknowledging that 

they did not consult the FBI or others about releasing the quantitative 

results, district postal managers noted that the investigative team was 

subject to strict rules and had agreed not to disclose information 

exchanged during its twice-daily conference calls. Second, they said 

that there was considerable uncertainty about what the results meant 

from the standpoint of worker safety and public health. The District 

Manager explained that in December 2001, interpretations about the 

meaning of the results were changing by the hour, depending on the 

views of individuals involved at the time. As a result, according to 

members of the investigative team, there was considerable daily 

discussion within the team about what the test results actually 

meant.[Footnote 34] CDC pointed out that it did not and still does not 

know how to interpret quantitative results such as the high spore count 

from a health risk standpoint. Nevertheless, CDC noted that the 

actions taken by the Postal Service when the contamination was found 

were very cautionary and prudent.:



The Postal Services Delay in Disclosing the December 2001 Quantitative 

Test Results Was Not Consistent with OSHAs Disclosure Requirements:



To help ensure that employees have safe and healthy work places, OSHA 

enforces a variety of standards that it developed to eliminate 

foreseeable and preventable hazards, such as worker exposure to 

asbestos, lead, and carbon monoxide. The risk of contamination from 

anthrax was not anticipated when these standards were developed. Thus, 

there is no specific OSHA standard governing the timing and disclosure 

of test results for anthrax and a host of other unanticipated 

substances that could harm workers. However, regardless of the 

contamination, OSHA regulations require employers to disclose exposure-

related test results whenever an employee or designated representative 

requests access to a record. . . .[Footnote 35] Employers are required 

to provide access to the records in a reasonable time, place, and 

manner. If access is not provided within 15 working days, employers 

must explain the delay and indicate when the record can be made 

available.[Footnote 36] OSHA has considerable discretion in enforcing 

this requirement and, depending upon the seriousness of the situation, 

can cite and even fine an employer for noncompliance.[Footnote 37]



The President of the Greater Connecticut Area Local American Postal 

Workers Union--a designated representative of many of the facilitys 

employees--triggered the OSHA requirement on January 29, 2002, when he 

requested postal facility managers to provide copies of all test 

results and all supporting and relevant documents for all anthrax 

testing conducted at the Wallingford facility in the fall of 

2001.[Footnote 38] The request was made pursuant to the unions 

collective bargaining agreement with the Postal Service. The Postal 

Service responded on February 6, 2002, with a summary listing of tests 

performed at the Wallingford facility, including information about 

whether the test was positive or negative for anthrax. The Postal 

Service did not (1) provide any of the actual laboratory reports for 

the tests or (2) inform the union leader that it had not disclosed all 

of the relevant records. According to the Postal Service, it viewed the 

union leaders request, like others it receives from the union, in the 

context of its collective bargaining agreement with the union, not 

within the context of OSHAs disclosure requirement. As a result, the 

Postal Service did not provide him with the earliest date when the 

other records would be made available, as required by OSHAs 

regulations.



Noting that the Postal Service had not provided him with certain test 

results, including results related to the decontamination of the four 

mail-sorting machines in December 2001, the union leader submitted an 

identical request for all of the records to the Postal Service on 

February 28, 2002--again under the collective bargaining agreement. The 

Postal Service provided the results of tests performed on November 11, 

2001, as well as the results of the December 2001 decontamination 

efforts. However, once again, according to the headquarters manager 

responsible for establishing and overseeing the Command Center, the 

Postal Service did not view the request within the context of the OSHA 

disclosure requirement. As a result, the Postal Service did not apprise 

the union leader of the reason for the delay in disclosing all of the 

records or the earliest date when the records would be made available.



According to the union leader, he believed that the Postal Service had 

provided him with all of the relevant information and did not pursue 

the matter further until April 2002--after he learned from a newspaper 

article that at least one of the facilitys test results had been 

quantified.[Footnote 39] According to the union leader and the Postal 

Service physician who had been responsible for providing medical advice 

to workers at the facility in December 2001, this was the first time 

that they were aware that any of the facilitys test results had been 

quantified.



The union leader told us that the news article alarmed him; as a 

result, he initiated action to obtain the quantified test results under 

the Freedom of Information Act. Specifically, on April 23, 2002, the 

union leader requested OSHA, the Connecticut Department of Public 

Health, and CDC to supply any and all documents regarding any and all 

investigations of hazardous conditions, or suspected hazardous 

conditions, including, but not limited to, all documents related to any 

and all investigations of contamination, or suspected contamination, of 

the anthrax virus at the [Wallingford facility] in 2001 and 2002.:



OSHA responded to the request but indicated that it did not have the 

test results and, therefore, it could not release the information. 

Second, while the Commissioner of the Connecticut Department of Public 

Health had discussed the December 2001 quantified results with the 

union leader on April 22, 2002, and the Chief Epidemiologist had 

briefed the facilitys workers about the quantitative results on April 

24, 2002, the department subsequently declined to release the actual 

results because of state prohibitions on releasing epidemiological 

investigative data.[Footnote 40] Finally, although CDC had previously 

(1) released the quantitative test results for the Wallingford facility 

at a March 2002 conference and (2) published some quantitative test 

results for the Brentwood facility in Washington, D.C.,[Footnote 41] it 

did not release the results to the union until March 28, 2003, because, 

according to a CDC official, the FBI had only recently notified CDC 

that it did not need to review CDCs records before the release of 

anthrax-related information.[Footnote 42]



Unsuccessful in obtaining the facilitys test results, the union leader 

filed a formal complaint with OSHA. The May 29, 2002, complaint alleged 

that the Postal Service had intentionally failed to properly and 

timely disclose to the employees working at [the facility] and to their 

union representatives the actual level of anthrax contamination found 

on four (4) automated processing machines back in December 2001. The 

letter noted that the Postal Service was aware of the quantified test 

results on or about December 12, 2001 yet did not inform the 

facilitys workers. Absent knowledge of the actual amount of 

contamination at the facility, the union leader charged that employees 

had inadequate information for making informed decisions, such as 

decisions about whether to continue (1) taking antibiotics and (2) 

working in the facility. The union leader and other union 

representatives subsequently explained to us that, according to their 

discussions with workers at the facility, many of the employees either 

(1) did not take their antibiotics or (2) stopped taking their medicine 

prematurely on the basis of the Postal Services use of trace and 

concentration to characterize the extent of contamination in the 

facility.



The complaint resulted in an OSHA investigation and the Postal 

Services subsequent release of test results from samples collected in 

November and December 2001. This included the actual laboratory record 

for the sample that identified about 3 million spores in a sample 

collected from one mail-sorting machine on November 28, 2001. The 

Postal Service provided the quantified results to union representatives 

and to members of the facilitys Safety and Health Committee on 

September 4, 2002, along with a letter describing the Postal Services 

reasons for not releasing the results earlier. Specifically, the Postal 

Service indicated that the results could not be validated because the 

laboratory that produced the results was not hired by or working 

directly for the Postal Service. As a result, the letter cautioned 

recipients not to use the information to interpret the risk to 

employees who had been working in the facility in December 2001.



At the conclusion of the inspection, OSHAs area office in Bridgeport, 

Connecticut, reported that its inspection had revealed conditions of 

significant findings, which--while not warranting a citation for a 

regulatory violation--were of sufficient importance to require [the 

Facility Managers] attention. OSHAs October 7, 2002, letter to the 

Postal Service also stressed the importance of timely communication of 

test results and stated that a failure to effectively communicate 

issues which can have an effect on a workers health and safety, can 

lead to fear and mistrust. Furthermore, the letter informed the Postal 

Service that effective and forthright communication of any and all 

information relating to exposure records, both quantitative and 

qualitative, to toxic substances and harmful physical agents should 

take place in a timely manner.:



According to OSHA officials, OSHA typically sends a letter of 

significant findings when the employer has disclosed information 

requested by an employee or his or her designated representative while 

the complaint is still open--as the Postal Service did on September 4, 

2002, prior to the end of OSHAs investigation. Although OSHA did not 

believe that a citation was warranted, OSHA officials stated that they 

used a letter of significant findings to establish a basis for a future 

violation if the problem reoccurs.



Dissatisfied with OSHAs decision not to take regulatory action, on 

October 17, 2002, the union leader requested that OSHAs Regional 

Administrator in Boston, Massachusetts, review the matter. The request 

was based, in part, on the fact that the Postal Service did not release 

the quantified results until September 4, 2002--more than 3 months 

after the union filed its complaint with OSHA and more than 7 months 

after the union had first requested all test results directly from the 

Postal Service. The request also cited conflicting information that had 

been received by OSHA about whether postal managers were still in 

possession of the December 2001 quantified results in June 2002, when 

OSHA initiated its investigation, and thus whether the Postal Service 

could have supplied the information to the union earlier.[Footnote 43] 

In his request, the union leader argued that a regulatory citation was 

needed because, otherwise, there would be no incentive for the Postal 

Service to prevent a similar situation from reoccurring. OSHAs 

Regional Administrator reviewed the matter and, by a letter dated 

November 26, 2002, affirmed OSHAs prior decision not to issue a 

regulatory citation.



