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 
The Wallingford facility first tested positive for anthrax in early December 

2001. The contamination was found in samples collected from four mailsorting machines in November. Analyses of the samples produced quantified 

results, including about 3 million anthrax colonies, or living anthrax cells, in 

one of the samples. While this was far more than the amount needed to 

cause death, none of the employees at the facility became sick from the 

anthrax contamination. 

The Postal Service’s decision not to inform workers about the number of 

anthrax colonies identified in December 2001 appears consistent with its 

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

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

an employee union requested all the facility’s test results in January and 

February 2002, was not consistent with OSHA’s requirement for disclosing 

test results that are requested. An OSHA investigation resulted in the 

Service’s release of the quantitative test results in September 2002—about 9 

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

regulatory citation, it expressed concern about communication deficiencies. 

In retrospect, the Service’s decision not to release the quantitative test 

results in December 2001 was understandable given the challenging 

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

health officials, an ongoing criminal investigation, and uncertainties about 

the sampling methods used. However, numerous lessons can be learned 

from the experience, such as the need for more complete and timely 

information to workers to maintain trust and credibility and to help ensure 

that workers have essential information for making informed health 

decisions. Federal guidelines developed in 2002 by GSA and the National 

Response Team suggest that more—rather than less—information should be 

disclosed. However, neither the Service’s guidelines nor the more recent 

federal guidelines fully address the communication-related issues that 

developed in Wallingford. For example, none of the guidelines specifically 

require the full disclosure of quantified test results. Likewise, OSHA’s 

regulations do not require employers to disclose test results to workers 

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

and know about this requirement. 

Decontamination Efforts at the Wallingford, Connecticut, Facility 

 

Source: U.S. Postal Service.

U.S. POSTAL SERVICE 

Better Guidance Is Needed to Improve 

Communication Should Anthrax 

Contamination Occur in the Future 

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. 

Highlights of GAO-03-316, a report to the 

Ranking Minority Member, Committee on 

Governmental Affairs, U.S. Senate 

April 2003 

In 2001, letters contaminated with 

anthrax resulted in 23 cases of the 

disease, 5 deaths, and the 

contamination of numerous U.S. 

Postal Service facilities, including 

the Southern Connecticut Processing 

and Distribution Center in 

Wallingford, Connecticut (the 

Wallingford facility). GAO was asked 

to address, among other matters, 

whether (1) the Postal Service 

followed applicable guidelines and 

requirements for informing 

employees at the facility about the 

contamination and (2) lessons can be 

learned from the response to the 

facility’s contamination. 

To help prevent a reoccurrence of 

communication problems, GAO 

recommends that the Postal Service, 

OSHA, GSA, and the National 

Response Team—a group chaired by 

the Administrator of EPA and 

comprising 16 federal agencies with 

responsibilities for planning, 

preparing, and responding to 

activities related to the release of 

hazardous substances—work 

together to revise their existing 

guidelines or regulations to, among 

other things, require prompt 

communication of available test 

results, including quantitative 

results, to workers and others, as 

applicable. The Service, EPA, and 

GSA generally agreed with our 

recommendations, indicating that 

they would work together to revise 

their guidelines. OSHA did not 

comment on our recommendations. 
Page i GAO-03-316 U.S. Postal Service 

Letter 1

Results in Brief 3

Background 6

Anthrax Contamination Was First Identified at Wallingford in 

December 2001 after an Extensive Multiagency Investigation 10

Quantitative Test Results Were Provided to Workers in April 

2002—but Not in December 2001 14

Disclosure of Anthrax Test Results 19

Lessons Learned at the Wallingford Facility Suggest the Need for 

More Complete and Timely Information to Workers 29

Conclusions 34

Recommendations for Executive Action 35

Agency Comments and Our Evaluation 36

Appendix I Objectives, Scope, and Methodology 45 

Appendix II Summary of Anthrax Testing at the Wallingford 

Facility between November 2001 and April 2002 48 

Appendix III Comments from the Environmental Protection 

Agency 51 

Appendix IV Comments from the U.S. Postal Service 53 

Appendix V Comments from the American Postal Workers 

Union 55 

Table 

Table 1: Summary of Sampling for Anthrax Contamination between 

November 2001 and April 2002 and the Associated Test 

Results 10

Contents 
Page ii GAO-03-316 U.S. Postal Service 

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 

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Page 1 GAO-03-316 U.S. Postal Service 

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.1

 The 

contaminated letters caused 23 illnesses and resulted in 5 deaths from 

inhalation anthrax and the contamination of numerous postal facilities. 

The U.S. Postal Service initially responded to this crisis by collecting and 

testing samples from over 280 of its facilities, including the Southern 

Connecticut Processing and Distribution Center in Wallingford, 

Connecticut (the Wallingford facility). The facility was first tested on 

November 11, 2001, and no contamination was found. 

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

people who died—spurred an extensive investigation by a multiagency 

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

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

that had been contaminated as it passed through the Wallingford facility, 

federal and state investigators conducted more extensive testing of the 

facility. Facility workers received antibiotics on November 21, 2001—the 

day that the elderly woman died. The antibiotics were provided as a 

precautionary measure, since the Postal Service’s earlier testing of the 

facility had not identified any contamination. At about the same time, the 

Postal Service also initiated a medical surveillance program to monitor the 

health of the facility’s employees. The investigative team sampled the 

facility on numerous occasions between November and December 2001 

and, in early December, identified anthrax on four mail-sorting machines. 

Anthrax also was identified in areas above the mail-sorting machines in 

 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. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-03-316 U.S. Postal Service 

April 2002.2 On both occasions, the affected areas were decontaminated, 

while mail processing continued in other areas of the facility. 

Perhaps because the facility’s workers had been provided with antibiotics, 

none of the employees at the Wallingford facility became sick from 

anthrax. However, you requested that we review the Postal Service’s 

disclosure of anthrax test results to the facility’s workers. As agreed, in 

this report, we address (1) how and when contamination was identified at 

the Wallingford facility, (2) what and when information was 

communicated to facility workers, (3) whether the Postal Service followed 

applicable guidelines and requirements for informing facility workers 

about the contamination, and (4) whether lessons can be learned from the 

response to contamination at the facility. As agreed, our future work will 

compare the treatment of postal workers at the Wallingford facility with 

the treatment of employees at other postal facilities contaminated with 

anthrax in the fall of 2001. 

To address our reporting objectives, we interviewed federal and state 

officials involved in investigating and responding to anthrax 

contamination at the Wallingford facility, including officials from the 

Postal Service’s headquarters office, its Connecticut district, and the 

Wallingford facility; the Connecticut Department of Public Health; and 

numerous federal agencies. We also interviewed representatives of 

employees at the facility, including the national American Postal Workers 

Union and its Greater Connecticut Area Local Union. We discussed, 

among other matters, the officials’ roles and involvement in responding to 

the crisis and lessons that can be learned from the response. We obtained 

and reviewed documentation related to the sampling and testing of the 

facility, including laboratory test results; information about when and how 

test results and associated health risks were communicated to facility 

workers; the Postal Service’s guidelines for releasing and communicating 

test results; the Occupational Safety and Health Administration’s (OSHA) 

regulatory requirements for disclosing test results to workers; more recent 

federal guidelines developed in 2002 by the General Services 

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

by the Administrator of the Environmental Protection Agency (EPA) and 

comprising 16 federal agencies with responsibility for planning, preparing, 

and responding to activities related to the release of hazardous substance; 

 2

The elevated areas of the facility—known as the “high bay”—include pipes, ducts, lights, 

joists, beams, and overhead conveyors. 
Page 3 GAO-03-316 U.S. Postal Service 

and other documents related to the facility’s contamination. Additional 

information on our scope and methodology appears in appendix I. 

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 colonyforming units of anthrax in a sample collected from one of the mail-sorting 

machines.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 mailsorting 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 colonyforming units) of anthrax spores, the Chief Epidemiologist—who helped 

lead the investigation—told district postal managers that it would be 

accurate to use the term “trace” to describe the extent of contamination. 

On December 2, postal managers also relayed the Chief Epidemiologist’s 

health-related recommendations to the facility’s employees. For example, 

although the Chief Epidemiologist viewed the health risk as “minimal,” 

workers were advised, as a precautionary measure, to continue taking the 

antibiotics they received on November 21, 2001—the day that the 

Connecticut woman died from inhalation anthrax. On December 12, 

 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. 

Results in Brief 
Page 4 GAO-03-316 U.S. Postal Service 

2001—2 days after district postal managers said they received written 

confirmation of the presence of about 3 million spores in a sample 

collected on November 28 and, possibly, 4 days after headquarters postal 

managers received the results—postal managers once again relayed the 

Chief Epidemiologist’s views and health-related recommendations to 

employees at the facility. Specifically, district postal managers told us that 

they informed workers that, while trace amounts of anthrax existed on 

three mail-sorting machines, a “concentration” of spores had been 

identified in a sample collected from a fourth machine. Although the 

extent of contamination was much greater than initially believed, 

following the assurances of the Chief Epidemiologist, postal managers said 

they informed workers that there was “no additional risk” to employees 

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

April 2002, the Postal Service provided employees with the actual 

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

collected in April from areas above the previously contaminated mailsorting machines. 

