a

GAO

United States Government Accountability Office

Report to Congressional Requesters

September 2004 U.S. POSTAL 

SERVICE

Better Guidance Is 

Needed to Ensure an 

Appropriate Response 

to Anthrax 

Contamination

GAO-04-239
www.gao.gov/cgi-bin/getrpt?GAO-04-239.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Mark L. 

Goldstein at (202) 512-2834 or 

goldsteinm@gao.gov. 

Highlights of GAO-04-239, a report to 

congressional requesters 

September 2004

U.S. POSTAL SERVICE

Better Guidance Is Needed to Ensure an 

Appropriate Response to Anthrax 

Contamination 

In September and October 2001, at 

least four letters containing 

anthrax spores were mailed to 

news media personnel and two U.S. 

Senators, leading to the first cases 

of bioterrorism-related anthrax in 

the United States. The 

contaminated letters, which were 

delivered through the U.S. mail 

system, caused 22 cases of anthrax, 

5 of them fatal. Nine postal 

employees associated with two 

postal facilities that processed the 

letters—Trenton in New Jersey and 

Brentwood in Washington, D.C.—

contracted anthrax and two 

Brentwood employees died. 

The U.S. Postal Service closed 

Trenton and Brentwood, but other 

contaminated postal facilities 

remained open. GAO’s review 

covers Trenton, Brentwood, and 

three of these other facilities. As 

requested, this report describes (1) 

the factors considered in deciding 

whether to close the five facilities, 

(2) the information communicated 

to postal employees about health 

risk and the extent of the facilities’ 

contamination, and (3) how lessons 

learned from the response to the 

contamination could be used in 

future situations. 

GAO is making recommendations 

to help ensure that the Postal 

Service has comprehensive, clear, 

accurate, and up-to-date guidance 

for any future anthrax response. 

The Postal Service indicated that it 

had taken or would take action on 

GAO’s recommendations. 

According to Postal Service managers, public health officials, and union 

representatives, the Postal Service considered the health risks to its 

employees ahead of its mission to deliver the mail in deciding whether to 

close postal facilities. The Postal Service relied on public health agencies to 

assess the health risks to its employees. These agencies believed the risks to 

be minimal until the Centers for Disease Control and Prevention (CDC) 

confirmed cases of anthrax in postal employees at Trenton and Brentwood. 

The Postal Service then closed these facilities. Public health agencies 

underestimated the health risks to postal employees, in part, because they 

did not know that anthrax spores could leak from taped, unopened letters in 

sufficient quantities to cause a fatal form of anthrax. The Postal Service kept 

the three other facilities covered by GAO’s review open because public 

health officials had advised the agency that employees at those centers were 

at minimal risk. CDC and the Postal Service have said they would have 

made different decisions if they had earlier understood the health risks to 

postal employees. 

The Postal Service communicated information to affected postal employees 

about the health risks posed by, and the extent of, anthrax contamination at 

the five facilities in GAO’s review, but problems with accuracy, clarity, and 

timeliness led employees to question the information they received. 

Problems with accuracy stemmed from incomplete information about health 

risks, and problems with clarity occurred as information on the medical 

response to anthrax contamination changed with experience. Problems with 

timeliness occurred when the Postal Service delayed the release of 

quantitative data (anthrax spore counts) for one facility, in part because it 

was uncertain what the results meant for worker safety and public health. 

To communicate more effectively, the Postal Service has established a 

center to coordinate information within the postal system and has worked 

with other agencies to develop guidelines for responding to anthrax. 

The response to anthrax contamination revealed several lessons, the most 

important of which is that agencies need to choose a course of action that 

poses the least risk of harm when considering actions to protect people from 

uncertain and potentially life-threatening health risks. Because public health 

officials underestimated the health risks involved, actions to protect postal 

employees were delayed. In addition, agencies’ guidance did not cover all of 

the circumstances that occurred. The Postal Service has since revised its 

guidance, but the revised guidance (1) does not define some key terms, 

including those that would trigger a decision to evacuate a facility, (2) 

includes some outdated references that could cause confusion during a 

future response, and (3) does not address certain issues, such as what steps 

would be taken during the interval between a diagnosis of anthrax in a postal

employee and confirmation of the disease. In addition, the guidance does 

not reflect proactive measures, including facility closures, that the Postal 

Service has recently implemented in response to suspected contamination. 
Page i GAO-04-239 U.S. Postal Service

Contents

Letter 1

Results in Brief 4

Background 8

Postal Service Primarily Considered Health Risks to Employees in 

Deciding to Close Facilities 17

Communication Problems Raised Employees’ Concerns 28

Several Lessons Emerged from the Response to Anthrax 

Contamination 37

Conclusions 54

Recommendations for Executive Action 55

Agency Comments and Our Evaluation 56

Appendixes

Appendix I: Comparison of Medical Services and Reassignment Benefits 

Provided to Postal Employees at Selected Facilities 59

Similar Medical Services Were Provided to Employees at the Five 

Facilities, but the Timing of the Services Varied 59

Employees at the Two Closed Facilities Received Various 

Reassignment Benefits That Lasted for Different Periods of 

Time 61

Appendix II: Objectives, Scope, and Methodology 65

Appendix III: Time Line of Key Events, Fall 2001 70

Appendix IV: Comments from the U.S. Postal Service 73

Appendix V: Comments from the Centers for Disease Control and 

Prevention 75

Tables Table 1: Characteristics of the Five Processing and Distribution 

Centers in Our Review, Fall 2001 11

Table 2: Distribution of Anthrax Cases, Fall 2001 15

Table 3: Key Events and Selected Medical Services Provided to 

Employees at the Five Postal Facilities 60

Table 4: Postal Facilities Closed for Other Emergencies, January 1, 

1998, through December 31, 2002 64

Figure Figure 1: Date in 2001, Type, and Location of Anthrax Cases 13
Contents

Page ii GAO-04-239 U.S. Postal Service

Abbreviations

ABC American Broadcasting Company

CBS Columbia Broadcasting System

CDC Centers for Disease Control and Prevention 

FBI Federal Bureau of Investigation 

GAO Government Accountability Office

HEPA high efficiency particulate air

NBC National Broadcasting Company

OSHA Occupational Safety and Health Administration 

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Page 1 GAO-04-239 U.S. Postal Service

United States Government Accountability Office

Washington, D.C. 20548

A

September 9, 2004 Letr

The Honorable Joseph I. Lieberman

Ranking Minority Member

Committee on Governmental Affairs

United States Senate 

The Honorable Christopher H. Smith

House of Representatives

The Honorable Eleanor Holmes Norton 

House of Representatives

The first cases of bioterrorism-related anthrax in the United States 

occurred in September and October 2001 when at least four letters 

containing anthrax1

 spores were mailed to news media personnel and two 

U.S. Senators. The contaminated letters, which were delivered through the 

U.S. mail system, caused 22 cases of anthrax during the fall of 2001—11 

from inhalation anthrax, an often-fatal form of the disease, and 11 from 

cutaneous (skin) anthrax, a readily treatable form.2

 Nine of the 22 cases of 

anthrax involved postal employees, including two of the five individuals 

who died from inhalation anthrax. 

The U.S. Postal Service responded to this crisis by testing and closing two 

heavily contaminated processing and distribution centers—the Trenton 

facility in Hamilton, New Jersey, and the Brentwood facility in Washington, 

D.C.3

 Testing also identified contamination at 21 other postal facilities, 

including 3 processing and distribution facilities in West Palm Beach, 

Florida; New York City, New York (the Morgan facility); and Wallingford,

1

Technically, the term “anthrax” refers to the disease caused by the bacterium Bacillus 

anthracis, not to the bacterium or its spores. However, for ease of reading and consistency 

with the terminology commonly used in the media and by the general public, this report 

generally uses the term to refer to both the disease and the bacterium.