We discussed OSHAs findings with officials responsible for the 

inspection. They noted that OSHA was not involved at the facility until 

April 2002--well past the December 2001 period in question. 

Nevertheless, they cited the emergency situation that had existed at 

that time and indicated that, on the basis of their subsequent 

knowledge of the events that had transpired, they believed the Postal 

Service had taken reasonable and prudent actions to protect its 

employees throughout the period of the facilitys contamination. As a 

result, any hazard associated with the Postal Services nondisclosure 

of the quantitative test results had been eliminated in December 2001-

-about 6 months before OSHAs investigation began. Also, the OSHA 

officials noted that because the Postal Service had subsequently 

released the requested data, in their view, it would not be appropriate 

to issue a regulatory citation.



In a February 2003 letter to the union leader, OSHAs Regional 

Administrator reaffirmed OSHAs decision not to cite the Postal 

Service. According to the Regional Administrator, the agencys decision 

was influenced by several factors, including the (1) national panic 

about the anthrax threat in the fall of 2001; (2) lack of information 

about the significance, in terms of employee exposure, of anthrax 

spores found in the facility; and (3) existence of an ongoing criminal 

investigation into the source of the anthrax spores that involved 

several federal agencies.[Footnote 44] Nevertheless, she emphasized the 

need for better communication by the Postal Service and reaffirmed 

OSHAs concern about the failure of communication and openness 

exhibited by the Postal Service in this case.



Lessons Learned at the Wallingford Facility Suggest the Need for More 

Complete and Timely Information to Workers:



Although OSHA and members of the investigative team in December 2001 

were not critical of the Postal Services decision not to release the 

December 2001 quantified results when they were first known, in 

hindsight and within the context of lessons learned, they said there 

was no reason why the results and any limitations associated with the 

results could not have been disclosed at that time. They explained that 

from their perspectives, full and timely disclosure of laboratory 

results is the best method for communicating test results. For example, 

the Chief Epidemiologist from the Connecticut Department of Public 

Health emphasized that it is important to put the information out 

there frankly and then discuss it. Similarly, CDC officials stated 

that the principle is to get all of the information out to employees 

regarding their health risks. Finally, although not a member of the 

investigative team, an OSHA official who was involved in the facilitys 

decontamination in April 2002 told us that he advised the Postal 

Service to provide employees with the raw data sheets of test results 

to avoid miscommunication, confusion, and concern about how the data 

may have been interpreted.



Two recent guidelines developed by GSA and the National Response Team 

stress the importance of complete and timely information. The 

guidelines are intended to disseminate information learned from the 

response to anthrax contamination at postal and nonpostal facilities in 

the fall of 2001, including lessons relating to the communication of 

test results. GSA released its guidelines in July 2002.[Footnote 45] 

The guidelines are written in the form of a policy advisory--not as 

regulations or explicit directives--and primarily apply to the 

operation of mail centers located in federal agencies in the 

Washington, D.C., area. While not requirements, GSAs recommendations 

for communicating test results to workers, in our view, are relevant to 

the Postal Service and others. The guidelines emphasize the importance 

of the integrity of the information communicated to workers and stress 

the need for timely, clear, consistent, and factual information about 

risk levels and any limitations associated with the information. The 

guidelines conclude that people need solid information to have the 

confidence to make informed choices.:



The National Response Team developed the other guidelines, which are 

still in draft. The most recent version of the guidelines is dated 

September 30, 2002, and is entitled Technical Assistance for Anthrax 

Response.[Footnote 46] Although not a member of the National Response 

Team, the Postal Service assisted in the development of the guidelines. 

The guidelines (1) suggest that more--rather than less--information 

should be disclosed and (2) provide a number of recommendations about 

communicating information during emergency situations. For example, the 

guidelines advise agencies to consider that different audiences (e.g., 

employees, reporters, local politicians) may need different types of 

information and to anticipate what information people need and in 

what form. Further, although the guidelines caution against passing on 

everything you know, it points out the consequences of not fully 

disclosing information. Specifically, the guidelines warn, . . . do 

not withhold information . . . it is very likely that the withheld 

information will be found out, which will cripple your credibility. . . 

. Finally, the guidelines advise agencies to admit when you have made 

a mistake or do not know the information.:



Although helpful in ensuring the integrity of information to be 

released, neither of the two recent guidelines nor the Postal Services 

guidelines explicitly address all of the communication issues that 

arose at the Wallingford facility.[Footnote 47] None of these 

guidelines:



* explicitly require disclosure of quantitative test results, when 

available, or specify the terminology (e.g., number of colony-forming 

units per gram or square inch of material sampled) that should be used 

to communicate the results to workers or others, along with any 

limitations associated with the results, or:



* specify the actions that should be taken if test results cannot be 

validated, including a strategy for communicating unvalidated test 

results to workers.



Furthermore, the Postal Services guidelines do not define the meaning 

of validation or specify the steps that must be taken to validate 

test results. The Postal Service headquarterss manager who was 

responsible for establishing and overseeing the Command Center told us 

that the term was intended to describe a method for ensuring that work 

had been done in accordance with the Postal Services sampling and 

testing procedures and, therefore, for coordinating the release of 

validated results. However, the guidelines do not specify who is to do 

the validation or how it is to be done, particularly when the testing 

is not done or sponsored by the Postal Service.



The experts whom we consulted (1) told us that the sampling method 

(HEPA vacuums) used to collect the samples that were quantified was 

appropriate and (2) agreed that the lack of documentation about the 

extent of surface area sampled, especially given the complexity of the 

facilitys mail-sorting machines, could have made interpretations about 

the results difficult.[Footnote 48] Nevertheless, they noted that the 

method of counting colony-forming units is a long-standing, definitive, 

and universally accepted microbiological technique for determining the 

amount of bacteria in a given sample, including anthrax. The results 

show how many spores have replicated to form colonies, which can be 

seen by the naked eye. Thus, regardless of the sampling issues at 

Wallingford, none of the agencies involved provided any evidence 

indicating that the number of colony-forming units identified by the 

laboratory was incorrect. Accordingly, although the sampling issues may 

have hindered the interpretation of the test results,[Footnote 49] 

according to these experts, the use of the term concentration to 

convey the finding of about 3 million spores in one sample may have 

been misleading because it did not adequately convey the health risk 

associated with the sample. According to the experts with whom we 

talked, providing information about the actual test results to workers 

would have given them better information for making informed medical 

decisions.



In this case, according to the experts we consulted, an appropriate way 

to communicate the results to workers would have been to indicate that 

2.9 million colony-forming units (from 0.55 grams of dust) were found 

in a sample from one machine, along with appropriate limitations 

regarding the sampling procedures used. Although a precise 

interpretation of the health risks associated with the quantitative 

test results was problematic, providing the quantitative results would 

have given workers a framework for evaluating the information they were 

previously given regarding the 8,000 to 10,000 spores believed--at that 

time--to be needed to cause inhalation anthrax and would have provided 

some indication of the magnitude of the anthrax present in the 

facility. According to CDC, although the number of anthrax colonies can 

be counted, it is not possible to count the exact amount of anthrax in 

the environment because of uncertainties about how well a sample picks 

up anthrax. In other words, there could be more anthrax in the 

environment than can be picked up by a sample.



An additional problem relating to the existing guidelines is that none 

of them (1) specify who should be involved in deciding what to 

communicate to workers and others, as appropriate; (2) describe the 

documentation agencies should maintain, including the advice agencies 

receive from public health officials or others about the communication 

of test results to workers; or (3) discuss the actions that should be 

taken if test data are requested by an employee or a designated 

representative. As previously discussed, OSHA representatives were not 

involved in the December 2001 discussions about what to communicate to 

workers. This deprived the Postal Service of the insights and 

suggestions that OSHA could have offered. Furthermore, although the 

Postal Service representatives cited uncertainty over what information 

could be released given the ongoing criminal investigation, the Postal 

Service did not consult with the FBI on this issue. According to FBI 

officials we interviewed in Connecticut, the test results were of no 

value to their investigation and, had they been consulted, they said 

that they would have allowed the results to be released.