Although the Postal Service’s communication of anthrax test results 

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

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

found in the positive samples)—after being requested to do so by an 

employee union—did not satisfy OSHA’s disclosure requirements. The 

Postal Service generally provided the facility’s test results to workers 

within 1 day of receiving the test results. Such timely disclosure is 

consistent with the Postal Service’s guidelines to notify workers “as soon 

as possible.” However, for a period of 2 days, district managers delayed 

informing the facility’s workers about the documented test results that the 

district postal managers received on December 10, 2001. According to the 

Postal Service, the additional time was needed to obtain advice from 

public health officials about the meaning of the results, particularly the 

result indicating the presence of about 3 million spores in a sample 

collected from one mail-sorting machine. According to Postal Service 

managers, the December 2001 decision not to release the quantitative 

results—even after being requested to do so by a union leader—was also 

consistent with the Postal Service’s guidelines because, according to the 

managers, the Postal Service could not ensure that the sampling had been 

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

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

Postal Service’s decision not to release the December 2001 quantitative 

test results after a union leader requested all of the facility’s test results on 

January 29, 2002, and February 6, 2002, was not consistent with OSHA’s 

regulations for disclosing test results that are requested by workers or 
Page 5 GAO-03-316 U.S. Postal Service 

their designated representatives. OSHA’s regulations require employers to 

disclose test results within 15 working days of the request or explain the 

delay and provide the requester with a time frame for releasing the results. 

OSHA’s subsequent investigation into this matter resulted in the Postal 

Service’s release of the December 2001 quantitative test results in 

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

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

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

disclosing the quantitative test results earlier; however, in an October 7, 

2002, letter to the Postal Service, OSHA noted that a “failure to effectively 

communicate issues which can have an effect on a worker’s health and 

safety, can lead to fear and mistrust.” 

While the Postal Service’s decision not to release the quantitative test 

results in December 2001 is understandable given all of the circumstances 

that existed at the time, the lessons learned from this experience suggest 

the need for more complete and timely information to workers to maintain 

trust and credibility. Officials from OSHA and members of the 

investigative team did not specifically fault the Postal Service for not 

releasing the quantified results when they were first known in December 

2001. However, they said full and timely disclosure of test results is the 

best method for communicating with employees and others. Two federal 

guidelines developed in 2002 by GSA and the National Response Team 

suggest that more—rather than less—information should be disclosed. For 

example, GSA’s guidelines emphasize the need for “timely, clear, 

consistent, and factual” information, including any limitations associated 

with the information, so that people can make informed decisions. The 

other set of guidelines, developed by the National Response Team, warns 

agencies not to withhold information because it could affect the agency’s 

credibility. However, neither the Postal Service’s guidance nor the more 

recent federal guidelines fully address the anthrax communication-related 

issues that developed at the Wallingford facility. For example, none of the 

guidelines specifically require the full disclosure of all test results, 

including quantitative test results. Likewise, OSHA’s regulations for 

communicating test results to workers do not address the need for full, 

immediate, and proactive disclosure. We are making several 

recommendations to minimize the likelihood that the communicationrelated 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 
Page 6 GAO-03-316 U.S. Postal Service 

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

not adequately reflect the union’s perspective of the facts and that a 

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

We believe that our conclusions are fully supported by the evidence 

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

balanced depiction of the facts as best we could determine them. 

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.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; 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 

 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. 

Background 
Page 7 GAO-03-316 U.S. Postal Service 

person’s body and in the environment. Laboratories report anthrax test 

results either qualitatively (e.g., as “positive” or “negative”) or 

quantitatively (e.g., as a specific number of colony-forming units per gram 

or square inch of material sampled or in milligrams per microliter). 

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

States had been linked mainly to occupational exposure. However, 

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

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

Sverdlovsk in the Former Soviet Union. The release of anthrax, which had 

been prepared in a powder form, reportedly caused the death of 66 people 

and demonstrated the lethal potential of aerosolized anthrax as a weapon.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.7

 However, given that 

anthrax spores were never discovered in the Connecticut woman’s home 

or places that she frequented,8

 experts we consulted now believe that the 

number of spores needed to cause inhalation anthrax could be very small, 

depending on a person’s health status and the aerosolization capacity of 

the anthrax spores. 

The Postal Service’s infrastructure includes, in part, its headquarters office 

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

approximately 350 mail processing and distribution centers, including the 

Wallingford facility; and about 38,000 post offices, stations, and branches. 

The area offices are further divided into 85 postal districts throughout the 

United States, including the Connecticut district in Hartford, which 

oversees operations at the Wallingford facility. The Wallingford facility is 

 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, DST161OF-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. 
Page 8 GAO-03-316 U.S. Postal Service 

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.9

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

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

day and operates 24 hours a day with employees who work one of three 8-

hour shifts. Two unions—the Greater Connecticut Area Local American 

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

Union in Boston, Massachusetts—represent workers at the facility. 

In October 2001, the Postal Service established a Unified Incident 

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

other things, manage the Postal Service’s response to anthrax 

contamination in its facilities. The Command Center was staffed by Postal 

Service employees and supported by several agencies, including EPA; 

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

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

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

government agencies with responsibilities for law enforcement (the 

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

Connecticut Department of Environmental Protection); public health (the 

Connecticut Department of Public Health, local health departments, and 

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

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

and subsequently died from inhalation anthrax. The Chief Epidemiologist 

 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. 
Page 9 GAO-03-316 U.S. Postal Service 

for the Connecticut Department of Public Health (Chief Epidemiologist),10

an on-site CDC team leader, and a CDC team leader in Atlanta, jointly led 

the on-site investigation team. The team communicated with one another 

largely through twice-daily confidential telephone conference calls during 

which information was shared, possible actions were discussed, and 

decisions were made. Once contamination was identified in the 

Wallingford facility, a facility-specific response team was formed 

consisting of the National Institute for Occupational Safety and Health, the 

Agency for Toxic Substances and Disease Registry, and CDC—all within 

the Department of Health and Human Services (HHS); the Corps of 

Engineers; the Postal Service; EPA; and the Connecticut Department of 

Public Health. The team was led by the Postal Service’s Command Center. 

OSHA—an agency within the Department of Labor that enforces safety 

and health standards in the workplace—was not part of the response 

team. 

The Postal Service requested and the investigative team agreed that the 

Postal Service would be the sole party responsible for communicating test 

results and other information to the workers at the facility. In this regard, 

the physician under contract with the Postal Service informed the facility’s 

workers that, according to her research, inhalation of 8,000 to 10,000 

spores would likely be needed to cause inhalation anthrax. 

 10Epidemiology is a branch of medical science that investigates the incidence, distribution, 

and control of disease in a population. 
Page 10 GAO-03-316 U.S. Postal Service 

The Wallingford facility was tested on numerous occasions between 

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

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

the Postal Service’s effort to identify facilities that may have been 

contaminated with anthrax. The contractor collected 53 samples using dry 

swabs.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: Summary of Sampling for Anthrax Contamination between November 2001 

and April 2002 and the Associated Test Results 

Sampling date Type (Number of samples) Result 

Agency that collected 

the samplesa

11/11/01 Dry swabs (53) Negative Postal Service 

11/21/01 Dry swabs (64) Negative Postal Service 

11/25/01 Wet swabs (60) Negative CDC 

11/28/01 

Wet wipes and HEPA 

vacuums (212) Positive CDC 

12/02/01 Wet wipes (200) Positive CDC 

4/21/02 HEPA vacuums (101) Positive 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. 

Following confirmation on November 20, 2001, that the elderly 

Connecticut woman had contracted inhalation anthrax, the multiagency 

 11Swabs 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. 

Anthrax 

Contamination Was 

First Identified at 

Wallingford in 

December 2001 after 

an Extensive 

Multiagency 

Investigation 
Page 11 GAO-03-316 U.S. Postal Service 

state and federal investigative team targeted mail as one possible source of 

her exposure. Having found no contamination at the Wallingford facility or 

at the woman’s home and other places she frequented in the 2 months 

preceding her death, CDC and the Agency for Toxic Substances and 

Disease Registry resampled the facility on November 25, 2001, using wet 

swabs—not dry swabs. These 60 samples also tested negative. The 

laboratory informed the Chief Epidemiologist of the results, and he, in 

turn, called district postal managers to relay the results. 

Determined to ascertain the role that mail may have played in the woman’s 

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

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

Service, performed what officials termed a “targeted” and “extensive” 

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

which were from machines that could have been used to process mail to 

the deceased woman’s home. The team also used different collection 

methods than had been used earlier—that is, the team collected samples 

using two methods: wet wipes and HEPA vacuums rather than dry swabs 

or wet swabs alone.12 The use of these sampling methods resulted in the 

identification of anthrax on 4 of the facility’s 13 mail-sorting machines. 