2

Another case of cutaneous anthrax was confirmed in March 2002 in a laboratory worker 

who contracted the disease by processing environmental samples in support of the 

investigations. 

3

The nine affected postal employees were all associated with one of the two facilities. Four 

of the employees worked at Brentwood, four worked at Trenton, and one worked at a post 

office that received mail from Trenton.
Page 2 GAO-04-239 U.S. Postal Service

Connecticut.4 Brentwood was decontaminated and renovated and was fully 

operational as of December 22, 2003.5 Trenton also has been 

decontaminated and is expected to reopen in February 2005. Contaminated 

areas in the three other processing and distribution centers were isolated 

and decontaminated while operations continued elsewhere in the 

centers.6

We previously reported on the Postal Service’s response to anthrax 

contamination at the Wallingford processing and distribution center in 

Connecticut7

 and testified on specific issues related to the reopening of the 

Brentwood facility.8 Our work at the Wallingford facility identified 

communication difficulties and delays in disclosing test results to 

employees. Our testimony identified other communication problems 

associated with the reopening of the Brentwood facility. As you requested, 

for this report, we reviewed the Postal Service’s response to anthrax 

contamination at five contaminated processing and distribution centers—

the Trenton, Brentwood, Morgan, Wallingford, and West Palm Beach postal 

processing and distribution centers.9

 Specifically, you asked us to describe

• the factors considered in deciding whether to close the five facilities and 

the actions taken to protect postal employees;

4

For clarity, we refer to the five facilities as the Trenton, Brentwood, West Palm Beach, 

Morgan, and Wallingford postal facilities. 

5

The Brentwood facility has been renamed the Joseph Curseen Jr. and Thomas Morris Jr. 

Processing and Distribution Center in memory of the two Brentwood employees who died 

of inhalation anthrax.

6

Issues related to contamination at the other 18 facilities that tested positive for anthrax 

were beyond the scope of this review. 

7

GAO, U.S. Postal Service: Better Guidance Is Needed to Improve Communication Should 

Anthrax Contamination Occur in the Future, GAO-03-316 (Washington, D.C.: Apr. 7, 2003).

8

GAO, U.S. Postal Service: Clear Communication with Employees Needed before 

Reopening the Brentwood Facility, GAO-04-205T (Washington, D.C.: Oct. 23, 2003).

9

Each of the five facilities was apparently contaminated as (1) envelopes containing anthrax 

or (2) cross-contaminated envelopes passed through high-speed mail-sorting machines in 

the facilities. Two other processing and distribution centers, one in Raleigh, North Carolina, 

and the other in Bellmawr, New Jersey, also tested positive for anthrax, but they are not 

believed to have processed contaminated mail. 
Page 3 GAO-04-239 U.S. Postal Service

• the information communicated to affected postal employees about the 

health risks posed by, and the extent of, contamination in the five 

facilities; and

• how lessons learned from the response to the contamination could be 

used in future situations.

You also asked us to determine what, if any, medical services and 

reassignment benefits were provided to employees at the five facilities and 

how these benefits compared across these facilities as well with those 

provided to employees at facilities closed for other emergencies between 

January 1, 1998, and December 31, 2002. A lesson learned related to the 

need for an emergency medical plan is discussed toward the end of this 

report, and a description of the medical services and reassignment benefits 

is discussed in appendix I. 

To address our reporting objectives, we analyzed, among other things, 

pertinent reports, studies, scientific literature, and guidance for responding 

to anthrax, including public health and postal guidance for closing postal 

facilities. We also interviewed federal, state, and local officials involved in 

investigating and responding to anthrax contamination at the five postal 

processing and distribution centers in our review.10 We discussed, among 

other matters, the roles, responsibilities, activities, and lessons learned by 

the U.S. Postal Service, the Centers for Disease Control and Prevention 

(CDC) and its National Institute for Occupational Safety and Health within 

the Department of Health and Human Services, the Federal Bureau of 

Investigation (FBI) within the Department of Justice, the Environmental 

Protection Agency, the Occupational Safety and Health Administration 

(OSHA) within the Department of Labor, and the U.S. Army Medical 

Research Institute of Infectious Diseases within the Department of 

Defense. We also interviewed local public health officials, postal managers, 

and union representatives associated with each of the five processing and 

distribution centers. In addition, we met with representatives of a group of 

employees who worked at the Brentwood facility prior to its closure. We 

did not examine issues related to the other 18 postal facilities that tested

10Our work related to the Wallingford facility in Connecticut was principally derived from 

previous work we conducted between September 2002 and March 2003. We updated this 

information, obtained additional supporting information, and incorporated the information, 

as appropriate, to address our reporting objectives at the five facilities. 
Page 4 GAO-04-239 U.S. Postal Service

positive for anthrax or matters that are being litigated.11 Likewise, we did 

not assess the response to the anthrax contamination at the Hart Senate 

Office Building in Washington, D.C., because these activities were also 

outside the scope of our work. However, a previous GAO report provides 

information on this topic,12 which we incorporated in this report as 

appropriate. We performed our work from January 2003 through July 2004 

in accordance with generally accepted government auditing standards. 

Further details about our scope and methodology appear in appendix II.

Results in Brief According to postal managers, public health officials, and union 

representatives, the Postal Service considered the health risks to its 

employees ahead of its mission to deliver the mail in deciding whether to 

close postal facilities. Although the Postal Service had guidance that called 

for closure following the discovery of a suspicious letter or a powder spill 

at a facility, it did not consider this guidance applicable because neither a 

suspicious letter nor a powder spill was discovered at Trenton or 

Brentwood. As a result, the Postal Service relied on public health agencies 

to assess the health risks to its employees, and as long as these agencies 

advised the Postal Service that the health risks were minimal, it kept the 

facilities open. When CDC confirmed that employees at Trenton and 

Brentwood had contracted cutaneous and inhalation anthrax, respectively, 

the Postal Service closed these facilities within hours. At the time, CDC 

recommended that facilities be closed for inhalation anthrax, but not for 

cutaneous anthrax, since this form of the disease is considered readily 

treatable. Nevertheless, New Jersey public health officials recommended 

that Trenton be closed to facilitate environmental testing. The Postal 

Service kept the three other processing and distribution centers open 

because public health officials had advised the agency that employees at 

those centers were at minimal risk. During the anthrax response, the Postal 

Service took steps to protect its employees, such as providing gloves and 

disposable masks and reminding employees to wash their hands with soap 

and water if they encountered a suspicious letter or package. Later, the 

Postal Service began testing and installing detection systems at some of its 

11See, e.g., Briscoe v. Potter, No. 1:03cv2084 (DC DC filed Sept. 15, 2003); Hubbard v. Potter, 

No. 1:03cv1062 (DC DC filed Feb. 13, 2004); Trenton Metropolitan Area Local v. the United 

States Postal Service, No. 04-1628(6EB) (DC NJ filed Apr. 6, 2004). 

12See GAO, Bioterrorism: Public Health Response to Anthrax Incidents of 2001, 

GAO-04-152 (Washington, D.C.: Oct. 15, 2003).
Page 5 GAO-04-239 U.S. Postal Service

processing facilities. While union leaders acknowledged the Postal 

Service’s efforts during the response, some postal employees maintain that 

the Postal Service should have taken earlier action to protect them. 

However, critical information that could have alerted public health 

agencies and the Postal Service to the health risks that postal employees 

faced, such as the way the spores were prepared and the potential for 

anthrax spores to leak from taped, unopened envelopes in sufficient 

quantities to cause inhalation anthrax, was not available to them until after 

Brentwood’s closure. According to CDC and the Postal Service, they would 

have made different decisions if they had understood the health risks to 

postal employees earlier. 

The Postal Service communicated information to affected postal 

employees about the health risks posed by, and the extent of, anthrax 

contamination at the five facilities in our review, but problems with the 

accuracy, clarity, and timeliness of the information provided led employees 

to question the information they received. Problems with accuracy 

occurred because the early health risk information public health officials 

provided was based on their existing knowledge and experience that 

proved to be far more uncertain than the officials initially recognized and 

which resulted in underestimating the health risks to postal employees. 