As previously discussed, another issue that arose in the Wallingford 

case involved differing recollections among the various parties 

regarding who participated in certain discussions and about what advice 

was given. For example, in contrast to the recollections of officials 

from CDC and the Connecticut Department of Public Health, postal 

managers told us that they did not participate in a December 6, 2001, 

telephone conversation in which the quantitative test results were 

first discussed. Further, postal managers have different recollections 

about the advice they received from the Chief Epidemiologist than the 

information that he recalls. Also, in the Wallingford case, the Postal 

Service said that it did not associate the union leaders request for 

the test results with OSHAs regulatory requirement and, therefore, did 

not realize that it was obligated to either provide the results within 

15 days or provide the reasons for the delay along with a time frame 

for providing the results. Related to this, OSHAs disclosure 

requirements do not fully address the emergency situation that arose at 

Wallingford, where workers were exposed to an unanticipated and 

externally introduced hazard capable of causing serious health 

problems, including death. The regulations are not applicable until an 

employee or a designated representative requests test results and, even 

then, the employer has up to 15 days to provide the information or 

explain why it is not providing the information. The 15-day time frame 

is far more than the number of days needed to contract inhalation 

anthrax.



We discussed OSHAs regulatory requirements with OSHAs Director of 

Enforcement Programs. The Director told us that OSHAs standards were 

written for airborne exposure to chemical and physical agents in the 

workplace, and, at the time they were drafted, OSHA did not envision 

biological hazards, such as anthrax. According to the Director, OSHAs 

current regulatory agenda do not include any planned modifications to 

its requirements, including any changes to require the immediate and 

proactive disclosure of records related to an employees exposure to 

unforeseen hazards, such as anthrax, regardless of whether the records 

are requested by workers or their designated representatives.



Conclusions:



In retrospect, the Postal Services decision not to release the 

quantitative test results in December 2001 was understandable given (1) 

the circumstances that existed at that time, (2) the advice it received 

from public health officials, (3) an ongoing criminal investigation, 

and (4) uncertainties surrounding the validation of the sampling 

methods used and the meaning of the test results. However, the decision 

deprived facility employees of information that may have been useful in 

making informed decisions about whether to take or continue taking 

antibiotics and whether to continue working in the facility. 

Furthermore, in hindsight, it is clear that not fully disclosing 

quantified test results can affect an agencys credibility and lead to 

worker distrust. It is also apparent now that not consulting relevant 

agencies--in this case, OSHA and the FBI--regarding its December 2001 

decision about what to disclose to employees deprived the Postal 

Service of information that could have been useful in deciding what to 

communicate to its workers. Finally, the Postal Services failure to 

document the discussions that it had with other agency personnel on 

communication issues makes it difficult to resolve discrepancies in 

recollections that arose. As demonstrated at Wallingford, documentation 

of the advice and recommendations received from others, either at the 

time they are received or shortly thereafter for emergencies, could 

help resolve questions that may arise later about what was done and 

why.



The agencies involved in the investigation and response to anthrax at 

Wallingford have learned a number of lessons from their experiences, 

including the need for more effective sampling methods and more 

explicit and consistent guidance concerning the communication of test 

results for hazardous substances, such as anthrax. However, the 

guidelines developed by the Postal Service, GSA, and the National 

Response Team are still too general to prevent problems like those that 

occurred at the Wallingford facility. Specifically, the current 

guidelines do not (1) require the prompt disclosure of all available 

test results, using specified terminology; (2) define how test results 

should be validated or the actions that should be taken when results 

cannot be validated; (3) specify which agencies should be involved in 

deciding what to communicate to workers and others; or (4) require 

documentation of the advice and recommendations from other 

organizations involved in deciding the actions to be taken during a 

crisis. Moreover, since employees and their designated representatives 

may not know that test results are available or that they can be 

requested, it appears incumbent upon employers to, in emergency 

situations, immediately disclose test results without waiting for an 

employee or representative to request them. Because current OSHA 

regulations require the disclosure of test results only when an 

employee or representative requests them, such as occurred in the 

Wallingford case, organizations can still decide to withhold essential 

information. Lastly, agency officials dealing with an anthrax situation 

or similar emergency may not be aware of, or associate an employees 

request for test data with, OSHAs regulations, which can result in 

penalties for noncompliance.



Recommendations for Executive Action:



To help prevent the reoccurrence of the communications problems that 

occurred at the Wallingford facility, we recommend that the Postmaster 

General; the Administrator of GSA; and the Administrator of EPA, as 

Chairperson of the National Response Team, work together to, where 

applicable, revise guidelines to:



* require prompt communication of test results, including quantified 

results when available, to workers and others;



* specify the terminology that should be used to communicate 

quantitative test results to employees and others (e.g., the number of 

colony-forming units per gram or square inch of material sampled) and 

any limitations associated with the test results;



* define what is meant by the validation of test results and explain 

the steps that must be taken to validate sampling or testing methods 

that are undertaken by the agency itself or by another organization;



* specify the actions that should be taken if test results cannot be 

validated, including a strategy for communicating unvalidated results;



* specify the agencies that should be involved in deciding what to 

communicate to workers and others, as appropriate;



* require documentation of the basis for decisions made, including the 

(1) advice the organization receives from public health officials and 

others about the communication of health-related information to workers 

and others, as appropriate, and (2) specific content of what the 

organizations communicate to workers and others; and:



* reflect OSHAs regulations for disclosing test results requested by 

workers or their designated representatives.



In light of new concerns about the possibility and impact of future 

terrorist actions using unforeseen hazardous substances, we also 

recommend that the Assistant Secretary for Occupational Safety and 

Health consider whether OSHA regulations should require--in emergency 

situations--full and immediate disclosure of test results to workers, 

regardless of whether the information is requested by an employee or 

his or her designated representative.



Agency Comments and Our Evaluation:



We requested comments on a draft of this report from the Postmaster 

General; the Commissioner of the Connecticut Department of Public 

Health; the Secretaries of HHS, Labor, and Homeland Security; the 

Attorney General--for the FBI; the Administrators of EPA and GSA; and 

the President of the American Postal Workers Union. EPA, the Postal 

Service, GSA, the union, and the FBI provided comments on our 

conclusions and/or recommendations. Their comments are summarized 

below.



EPAs Assistant Administrator provided comments on March 21, 2003, in 

EPAs capacity as the Chair for the National Response Team. According 

to the EPA Assistant Administrator, OSHA, GSA, HHS (specifically the 

National Institute of Occupational Safety and Health), and the Postal 

Service were consulted in preparing the response. EPA indicated that 

the members of the National Response Team believe that our draft report 

provided a balanced presentation of anthrax testing and communications 

with employees at the Wallingford postal facility. While stating that 

the National Response Team agrees with our references and 

recommendations regarding the content of its guidelines--Technical 

Assistance for Anthrax Response--EPA stated that the guidelines had 

been carefully written as a technical resource document, as opposed to 

a directive or guidance, and that knowledge on anthrax is evolving 

rapidly. Thus, EPA noted that each response situation is unique. As a 

result, EPA stated that the guidelines were intended to provide 

scientific background and viable options for responders to consider in 

addressing specific circumstances. Nevertheless, EPA indicated that 

certain improvements could be made to the guidelines that would be 

responsive to our recommendations. The letter did not specify the 

nature of the planned improvements. EPA also provided technical 

comments, which we included, as appropriate. EPAs letter is reproduced 

in appendix III.



In his March 31, 2003, comments on our draft report, the Postal 

Services Chief Operating Officer and Executive Vice President stressed 

that the safety and security of its employees and its customers were 

then and now of the utmost importance. The Postal Service also 

emphasized that, when the anthrax crisis unfolded in the fall of 2001, 

there were no guidelines and no designated regulatory agency for 

dealing with the crisis. While stating that the Postal Service acted 

quickly and prudently to communicate pertinent information to its 

employees, the Postal Service acknowledged that there are always 

opportunities to improve communications regarding anthrax and other 

biohazards. In this regard, the Postal Service stated that it is 

committed to working with the National Response Team to revise the 

teams technical assistance guidelines for anthrax and, when completed, 

that it planned to ensure that its guidelines are consistent with the 

teams updated guidelines. The Postal Service also noted that it agreed 

with many of our specific recommendations. For example, the Postal 

Service agreed that test results, including quantified results, should 

be released to employees and others as quickly as possible. The Postal 

Service also agreed that any limitations associated with the results 

should be explained. Further, the Postal Service recognized the 

importance of developing and maintaining sufficient records concerning 

its communication of health-related information to employees and 

others. Finally, the Postal Service indicated that it is aware of its 

obligation to release testing information to employees and their 

unions, when requested to do so. The Postal Services letter, which is 

reproduced in appendix IV, did not comment on our other 

recommendations. The Postal Service also provided technical comments, 

which we included, as appropriate.