The Chief Epidemiologist first knew the results of the November 28, 2001, 

sampling effort on December 2, when samples collected from three of the 

mail-sorting machines tested “positive” for anthrax. Shortly thereafter, a 

fourth machine—which also had been sampled on November 28, 2001—

also tested positive for anthrax.13 The laboratory analyzed the November 

28, 2001, samples and provided two quantified results. The results 

indicated that although all four of the machines were contaminated, one of 

the machines was heavily contaminated. Specifically, on the basis of the 

laboratory’s quantified results, the Chief Epidemiologist identified 2.9 

million colony-forming units of anthrax—about 3 million spores—in a 

sample of 0.55 grams of material (dust) collected from the heavily 

 12Wet 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. 

13This machine was suspected of being positive for anthrax on December 2, but that 

suspicion was not confirmed until later. 
Page 12 GAO-03-316 U.S. Postal Service 

contaminated machine.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.15

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

Chief Epidemiologist on December 6. After subsequent discussions with 

the laboratory concerning the results as well as related discussions over 

the next few days with members of the investigative and response teams, 

the Chief Epidemiologist faxed the results on December 9 to the Postal 

Service’s district Human Resource Manager, who, according to the 

manager, received them on December 10. Precisely when Postal Service 

headquarters and district managers first became aware of the quantified 

test results is unclear. According to CDC officials and the Chief 

Epidemiologist, they began discussing the quantitative results with team 

members, which they believe included a district postal manager, on 

December 6, 2001. However, district postal managers said that they were 

not involved in discussions about the quantitative results until December 

9. District postal managers confirmed that the Chief Epidemiologist faxed 

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

district postal managers received the fax on December 10. However, a 

chronology of the events prepared in January 2002 by Postal Service 

employees and shared with CDC indicates that postal managers at 

headquarters may have received the documented results on or about 

December 8, 2001. We discussed the chronology with postal headquarters 

managers in March 2003 and they told us that, according to their 

recollections, there were errors in the chronology that were not corrected. 

They also said that they do not otherwise recall precisely when they 

received the documented quantitative results. Absent definitive 

documentation of when Postal Service headquarters received the test 

results and documentation of the discussions between public health and 

 14The 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. 

15The 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. 
Page 13 GAO-03-316 U.S. Postal Service 

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.16 

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

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

areas above the previously contaminated machines using HEPA vacuums. 

The sampling was performed because of a Postal Service requirement for 

testing prior to the routine cleaning of elevated areas in facilities that had 

previously tested positive for anthrax. The effort was undertaken to 

protect workers from the possibility of exposure to spores that may have 

blown into these areas as a result of the Postal Service’s prior use of 

compressed air to clean its facilities. The laboratory relayed the results 

 16According to the contractor’s report on the decontamination, the mail-sorting machines 

were enclosed in “6-mil polyethylene sheeting” supported by wood frames. Further, 

according to the report, air filtration devices, with exhausts to the outside, were installed to 

maintain negative air pressure inside each of the four enclosures. 
Page 14 GAO-03-316 U.S. Postal Service 

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.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.18

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

“negative”) results from samples collected between November 2001 and 

April 2002 to employees on each of the facility’s three work shifts. The 

specific content of the information disclosed varied. The Postal Service 

began communicating the results of the first samples—which were 

collected on November 11, 2001—on November 15, the day after the Postal 

Service received the negative results. The Facility Manager informed 

supervisors and union officials of the results, and the supervisors, in turn, 

informed employees at the facility. According to a district manager, the 

test results also were posted on designated bulletin boards at the facility. 

The Postal Service began relaying the results of the November 21, 2001, 

sampling effort, which were also negative, to employees in a briefing on 

November 23, the day that district postal managers were notified of the 

results. On November 27, the day that district managers received the 

results from the third sampling done on November 25, 2001, the Facility 

Manager once again began briefing employees about the negative results. 

According to district postal managers, they began informing employees 

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

they learned that the facility was contaminated. The positive results were 

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

to district postal managers in a telephone call from the Chief 

Epidemiologist. The Chief Epidemiologist met with district postal facility 

managers, union representatives, and a physician under contract with the 

Postal Service on December 2, 2001, to discuss the results. District postal 

 17Specifically, 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. 

18During the period of decontamination, many of the facility’s mail processing operations 

were transferred to other postal facilities. 

Quantitative Test 

Results Were 

Provided to Workers 

in April 2002—but Not 

in December 2001 
Page 15 GAO-03-316 U.S. Postal Service 

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 mailsorting machines.19 According to the Chief Epidemiologist, although the 

laboratory initially reported only a positive finding, his subsequent 

discussions with laboratory personnel indicated that the samples 

contained “one or two” colony-forming units of anthrax. Thus, he said, he 

used the term to denote a small amount of contamination. Also, he said, 

“trace” seemed appropriate given the number of sampling efforts 

undertaken before any contamination was found in the facility. 

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

pressed the Chief Epidemiologist about any possible risk to workers at the 

facility and were assured that for a variety of reasons, there was no 

additional health risk. First, as a precautionary measure, workers had been 

provided antibiotics on November 21, the day the Connecticut woman died 

from inhalation anthrax. Second, even if workers had not chosen to take 

the antibiotics, the results of the Postal Service’s medical surveillance 

program indicated that none of the facility’s workers had contracted the 

disease. Further, in the view of the Chief Epidemiologist and CDC 

officials, workers were not expected to contract the illness because the 

contamination was found weeks after what public health officials 

considered the likely incubation period for the disease.20 Third, the 

contaminated machines were being isolated and decontamination was 

scheduled to begin the next day. Fourth, there was no evidence that the 

anthrax was airborne because no spores had been found in the facility’s 

heating, ventilating, and air conditioning systems. Finally, related to this 

last issue, the Chief Epidemiologist told us that the likelihood of spores 

being blown within the facility (becoming airborne) had been greatly 

reduced by the Postal Service’s decision on October 23, 2001, to stop using 

compressed air to clean its facilities. Nevertheless, as a precautionary 

 19As 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. 

20Although 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. 
Page 16 GAO-03-316 U.S. Postal Service 

measure, the Chief Epidemiologist recommended that the Postal Service 

advise facility workers to continue taking antibiotics. 

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

meeting with the Chief Epidemiologist; the physician and postal managers, 

including the Facility Manager, began briefing employees on each of the 

facility’s three shifts. The managers relayed the Chief Epidemiologist’s 

views that there was no additional health risk associated with the test 

results. According to the managers, they also informed workers about 

planned actions to remediate the contamination.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 colonyforming units per 0.55 grams of sample material (dust) collected from one 

of the four contaminated mail-sorting machines. The Chief Epidemiologist 

told us that he discussed the results with laboratory personnel and, after 

these discussions, concluded that the results revealed the presence of 

“about 3 million spores.” According to district postal managers, the test 

results were discussed at length in teleconferences between them, the 

Chief Epidemiologist, and other members of the investigation team on 

December 9 and 10. District postal managers said that they were 

concerned about the test results and asked whether the facility’s 

employees were at risk. Although we were told that no documentation 

exists about the advice the Postal Service received at the time, according 

to district postal managers, the Chief Epidemiologist informed them that 

there was “no additional risk” to employees for the same reasons 

previously cited—the contaminated machines had already been isolated 

and were being decontaminated; the anthrax was not believed to be 

airborne; employees at the facility had already been offered antibiotics; 

and, in the view of public health officials, the incubation period for the 

 21The 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. 
Page 17 GAO-03-316 U.S. Postal Service 

disease had already passed without illness. Nevertheless, as a 

precautionary measure, the Chief Epidemiologist recommended that the 

Postal Service managers advise workers to continue taking their 

antibiotics. CDC concurred with the Chief Epidemiologist’s 

recommendation and assessment about the health risk. 

According to participants in the teleconferences, they also discussed how 

to communicate the quantitative test results to workers at the facility. As a 

result of these conversations, we were told, the participants agreed that 

using the term “trace”—after the finding of about 3 million spores in a 

sample from one of the four mail-sorting machines—was no longer 

appropriate in describing the extent of contamination at the facility. As a 

result, district managers asked the Chief Epidemiologist how the results 

could be communicated to employees and others. According to district 

postal managers, the Chief Epidemiologist advised them that it would be 

accurate to characterize the contamination as a “concentration of spores” 

on one mail-sorting machine and “trace” amounts on three others. The 

Chief Epidemiologist agreed that he used the terms “trace” and 

“concentration” to describe contamination at the facility. However, he 

subsequently informed us that he did not provide a single description of 

the extent of contamination in the facility but, instead, told postal 

managers that this was one way to discuss the extent of contamination to 

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

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

postal manager told us that he relayed information about the 

concentration of spores in the facility—one of the interpretations provided 

by the Chief Epidemiologist—to the Facility Manager, without any 

information about the actual quantitative results. The Chief Epidemiologist 

and district postal managers agree that they never discussed whether the 

Postal Service should disclose the quantified test results to employees. 