Problems with clarity occurred because information on the medical 

response to anthrax contamination changed as knowledge evolved. For 

example, the Postal Service published and then corrected treatmentrelated information, and CDC revised its treatment recommendations as it 

gained more experience with anthrax. Problems with the accuracy and 

clarity of information communicated were exacerbated by (1) postal 

employees’ perceptions of unequal treatment between the responses to 

anthrax contamination on Capitol Hill and at postal facilities and (2) longstanding distrust of postal management. Problems with timeliness 

occurred when the Postal Service delayed the release of quantitative data 

(anthrax spore counts) from environmental tests at one of the five 

facilities. A union representative had requested this information, and the 

Postal Service was required to disclose it, but the Postal Service delayed 

disclosure in part because it was uncertain what the results meant for 

worker safety and public health. The Postal Service has taken steps aimed 

at communicating more effectively, including establishing a center to 

coordinate information within the postal system and working with other 

agencies to develop guidelines for responding to anthrax. 

The response to anthrax contamination afforded multiple lessons, two of 

which are key. First, it is important for agencies to err on the side of 
Page 6 GAO-04-239 U.S. Postal Service

caution—meaning that agencies should choose a course of action that 

poses the least risk of harm to individuals—when considering actions to 

protect people from uncertain and potentially life-threatening health risks. 

Because public health officials underestimated the health risks involved 

and did not communicate any uncertainty associated with the inferences 

they made based on scientific knowledge and experience, actions to 

protect postal employees were delayed. Furthermore, existing guidance did 

not address certain circumstances, such as the unobservable 

contamination that the Postal Service faced at the Trenton and Brentwood 

facilities in 2001. The Postal Service twice revised its guidance to address 

some of the circumstances it faced; however, the most recent guidance—

issued in December 2003—(1) does not define some key terms, including 

those that would trigger a decision to evacuate a facility, (2) includes some 

outdated references that could cause confusion during a future response, 

and (3) does not address some of the circumstances that the Postal Service 

faced and could face again, such as what steps would be taken in the period 

between a diagnosis of inhalation anthrax in a postal employee and 

confirmation of the disease. Additionally, the revised guidance does not 

reflect the proactive measures that the Postal Service has recently taken, 

such as closing 11 postal facilities in November 2003 after a preliminary 

test—not a confirmed result—from a routine air sample at a U.S. Navy 

mail-processing facility indicated the possibility of anthrax contamination.

The second key lesson is that agencies need to share information in a 

timely manner. Collocating liaisons from CDC and the Postal Inspection 

Service with FBI headquarters officials—who were in charge of the 

investigation—facilitated timely information sharing. Nevertheless, 

agencies reported that information was not always shared within and 

among public health agencies and the Postal Service. Several factors may 

have hindered the prompt exchange of information, including unclear 

responsibilities for decision making and postal employees’ distrust of 

postal management. Agencies have taken steps to improve information 

sharing. Additionally, the Postal Service is working with the Department of 

Homeland Security and other entities responsible for dealing with terrorist 

activity to formulate governmentwide policies and procedures for, among 

other things, paying for emergency medical services. While these policies 

and procedures should help avoid future confusion about such matters as 

where employees should go for emergency medical services and who will 

pay for them, it is not known when they will be available. As a result, if 

another emergency arises in the interim, confusion—such as occurred in 

New Jersey—could again cause delays in payments to providers and/or 

disputes over payments.
Page 7 GAO-04-239 U.S. Postal Service

We are making several recommendations to help ensure that the Postal 

Service has accurate, clear, comprehensive, and up-to-date guidance for 

responding to a future anthrax emergency. Specifically, we are 

recommending that the Postal Service revise its December 2003 guidelines 

to (1) define key terms, including those that would trigger a decision to 

evacuate a facility; (2) ensure that any references to earlier guidance are 

still applicable; and (3) clarify the actions that the Postal Service would 

take under various scenarios, such as when it receives preliminary 

evidence of anthrax contamination. In addition, to ensure timely payment 

to medical providers for emergency medical services provided to postal 

employees exposed to anthrax or other life-threatening substances, we are 

recommending that the Postal Service establish and meet a definitive time 

frame for developing interim policies and procedures on paying for such 

services. 

We requested comments on a draft of this report from the Postal Service, 

CDC, the FBI, the U.S. Army Medical Research Institute of Infectious 

Diseases, and representatives of three postal unions (the American Postal 

Workers Union, the National Postal Mailhandlers Union, and the National 

Association of Letter Carriers). Most of these organizations provided 

technical comments, which we incorporated as appropriate. 

The Postal Service’s written response to our draft report agreed with the 

thrust of our recommendations. For example, the Postal Service said that it 

either (1) had revised or (2) would revise and clarify its guidance, and we 

eliminated one proposed recommendation to reflect its action. The Postal 

Service also said that it was taking alternative action to address our 

recommendation about the need for policies and procedures for paying 

providers of emergency medical services. Finally, although the Postal 

Service said that we concluded that its decisions in 2001 were appropriate 

under the circumstances, we did not draw conclusions on this issue. As 

stated in our report, our first objective was to describe the factors 

considered in deciding whether to close the five postal facilities and the 

actions taken to protect postal employees—not to assess the 

appropriateness of the Postal Service’s actions and decisions. 

CDC provided detailed written comments to clarify portions of the draft 

report. For example, in its general comments, CDC objected to our use of 

the term “assumptions” to describe how it arrived at its public health 

recommendations. CDC noted that its recommendations were based on the 

best available science as well as its “inferences from previous experience 

and [its] epidemiological observations in Florida and New York, where no 
Page 8 GAO-04-239 U.S. Postal Service

disease occurred among postal workers.” We revised the report to more 

clearly describe the limitations of available knowledge and experience in 

the fall of 2001 and how these limitations led to the development of 

incorrect inferences and working assumptions about the health risk to 

postal employees. We also addressed CDC’s technical comments, as 

appropriate, in the body of the report. 

Background 

Health Effects of Anthrax Anthrax is an acute infectious disease that is caused by the Bacillus 

anthracis bacterium, which is commonly found in the soil and forms 

spores (like seeds) that can remain dormant for many years. Although 

anthrax can infect humans, it occurs most commonly in plant-eating 

animals. Human anthrax infections are rare in the United States and have 

usually resulted from occupational exposure to infected animals or 

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

occur in three forms, two of which are relevant to this report—cutaneous 

anthrax, which occurs from exposure to spores through a cut or abrasion,13

and inhalation anthrax, which results from breathing airborne spores into 

the lungs.14 After anthrax spores enter the body, they can germinate into 

vegetative cells, which then multiply and secrete toxins that can produce 

local swelling and tissue death. The symptoms differ for each form of 

infection. According to a June 4, 2004, CDC Morbidity and Mortality Report, 

the incubation period for anthrax is usually less than 2 weeks; however, 

because spores can remain dormant for a long time and may be slow to 

clear from the lungs, the incubation period for inhalation anthrax can be 

prolonged for months.

13Cutaneous means “of, relating to, or affecting the skin.” Cutaneous anthrax is 

characterized by skin lesions.

14The third form of anthrax, gastrointestinal, results from ingesting undercooked 

contaminated meat. 
Page 9 GAO-04-239 U.S. Postal Service

People exposed to anthrax in its natural environment generally do not 

contract inhalation anthrax. Before the fall of 2001, no cases of inhalation 

anthrax had been reported in the United States since 1976.15 In the fall of 

2001, information on the effects of exposure to refined anthrax was 

limited,16 but some information was available about a suspected release in 

1979 of anthrax from a bioweapons facility in the former Soviet Union. 