The Postal Services commitment to work with the National Response Team 

in revising the teams anthrax-related guidelines and, thereafter, to 

ensure that its guidelines are consistent with the revisions made to 

the teams Technical Assistance for Anthrax Response, should go a long 

way in ensuring that the Postal Services employees have all of the 

information they need to make informed decisions about their health and 

safety in a timely manner. However, because the National Response Team 

did not specify the nature of its planned revisions to its technical 

assistance, we believe that the Postal Service should also revise its 

guidelines to address any recommendations that are not eventually 

included in the National Response Teams revised technical assistance, 

particularly with respect to issues related to the meaning of 

validation, the steps that must be taken to verify sampling methods 

or test results, and the release of test results that cannot be 

validated.



On March 31, 2003, GSAs Associate Administrator provided oral comments 

on our draft report. GSA said that it had consulted with the National 

Response Team and with key members of an Interagency Working Group that 

had participated in the development of GSAs anthrax-related 

guidelines. According to GSA, the other members of the working group 

had similar comments. Overall, GSA said that our draft report provided 

a balanced presentation of anthrax testing and communications with 

employees at the Wallingford facility and that it generally agrees with 

our references to, and recommendations regarding, its guidelines. Like 

the comments we received on behalf of the National Response Team, GSA 

also emphasized that its guidelines were written as a policy advisory 

and that they were not intended to prescribe specific actions that 

should be taken in every case. Instead, GSA indicated that its 

guidelines are intended to provide background information and viable 

options for managers who operate federal mail centers in the 

Washington, D.C., area. GSA also explained that its guidelines deal 

primarily with the actions that these managers should take to prepare 

for possible anthrax threats and to determine whether an anthrax threat 

is credible. Once a credible threat has been identified, responsibility 

for managing the situation passes from the manager of the mail center 

to law enforcement, public health, and other authorities. As a result, 

GSA emphasized that the guidelines developed by the National Response 

Team should be the primary source of advice for anyone managing a 

credible threat.



GSA noted that it needs to consult with the entire Interagency Working 

Group before implementing specific changes to its guidelines. However, 

GSA informed us that it agreed with three of our recommendations and 

indicated that it would work with other members to revise its 

guidelines related to (1) the prompt disclosure of all test results, 

including any available quantified results; (2) the need for adequate 

documentation of the advice an agency receives from public health 

officials and others and its related communications with employees and 

others; and (3) OSHAs regulations for disclosing test results 

requested by workers or their designated representatives.



GSA also said that it would address the issues covered in three of our 

other recommendations somewhat differently than in the manner that we 

suggested. Nevertheless, GSA indicated that it would work with the 

Interagency Working Group to address the concerns raised in our report. 

The three recommendations in question relate to the need for (1) common 

terminology in communicating quantitative test results, (2) 

understanding what is meant by the validation of sampling methods and 

test results, and (3) specifying the actions to be taken if test 

results cannot be validated. Specifically, while GSA commented that it 

agrees that all test results should be conveyed to workers promptly, it 

said that it does not believe that quantitative test results should be 

used in all cases. GSA explained that appropriate testing methods vary 

according to site-specific circumstances and the ability to quantify 

results depends on the testing methods used. GSA also noted that the 

term validation has various meanings. Rather than promote confusion or 

add unnecessary detail to distinguish the different types of 

validation, GSA said that it would address our recommendations by 

adding a statement in its guidelines that recommends sharing all 

available test results; specifying the testing methods used; and 

explaining the limitations, if any, of the results and the testing 

methods.



We appreciate GSAs commitment to address the concerns raised in our 

report. From GSAs comments, it appears that further clarification of 

our view may be warranted. We did not mean to imply that quantitative 

results should be used in all cases. As indicated in our report, 

quantitative results are not always available, depending on the 

sampling methods used. In fact, in the case of the Wallingford 

facility, quantified results were rarely available. However, when 

quantitative results are available, like GSA, we continue to believe 

that it is important to disclose them to all affected parties. We 

clarified our recommendation to avoid any misunderstandings in this 

area.



Regarding our final recommendation, GSA indicated that parties involved 

in responding to anthrax may change over time and, as a result, it 

believes that its guidelines--in a general fashion--adequately identify 

the types of parties that should be involved in deciding what to 

communicate to workers and others. Nevertheless, GSA said that, in 

consultation with the Interagency Working Group, it would look for ways 

to enhance this part of its guidelines.



The President of the American Postal Workers Union commented on our 

draft report in a letter dated March 25, 2003. The union said that it 

agreed with our recommendations to better coordinate communication 

between federal agencies when events occur. However, the union said 

that our report did not adequately reflect the unions perspective of 

the facts and that a number of our conclusions were not supported by 

the facts. We disagree. We believe that our conclusions are fully 

supported by the evidence presented in this report and that the report 

presents a fair, objective, and balanced depiction of the facts as best 

we could determine them. We also disagree that the report does not 

adequately reflect the unions perspective. Our report clearly 

concludes that the Postal Services December 2001 decision not to 

disclose the quantitative results deprived workers of essential 

information for making informed decisions related to their health and 

safety. In addition, the report lays out a number of lessons that can 

be learned to avoid similar problems in the future. Furthermore, the 

report contains several recommendations for improving communication 

with postal and other workers in the future if another bioterrorist 

attack occurs. The unions letter is reproduced in appendix V.



The union disagreed with a number of our conclusions. First, the union 

disagreed that the Postal Services decision not to release the 

quantitative results to workers in December 2001 appeared consistent 

with its guidelines. The union reiterated the requirements in the 

Postal Services guidelines which, as discussed in this report, specify 

that confirmed test results must be validated before being sent to the 

Postal Services Command Center and, once the data are confirmed and 

validated, the guidelines state that the Manager of the Command Center 

is to release the data to, among other parties, affected postal 

managers and state health departments. Thus, in the unions view, the 

test results are considered to be validated when they are reported by 

the Manager of the Command Center. However, this is not what happened 

in Wallingford. In the Wallingford case, the laboratory reported the 

quantitative results directly to the Connecticut Department of Public 

Health and CDC--not to the Postal Services Command Center--and the 

Chief Epidemiologist provided the test results directly to the Postal 

Services district office. Thus, the results were not reported by the 

Command Center as anticipated by the guidelines. According to the 

Postal Service, the December 2001 quantitative results could not be 

validated, within the context of the Postal Services guidelines, 

because the party that collected the samples did not work for the 

Postal Service and the Postal Service could not ensure that the samples 

had been collected in accordance with procedures set forth in its 

guidelines. While we believe that the Postal Services decision not to 

release the quantitative test results in December 2001 appears 

consistent with its guidelines on the basis of its interpretation of 

the validation requirement, we also believe that the use of the term 

validation in the context of anthrax testing can be problematic. 

Therefore, our report contains a recommendation to define what is meant 

by validation and explain the steps that must be taken to validate test 

results.



Second, the union stated that, in its view, it is unacceptable to 

withhold exposure information under any circumstances. While we agree 

in principle, our conclusion that the Postal Services decision not to 

release the quantified test results in December 2001 was understandable 

is based on the particularly challenging and difficult circumstances 

that existed at that specific point in time. As discussed in this 

report, these circumstances included an ongoing investigation of the 

bioterrorist attack; the advice that the Postal Service received from 

public health officials; uncertainties surrounding the validation of 

the sampling methods used and the meaning of the test results. In 

addition, while the Postal Services existing guidelines do not address 

all of the conditions that existed at the Wallingford facility, the 

decision not to disclose the quantified results in December 2001 

appears consistent with the existing guidelines. Furthermore, neither 

OSHA nor the members of the investigative team, including CDC, the 

Connecticut Department of Public Health, the FBI, and EPA, specifically 

faulted the Postal Service for not releasing the quantitative results 

at that time. Nevertheless, our report clearly states that, in 

hindsight, not disclosing test results can be problematic and that the 

decision not to disclose the December 2001 quantified results deprived 

workers of important information. Consequently, we are making several 

recommendations to improve future communication of test results, 

including the prompt disclosure of available qualitative and 

quantitative results, and any limitations associated with the sampling 

methods or test results.



Third, the union stated that our report concluded that it was 

understandable and acceptable that the Postal Service failed to follow 

OSHAs regulatory disclosure requirements and, as a result, that it was 

acceptable to withhold the quantitative results for 9 months. We 

disagree with the unions characterization of our conclusion. Our 

report clearly states that the Postal Services decision not to release 

the test results in response to two union requests in January and 

February 2002 was not consistent with OSHAs regulations. To help 

ensure that similar situations do not occur in the future, we are 

recommending that EPA, the Postal Service, and GSA revise their 

guidelines to reflect OSHAs regulations for disclosing test results 

requested by workers. Related to this, we are also recommending that 

OSHA consider strengthening its regulatory requirements to require--in 

emergency situations--full and immediate disclosure of test results to 

workers, regardless of whether the information is requested by an 

employee or his or her designated representative.