According to the Chief Epidemiologist, at the invitation of district postal 

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

12 to discuss the test results and to answer questions about his health 

recommendations.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 

 22In 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. 
Page 18 GAO-03-316 U.S. Postal Service 

officials we spoke to do not recall this meeting. However, district postal 

managers issued a press release on December 12 containing the 

terminology that the Chief Epidemiologist said he had used. Further, 

district postal managers told us that supervisors on each of the facility’s 

three work shifts began relaying the Chief Epidemiologist’s views and 

health-related recommendations directly to the facility’s employees on 

December 12. Union representatives told us that they did not recall any 

supervisory briefings on December 12.23 Although no documentation of 

these briefings is available, postal headquarters officials said that the 

December 12 press release would have been made widely available per the 

Service’s standard operating procedures and that a local Connecticut 

newspaper reported the information contained in the press release on 

December 13. 

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

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

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

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

that all of the follow-up samples had tested negative for contamination. On 

December 21, the Postal Service issued a press release stating that the four 

mail-sorting machines had been completely decontaminated and returned 

to service. 

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

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

facility’s elevated areas. An OSHA official involved in sampling the 

facility’s elevated areas—OSHA was not involved in December 2001—

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

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

samples, were provided to union representatives in a meeting on April 24, 

the same day that postal managers were notified of the results. Later that 

day, facility managers and the Chief Epidemiologist began briefing 

employees about the results, indicating that 3 of 101 samples collected 

from 71 locations were contaminated.24 According to the President of the 

 23The 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. 

24According 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. 
Page 19 GAO-03-316 U.S. Postal Service 

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.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. 

Consistent with its guidelines, the Postal Service generally provided the 

facility’s test results to workers within 1 day of receiving the results. The 

one exception to this practice involved the December 2001 quantitative 

test results. In this case, there was a delay of at least 2 days between the 

date that the Postal Service received documentation of the quantified test 

results and the date that it notified its workers about the “concentration of 

spores” on one mail-sorting machine. It is not clear precisely when in 

December 2001 the Postal Service first received the documented test 

results. While the Postal Service informed workers of the results in a 

qualitative manner, it did not disclose the actual quantitative results to 

workers until September 2002. The Postal Service’s decision not to release 

the quantitative test results in December 2001 appears to have been 

consistent with its guidelines because the sampling methods used could 

not be validated, as required. However, its decision not to release the 

December 2001 quantitative test results in response to two requests by a 

local union leader in January 2002 and February 2002 was not consistent 

with OSHA’s regulations for disclosing test results that are requested by 

workers or their designated representatives. OSHA’s subsequent 

 25The Postal Service also issued a press release communicating similar information. 

Disclosure of Anthrax 

Test Results 
Page 20 GAO-03-316 U.S. Postal Service 

investigation into this matter resulted in the Postal Service’s release of the 

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

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

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

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

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

noted that a “failure to effectively communicate issues which can have an 

effect on a worker’s health and safety, can lead to fear and mistrust.” 

Following the anthrax contamination of several postal facilities, the Postal 

Service, in consultation with public health and other organizations that 

were members of the Postal Service’s Command Center, issued—in 

December 2001—policies and procedures for, among other things, 

releasing and communicating anthrax test results.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.27 Once data are confirmed and 

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

to release the data to affected district and facility managers, the affected 

state health department(s), and the CDC liaison at the Command Center. 

According to the guidelines, when a Facility Manager receives the results, 

he or she is to ensure that employees, union representatives, and other 

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

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

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

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

the qualitative results. Such prompt disclosure is consistent with the 

Postal Service’s guidelines, which require facility managers to notify 

workers of sample results “as soon as possible” if the results are 

confirmed and validated. The one exception to this practice appears to 

 26U.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. 

27The Postal Service’s guidelines do not define the meaning of the terms “confirmed” and 

“validated.” 

The Postal Service’s 

Release of the December 

2001 Test Results Appears 

Consistent with Its 

Guidelines 
Page 21 GAO-03-316 U.S. Postal Service 

have occurred after the Postal Service received written confirmation of the 

results from the two quantified samples collected on November 28, 2001. 

According to district postal managers, they began relaying the results to 

facility workers on December 12, 2001—2 days after district postal 

managers said they first received written confirmation of the laboratory’s 

quantified results from the Chief Epidemiologist. District postal managers 

provided several reasons for their 2-day delay in notifying workers of the 

results.28 First, they said they needed time to consult with public health 

officials from Connecticut’s Department of Public Health and CDC about 

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

describe the results and associated health risks to employees at the 

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

obtain advice from Postal Service headquarters and to draft a press 

release. Although the district did not receive the quantitative results until 

December 10, as previously discussed, a chronology of events prepared in 

January 2002 by Postal Service employees and shared with CDC indicates 

that postal managers at headquarters may have received the documented 

results on or about December 8, 2001—4 days before workers were 

informed of the test results.29 The length of the delay in informing workers 

cannot be specifically determined because postal headquarters managers 

do not recall when they first obtained the written test results. 

According to Postal Service managers, the decision to withhold the actual 

quantified results from facility workers also was consistent with the 

guidelines because the Postal Service could not ensure that the 

contractor’s sampling procedures were consistent with the procedures 

and protocols specified in the guidelines. As a result, according to the 

Postal Service, it was unable to validate the results as required by its 

 28Although 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. 

29As 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. 
Page 22 GAO-03-316 U.S. Postal Service 

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.30 Also, the team used various sampling 

methods, and there was no way to correlate the results from the various 

methods used.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.32

Aside from the requirements in its guidelines, district postal managers said 

two other factors influenced their decision not to disclose the quantified 

results in December 2001. First, district postal managers said that they 

were uncertain about whether they could release the results given the 

ongoing FBI criminal investigation related to the facility’s contamination.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 

 30In its technical comments on our draft report, CDC noted that the HEPA vacuum sample, 

which identified 2.9 million colony-forming units of anthrax, had been taken on the feeder 

mechanism of a mail-sorting machine. While the precise surface area of the feeder 

mechanism would be difficult to measure, CDC noted that the mechanism is an important 

part of the mail’s pathway through the machine. Thus, even though there are limitations in 

the ability to measure such areas, CDC pointed out that there is value in sampling these 

types of complex mail processing surfaces. 

31For 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). 

32Unlike its actions in December 2001, the Postal Service immediately provided all of the 

test results, including the quantified results of from 1 to 18 colony-forming units, to 

employees at the facility in April 2002. Full and immediate disclosure of the April 2002 test 

results had been recommended by an OSHA official to avoid miscommunication, 

confusion, and workers’ concern about how the data may have been interpreted. The 

decision to release the results also appears consistent with the Postal Service’s guidelines 

because, according to the Postal Service, the sampling and analyses were performed by a 

Service contractor in accordance with the Service’s procedures and protocols for sampling. 

According to the Manager of the Command Center, this allowed the Postal Service to 

validate the results. 

33In addition to its participation on the investigation team at Wallingford, the FBI also was 

conducting a separate criminal investigation related to the facility’s contamination. The 

U.S. Postal Inspectors, the U.S. Attorney’s Office, the Connecticut Department of Public 

Health, and CDC were also members of the criminal investigation team. 
Page 23 GAO-03-316 U.S. Postal Service 

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.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.” 

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. . . .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 

 34Since the amount of surface area collected for the sample containing about 3 million 

spores was not recorded, investigators could not determine whether the spores had been 

spread over the sample area or clumped together in one spot. Also, according to a team 

member, it was not clear how to extrapolate the result from the surface sample into its 

potential for existing in the air. (Additional information on the interpretation of surface 

sampling results is contained in CDC’s MMWR Weekly, December 21, 2001, and in its fact 

sheet entitled Comprehensive Procedures for Collecting Environmental Samples for 

Culturing Bacillus anthracis (revised April 2002). 

35Within 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.” 

The Postal Service’s Delay 

in Disclosing the 

December 2001 

Quantitative Test Results 

Was Not Consistent with 

OSHA’s Disclosure 

Requirements 
Page 24 GAO-03-316 U.S. Postal Service 

made available.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.37

The President of the Greater Connecticut Area Local American Postal 

Workers Union—a designated representative of many of the facility’s 

employees—triggered the OSHA requirement on January 29, 2002, when 

he requested postal facility managers to provide copies of all test results 

and all supporting and relevant documents for all anthrax testing 

conducted at the Wallingford facility in the fall of 2001.38 The request was 

made pursuant to the union’s collective bargaining agreement with the 

Postal Service. The Postal Service responded on February 6, 2002, with a 

summary listing of tests performed at the Wallingford facility, including 

information about whether the test was positive or negative for anthrax. 

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

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

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

leader’s request, like others it receives from the union, in the context of its 

collective bargaining agreement with the union, not within the context of 

OSHA’s disclosure requirement. As a result, the Postal Service did not 

provide him with the earliest date when the other records would be made 

available, as required by OSHA’s regulations. 

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

results, including results related to the decontamination of the four mailsorting 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 

 3629 C.F.R. § 1910.1020 (e)(1)(i). 

37OSHA may cite the following violations with or without a fine: “Other than Serious,” 

“Serious,” “Repeated,” “Failure to Abate,” and “Willful.” 