According to published accounts, the release—which U.S. authorities 

believe was accidental—resulted in 79 cases of inhalation anthrax, 68 of 

which were fatal. The effects of exposure depend on the amount and form 

of exposure as well as the health of the individual exposed. A person can be 

exposed to anthrax and not develop the disease. 

Anthrax is treatable with a variety of antibacterial drugs, such as 

amoxicillin, ciprofloxacin, and doxycycline. The optimal duration of 

preventive treatment for anthrax, known as prophylaxis, is uncertain; 

however, because of prolonged incubation—when inhaled spores can 

remain in the lungs and then germinate and cause disease—CDC currently 

recommends at least 60 days of antibacterial drugs and enrollment in an 

investigational new drug protocol to receive the anthrax vaccine. Fatalities 

are rare for cutaneous anthrax.17 Inhalation anthrax is far more lethal. 

According to CDC, the reported fatality rate was approximately 75 percent 

for the 18 cases of inhalational disease detected in the United States in the 

20th century. In 2001, with antibacterial drugs and aggressive care, about 

half the cases ended in death. 

A diagnosis of anthrax is based on a review of a person’s symptoms and the 

results of initial tests, which are confirmed by additional laboratory testing. 

While a range of laboratory tests exists for detecting anthrax in the 

15In 1976 a self-employed weaver in California contracted the disease from exposure to 

contaminated imported yarn containing goat hair. Between 1950 and August 2001, CDC 

investigated nine cases of inhalation anthrax, six of which occurred in 1957. Five of the 1957 

cases were caused by exposure to contaminated goat hair at a textile mill in New 

Hampshire. Between 1944 and 1994, 224 cases of cutaneous anthrax were identified. See 

“Anthrax as a Biological Weapon, 2002: Updated Recommendations,” Journal of the 

American Medical Association, 287 (2002): 2236-2252.

16The process of refining a substance purifies it. The more refinement that occurs, the more 

highly purified a substance becomes.

17According to information available on CDC’s Web site as of June 14, 2004, early treatment 

with antibacterial drugs cures most cases of cutaneous anthrax. Even if untreated, CDC 

reported that “80 percent of the people who become infected with cutaneous anthrax do not 

die.” 
Page 10 GAO-04-239 U.S. Postal Service

environment and in a person’s body, analysis of the bacteria’s growth in a 

culture is considered the most reliable method for confirming the presence 

of anthrax. 

CDC classifies illness as “confirmed” or “suspected.” According to CDC, a 

confirmed case of anthrax is clinically compatible with the disease and was 

either (1) confirmed by isolating anthrax bacteria cultured from a patient’s 

clinical specimens or (2) associated with other laboratory evidence of 

anthrax infection obtained from at least two supportive tests. A suspected 

case is clinically compatible with anthrax but cannot be definitively 

confirmed by laboratory tests—possibly because the person has begun 

taking medication.18 According to CDC, a case would be classified as 

“suspected” if there was no alternative diagnosis and no anthrax bacteria 

were isolated, but there was either (1) laboratory evidence of anthrax 

obtained from one supportive laboratory test or (2) an epidemiological link 

to an environmental anthrax exposure.19

The U.S. Mail System The mission of the Postal Service is to provide affordable, universal mail 

service. As of May 28, 2004, the Postal Service had over 800,000 employees 

who process more than 200 billion pieces of mail per year. The Postal 

Service’s infrastructure includes its headquarters office in Washington, 

D.C.; 9 area offices; approximately 350 mail processing and distribution 

centers, including the 5 facilities in our review; and about 38,000 post 

offices, stations, and branches. The processing and distribution centers 

vary widely in size and capacity, as illustrated by the differences among the 

facilities in our review (see table 1).

18CDC classified 4 of the 22 anthrax cases as suspected. All 4 were cases of cutaneous 

anthrax.

19Centers for Disease Control and Prevention, Department of Health and Human Services, 

Emerging Infectious Diseases, vol. 8, No. 10 (October 2002): 1020.
Page 11 GAO-04-239 U.S. Postal Service

Table 1: Characteristics of the Five Processing and Distribution Centers in Our 

Review, Fall 2001

Source: GAO presentation of Postal Service data.

Note: Numbers are approximate.

Mail processing facilities use several types of high-speed machines to 

process letters. First, at the facility that initially receives a letter for 

mailing, an Advanced Facer-Canceller System cancels the postage stamp, 

among other functions. Other machines with optical character readers 

apply bar codes and markings to the envelopes for identification and 

sorting. The bar codes and markings identify, among other things, the time 

and date of processing, the machine and facility that processed the 

envelope, and the delivery destination. During the fall of 2001, the Postal 

Service used this information to track the path of contaminated envelopes 

through the U.S. mail system. Subsequently, a Delivery Bar Code Sorter 

machine sorts the mail using the bar codes. These machines process about 

37,000 letters per hour, using belts and rollers that repeatedly squeeze the 

letters. During processing, paper dust accumulates, particularly on pinch 

rollers that move the mail through the machines. These rollers are hard to 

access using vacuum nozzles and, as a result, compressed air was typically 

used to blow debris out of the machines until it was banned in October 

2001, due to concerns about the potential for spreading anthrax in mail 

processing facilities.

The Postal Service provides for the security of the mail and the 

enforcement of federal postal laws through its Postal Inspection Service, 

which employs approximately 1,970 fact-finding and investigative postal 

inspectors and 1,100 uniformed postal police officers.

Facility

Size (in square

feet)

Mail volume/capacity 

per day

Number of

employees

Trenton 282,000 4 million 960

Brentwood 684,000 5 million 2,490

Morgan 2.1 million 12.5 million 5,000

West Palm Beach 185,000 6 million 930

Wallingford 350,000 3 million 1,120 
Page 12 GAO-04-239 U.S. Postal Service

Fall 2001 Anthrax Incidents During the fall of 2001, at least four letters containing anthrax spores were 

sent through the U.S. mail—two to media personnel and two to U.S. 

Senators. The first two recovered letters were sent on September 18, 2001, 

to a television news anchor at the National Broadcasting Company (NBC) 

and to the editor of the New York Post in New York City. At about the same 

time, investigators suspect that other letters containing anthrax were 

mailed to employees at the American Broadcasting Company (ABC) and 

the Columbia Broadcasting System (CBS) in New York City and at 

American Media Incorporated—a company that publishes the National 

Enquirer in Boca Raton, Florida—although no contaminated envelopes 

were recovered from these locations.20 About 3 weeks later—on October 

9—a letter containing anthrax spores was sent to Senator Thomas Daschle. 

The letter was opened in the Hart Senate Office Building on October 15 and 

was immediately viewed as high risk to Senator Daschle’s staff and first 

responders because the envelope contained a visible white powder that the 

accompanying letter identified, and testing quickly confirmed, as anthrax. 

Another letter containing anthrax spores was mailed to Senator Patrick 

Leahy at about the same time; however, it was not discovered until 

November 16, 2001. The letter was found unopened in a barrel of 

government mail that the FBI had impounded following the release of 

anthrax contained in Senator Daschle’s letter. The two recovered letters to 

NBC and the Post were processed on high-speed mail-sorting machines at 

the Trenton and Morgan facilities. The letters to the two Senators were 

similarly processed at Trenton and at the Brentwood facility in Washington, 

D.C.

Processing and delivering the letters contaminated or cross-contaminated 

numerous facilities, including the Hart Senate Office Building and 23 postal 

facilities, and resulted in the deaths of five people, including two postal 

employees. Investigators have not yet identified the person or persons 

responsible for these mailings. Meanwhile, the Postal Service has reported 

about 20,000 incidents involving suspicious packages or powder spills 

since the fall of 2001. (Fig. 1 shows the date of confirmed or suspected 

illness, type, and location of the anthrax cases that resulted from the fall 

2001 mailings.) 