Finally, the union said that the report concluded that the Postal 

Service followed its guidelines with one exception, without 

explaining that the exception involved the sample containing about 3 

million spores on one heavily contaminated mail-sorting machine. 

According to the union, this exception placed employees at considerable 

risk. As discussed in this report, we agree that the Postal Services 

decision not to release the quantitative results in December 2001 

deprived the facility employees of information that may have been 

useful to them in making informed decisions about whether to take or 

continue taking antibiotics and whether to continue working in the 

facility. However, we disagree that we have not adequately explained 

the circumstances associated with this situation. Throughout the report 

we discuss the results in question as well as the fact that the 

quantitative test results were not communicated to workers. 

Furthermore, the report clearly discusses the actual finding of about 

3 million spores, the concentration of spores that was communicated 

to workers, as well as the fact that exposure to 3 million spores is 

far more than the amount considered necessary to contract the disease.



On March 27, 2003, we received technical comments from an FBI unit 

chief responsible for dealing with threats from weapons of mass 

destruction. The FBI noted conditions that existed in the fall of 2001 

that it believes might have contributed to some of the problems that we 

identified at the Wallingford facility. These conditions included 

uncertainties about anthrax testing and the interpretation of test 

results and conflicting information about (1) what constituted a lethal 

dose of anthrax and (2) the amount of spores needed to contract 

inhalation anthrax. The FBI also commented on our recommendation that 

agency guidelines specify the terminology that should be used to 

communicate quantitative test results. Specifically, the FBI noted that 

it believes that quantitative test results are not as helpful to 

employees as qualitative information. The FBI also said that, in its 

view, quantitative data are less applicable to the health and safety of 

employees than qualitative information. As a result, the FBI suggested 

that we revise our recommendation to specify that qualitative--rather 

than quantitative--test results should be disclosed to workers.



While we agree that the prompt disclosure of qualitative test results 

is important, we continue to believe that available guidelines need to 

be revised to ensure that any quantitative test results are properly 

disclosed. Thus, we have not revised our recommendation in this area. 

Experts that we interviewed believe that, when available, quantitative 

test result data can be helpful to employees. Further, CDC, the 

Connecticut Public Health Department, and OSHA officials told us that 

the full disclosure of test results is appropriate and that full 

disclosure can help avoid misunderstandings, miscommunication, 

confusion, and mistrust. Similarly, the experts we consulted--including 

the former Director and Chief Executive Officer of the British Center 

for Applied Microbiology Research--said that if the actual results had 

been provided to postal employees, they would have had better 

information for making informed medical decisions, particularly since 

the amount of anthrax in the facility was much higher than the 8,000 to 

10,000 spores that postal employees had been advised would likely be 

needed to contract inhalation anthrax. A final reason for not revising 

our recommendation is that by not providing quantitative test results 

when requested by employees or their designated representatives, an 

agency could be found in violation of OSHA regulations and, therefore, 

subject to penalties for noncompliance.



OSHA and two HHS components--CDC and the Agency for Toxic Substances 

and Disease Registry--provided technical comments via E-mail, which we 

incorporated, as appropriate. OSHA did not comment on our 

recommendation that the Assistant Secretary for Occupational Safety and 

Health consider whether OSHA regulations should require--in emergency 

situations--full and immediate disclosure of test results to workers, 

regardless of whether the information is requested by an employee or 

his or her designated representative. We also received technical 

comments from the Chief Epidemiologist of the Connecticut Department of 

Public Health in which he stated that, overall, the report accurately 

portrays his role as well as the role of the Connecticut Department of 

Public Health as it relates to the situation at the Wallingford 

facility. He suggested a number of revisions to clarify this report, 

which we incorporated. In a March 31, 2003, letter, HHSs Acting 

Principal Deputy Inspector General said that the department had no 

comments aside from the technical comments provided by two of its 

components. Finally, we requested comments from the Secretary of 

Homeland Security, but we did not receive any.



:



As arranged with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days 

after the date of this letter. At that time, we will send copies to the 

Chairman of the Senate Committee on Governmental Affairs; the Chairman 

and Ranking Minority Member of the House Committee on Government 

Reform; the Postmaster General; the Secretaries of HHS, Labor, and 

Homeland Security; the Administrators of EPA and GSA; the Assistant 

Secretary for Occupational Safety and Health; the Attorney General; the 

Connecticut Department of Public Health; CDC; the Agency for Toxic 

Substances and Disease Registry; the national American Postal Workers 

Union; and other interested parties. Copies will be made available to 

others on request and are also available at no charge on our Web site 

at http://www.gao.gov.



If you have any questions about this report, please contact me on (202) 

512-2834 or at ungarb@gao.gov. Key contributors to this assignment 

were Don Allison, Hazel Bailey, Bert Japikse, Latesha Love, 

Cady Summers, and Kathleen Turner. Jack Melling and Sushil K. Sharma 

provided technical expertise.



Sincerely yours,



Bernard L. Ungar

Director, Physical Infrastructure Issues:



Signed by Bernard L. Ungar:



[End of section]



Appendix I: Objectives, Scope, and Methodology:



Our objectives for this report were to determine (1) how and when 

contamination was identified at the U.S. Postal Services Southern 

Connecticut Processing and Distribution Center in Wallingford, 

Connecticut (Wallingford facility); (2) what and when information about 

contamination was communicated to facility workers; (3) whether the 

Postal Service followed applicable guidelines and requirements for 

informing facility workers about the contamination; and (4) whether 

lessons can be learned from the response to contamination at the 

facility.



To address these objectives, we identified and, with Postal Service 

headquarters, district, and facility managers, discussed the roles of 

the agencies involved in investigating and responding to anthrax at the 

Wallingford facility. We met with officials from the Postal Service, 

the Connecticut Department of Public Health, the Centers for Disease 

Control and Prevention (CDC), the Agency for Toxic Substances and 

Disease Registry, the Occupational Safety and Health Administration 

(OSHA), the Environmental Protection Agency, the Federal Bureau of 

Investigation, the national American Postal Workers Union, and its 

Greater Connecticut Area Local Union. We also requested and reviewed 

agency documentation related to the testing of the facility and the 

subsequent finding of anthrax contamination as well as documentation 

about how, when, and what information the Postal Service communicated 

to workers about the extent of contamination at the facility. The 

information documented, among other things, the various roles of the 

agencies involved, the laboratories test results, sampling plans and 

testing protocols, press releases, information about the content of 

employee briefings, the Postal Services guidelines for testing and 

communicating anthrax test results, OSHA requirements for disclosing 

records related to employee health risks, and more recent anthrax 

guidelines developed by the General Services Administration and the 

National Response Team.



We also interviewed officials from involved agencies to determine their 

views and the extent of their involvement in the response to the 

facilitys contamination between November 2001 and June 2002. 

Specifically, (1) what information was provided to employees at the 

facility and when, and by whom, it was provided and (2) what lessons 

can be learned about the response to contamination at the facility. 

Finally, we reviewed published literature, including technical reports 

on anthrax, and consulted several experts. We did not independently 

assess or verify any of the laboratory test results, sampling plans, or 

testing protocols to determine their accuracy or adequacy. Moreover, 

because the Postal Service did not document all of the advice that it 

received from public health officials or the precise information it 

communicated to workers at the facility, we largely relied on the 

recollections of Postal Service, public health, and other officials to 

reconstruct these events. We conducted our review from September 2002 

through March 2003 in Hartford, North Haven, New Haven, and Bridgeport, 

Connecticut; Washington, D.C.; and Atlanta, Georgia, in accordance with 

generally accepted government auditing standards.



[End of section]



Appendix II: Summary of Anthrax 

Testing at the Wallingford Facility between November 2001 and April 

2002:



[See PDF for image]



[End of figure]



[A] A fourth machine was suspected of being positive for anthrax on 

December 2 but was not confirmed to be positive until later.



[B] Precisely when Postal Service headquarters and district managers 

first became aware of the quantified test results is unclear. According 

to CDC officials and the Chief Epidemiologist, they began discussing 

the quantitative results with investigative team members, which they 

believe included a district postal manager, on December 6, 2001. 

However, district postal managers said that they were not involved in 

discussions about the quantitative results until December 9. Absent 

documentation, we were unable to reconcile these views.



[C] According to CDC, although the number of anthrax colonies can be 

counted, it is not possible to count the exact amount of anthrax in the 

environment because of uncertainties about how well a sample picks up 

anthrax. In other words, there could be more anthrax in the environment 

than can be picked up by a sample.



[D] District postal managers confirmed that the Chief Epidemiologist 

faxed the quantitative results to the district office on December 9 (a 

Sunday), and that district managers received the fax on December 10. 

However, other documentation suggests that postal managers at 

headquarters may have received the documented results on or about 

December 8. Postal headquarters managers said that they do not recall 

precisely when they received the documented results, and absent 

definitive documentation, we were unable to determine when they first 

knew about the quantitative test results.