38The union leader also requested test results from the post office in Seymour, 

Connecticut—the post office that delivered mail to the deceased woman’s home. 
Page 25 GAO-03-316 U.S. Postal Service 

leader of the reason for the delay in disclosing all of the records or the 

earliest date when the records would be made available. 

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

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

matter further until April 2002—after he learned from a newspaper article 

that at least one of the facility’s test results had been quantified.39

According to the union leader and the Postal Service physician who had 

been responsible for providing medical advice to workers at the facility in 

December 2001, this was the first time that they were aware that any of the 

facility’s test results had been quantified. 

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

initiated action to obtain the quantified test results under the Freedom of 

Information Act. Specifically, on April 23, 2002, the union leader requested 

OSHA, the Connecticut Department of Public Health, and CDC to supply 

“any and all documents regarding any and all investigations of hazardous 

conditions, or suspected hazardous conditions, including, but not limited 

to, all documents related to any and all investigations of contamination, or 

suspected contamination, of the anthrax virus at the [Wallingford facility] 

in 2001 and 2002.” 

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

results and, therefore, it could not release the information. Second, while 

the Commissioner of the Connecticut Department of Public Health had 

discussed the December 2001 quantified results with the union leader on 

April 22, 2002, and the Chief Epidemiologist had briefed the facility’s 

workers about the quantitative results on April 24, 2002, the department 

subsequently declined to release the actual results because of state 

prohibitions on releasing epidemiological investigative data.40 Finally, 

although CDC had previously (1) released the quantitative test results for 

 39A March 26, 2002, article in The New York Times discussed a presentation by the Chief 

Epidemiologist about contamination at the facility, including the finding of “about 3 million 

spores” from a sample collected in November 2001. The Chief Epidemiologist told us that 

he presented this information at an international conference on emerging infectious 

diseases because he wanted to emphasize the importance of maintaining the Postal 

Service’s restriction on the use of compressed air to clean its facilities to ensure that any 

residual spores at Wallingford and other postal facilities are not blown elsewhere in the 

facilities. 

40The 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. 
Page 26 GAO-03-316 U.S. Postal Service 

the Wallingford facility at a March 2002 conference and (2) published 

some quantitative test results for the Brentwood facility in Washington, 

D.C.,41 it did not release the results to the union until March 28, 2003, 

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

CDC that it did not need to review CDC’s records before the release of 

“anthrax-related information.”42

Unsuccessful in obtaining the facility’s test results, the union leader filed a 

formal complaint with OSHA. The May 29, 2002, complaint alleged that the 

Postal Service had “intentionally failed to properly and timely disclose to 

the employees working at [the facility] and to their union representatives 

the actual level of anthrax contamination found on four (4) automated 

processing machines back in December 2001.” The letter noted that the 

Postal Service was aware of the quantified test results “on or about 

December 12, 2001” yet did not inform the facility’s workers. Absent 

knowledge of the actual amount of contamination at the facility, the union 

leader charged that employees had inadequate information for making 

informed decisions, such as decisions about whether to continue (1) 

taking antibiotics and (2) working in the facility. The union leader and 

other union representatives subsequently explained to us that, according 

to their discussions with workers at the facility, many of the employees 

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

medicine prematurely on the basis of the Postal Service’s use of “trace” 

and “concentration” to characterize the extent of contamination in the 

facility. 

The complaint resulted in an OSHA investigation and the Postal Service’s 

subsequent release of test results from samples collected in November and 

December 2001. This included the actual laboratory record for the sample 

that identified about 3 million spores in a sample collected from one mailsorting machine on November 28, 2001. The Postal Service provided the 

quantified results to union representatives and to members of the facility’s 

Safety and Health Committee on September 4, 2002, along with a letter 

 41Sampling 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. 

42According 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. 
Page 27 GAO-03-316 U.S. Postal Service 

describing the Postal Service’s reasons for not releasing the results earlier. 

Specifically, the Postal Service indicated that the results could not be 

validated because “the laboratory that produced the results was not hired 

by or working directly for the Postal Service.” As a result, the letter 

cautioned recipients not to use the information to interpret the risk to 

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

At the conclusion of the inspection, OSHA’s area office in Bridgeport, 

Connecticut, reported that its inspection had “revealed conditions of 

significant findings,” which—while not warranting a citation for a 

regulatory violation—were of “sufficient importance to require [the 

Facility Manager’s] attention.” OSHA’s October 7, 2002, letter to the Postal 

Service also stressed the importance of timely communication of test 

results and stated that a “failure to effectively communicate issues which 

can have an effect on a worker’s health and safety, can lead to fear and 

mistrust.” Furthermore, the letter informed the Postal Service that 

“effective and forthright communication of any and all information relating 

to exposure records, both quantitative and qualitative, to toxic substances 

and harmful physical agents should take place in a timely manner.” 

According to OSHA officials, OSHA typically sends a letter of significant 

findings when the employer has disclosed information requested by an 

employee or his or her designated representative while the complaint is 

still open—as the Postal Service did on September 4, 2002, prior to the end 

of OSHA’s investigation. Although OSHA did not believe that a citation 

was warranted, OSHA officials stated that they used a letter of significant 

findings to establish a basis for a future violation if the problem reoccurs. 

Dissatisfied with OSHA’s decision not to take regulatory action, on 

October 17, 2002, the union leader requested that OSHA’s Regional 

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

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

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

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

union had first requested all test results directly from the Postal Service. 

The request also cited conflicting information that had been received by 

OSHA about whether postal managers were still in possession of the 

December 2001 quantified results in June 2002, when OSHA initiated its 

investigation, and thus whether the Postal Service could have supplied the 
Page 28 GAO-03-316 U.S. Postal Service 

information to the union earlier.43 In his request, the union leader argued 

that a regulatory citation was needed because, otherwise, there would be 

no incentive for the Postal Service to prevent a similar situation from 

reoccurring. OSHA’s Regional Administrator reviewed the matter and, by a 

letter dated November 26, 2002, affirmed OSHA’s prior decision not to 

issue a regulatory citation. 

We discussed OSHA’s findings with officials responsible for the inspection. 

They noted that OSHA was not involved at the facility until April 2002—

well past the December 2001 period in question. Nevertheless, they cited 

the emergency situation that had existed at that time and indicated that, 

on the basis of their subsequent knowledge of the events that had 

transpired, they believed the Postal Service had taken “reasonable and 

prudent” actions to protect its employees throughout the period of the 

facility’s contamination. As a result, any hazard associated with the Postal 

Service’s nondisclosure of the quantitative test results had been eliminated 

in December 2001—about 6 months before OSHA’s investigation began. 

Also, the OSHA officials noted that because the Postal Service had 

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

appropriate to issue a regulatory citation. 

In a February 2003 letter to the union leader, OSHA’s Regional 

Administrator reaffirmed OSHA’s decision not to cite the Postal Service. 

According to the Regional Administrator, the agency’s decision was 

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

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

significance, in terms of employee exposure, of anthrax spores found in 

the facility; and (3) existence of an ongoing criminal investigation into the 

 43According to a November 26, 2002, OSHA letter to the union leader, the Postal Service did 

not have a copy of the December 2001 quantified results until August 13, 2002. Our work 

showed that the Postal Service headquarters may have received documentation of the 

quantified test results on or about December 8, 2001, and that the district had the written 

results on December 10. Further, both of the offices maintained copies of the results 

throughout the period in question. Postal Service officials told us they did not know why 

OSHA was unaware that they had the results. Although OSHA provided us with 

documentation associated with its investigation, the source of misinformation about the 

Postal Service’s possession of the quantitative test results could not be discerned from the 

material provided. Furthermore, our discussions with postal and OSHA officials did not 

enable us to resolve this issue. 
Page 29 GAO-03-316 U.S. Postal Service 

source of the anthrax spores that involved several federal agencies.44

Nevertheless, she emphasized the need for better communication by the 

Postal Service and reaffirmed OSHA’s concern about the “failure of 

communication and openness” exhibited by the Postal Service in this case. 

Although OSHA and members of the investigative team in December 2001 

were not critical of the Postal Service’s decision not to release the 

December 2001 quantified results when they were first known, in hindsight 

and within the context of lessons learned, they said there was no reason 

why the results and any limitations associated with the results could not 

have been disclosed at that time. They explained that from their 

perspectives, full and timely disclosure of laboratory results is the best 

method for communicating test results. For example, the Chief 

Epidemiologist from the Connecticut Department of Public Health 

emphasized that it is important to “put the information out there frankly 

and then discuss it.” Similarly, CDC officials stated that the principle is to 

get all of the information out to employees regarding their health risks. 

Finally, although not a member of the investigative team, an OSHA official 

who was involved in the facility’s decontamination in April 2002 told us 

that he advised the Postal Service to provide employees with the “raw data 

sheets” of test results to avoid miscommunication, confusion, and concern 

about how the data may have been interpreted. 

Two recent guidelines developed by GSA and the National Response Team 

stress the importance of complete and timely information. The guidelines 

are intended to disseminate information learned from the response to 

anthrax contamination at postal and nonpostal facilities in the fall of 2001, 

including lessons relating to the communication of test results. GSA 

released its guidelines in July 2002.45 The guidelines are written in the form 

of a policy advisory—not as regulations or explicit directives—and 

 44According 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. 