20Individuals at these locations developed the disease, indicating that contaminated letters 

may also have been delivered there. Employees of American Media Incorporated in Florida 

developed inhalation anthrax, whereas individuals in New York initially developed only the 

cutaneous form of the disease.
Page 13 GAO-04-239 U.S. Postal Service

Figure 1: Date in 2001, Type, and Location of Anthrax Cases

Note: The date reflects when CDC either (1) confirmed a case of anthrax or (2) suspected a case of 

anthrax that could not be confirmed.

Trenton

Wallingford

New York City

West Palm Beach

Boca Raton

Washington, D.C.

2001

Maryland

Connecticut

Florida

New Jersey

New York

Pennsylvania

Virginia

10/4

10/12

10/15

Inhalation (confirmed), Floridab

Inhalation (confirmed), New Jerseya, c

Cutaneous (confirmed), New York

Inhalation (confirmed), New Jerseya, c

Cutaneous (confirmed), New Jersey

Inhalation (confirmed), New Yorkb

Inhalation (confirmed), Connecticutb

Inhalation (confirmed), Florida

Cutaneous (confirmed), New York 

Cutaneous (confirmed), New York

Cutaneous (suspected), New York

10/18

10/19

Inhalation (confirmed), Virginiaa, d

Inhalation (confirmed), Virginia

Inhalation (confirmed), Marylanda, d

Cutaneous (suspected), New York

Inhalation (confirmed), Marylanda, b, d

Inhalation (confirmed), Marylanda, b, d

Cutaneous (suspected), New Jerseya, c

Cutaneous (confirmed), New Jerseya, c

Cutaneous (confirmed), New York 

Cutaneous (confirmed), Pennsylvaniaa, c

Cutaneous (suspected), New York 

10/21

10/22

10/23

10/25

10/26

10/28

10/30

10/29

11/21

Source: GAO analysis of CDC documentation.
Page 14 GAO-04-239 U.S. Postal Service

a

This case involved a postal employee. 

b

This person died from inhalation anthrax.

c

This person worked at or was associated with the Trenton facility in New Jersey.

d

This person worked at the Brentwood facility in Washington, D.C.

As shown in figure 1, CDC confirmed the first case of anthrax on October 4, 

2001, in an employee of American Media Incorporated in Boca Raton, 

Florida. He died the following day from inhalation anthrax. Ten days after 

his death, CDC confirmed that a coworker—a mailroom employee at the 

company—also had inhalation anthrax. The coworker subsequently 

recovered. Even though the source of contamination was never found, 

investigators thought that the two employees contracted the disease 

through their proximity to an opened letter or letters containing anthrax 

spores.21 If there was such a letter (or letters), it would likely have been 

processed on high-speed mail-sorting machines at the West Palm Beach, 

Florida, facility. Between October 12 and October 28, 2001, six media 

employees and the child of an ABC employee who had visited ABC 

developed cutaneous anthrax in New York City—the second location with 

anthrax cases. Investigators thought that these cases resulted from either 

handling envelopes containing anthrax spores or being exposed to 

contaminated work sites. On October 30, an eighth case of anthrax was 

confirmed in New York—the only inhalation case there.22 The initial cases 

at the third location with anthrax cases—New Jersey—involved, for the 

first time, postal employees, two of whom were confirmed with cutaneous 

anthrax on October 18 and 19, 2001.23 Investigators thought that the 

employees had contracted the disease by handling the mail, rather than by 

opening or being exposed to opened letters containing anthrax spores. (See 

app. III for a timeline of key events.)

21Given that a contaminated envelope or package was not recovered, investigators could not 

initially establish how the anthrax had been delivered to American Media Incorporated—by 

U.S. mail or by some other means, such as a courier delivery. According to CDC, 

investigators began to explore the possibility that the Postal Service may have delivered a 

letter containing anthrax as early as October 10, 2001. However, according to the Postal 

Service, it was not until October 12—when it learned that it had delivered the letter 

recovered at NBC—that the link to the U.S. mail system was clearly established. 

22Unlike the other cases in New York, this individual was a hospital employee while the 

other seven were media employees or their children. Investigators believe that she was 

probably exposed to mail that had been cross-contaminated by its proximity to one of the 

letters containing anthrax spores.

23On October 18, 2001, CDC classified another New Jersey postal employee as having a 

“suspected” case of cutaneous anthrax.
Page 15 GAO-04-239 U.S. Postal Service

The first postal employee confirmed with inhalation anthrax worked at the 

Brentwood facility in Washington D.C.—the fourth location with anthrax 

cases. The confirmation of a case of inhalation anthrax revealed that 

processing unopened mail could release enough anthrax spores to cause 

inhalation anthrax, depending on the health of the person exposed and the 

aerosolization capacity of the anthrax spores. Subsequent inhalation cases, 

including the case involving the Wallingford, Connecticut postal facility—

the fifth location with an anthrax case—underscored this finding. (Table 2 

summarizes, for each location, the number of confirmed or suspected cases 

of cutaneous and inhalation anthrax among postal employees and others.)

Table 2: Distribution of Anthrax Cases, Fall 2001 

Source: GAO analysis of CDC information.

Roles and Responsibilities 

of Responders

Responding to health emergencies, including bioterrorist attacks, is 

generally a local responsibility, but localities can—and did—request CDC’s 

assistance in the fall of 2001. State and local health departments and 

CDC—which has responsibility for the nationwide surveillance of specific 

diseases, including anthrax—provided public health advice and assistance 

to the Postal Service. CDC also performed tests needed to confirm the 

cases of anthrax and conducted epidemiological investigations to

Type of anthrax and affected population 

Cutaneous Inhalation 

Facility location

Number of 

confirmed or 

suspected 

cases

Postal 

employees Others

Postal 

employees Others

Florida 2 0 0 0 2

New York 8 0 7 0 1

New Jersey 6 3 1 2 0

Washington, D.C. 5 0 0 4 1

Connecticut 1 0 0 0 1

Total 22 3 8 6 5
Page 16 GAO-04-239 U.S. Postal Service

determine, among other things, how the disease had occurred at the 

affected locations.24

Numerous other federal agencies were responsible for investigating and 

responding to the anthrax mailings. The FBI was, and still is, responsible 

for the criminal investigation. The Postal Service’s Inspection Service 

continues to assist the FBI in the investigation. Other agencies, including 

the National Institute for Occupational Safety and Health and the Agency 

for Toxic Substances and Disease Registry, also within the Department of 

Health and Human Services, helped the Postal Service conduct 

environmental tests of its facilities and advised the agency about the 

facilities’ decontamination.25 The agencies collected samples from multiple 

locations throughout the facilities, analyzed the samples, and used the 

results of their analyses to guide decontamination activities in the facilities. 

The U.S. Army Medical Research Institute of Infectious Diseases—which 

conducts basic and applied research in the diagnosis, treatment, and 

prevention of hazardous infectious diseases for the military—analyzed 

environmental samples from some postal facilities. In addition, it analyzed 

the substances in the anthrax-contaminated letters recovered in New York 

and Washington, D.C., for the FBI. OSHA, which has responsibility for 

employee health and safety issues, provided technical assistance and 

guidance to the Postal Service on the decontamination of postal facilities. 

At Wallingford, OSHA also investigated the Postal Service’s disclosure of 

test results at the facility after a union leader filed a complaint with OSHA 

alleging that the Postal Service had not complied with OSHA’s requirements 

for disclosing such results.

On October 8, 2001, the President created the Office of Homeland Security 

to develop and coordinate a comprehensive national strategy for dealing 

24Epidemiological investigations involve interviews with family members, associates, 

coworkers, and other possible contacts for the purpose of eliminating some possibilities 

and focusing on others. For example, according to a handbook prepared by the FBI, if 

interviews with coworkers prove to be negative and no one else at work is affected, then 

public health investigators may be able to rule out the workplace as the source for the 

disease. Similarly, if interviews suggest the individual’s associates have signs of the disease 

and that they shared a common experience, such as attending the same event, investigators 

may be able to focus their investigation on the common experience. The FBI prepared the 

Criminal and Epidemiological Investigation Handbook (2003) in consultation with public 

health officials and the U.S. Army Soldier and Biological Chemical Command.