[End of section]



Appendix III: Comments from the Environmental Protection Agency:



UNITED STATES ENVIRONMENTAL PROTECTION AGENCY:



WASHINGTON, D.C. 20460:



MAR 21 2003:



OFFICE OF SOLID WASTE AND EMERGENCY RESPONSE:



Bernard L. Ungar:



Director, Physical Infrastructure Issues:



United States General Accounting Office (GAO) Washington, D.C. 20548:



Dear Mr. Ungar:



Thank you for the opportunity to review and comment on the draft report 

entitled  U.S. Postal Service: Better Guidance is Needed to Improve 

Communication Should Anthrax Contamination Occur in the Future  (GAO-

03-316). The Environmental Protection Agency (EPA), as Chair of the 

National Response Team (NRT), provides this statement. The NRT 

consulted with its members, including the Occupational Safety and 

Health Administration (OSHA), the General Services Administration 

(GSA), the Department of Health and Human Services (specifically, the 

National Institute of Occupational Safety and Health), and the U.S. 

Postal Service in preparing this letter.



The NRT believes the report provides a balanced presentation on anthrax 

testing and communications with employees at the Wallingford, 

Connecticut postal facility. We appreciate GAO efforts to produce an 

accurate report. In general, the NRT agrees with the references and 

recommendations regarding the content of the NRT s Technical 

Assistance for Anthrax Response (TAD). It is important to note, 

however, that the TAD was carefully written as a technical resource 

document, as opposed to a directive or guidance. Knowledge on anthrax 

response is evolving rapidly, and each situation is unique. As a 

result, the TAD does not prescribe specific actions that should be 

taken in every case, but provides scientific background and viable 

options for responders to consider in addressing specific 

circumstances. However, we believe that we can make certain 

improvements to the TAD that will be responsive to GAO s 

recommendations.



The enclosure provides EPAs technical comments for GAOs consideration 

when preparing the final report. If you have questions about any of 

these comments, please contact Karen Burgan at (703) 603-9917.



Sincerely,



Marianne Lamont Horinko

Assistant Administrator



Signed by Marianne Lamont Horinko



Enclosure:



Enclosure:



EPA Comments on Technical Accuracy of the GAO Report:



1) The total number of cases of anthrax resulting from the 2001 attacks 

was 23, not 22 as stated in the Highlights section and in the first 

paragraph of the letter to Senator Lieberman. There were 11 cases of 

inhalational anthrax and 12 cases of cutaneous anthrax. The last case 

of cutaneous anthrax occurred in a laboratory worker who was handling a 

sample known to contain anthrax spores from the bioterrorism attack. 

The worker cut himself shaving earlier in the day in which he was 

working with the anthrax sample. He failed to follow proper precautions 

in handling the material and thereafter developed cutaneous anthrax at 

the site of the cut.



2) On page 3, it is not specified whether the area containing the 

contaminated sorting machines was re-opened for mail sorting after the 

December 2001 cleanup and before the April 2002 sampling event in which 

anthrax spores were found in the samples taken above the cleaned 

machines. This information should be included in the final report as it 

pertains to both risk assessment and risk communication to the affected 

postal workers.



3) On page 6, second paragraph, line 4, add  undercooked  between  

ingesting  and  contaminated meat. :



4) On page 7, second paragraph, it should be noted that anthrax spores 

were also not found in the home or workplace of the female hospital 

worker in New York City who died of inhalational anthrax in October 

2001. This fact is also relevant to the potential number of spores 

needed to cause disease/death in exposed persons.



5) Table 1, page 9, would be enhanced by including the number of 

samples taken in each of the six sampling events at Wallingford. The 

numbers of samples taken for the last three events are given in the 

text, but no numbers are presented for the first three sampling events. 

These numbers are relevant to the risk assessment/risk communication 

activities at Wallingford and should be included in the final report, 

both in the text and in Table 1.



6) On page 12, second paragraph, summary information on the manner in 

which the contaminated machines were cordoned off to prevent migration 

of contamination from that area to other parts of the facility should 

be included in the final report.



[End of section]



Appendix IV: Comments from the U.S. Postal Service:



PATRICK R. DONAHOE CHIEF OPERATING OFFICER AND ExECUTIVE VICE 

PRESIDENT:



UNITED STATES POSTAL SERVICE:



March 31, 2003:



Mr. Bernard L. Ungar:



Director, Physical Infrastructure Issues United States General 

Accounting Office Washington, DC 20548-0001:



Dear Mr. Ungar:



Thank you for providing the United States Postal Service the 

opportunity to review and comment on the GAO draft report, U.S. Postal 

Service: Better Guidance Is Needed to Improve Communication Should 

Anthrax Contamination Occur in the Future. This report examined events 

relating to the anthrax contamination of the Southern Connecticut 

Processing and Distribution Center located in Wallingford, Connecticut.



We stress that the safety and security of our employees and customers 

were at the time, and continue to be, of the utmost importance to the 

Postal Service. The Postal Service made every effort to move quickly to 

protect its employees and to safeguard the mail commencing November 20, 

2001, when notified that a Connecticut resident was suspected of having 

contracted inhalation anthrax. The Postal Service immediately began 

testing at the facility, informing its employees of the situation, and 

ensuring that antibiotics were provided to them. We note, as did GAO in 

its draft report, that none of the employees at the facility became ill 

as a result of the anthrax contamination.



We appreciate GAOs acknowledgement that decisions made by the Postal 

Service relating to events that transpired at the facility were 

understandable, given the circumstances at the time, advice received 

from public health agencies, an ongoing criminal investigation, and 

uncertainties surrounding the sampling methods used. It should be noted 

that, at the time, there were no guidelines and no designated 

regulatory agency for dealing with this type of situation. The Postal 

Service acted quickly and prudently to communicate pertinent 

information to its employees, rely-ing upon the advice of public health 

experts. We understand, however, that there are always opportunities 

for improvement in our future communication efforts regarding anthrax 

or other biohazards.



We realize that recollections of events occurring in a difficult 

atmosphere may vary, particularly after more than a year has passed. 

Nonetheless, our focus has been and will remain on provid-ing complete 

and accurate information to our employees as promptly as possible 

regarding any situation that may affect their health and safety.



With regard to GAOs specific recommendations, the Postal Service is 

committed to working with the National Response Team (NRT) in making 

appropriate revisions to the Technical Assistance Document (TAD) for 

Anthrax Response. The Postal Service fully realizes the challenges 

faced by the NRT in going forward on this issue. We plan to revise 

Postal Service guidelines in this area so that they are consistent with 

the TAD. We agree that test results, including quantified results if 

available, should be released to employees and others as quickly as 

possible. We further agree that in communicating available test 

results, the testing methods used should be specified and any 

limitations of either the testing methods or the test results should be 

explained. The Postal Service will make every effort, as it did at 

Wallingford, to consult with appropriate federal, state, and local 

agencies in deciding on appropriate communications to employees and

others. Also, we acknowledge the importance of attempting to develop 

and maintain sufficient records concerning communications on health-

related information to employees and others. The Postal Service is 

aware of its obligations to release testing information to employees 

and their unions when requested.



If you or your staff would like to discuss any of these comments, I am 

available at your convenience.



Sincerely,



Patrick R. Donahoe



Signed by Patrick R. Donahoe



[End of section]



Appendix V: Comments from the American Postal Workers Union:



American Postal Workers Union, AFL-CIO:



1300 L Street, NW, Washington, DC 20005:



March 25, 2003:



William Burrus President:



(202) 842-4246:



Mr. Bernard L. Ungar:



Director, Physical Infrastructure Issues General Accounting Office:



441 G Street, N.W., Mailroom #2T23B Washington, D.C. 20548:



Re: Review of Draft GAO-Pub No. (GAO-03-316):



Report to the Ranking Minority Member Committee on Government Affairs 

United States Senate:



Titled:



U.S. Postal Service:



Better Guidance Is Needed To Improve Communication Should Anthrax 

Contamination Occur in the Future:



Dear Mr. Ungar:



The following is presented as comments after APWUs review of the above 

referenced document. We viewed the document as very generous toward the 

USPS response to the events and lacks considerably in presenting the 

unions perspective of the facts. One of the most disturbing items is 

that the report portrays the events as acceptable based upon the 

circumstances, but fails to highlight that the actions were 

inconsistent with both Postal Service practice/policy and OSHA 

regulations.



The report provides a number of facts about the circumstances 

surrounding the events at the anthrax contamination Wallingford, CT 

facility, but a number of conclusions are not fully supported by the 

facts.



The claim by the Postal Service that the results had not been validated 

is not supported by the facts. The Manager of the Command center 

reported the results and the Postal Services own guideline required the 

reporting of validated results. (2-4.2.1 Noting Key Agencies and U.S. 