45GSA 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. 

Lessons Learned at 

the Wallingford 

Facility Suggest the 

Need for More 

Complete and Timely 

Information to 

Workers 
Page 30 GAO-03-316 U.S. Postal Service 

primarily apply to the operation of mail centers located in federal agencies 

in the Washington, D.C., area. While not requirements, GSA’s 

recommendations for communicating test results to workers, in our view, 

are relevant to the Postal Service and others. The guidelines emphasize the 

importance of the integrity of the information communicated to workers 

and stress the need for “timely, clear, consistent, and factual” information 

about risk levels and any limitations associated with the information. The 

guidelines conclude that people need “solid” information to have the 

“confidence to make informed choices.” 

The National Response Team developed the other guidelines, which are 

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

30, 2002, and is entitled Technical Assistance for Anthrax Response.

46

Although not a member of the National Response Team, the Postal Service 

assisted in the development of the guidelines. The guidelines (1) suggest 

that more—rather than less—information should be disclosed and (2) 

provide a number of recommendations about communicating information 

during emergency situations. For example, the guidelines advise agencies 

to consider that “different audiences (e.g., employees, reporters, local 

politicians) may need different types of information” and to “anticipate 

what information people need and in what form.” Further, although the 

guidelines caution against passing on “everything you know,” it points out 

the consequences of not fully disclosing information. Specifically, the 

guidelines warn, “. . . do not withhold information . . . it is very likely that 

the withheld information will be found out, which will cripple your 

credibility. . . .” Finally, the guidelines advise agencies to “admit when you 

have made a mistake or do not know the information.” 

Although helpful in ensuring the integrity of information to be released, 

neither of the two recent guidelines nor the Postal Service’s guidelines 

 46GSA 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. 
Page 31 GAO-03-316 U.S. Postal Service 

explicitly address all of the communication issues that arose at the 

Wallingford facility.47 None of these guidelines 

• explicitly require disclosure of quantitative test results, when available, or 

specify the terminology (e.g., number of colony-forming units per gram or 

square inch of material sampled) that should be used to communicate the 

results to workers or others, along with any limitations associated with the 

results, or 

• specify the actions that should be taken if test results cannot be validated, 

including a strategy for communicating unvalidated test results to 

workers. 

Furthermore, the Postal Service’s guidelines do not define the meaning of 

“validation” or specify the steps that must be taken to validate test results. 

The Postal Service headquarters’s manager who was responsible for 

establishing and overseeing the Command Center told us that the term 

was intended to describe a method for ensuring that work had been done 

in accordance with the Postal Service’s sampling and testing procedures 

and, therefore, for coordinating the release of validated results. However, 

the guidelines do not specify who is to do the validation or how it is to be 

done, particularly when the testing is not done or sponsored by the Postal 

Service. 

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

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

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

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

facility’s mail-sorting machines, could have made interpretations about the 

results difficult.48 Nevertheless, they noted that the method of counting 

colony-forming units is a long-standing, definitive, and universally 

 47GSA and EPA—as the Chair for the National Response Team—explained that, by design, 

their guidelines were not intended to prescribe specific actions because knowledge about 

how to respond to anthrax is evolving rapidly, and each situation is unique. Instead, the 

agencies indicated that their guidelines provide background information and viable options 

for individuals who, in the case of GSA’s guidelines, operate and manage federal mail 

centers or, in the case of guidelines developed by the National Response Team, respond to 

anthrax attacks. 

48We 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. 
Page 32 GAO-03-316 U.S. Postal Service 

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,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 

 49The National Response Team’s September 2002 draft guidelines agree that methods have 

not been validated for a variety of sampling techniques. Accordingly, the guidelines 

recommend that agencies use “a multi-disciplinary team” to help them interpret anthrax 

test results. Relating to this, according to CDC, it is important to scrutinize new sampling 

techniques, such as the HEPA vacuum, to understand the strengths and limitations of the 

methods so that the methods can be subsequently validated. 
Page 33 GAO-03-316 U.S. Postal Service 

agencies should maintain, including the advice agencies receive from 

public health officials or others about the communication of test results to 

workers; or (3) discuss the actions that should be taken if test data are 

requested by an employee or a designated representative. As previously 

discussed, OSHA representatives were not involved in the December 2001 

discussions about what to communicate to workers. This deprived the 

Postal Service of the insights and suggestions that OSHA could have 

offered. Furthermore, although the Postal Service representatives cited 

uncertainty over what information could be released given the ongoing 

criminal investigation, the Postal Service did not consult with the FBI on 

this issue. According to FBI officials we interviewed in Connecticut, the 

test results were of no value to their investigation and, had they been 

consulted, they said that they would have allowed the results to be 

released. 

As previously discussed, another issue that arose in the Wallingford case 

involved differing recollections among the various parties regarding who 

participated in certain discussions and about what advice was given. For 

example, in contrast to the recollections of officials from CDC and the 

Connecticut Department of Public Health, postal managers told us that 

they did not participate in a December 6, 2001, telephone conversation in 

which the quantitative test results were first discussed. Further, postal 

managers have different recollections about the advice they received from 

the Chief Epidemiologist than the information that he recalls. Also, in the 

Wallingford case, the Postal Service said that it did not associate the union 

leader’s request for the test results with OSHA’s regulatory requirement 

and, therefore, did not realize that it was obligated to either provide the 

results within 15 days or provide the reasons for the delay along with a 

time frame for providing the results. Related to this, OSHA’s disclosure 

requirements do not fully address the emergency situation that arose at 

Wallingford, where workers were exposed to an unanticipated and 

externally introduced hazard capable of causing serious health problems, 

including death. The regulations are not applicable until an employee or a 

designated representative requests test results and, even then, the 

employer has up to 15 days to provide the information or explain why it is 

not providing the information. The 15-day time frame is far more than the 

number of days needed to contract inhalation anthrax. 

We discussed OSHA’s regulatory requirements with OSHA’s Director of 

Enforcement Programs. The Director told us that OSHA’s standards were 

written for airborne exposure to chemical and physical agents in the 

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

biological hazards, such as anthrax. According to the Director, OSHA’s 
Page 34 GAO-03-316 U.S. Postal Service 

current regulatory agenda do not include any planned modifications to its 

requirements, including any changes to require the immediate and 

proactive disclosure of records related to an employee’s exposure to 

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

are requested by workers or their designated representatives. 

In retrospect, the Postal Service’s decision not to release the quantitative 

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

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

public health officials, (3) an ongoing criminal investigation, and (4) 

uncertainties surrounding the validation of the sampling methods used and 

the meaning of the test results. However, the decision deprived facility 

employees of information that may have been useful in making informed 

decisions about whether to take or continue taking antibiotics and 

whether to continue working in the facility. Furthermore, in hindsight, it is 

clear that not fully disclosing quantified test results can affect an agency’s 

credibility and lead to worker distrust. It is also apparent now that not 

consulting relevant agencies—in this case, OSHA and the FBI—regarding 

its December 2001 decision about what to disclose to employees deprived 

the Postal Service of information that could have been useful in deciding 

what to communicate to its workers. Finally, the Postal Service’s failure to 

document the discussions that it had with other agency personnel on 

communication issues makes it difficult to resolve discrepancies in 

recollections that arose. As demonstrated at Wallingford, documentation 

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

time they are received or shortly thereafter for emergencies, could help 

resolve questions that may arise later about what was done and why. 

The agencies involved in the investigation and response to anthrax at 

Wallingford have learned a number of lessons from their experiences, 

including the need for more effective sampling methods and more explicit 

and consistent guidance concerning the communication of test results for 

hazardous substances, such as anthrax. However, the guidelines 

developed by the Postal Service, GSA, and the National Response Team 

are still too general to prevent problems like those that occurred at the 

Wallingford facility. Specifically, the current guidelines do not (1) require 

the prompt disclosure of all available test results, using specified 

terminology; (2) define how test results should be validated or the actions 

that should be taken when results cannot be validated; (3) specify which 

agencies should be involved in deciding what to communicate to workers 

and others; or (4) require documentation of the advice and 

recommendations from other organizations involved in deciding the 

Conclusions 
Page 35 GAO-03-316 U.S. Postal Service 

actions to be taken during a crisis. Moreover, since employees and their 

designated representatives may not know that test results are available or 

that they can be requested, it appears incumbent upon employers to, in 

emergency situations, immediately disclose test results without waiting for 

an employee or representative to request them. Because current OSHA 

regulations require the disclosure of test results only when an employee or 

representative requests them, such as occurred in the Wallingford case, 

organizations can still decide to withhold essential information. Lastly, 

agency officials dealing with an anthrax situation or similar emergency 

may not be aware of, or associate an employee’s request for test data with, 

OSHA’s regulations, which can result in penalties for noncompliance. 