25The Environmental Protection Agency was also involved in discussions about and 

activities related to the decontamination of postal facilities, including the Brentwood 

facility. 
Page 17 GAO-04-239 U.S. Postal Service

with domestic terrorist threats or attacks. Because the office was just 

gearing up, it had limited involvement in the response to the 2001 anthrax 

incidents. The Homeland Security Act of 2002 created a cabinet-level 

agency, the Department of Homeland Security. The department is 

composed of 22 previously separate agencies and is responsible for 

coordinating the efforts of federal agencies that respond to acts of 

terrorism in the United States, including any future anthrax incidents. 

Postal Service 

Primarily Considered 

Health Risks to 

Employees in Deciding 

to Close Facilities 

In deciding whether to close the five facilities in our review, the Postal 

Service first considered the health risks to its employees and then 

considered its mission to process and deliver the mail. As long as public 

health agencies advised the Postal Service that health risks to its 

employees were minimal, it kept the facilities open. However, the Postal 

Service closed the facilities hours after CDC confirmed that employees at 

Trenton and Brentwood had contracted anthrax. The three other facilities 

remained open because public health officials had advised the Postal 

Service that employees at those facilities were at minimal risk. During the 

anthrax incidents, the Postal Service took steps to protect its employees, 

including providing gloves and disposable masks and reminding employees 

to wash their hands with soap and water if they encountered a suspicious 

letter or package. More recently, the Postal Service began testing and 

installing detection systems at some of its processing facilities. 

Nevertheless, some postal employees maintain that the Postal Service 

should have taken earlier action to protect them. Agencies lacked critical 

information, such as the potential for anthrax spores to leak from taped, 

sealed envelopes. According to CDC and the Postal Service, they would 

have made different decisions if they had understood the health risks to 

postal employees earlier. 
Page 18 GAO-04-239 U.S. Postal Service

The Postal Service 

Considered Health Risks to 

Employees Ahead of Other 

Factors

Postal managers, public health officials, and union representatives 

reported that the Postal Service considered several factors in deciding 

whether to close the five postal facilities in our review, but the health of its 

employees was its first concern. Unfortunately, however, CDC and local 

public health organizations—which relied on their knowledge and 

experience at that time—and the Postal Service, which relied on the advice 

it received from public health officials, incorrectly perceived the health risk 

to be minimal for several reasons. First, because postal employees did not 

contract anthrax during the earlier incidents in Florida and New York, CDC 

determined—consistent with its investigations of outbreaks involving 

naturally occurring infectious diseases—that postal employees were not at 

risk because the same conditions would likely apply to subsequent clusters 

of cases and letters.26 Second, the recovered envelopes—those sent to 

media representatives in New York and to the Senators—were taped and 

unopened when they arrived at their destinations, suggesting that the 

addressees, rather than postal employees, were the targets of the attacks 

and the persons whose health could be at risk. Third, the available 

scientific information indicated that (1) anthrax spores in nature typically 

aggregate to form particles that do not readily aerosolize and (2) exposure 

to thousands of spores would be needed to cause inhalation anthrax.27 This 

information led CDC and others to conclude that the anthrax particles in 

the contaminated letters would generally not leak through taped, unopened 

envelopes in sufficient quantities to cause inhalation anthrax. While public 

health officials recognized that handling unopened, contaminated letters 

might result in exposure to some spores that could possibly cause 

cutaneous anthrax, they believed that wearing gloves would protect postal 

employees from this readily treatable condition and did not think that 

26According to CDC, once risk is understood in cases involving a naturally occurring disease, 

it generally remains constant. Thus, early cases often provide clues to the mode and source 

of exposure. For bioterrorism-related diseases, however, the characteristics of the initial 

cases can be misleading because, as CDC and others learned in the fall of 2001, the 

perpetrator may vary the mode of transmission and source of exposure. 

27Various estimates of the amount of spores needed to cause inhalation anthrax existed in 

the fall of 2001. For example, according to a letter to members of the American Postal 

Workers Union in December 2001, early on, the medical community had suggested that 

8,000 to 10,000 spores would be needed to cause the disease. Other estimates ranged from 

8,000 to 22,000 and 2,500 to 55,000. In its technical comments on our draft report, CDC 

informed us that—based on research of primates—exposure to 8,000 to 50,000 aerosolized 

spores is sufficient to kill 50 percent of the animals exposed. However, CDC noted that the 

infectious dose in humans by any route is not known and the influence of the bacterial strain 

or host factors on the infectious dose is not completely understood. 
Page 19 GAO-04-239 U.S. Postal Service

postal facilities should be closed to avoid it. Accordingly, CDC advised the 

Postal Service that the health risks to postal employees from the 

contaminated letters were minimal and that there was no need to close 

facilities that had processed the contaminated letters. Absent evidence of 

illness among their employees and given the views of public health 

officials, postal managers said they focused on other factors, including (1) 

the psychological importance of keeping the mail moving in the aftermath 

of the September 11, 2001, attacks and (2) the widespread economic 

consequences of shutting down portions of the mail system. According to 

postal managers, it would have been irresponsible to close postal facilities 

without any recommendation to do so by public health or law enforcement 

authorities, such as the FBI. 

Neither Existing Closure 

Guidance Nor Later 

Instructions Were 

Applicable to the 

Circumstances Surrounding 

the Fall 2001 Anthrax 

Mailings

The Postal Service had guidance for responding to anthrax and other 

hazardous incidents, but this guidance did not address the events that the 

Postal Service faced in the fall of 2001. The existing guidance—“Emergency 

Response to Mail Allegedly Containing Anthrax”—was issued in October 

1999 in response to a growing number of suspicious incidents, including 

spills involving white powder. The guidance specified emergency response 

procedures and management actions for dealing with suspicious mail 

(letters, packages, and other pieces of mail) found in a U.S. postal facility. 

The guidance required postal managers to minimize the potential for 

employees to be exposed by quickly isolating any suspicious mail and 

promptly evacuating an affected facility.28 However, the guidance 

addressed discovered incidents—a suspicious piece of mail or a powder 

spill—not undetected incidents such as those that occurred at the five 

facilities in our review. Each of these facilities was apparently 

contaminated as (1) envelopes containing anthrax or (2) crosscontaminated envelopes passed through high-speed mail-sorting machines 

in the facilities.29 Because neither a suspicious piece of mail nor any 

leakage from a piece of mail was observed, there was a time lag between 

the exposure and the discovery of contamination. On October 19, 2001, as 

the anthrax events were unfolding, the Postal Service issued additional 

28According to the Postal Service, there are numerous possible indicators of a suspicious 

piece of mail, including stained mail or mail that emits an odor. Mail with a threatening 

message or containing loose sifting material may also cause suspicion, as may mail with 

excessive postage or weight, a handwritten or poorly typed address, no return address, and 

a lopsided or uneven envelope.

29Envelopes can be cross-contaminated when processed close to a letter containing anthrax.
Page 20 GAO-04-239 U.S. Postal Service

instructions for dealing with suspicious powder spills or the discovery of a 

suspicious piece of mail. However, these instructions—based on CDC 

advisories and termed “decision trees”—were intended to deal with the 

discovery of a suspicious package or piece of mail at a facility and, as 

subsequently became apparent, also did not address the circumstances that 

occurred in the fall of 2001 since no suspicious mail was discovered. 