Postal Service Officials. Results from anthrax sampling and analysis 

are not released to the affected facility or the public until the 

confirmed data is received from the CDC and/or State Public Health 

Laboratories. All confirmed data must be validated before it. is sent 

directly to the Managers, Safety Performance Management and 

Environmental Management Policy, at U.S. Postal Service Headquarters. 

In turn these managers will notes the U.S. Postal Service Headquarters 

Unified Incident Command Center managing all anthrax sampling, 

analysis, and decontamination work. The Headquarters Unified Incident 

Command Center Manager (or his/her designee) will release validated 

data simultaneously via FAX and phone to the following agencies, union 

representatives, management representatives, and the contractors

representatives] The conclusions must be that the results were 

considered validated when reported by the Manager of the Command 

Center. Further, the decision not to report the quantitative results 

even after a formal request by the local union president was made in 

spite of OSHA regulation requiring the employer to provide exposure 

data to employees and employee representatives. The Postal Services 

requirements are that the facility manager notifies employees and 

unions of the results. In essence the GAO concludes that it is 

understandable and even acceptable that the Postal Services, given the 

circumstances, failed to follow the law (OSHA Standards) providing 

essential worker protection.



The report concludes that the Postal Service followed its guidelines 

with one exception without noting that the exception involved those 

samples showing significant concentrations of anthrax spores. This 

exception placed the employees of the facility at considerable risk. It 

is very disturbing that the report draws the conclusion that under the 

circumstances it is understandable that the Postal Service did not 

report the quantitative results for nine months. We are unaware of any 

circumstances under which it is understandable to ignore statuary 

worker protection standards. The OSHA regulation 29 CFR 1910.1020 is 

clear in stating that exposure data must be provided to employees and 

employee representatives. It does not imply nor state that the employer 

may withhold exposure data if they so choose. If there were any 

question as to the accuracy or validity of the results it should have 

been explained not withheld.



The report states that the Postal Service followed the advice of the 

Chief Epidemiologist. This fact demonstrates that the Postal Service 

received validated information from an acceptable source, a local 

health department, to the postal guidance document. Further, the 

responsibility for worker protection in the workplace falls to OSHA, 

not CDC nor Local Health departments. Although advice was provided by a 

Local Health Department, it was nothing more than advice, and did not 

in any way relieve the Postal Service from compliance with workplace 

standards.



GAO has recommended that additional effort be made to better coordinate 

communication between Federal agencies when events occur.	We agree, but 

strongly believe that the Union must be an intrigual part of this 

process. Unions represent the worker and workers better understand the 

work process as it is performed if they and their representatives are 

informed.



As a statement of findings, the report concludes that none of the 

employees at the facility became sick from anthrax contamination. This 

statement without explanation is misleading. Employees were being 

treated with antibiotics since early in the process and this treatment 

was most likely a significant contributing factor in the lack of 

reported illness.



In closing, we thank you for your efforts in gathering the facts and 

reporting findings. We question the conclusions and most particular 

that GAO could find that under any circumstances it would be acceptable 

to withhold exposure information from the workers. In this time of 

heightened alert, the employer must provide adequate and timely 

information that the employee is afforded adequate protection from 

harm. It is never understandable that an employer can deny or inhibit 

this opportunity for self protection.



Sincerely,



William Burrus

President



WB:hfa:



opeiu #2/afl-cio::



[End of section]



FOOTNOTES



[1] Technically, the term anthrax refers to the disease caused by 

Bacillus anthracis and not the bacterium or its spores. In this report, 

we use the term anthrax for ease of reading and to reflect 

terminology commonly used in the media and by the general public. 



[2] The elevated areas of the facility--known as the high bay--

include pipes, ducts, lights, joists, beams, and overhead conveyors. 



[3] The term colony-forming units refers to the number of living 

cells in a sample and is typically reported per gram of material 

sampled for High Efficiency Particulate Air vacuum samples and per 

square inch for samples collected using wipes.



[4] Herbivores are animals that eat plants.



[5] Cutaneous means of, relating to, or affecting the skin. Cutaneous 

anthrax is characterized by lesions on the skin.





[6] The last cases of anthrax from this release occurred 43 days after 

the individuals exposure.



[7] According to CDC, the estimate of 8,000 to 10,000 spores is from a 

Department of Defense, Defense Intelligence Agency publication entitled 

Soviet Biological Warfare Threat, DST-161OF-057-86 (Washington, D.C.: 

1986).



[8] In commenting on our draft report, EPA noted that anthrax spores 

also were not found in the home or workplace of a female hospital 

worker who died from inhalation anthrax in October 2001 in New York 

City.



[9] Two other contaminated letters were sent to a television news 

anchor and the editor of The New York Post in New York City on or 

around September 18, 2001. Although the letters were processed through 

the Hamilton/Trenton facility, it is not known whether the letters 

contaminated the Wallingford facility.



[10] Epidemiology is a branch of medical science that investigates the 

incidence, distribution, and control of disease in a population.



[11] Swabs can be either wet or dry and have small surface areas 

(similar to Q-tips). Swabs are typically used to sample small, 

nonporous surface areas (less than 100 sq. cm) that do not have a large 

accumulation of dust. Depending upon the circumstances, wet swabs may 

attract more particles of sample material than dry swabs. 



[12] Wet wipes are sterile gauze pads, approximately 3 inches square. 

Wet wipes are typically used for sampling larger (more than 100 sq. 

cm), nonporous surface areas.



[13] This machine was suspected of being positive for anthrax on 

December 2, but that suspicion was not confirmed until later.



[14] The sample collected 0.55 grams of material (dust) from the 

heavily contaminated machine. The laboratory adjusted its analyses to 

reflect a full gram of sample and reported the presence of 5.5 million 

colony-forming units per gram of material sampled. The Chief 

Epidemiologist subsequently determined, through extrapolation, that 

the 0.55 grams of material sampled contained approximately 2.9 million 

colony-forming units of anthrax. According to the Chief Epidemiologist, 

this finding was equivalent to about 3 million spores. In this report, 

we refer to the 2.9 million colony-forming units for the 0.55 grams of 

material actually sampled.



[15] The number of colony-forming units was not provided for any of the 

other positive samples. The other samples were collected using wet 

wipes, which, according to the Chief Epidemiologist, did not allow for 

measuring the amount of dust collected. 



[16] According to the contractors report on the decontamination, the 

mail-sorting machines were enclosed in 6-mil polyethylene sheeting 

supported by wood frames. Further, according to the report, air 

filtration devices, with exhausts to the outside, were installed to 

maintain negative air pressure inside each of the four enclosures. 



[17] Specifically, the test results indicated (1) 1 colony from 7.50 

grams of material sampled, (2) 10 colonies and 11 colonies from 7.69 

grams of material sampled, and (3) 13 colonies and 18 colonies from 

5.67 grams of material sampled. 



[18] During the period of decontamination, many of the facilitys mail 

processing operations were transferred to other postal facilities. 



[19] As previously discussed, a fourth machine also tested positive for 

anthrax on the basis of samples collected on November 28, 2001. 

However, the positive results were not confirmed until after December 

2, 2001.



[20] Although individuals have contracted inhalation anthrax 43 days 

after their exposure to the disease, according to the Chief 

Epidemiologist and CDC literature, individuals exposed in the 2001 

anthrax incidents typically contracted inhalation anthrax within 4 to 6 

days. In the view of public health officials, the letters to Senators 

Daschle and Leahy entered the mail stream on or about October 9, 2001-

-weeks before contamination was identified at the facility and, thus, 

well after the period they viewed as the likely period of maximum risk 

of exposure to the disease. 



[21] The Postal Service also issued a statement to the news media on 

December 2, 2001. Referring to the November 28 sampling, the press 

release stated that trace amounts of anthrax had been identified on 

three mail-sorting machines in the facility. The press release quoted 

the Connecticut Commissioner of Public Health as saying that, This is 

a very small amount of anthrax. The press release further indicated 

that, according to public health officials, the contamination posed no 

health risk to postal employees or their customers, in part because 

the machines had already been isolated and were to be decontaminated. 



[22] In commenting on our draft report, postal headquarters officials 

also indicated that, on December 12, 2001, the District Manager and the 

Inspector in Charge for the Northeast Area met with the Chief 

Epidemiologist, the Commissioner of the Connecticut Department of 

Public Health, and the Connecticut Governor and his staff. 



[23] The President of the Greater Connecticut Area Local American 

Postal Workers Union indicated that there is no record or evidence 

indicating that the union leadership or workers were ever advised about 

the change in the level of contamination from trace amounts to a 

concentration of spores on one of the mail-sorting machines. 