To help prevent the reoccurrence of the communications problems that 

occurred at the Wallingford facility, we recommend that the Postmaster 

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

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

applicable, revise guidelines to 

• require prompt communication of test results, including quantified results 

when available, to workers and others; 

• specify the terminology that should be used to communicate quantitative 

test results to employees and others (e.g., the number of colony-forming 

units per gram or square inch of material sampled) and any limitations 

associated with the test results; 

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

that must be taken to validate sampling or testing methods that are 

undertaken by the agency itself or by another organization; 

• specify the actions that should be taken if test results cannot be validated, 

including a strategy for communicating unvalidated results; 

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

communicate to workers and others, as appropriate; 

• require documentation of the basis for decisions made, including the (1) 

advice the organization receives from public health officials and others 

about the communication of health-related information to workers and 

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

communicate to workers and others; and 

• reflect OSHA’s regulations for disclosing test results requested by workers 

or their designated representatives. 

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

terrorist actions using unforeseen hazardous substances, we also 

recommend that the Assistant Secretary for Occupational Safety and 

Recommendations for 

Executive Action 
Page 36 GAO-03-316 U.S. Postal Service 

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 requested comments on a draft of this report from the Postmaster 

General; the Commissioner of the Connecticut Department of Public 

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

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

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

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

conclusions and/or recommendations. Their comments are summarized 

below. 

EPA’s Assistant Administrator provided comments on March 21, 2003, in 

EPA’s capacity as the Chair for the National Response Team. According to 

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

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

Service were consulted in preparing the response. EPA indicated that the 

members of the National Response Team believe that our draft report 

provided a balanced presentation of anthrax testing and communications 

with employees at the Wallingford postal facility. While stating that the 

National Response Team agrees with our references and 

recommendations regarding the content of its guidelines—Technical 

Assistance for Anthrax Response—EPA stated that the guidelines had 

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

directive or guidance, and that knowledge on anthrax is evolving rapidly. 

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

stated that the guidelines were intended to provide scientific background 

and viable options for responders to consider in addressing specific 

circumstances. Nevertheless, EPA indicated that “certain improvements” 

could be made to the guidelines that would be responsive to our 

recommendations. The letter did not specify the nature of the planned 

improvements. EPA also provided technical comments, which we 

included, as appropriate. EPA’s letter is reproduced in appendix III. 

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

Chief Operating Officer and Executive Vice President stressed that the 

safety and security of its employees and its customers were then and now 

of the utmost importance. The Postal Service also emphasized that, when 

the anthrax crisis unfolded in the fall of 2001, there were no guidelines and 

no designated regulatory agency for dealing with the crisis. While stating 

Agency Comments 

and Our Evaluation 
Page 37 GAO-03-316 U.S. Postal Service 

that the Postal Service acted quickly and prudently to communicate 

pertinent information to its employees, the Postal Service acknowledged 

that there are always opportunities to improve communications regarding 

anthrax and other biohazards. In this regard, the Postal Service stated that 

it is committed to working with the National Response Team to revise the 

team’s technical assistance guidelines for anthrax and, when completed, 

that it planned to ensure that its guidelines are consistent with the team’s 

updated guidelines. The Postal Service also noted that it agreed with many 

of our specific recommendations. For example, the Postal Service agreed 

that test results, including quantified results, should be released to 

employees and others as quickly as possible. The Postal Service also 

agreed that any limitations associated with the results should be 

explained. Further, the Postal Service recognized the importance of 

developing and maintaining sufficient records concerning its 

communication of health-related information to employees and others. 

Finally, the Postal Service indicated that it is aware of its obligation to 

release testing information to employees and their unions, when requested 

to do so. The Postal Service’s letter, which is reproduced in appendix IV, 

did not comment on our other recommendations. The Postal Service also 

provided technical comments, which we included, as appropriate. 

The Postal Service’s commitment to work with the National Response 

Team in revising the team’s anthrax-related guidelines and, thereafter, to 

ensure that its guidelines are consistent with the revisions made to the 

team’s Technical Assistance for Anthrax Response, should go a long way 

in ensuring that the Postal Service’s employees have all of the information 

they need to make informed decisions about their health and safety in a 

timely manner. However, because the National Response Team did not 

specify the nature of its planned revisions to its technical assistance, we 

believe that the Postal Service should also revise its guidelines to address 

any recommendations that are not eventually included in the National 

Response Team’s revised technical assistance, particularly with respect to 

issues related to the meaning of “validation,” the steps that must be taken 

to verify sampling methods or test results, and the release of test results 

that cannot be validated. 

On March 31, 2003, GSA’s Associate Administrator provided oral 

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

National Response Team and with key members of an Interagency 

Working Group that had participated in the development of GSA’s anthraxrelated 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 
Page 38 GAO-03-316 U.S. Postal Service 

with employees at the Wallingford facility and that it generally agrees with 

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

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

also emphasized that its guidelines were written as a policy advisory and 

that they were not intended to prescribe specific actions that should be 

taken in every case. Instead, GSA indicated that its guidelines are intended 

to provide background information and viable options for managers who 

operate federal mail centers in the Washington, D.C., area. GSA also 

explained that its guidelines deal primarily with the actions that these 

managers should take to prepare for possible anthrax threats and to 

determine whether an anthrax threat is credible. Once a credible threat 

has been identified, responsibility for managing the situation passes from 

the manager of the mail center to law enforcement, public health, and 

other authorities. As a result, GSA emphasized that the guidelines 

developed by the National Response Team should be the primary source 

of advice for anyone managing a credible threat. 

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

Group before implementing specific changes to its guidelines. However, 

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

indicated that it would work with other members to revise its guidelines 

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

available quantified results; (2) the need for adequate documentation of 

the advice an agency receives from public health officials and others and 

its related communications with employees and others; and (3) OSHA’s 

regulations for disclosing test results requested by workers or their 

designated representatives. 

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

other recommendations somewhat differently than in the manner that we 

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

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

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

terminology in communicating quantitative test results, (2) understanding 

what is meant by the “validation” of sampling methods and test results, 

and (3) specifying the actions to be taken if test results cannot be 

validated. Specifically, while GSA commented that it agrees that all test 

results should be conveyed to workers promptly, it said that it does not 

believe that quantitative test results should be used in all cases. GSA 

explained that appropriate testing methods vary according to site-specific 

circumstances and the ability to quantify results depends on the testing 

methods used. GSA also noted that the term validation has various 

meanings. Rather than promote confusion or add unnecessary detail to 
Page 39 GAO-03-316 U.S. Postal Service 

distinguish the different types of validation, GSA said that it would address 

our recommendations by adding a statement in its guidelines that 

recommends sharing all available test results; specifying the testing 

methods used; and explaining the limitations, if any, of the results and the 

testing methods. 

We appreciate GSA’s commitment to address the concerns raised in our 

report. From GSA’s comments, it appears that further clarification of our 

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

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

are not always available, depending on the sampling methods used. In fact, 

in the case of the Wallingford facility, quantified results were rarely 

available. However, when quantitative results are available, like GSA, we 

continue to believe that it is important to disclose them to all affected 

parties. We clarified our recommendation to avoid any misunderstandings 

in this area. 

Regarding our final recommendation, GSA indicated that parties involved 

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

that its guidelines—in a general fashion—adequately identify the types of 

parties that should be involved in deciding what to communicate to 

workers and others. Nevertheless, GSA said that, in consultation with the 

Interagency Working Group, it would look for ways to enhance this part of 

its guidelines. 

The President of the American Postal Worker’s Union commented on our 

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

with our recommendations to better coordinate communication between 

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

report did not adequately reflect the union’s perspective of the facts and 

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

disagree. We believe that our conclusions are fully supported by the 

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

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

them. We also disagree that the report does not adequately reflect the 

union’s perspective. Our report clearly concludes that the Postal Service’s 

December 2001 decision not to disclose the quantitative results deprived 

workers of essential information for making informed decisions related to 

their health and safety. In addition, the report lays out a number of lessons 

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

the report contains several recommendations for improving 

communication with postal and other workers in the future if another 

bioterrorist attack occurs. The union’s letter is reproduced in appendix V. 
Page 40 GAO-03-316 U.S. Postal Service 

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

disagreed that the Postal Service’s decision not to release the quantitative 

results to workers in December 2001 appeared consistent with its 

guidelines. The union reiterated the requirements in the Postal Service’s 

guidelines which, as discussed in this report, specify that confirmed test 

results must be validated before being sent to the Postal Service’s 

Command Center and, once the data are confirmed and validated, the 

guidelines state that the Manager of the Command Center is to release the 

data to, among other parties, affected postal managers and state health 

departments. Thus, in the union’s view, the test results are considered to 

be validated when they are reported by the Manager of the Command 

Center. However, this is not what happened in Wallingford. In the 

Wallingford case, the laboratory reported the quantitative results directly 

to the Connecticut Department of Public Health and CDC—not to the 

Postal Service’s Command Center—and the Chief Epidemiologist provided 

the test results directly to the Postal Service’s district office. Thus, the 

results were not reported by the Command Center as anticipated by the 

guidelines. According to the Postal Service, the December 2001 

quantitative results could not be validated, within the context of the Postal 

Service’s guidelines, because the party that collected the samples did not 

work for the Postal Service and the Postal Service could not ensure that 

the samples had been collected in accordance with procedures set forth in 

its guidelines. While we believe that the Postal Service’s decision not to 

release the quantitative test results in December 2001 appears consistent 

with its guidelines on the basis of its interpretation of the validation 

requirement, we also believe that the use of the term “validation” in the 

context of anthrax testing can be problematic. Therefore, our report 

contains a recommendation to define what is meant by validation and 

explain the steps that must be taken to validate test results. 