Postal Service Closed 

Facilities after CDC 

Confirmed Illness 

Once CDC confirmed that postal employees had contracted anthrax, the 

Postal Service closed Trenton and Brentwood. It closed Trenton on 

October 18, 2001, within hours after CDC confirmed that a letter carrier—

the first postal employee affected—had cutaneous anthrax. Initially, CDC 

did not recommend that the entire Trenton facility be closed because, at 

the time, it viewed facility closures as unnecessary for cases of cutaneous 

anthrax, since this form of the disease is readily treatable with antibacterial 

medication. Nevertheless, public health officials from the New Jersey 

Department of Health and Senior Services recommended that Trenton be 

closed to facilitate environmental testing of the facility.30 According to 

CDC, it concurred with this decision. The mail-processing area on the first 

floor of Brentwood was closed on October 21, 2001, after CDC confirmed 

that an employee there had inhalation anthrax. This is the same day that 

the first of two postal employees died.31 The second floor of the facility, 

which housed administrative offices, was subsequently closed on October 

22, 2001. Public health authorities began dispensing antibacterial drugs to 

the two facilities’ postal employees soon after the closures.

30On October 28 and 29—about a week and a half later—CDC confirmed cases of inhalation 

anthrax in two Trenton employees, and Trenton remained closed.

31The two deceased employees sought medical attention but were not diagnosed with the 

disease before they died. 
Page 21 GAO-04-239 U.S. Postal Service

The Postal Service kept West Palm Beach, Morgan, and Wallingford open 

based on the advice of public health officials who indicated that postal 

employees were at minimal risk.32 While CDC and local public health 

agencies did not believe that the employees were at risk, they nevertheless 

offered antibacterial drugs to employees at the three facilities. At these 

facilities, the contaminated areas were isolated and decontaminated while 

operations continued elsewhere in the facilities. 

The Postal Service Took 

Steps to Protect Its 

Employees, Including 

Revising Its Guidelines on 

Facility Closures 

Nationwide, the Postal Service took several actions to protect its 

employees from anthrax. For example, during the response, it provided 

employees with protective equipment, such as gloves and disposable 

masks, and information on handling suspicious mail. Consistent with CDC’s 

advice, the Postal Service also reminded employees to wash their hands 

with soap and water if they encountered a suspicious letter or package. In 

addition, the Postal Service required postal managers to update their 

facilities’ emergency action plans and on October 16, 2001, restricted the 

use of high-pressure compressed air to clean mail-sorting equipment. For 

routine cleaning, employees were advised to vacuum the equipment first 

and, if more effective methods were needed, to use compressed air, but to 

limit the amount of pressure they used. On October 26, 2001, the Postal 

Service banned the use of compressed air altogether. The initial restriction 

and subsequent ban were intended as a precaution to help ensure that dirt, 

paper dust, and any existing spores would not be blown around a postal 

facility. According to postal managers, these actions seemed sufficient in 

view of the health risk information available to them at the time. 

32By the time environmental testing revealed contamination, the typical incubation period 

for inhalation anthrax (less than 2 weeks) had already passed. The West Palm Beach and 

Morgan facilities are believed to have been contaminated by letters sent in mid-September 

2001. Thus, when contamination was identified in the facilities on October 29 and October 

23, respectively, the most likely period of incubation had already passed. Wallingford was 

believed to have been contaminated in mid-October; however, the contamination was not 

identified until December 2, about 6 weeks later. 
Page 22 GAO-04-239 U.S. Postal Service

After closing Trenton on October 18, the Postal Service took additional 

steps to protect Brentwood employees. For example, although the Postal 

Service—following CDC’s advice—kept Brentwood open until CDC 

confirmed a case of inhalation anthrax, postal officials said that they 

consulted public health officials about the possible health risks to 

Brentwood employees. These consultations occurred after the Postal 

Service learned that the letter to Senator Daschle contained anthrax and 

had been processed through the U.S. mail—rather than delivered through 

another means, such as a courier—which meant that it would have been 

processed at Brentwood. In addition, on October 17, 2001, the Postal 

Service arranged for a series of environmental tests at Brentwood after it 

became aware that the Senate mailroom had tested positive for anthrax. 

The Postal Service arranged for the tests even though CDC determined 

from its epidemiological investigations that testing was not needed. The 

first tests—called “quick tests”—occurred on October 18, the same day that 

Trenton was closed. A local hazardous materials response team conducted 

these two quick tests, and the results, which were available later that day, 

were negative.33 According to the contractor’s documentation, the positive 

results from other tests—also taken on October 18—were not available 

until October 22—the day after a Brentwood employee was confirmed with 

inhalation anthrax and the facility was closed.34 In addition, the Postal 

Service reported that it requested both nasal swabs and medication for 

Brentwood employees in the days before the facility was closed.35

However, according to postal managers, the requests were not

33The tests were taken using hand-held assays that instantaneously analyze samples for 

anthrax. According to CDC, these tests are not reliable for detecting anthrax. 

34In contrast to the quick tests, these samples were cultured and analyzed in a laboratory 

setting.

35Nasal swabs are samples taken from an individual’s nasal passages, preferably soon after a 

possible exposure to contamination. During the fall of 2001, the samples were sometimes 

taken to determine the location and extent of contamination at a facility or site. However, 

nasal swabs are not useful in diagnosing the disease in an individual or in evaluating an 

individual’s risk of disease, in part, because a negative result does not mean a person will 

not contract the disease. In addition, a positive result does not mean that a person has 

contracted the disease because, among other reasons, spores can wash out of the person’s 

nasal passages before being inhaled.
Page 23 GAO-04-239 U.S. Postal Service

initially successful because public health officials informed them that 

neither was necessary.36

While noting that Postal Service officials could have taken other actions to 

respond to the anthrax incidents, postal union leaders nevertheless praised 

the Postal Service for its efforts to provide a safe work environment and to 

prevent future occurrences, as well as to involve them in the response and 

to keep employees informed. For example, in testimony delivered to the 

House Committee on Government Reform on October 30, 2001, two union 

leaders stressed that the Postal Service had acted in good faith and that its 

decisions, including those about Brentwood, were guided by the advice and 

recommendations it received from the medical community. 

Although the Postal Service sought the advice of public health agencies and 

took more precautions than had been recommended, some employees 

maintained that it did not act quickly enough to protect them. The 

employees cited a number of factors that, in their view, should have caused 

the Postal Service and others to conclude sooner that postal employees 

could be at risk. First, according to these employees, the fact that the 

anthrax was contained in an ordinary envelope—not packed in multiple 

layers to prevent leakage and damage—should, by itself, have caused 

authorities to conclude that spores could have escaped from the

36In its technical comments on a draft of our report, CDC noted that nasal swab samples 

were collected on October 21 - 22, 2001—after the facility closed. Public health officials 

collected the samples as they distributed antibacterial drugs to employees of and visitors to 

the Brentwood facility. According to CDC, 3,110 nasal swabs were collected, all of which 

were negative for anthrax.
Page 24 GAO-04-239 U.S. Postal Service

envelopes.37 Second, apart from whether the packaging was adequate, 

employees noted that mail-processing machines function at high speeds 

and that the machines’ mechanisms repeatedly squeeze mail as it moves 

through the mail system. This process creates a great deal of dirt and paper 

dust, demonstrating, according to the employees, that mail can leak—a 

possibility that they said the Postal Service should have recognized earlier. 

Compounding this risk, they said, was the long-standing use of compressed 

air to clean postal processing machines. The Postal Service terminated the 

use of compressed air on October 26, 2001, but until then, the employees 

say, its use re-aerosolized spores that had accumulated within mailprocessing machines.38 Finally, some employees expressed concern about 

what they perceived as a delay in closing postal facilities. They compared 

the decision to close congressional offices soon after anthrax was 

identified in the letter to Senator Daschle on October 15 with the Postal 

Service’s decision to wait until cases of anthrax were confirmed, leading 

some employees to conclude that their health was of less concern than that 

of congressional employees.39 This perception was particularly an issue at 

Brentwood, where two employees died and some postal employees 

attributed the differences in the responses to unequal treatment. 