[24] According to the Chief Epidemiologist and district postal 

managers, the Chief Epidemiologist also informed workers about the 

December 2001 quantified results, including the finding of about 3 

million spores on one mail-sorting machine. 



[25] The Postal Service also issued a press release communicating 

similar information. 



[26] U.S. Postal Service, Interim Guidelines for Sampling, Analysis, 

Decontamination, and Disposal of Anthrax for U.S. Postal Service 

Facilities (Dec. 4, 2001). The guidelines were developed as the anthrax 

crisis unfolded with input and guidance from several federal agencies, 

including CDC and OSHA, and the national unions that represent postal 

workers. 



[27] The Postal Services guidelines do not define the meaning of the 

terms confirmed and validated.



[28] Although the Postal Service began relaying information about the 

concentration of spores on one machine on December 12, we were unable 

to determine whether the Postal Service also relayed the specific 

results of samples collected on December 2. As discussed in appendix 

II, the Postal Service received these results on or around December 9. 

The results identified unspecified amounts of contamination (i.e., 

positives) on (1) 30 of 52 samples collected from the heavily 

contaminated machine, (2) 3 of 52 samples from a second machine, and 

(3) 1 of 48 samples from each of the two other mail-sorting machines.



[29] As previously discussed, in March 2003, postal headquarters 

managers told us that there were errors in this chronology that they 

believe were not corrected and that they do not recall precisely when 

they received the documented results. Absent definitive documentation 

of when Postal Service headquarters received the test results and 

documentation of the discussions between public health and postal 

managers, we were unable to determine when Postal Service headquarters 

managers first learned of the quantitative test results.



[30] In its technical comments on our draft report, CDC noted that the 

HEPA vacuum sample, which identified 2.9 million colony-forming units 

of anthrax, had been taken on the feeder mechanism of a mail-sorting 

machine. While the precise surface area of the feeder mechanism would 

be difficult to measure, CDC noted that the mechanism is an important 

part of the mails pathway through the machine. Thus, even though there 

are limitations in the ability to measure such areas, CDC pointed out 

that there is value in sampling these types of complex mail processing 

surfaces. 



[31] For additional information about the rationale for the sampling 

methods used at Wallingford as well as information about related 

validation issues, see CDC, Environmental Sampling for Spores of 

Bacillus anthracis. Emerging Infectious Diseases. Vol 8. No. 10. 

(October 2002).



[32] Unlike its actions in December 2001, the Postal Service 

immediately provided all of the test results, including the quantified 

results of from 1 to 18 colony-forming units, to employees at the 

facility in April 2002. Full and immediate disclosure of the April 2002 

test results had been recommended by an OSHA official to avoid 

miscommunication, confusion, and workers concern about how the data 

may have been interpreted. The decision to release the results also 

appears consistent with the Postal Services guidelines because, 

according to the Postal Service, the sampling and analyses were 

performed by a Service contractor in accordance with the Services 

procedures and protocols for sampling. According to the Manager of the 

Command Center, this allowed the Postal Service to validate the 

results. 



[33] In addition to its participation on the investigation team at 

Wallingford, the FBI also was conducting a separate criminal 

investigation related to the facilitys contamination. The U.S. Postal 

Inspectors, the U.S. Attorneys Office, the Connecticut Department of 

Public Health, and CDC were also members of the criminal investigation 

team. 



[34] Since the amount of surface area collected for the sample 

containing about 3 million spores was not recorded, investigators could 

not determine whether the spores had been spread over the sample area 

or clumped together in one spot. Also, according to a team member, it 

was not clear how to extrapolate the result from the surface sample 

into its potential for existing in the air. (Additional information on 

the interpretation of surface sampling results is contained in CDCs 

MMWR Weekly, December 21, 2001, and in its fact sheet entitled 

Comprehensive Procedures for Collecting Environmental Samples for 

Culturing Bacillus anthracis (revised April 2002).



[35] Within the context of the regulation, records include exposure 

and medical records. More specifically, records include environmental 

workplace monitoring or measuring of a toxic substance or harmful 

physical agent, including personal, area, grab, wipe, or other form of 

sampling, as well as related collection and analytical methodologies, 

calculations, and other background data relevant to interpretation of 

the results obtained.



[36] 29 C.F.R.  1910.1020 (e)(1)(i).



[37] OSHA may cite the following violations with or without a fine: 

Other than Serious, Serious, Repeated, Failure to Abate, and 

Willful. 



[38] The union leader also requested test results from the post office 

in Seymour, Connecticut--the post office that delivered mail to the 

deceased womans home.



[39] A March 26, 2002, article in The New York Times discussed a 

presentation by the Chief Epidemiologist about contamination at the 

facility, including the finding of about 3 million spores from a 

sample collected in November 2001. The Chief Epidemiologist told us 

that he presented this information at an international conference on 

emerging infectious diseases because he wanted to emphasize the 

importance of maintaining the Postal Services restriction on the use 

of compressed air to clean its facilities to ensure that any residual 

spores at Wallingford and other postal facilities are not blown 

elsewhere in the facilities.



[40] The Commissioner told us that he was not aware that his department 

had not provided the requested test results. We did not evaluate state 

laws related to the release of epidemiological data because doing so 

was outside the scope of our work. 



[41] Sampling performed by CDC investigators and Postal Service 

contractors at the Brentwood facility in October 2001 identified from 

8,700 to 2 million colony-forming units per gram of material collected 

from high-speed mail-sorting machines and areas near the machines. CDC 

published the results in December 2001. See MMWR Weekly, December 21, 

2001/50(50); 1129-1133.



[42] According to CDC, it consulted with the FBI to determine whether 

the request was subject to 45 C.F.R.  568, which permits CDC to 

withhold information that would interfere with ongoing law enforcement 

proceedings. 



[43] According to a November 26, 2002, OSHA letter to the union leader, 

the Postal Service did not have a copy of the December 2001 quantified 

results until August 13, 2002. Our work showed that the Postal Service 

headquarters may have received documentation of the quantified test 

results on or about December 8, 2001, and that the district had the 

written results on December 10. Further, both of the offices maintained 

copies of the results throughout the period in question. Postal Service 

officials told us they did not know why OSHA was unaware that they had 

the results. Although OSHA provided us with documentation associated 

with its investigation, the source of misinformation about the Postal 

Services possession of the quantitative test results could not be 

discerned from the material provided. Furthermore, our discussions with 

postal and OSHA officials did not enable us to resolve this issue.



[44] According to the Postal Service, district postal managers--through 

the U.S. Postal Inspection Service--contacted the FBI before releasing 

the December 2001 quantified test results in September 2002. According 

to the Postal Service, the FBI told a member of the Inspection Service 

that the quantified data could be released since the information 

already had been discussed at a CDC conference and reported in the 

newspapers.



[45] GSA is responsible for providing workspace and security for many 

federal agencies. The agency also offers guidance and policies for 

various government functions, including mail management. These 

guidelines are entitled GSA Policy Advisory: Guidelines for Federal 

Mail Centers in the Washington, DC Metropolitan Area for Managing 

Possible Anthrax Contamination.



[46] GSA emphasized that the guidelines developed by the National 

Response Team should be the primary source of advice for anyone 

managing a credible threat situation. GSA explained that its guidelines 

deal primarily with actions that managers of federal mail centers in 

the Washington, D.C., area should take to prepare for possible anthrax 

threats and to determine whether an anthrax threat is credible. As a 

result, once a credible threat has been identified, responsibility for 

managing the situation passes from the manager of the mail center to 

law enforcement, public health, and other authorities. 



[47] GSA and EPA--as the Chair for the National Response Team--

explained that, by design, their guidelines were not intended to 

prescribe specific actions because knowledge about how to respond to 

anthrax is evolving rapidly, and each situation is unique. Instead, the 

agencies indicated that their guidelines provide background information 

and viable options for individuals who, in the case of GSAs 

guidelines, operate and manage federal mail centers or, in the case of 

guidelines developed by the National Response Team, respond to anthrax 

attacks.



[48] We consulted with numerous experts in the field of microbiology, 

including Dr. Jack Melling, former Director and Chief Executive Officer 

of the British Center for Applied Microbiology Research; Dr. Paul Keim, 

Professor in Microbiology, Northern Arizona University; Col. Eric 

Henchal, Department of the Army; and Dr. Barbara Johnson, former Safety 

Officer at the Dugway Proving Grounds, Department of the Army. 



[49] The National Response Teams September 2002 draft guidelines agree 

that methods have not been validated for a variety of sampling 

techniques. Accordingly, the guidelines recommend that agencies use a 

multi-disciplinary team to help them interpret anthrax test results. 

Relating to this, according to CDC, it is important to scrutinize new 

sampling techniques, such as the HEPA vacuum, to understand the 

strengths and limitations of the methods so that the methods can be 

subsequently validated. 



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