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

exposure information under any circumstances. While we agree in 

principle, our conclusion that the Postal Service’s decision not to release 

the quantified test results in December 2001 was understandable is based 

on the particularly challenging and difficult circumstances that existed at 

that specific point in time. As discussed in this report, these circumstances 

included an ongoing investigation of the bioterrorist attack; the advice that 

the Postal Service received from public health officials; uncertainties 

surrounding the validation of the sampling methods used and the meaning 

of the test results. In addition, while the Postal Service’s existing 

guidelines do not address all of the conditions that existed at the 

Wallingford facility, the decision not to disclose the quantified results in 

December 2001 appears consistent with the existing guidelines. 
Page 41 GAO-03-316 U.S. Postal Service 

Furthermore, neither OSHA nor the members of the investigative team, 

including CDC, the Connecticut Department of Public Health, the FBI, and 

EPA, specifically faulted the Postal Service for not releasing the 

quantitative results at that time. Nevertheless, our report clearly states 

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

the decision not to disclose the December 2001 quantified results deprived 

workers of important information. Consequently, we are making several 

recommendations to improve future communication of test results, 

including the prompt disclosure of available qualitative and quantitative 

results, and any limitations associated with the sampling methods or test 

results. 

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

understandable and acceptable that the Postal Service failed to follow 

OSHA’s regulatory disclosure requirements and, as a result, that it was 

acceptable to withhold the quantitative results for 9 months. We disagree 

with the union’s characterization of our conclusion. Our report clearly 

states that the Postal Service’s decision not to release the test results in 

response to two union requests in January and February 2002 was not 

consistent with OSHA’s regulations. To help ensure that similar situations 

do not occur in the future, we are recommending that EPA, the Postal 

Service, and GSA revise their guidelines to reflect OSHA’s regulations for 

disclosing test results requested by workers. Related to this, we are also 

recommending that OSHA consider strengthening its regulatory 

requirements to require—in emergency situations—full and immediate 

disclosure of test results to workers, regardless of whether the 

information is requested by an employee or his or her designated 

representative. 

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

followed its guidelines “with one exception,” without explaining that the 

exception involved the sample containing about 3 million spores on one 

heavily contaminated mail-sorting machine. According to the union, this 

exception placed employees at considerable risk. As discussed in this 

report, we agree that the Postal Service’s decision not to release the 

quantitative results in December 2001 deprived the facility employees of 

information that may have been useful to them in making informed 

decisions about whether to take or continue taking antibiotics and 

whether to continue working in the facility. However, we disagree that we 

have not adequately explained the circumstances associated with this 

situation. Throughout the report we discuss the results in question as well 

as the fact that the quantitative test results were not communicated to 

workers. Furthermore, the report clearly discusses the actual finding of 
Page 42 GAO-03-316 U.S. Postal Service 

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. 
Page 43 GAO-03-316 U.S. Postal Service 

OSHA and two HHS components—CDC and the Agency for Toxic 

Substances and Disease Registry—provided technical comments via Email, which we incorporated, as appropriate. OSHA did not comment on 

our recommendation that the Assistant Secretary for Occupational Safety 

and Health consider whether OSHA regulations should require—in 

emergency situations—full and immediate disclosure of test results to 

workers, regardless of whether the information is requested by an 

employee or his or her designated representative. We also received 

technical comments from the Chief Epidemiologist of the Connecticut 

Department of Public Health in which he stated that, overall, the report 

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

Department of Public Health as it relates to the situation at the Wallingford 

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

incorporated. In a March 31, 2003, letter, HHS’s Acting Principal Deputy 

Inspector General said that the department had no comments aside from 

the technical comments provided by two of its components. Finally, we 

requested comments from the Secretary of Homeland Security, but we did 

not receive any. 

As arranged with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after the 

date of this letter. At that time, we will send copies to the Chairman of the 

Senate Committee on Governmental Affairs; the Chairman and Ranking 

Minority Member of the House Committee on Government Reform; the 

Postmaster General; the Secretaries of HHS, Labor, and Homeland 

Security; the Administrators of EPA and GSA; the Assistant Secretary for 

Occupational Safety and Health; the Attorney General; the Connecticut 

Department of Public Health; CDC; the Agency for Toxic Substances and 

Disease Registry; the national American Postal Workers Union; and other 

interested parties. Copies will be made available to others on request and 

are also available at no charge on our Web site at http://www.gao.gov. 

If you have any questions about this report, please contact me on (202) 

512-2834 or at ungarb@gao.gov. Key contributors to this assignment were 
Page 44 GAO-03-316 U.S. Postal Service 

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 
Appendix I: Objectives, Scope, and 

Methodology 

Page 45 GAO-03-316 U.S. Postal Service 

Our objectives for this report were to determine (1) how and when 

contamination was identified at the U.S. Postal Service’s Southern 

Connecticut Processing and Distribution Center in Wallingford, 

Connecticut (Wallingford facility); (2) what and when information about 

contamination was communicated to facility workers; (3) whether the 

Postal Service followed applicable guidelines and requirements for 

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

lessons can be learned from the response to contamination at the facility. 

To address these objectives, we identified and, with Postal Service 

headquarters, district, and facility managers, discussed the roles of the 

agencies involved in investigating and responding to anthrax at the 

Wallingford facility. We met with officials from the Postal Service, the 

Connecticut Department of Public Health, the Centers for Disease Control 

and Prevention (CDC), the Agency for Toxic Substances and Disease 

Registry, the Occupational Safety and Health Administration (OSHA), the 

Environmental Protection Agency, the Federal Bureau of Investigation, the 

national American Postal Workers Union, and its Greater Connecticut 

Area Local Union. We also requested and reviewed agency documentation 

related to the testing of the facility and the subsequent finding of anthrax 

contamination as well as documentation about how, when, and what 

information the Postal Service communicated to workers about the extent 

of contamination at the facility. The information documented, among 

other things, the various roles of the agencies involved, the laboratories’ 

test results, sampling plans and testing protocols, press releases, 

information about the content of employee briefings, the Postal Service’s 

guidelines for testing and communicating anthrax test results, OSHA 

requirements for disclosing records related to employee health risks, and 

more recent anthrax guidelines developed by the General Services 

Administration and the National Response Team. 

We also interviewed officials from involved agencies to determine their 

views and the extent of their involvement in the response to the facility’s 

contamination between November 2001 and June 2002. Specifically, (1) 

what information was provided to employees at the facility and when, and 

by whom, it was provided and (2) what lessons can be learned about the 

response to contamination at the facility. Finally, we reviewed published 

literature, including technical reports on anthrax, and consulted several 

experts. We did not independently assess or verify any of the laboratory 

test results, sampling plans, or testing protocols to determine their 

accuracy or adequacy. Moreover, because the Postal Service did not 

document all of the advice that it received from public health officials or 

the precise information it communicated to workers at the facility, we 

Appendix I: Objectives, Scope, and 

Methodology 
Appendix I: Objectives, Scope, and 

Methodology 

Page 46 GAO-03-316 U.S. Postal Service 

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. 
Appendix I: Objectives, Scope, and 

Methodology 

Page 47 GAO-03-316 U.S. Postal Service 

[This page is intentionally left blank]
Appendix II: Summary of Anthrax Testing at 

the Wallingford Facility between November 

2001 and April 2002 

Page 48 GAO-03-316 U.S. Postal Service 

Appendix II: Summary of Anthrax Testing at 

the Wallingford Facility between November 

2001 and April 2002 
Appendix II: Summary of Anthrax Testing at 

the Wallingford Facility between November 

2001 and April 2002 

Page 49 GAO-03-316 U.S. Postal Service 

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. 
Appendix II: Summary of Anthrax Testing at 

the Wallingford Facility between November 

2001 and April 2002 

Page 50 GAO-03-316 U.S. Postal Service 

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. 
Appendix III: Comments from the Environmental Protection Agency 

Page 51 GAO-03-316 U.S. Postal Service 

Appendix III: Comments from the 

Environmental Protection Agency 
Appendix III: Comments from the Environmental Protection Agency 

Page 52 GAO-03-316 U.S. Postal Service 
Appendix IV: Comments from the U.S. Postal 

Service 

Page 53 GAO-03-316 U.S. Postal Service 

Appendix IV: Comments from the U.S. Postal 

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

Service 

Page 54 GAO-03-316 U.S. Postal Service 
Appendix V: Comments from the American 

Postal Workers Union 

Page 55 GAO-03-316 U.S. Postal Service 

Appendix V: Comments from the American 

Postal Workers Union 
Appendix V: Comments from the American 

Postal Workers Union 

(543037) Page 56 GAO-03-316 U.S. Postal Service 
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