In November 2001, the Postal Service issued “interim guidance” for the 

sampling, analysis, decontamination, and disposal of anthrax in postal 

37By statute, infectious materials such as anthrax spores that are “disease germs or scabs, 

[or] other natural or artificial articles, compositions, or material which may kill or injure 

another” cannot be mailed. Such materials are termed “nonmailable matter.” Knowingly 

mailing such material is a criminal offense and doing so with the intent to kill or injure is a 

felony. When an etiologic material (infectious substance) is not “outwardly or of [its] own 

force dangerous or injurious to life, health, or property,” the Postal Service may allow it to 

be mailed subject to appropriate rules and regulations governing its preparation and 

packing. As a result, the Postal Service allows the mailing of small quantities of 

appropriately packaged infectious material, but only if it is intended for medical or 

veterinary use, research, or laboratory certification related to public health. In those 

instances, the infectious material must be contained within a securely sealed, pressure 

resistant, watertight primary receptacle surrounded with an absorbent and cushioning 

material. This in turn is enclosed in a securely sealed, watertight, and durable secondary 

packaging which must be enclosed in an outer packaging constructed of fiberboard or other 

equivalent material.

38As discussed earlier, the Postal Service placed limitations on the use of compressed air on 

October 16, 2001, and terminated its use on October 26, 2001.

39Differences between the responses to anthrax contamination on Capitol Hill and at postal 

facilities reflected differences in the circumstances at the locations (a powder identified in a 

letter and positively tested as anthrax on Capitol Hill versus no observable evidence of 

contamination at postal facilities). This topic is discussed in more detail later in this report.
Page 25 GAO-04-239 U.S. Postal Service

facilities that specified, among other things, factors to be considered in 

making future closure decisions.40 Such guidance did not exist before the 

fall 2001 anthrax incidents and, unlike the 1999 guidance, it specifically 

addressed unobserved exposures. According to the guidance, postal 

facilities would be closed (1) “if a confirmed case of inhalation anthrax is 

identified and a probable site of exposure is detected” or (2) when evidence 

suggests an aerosolization of anthrax in the facility (as evidenced by a 

positive sample from the heating and ventilation system).41 This guidance 

was consistent with guidance that CDC issued on November 9, 2001.42

Agencies Lacked Critical 

Information Needed to 

Accurately Assess Health 

Risk to Postal Employees

Agencies lacked critical information needed to accurately assess the health 

risk to postal employees. For example, officials from the Postal Service, 

CDC, and other public health agencies acknowledged that, early on, they 

had little knowledge of (1) the characteristics and properties of refined 

anthrax; (2) the potential for anthrax spores to leak from taped, sealed 

envelopes; or (3) the effects of these factors on individuals’ health. Public 

health officials, for example, told us that until the first cases of anthrax 

were confirmed in Trenton and Brentwood postal employees, there was no 

evidence that anyone handling unopened mail would be at risk of 

contracting inhalation anthrax. Analyses of the substance in the recovered 

envelopes contributed additional information to their understanding. For 

example, on October 19, the U.S. Army Medical Research Institute of 

Infectious Diseases relayed its observations to the FBI that the anthrax 

particles in the letter to Senator Daschle were as small as 1 micron in 

diameter.43 The Army Institute delivered a written report of the results of its

40Interim Guidelines for Sampling, Analysis, Decontamination, and Disposal of Anthrax 

for U.S. Postal Service Facilities, November 16, 2001. 

41In addition, the guidelines state that closure may occur if recommended by a state or local 

health department, the FBI, or the Postal Inspection Service. 

42CDC’s November 9, 2001, guidelines state that closing a facility may be indicated (1) after a 

case of inhalation anthrax is detected and a probable site of exposure is identified; (2) when 

there is a known aerosolization of anthrax in the facility; (3) where evidence strongly 

suggests an aerosolization of anthrax has occurred; or (4) as determined by law 

enforcement authorities in a criminal investigation. 

43A micron equals 1 millionth of a meter, or 1 thousandth of a millimeter. The period at the 

end of a sentence is approximately 500 microns in diameter. 
Page 26 GAO-04-239 U.S. Postal Service

analyses to the FBI on October 22—the day after Brentwood’s closure.44 At 

about the same time, the FBI analyzed the pore size of envelopes used for 

the mailings and determined that the envelopes were extremely porous.45

The results—available on October 23, 2001—revealed that the pores of the 

envelopes were larger than some of the anthrax particles, making it 

possible for the anthrax to escape through the envelopes. 

Over time, other important differences between the substances in the 

recovered letters became apparent. For example, on October 31, 2001, CDC 

testified before the Senate Committee on Governmental Affairs that it 

initially assumed that the characteristics of the anthrax in all of the letters 

were the same. However, according to descriptions that CDC received after 

the letters were recovered,46 the substance in the letter to NBC was brown 

and granular, whereas the substance in the letter to the New York Post was 

sandy. 

Furthermore, according to a report issued in February 2003 about the 

decontamination of the Morgan facility, the substances in both the NBC and 

the New York Post letters contained compounds that did not appear in the 

highly milled and potent white powder that CDC was told was found in the 

letters to Senators Daschle and Leahy.47

According to the Postmaster General’s October 30, 2001, testimony before 

the House Committee on Government Reform and other officials we talked 

to, it was not until more than a week after the Daschle letter was opened 

and days after Brentwood closed that these new pieces of information 

came together and officials realized that the anthrax spores in the letter to

44The report was also faxed to the FBI on Sunday, October 21, 2001.

45Each of the recovered envelopes was a franked (prepaid) Postal Service “blue eagle” 

envelope available from Postal Service vending machines. 

46The FBI recovered the contaminated letter to NBC and the New York Post on October 12 

and October 19, respectively.

47According to testimony by an FBI official before the House Committee on Government 

Reform on October 30, 2001, the various anthrax samples were “indistinguishable from one 

another on a DNA analysis.” The differences in the substance, according to a CDC 

publication, could be attributable to (1) differences in the spore preparation or (2) exposure 

to different environmental conditions (e.g., moisture) that created a different potential for 

aerosolization. 
Page 27 GAO-04-239 U.S. Postal Service

Senator Daschle were so highly refined that they could penetrate paper.48

Consequently, when decisions were being made about the risk to 

employees at Brentwood and Trenton, public health and Postal Service 

officials said they did not yet know that the substance in the letter to 

Senator Daschle was more easily aerosolized and, therefore, potentially 

more dangerous than the substances in the letters to media representatives 

in New York.

According to CDC, it likely would have made different decisions in some 

facilities and circumstances had it known more about the characteristics of 

the highly refined substance in the letter to Senator Daschle and better 

understood (1) the significance of the information that it was provided or 

(2) how infections arising from bioterrorism incidents differ from 

outbreaks of naturally occurring disease. CDC explained that in outbreaks 

involving naturally occurring disease, early clues generally provide reliable 

information on the mode and source of exposure, whereas—as learned in 

the fall of 2001—the characteristics of the initial cases for bioterrorismrelated disease may be misleading since the perpetrator can vary the mode 

of transmission and source of exposure.49 In testimony before a 

subcommittee of the House Government Reform Committee in July 2002, 

CDC’s Associate Director for Science, National Institute for Occupational 

Safety and Health, admitted that CDC “clearly did not know what we did 

not know last October [2001] and that is the cardinal sin that resulted in 

deaths.”

Postal managers also told us that they would have made different decisions 

if they had understood that CDC’s health risk information had limitations 

and that their employees could be at risk. According to the former plant 

manager at Brentwood, he and others did everything they could to ensure 

that postal employees were safe. For example, the Deputy Director of the 

FBI, the Postmaster General, and a number of other high-ranking postal 

managers conducted a press conference at the facility to assure employees 

and the public that all appropriate steps were being taken to protect them. 

The former plant manager noted that none of the officials wore protective 

48The Army Institute did not analyze the size of the particles in the letter to NBC because of 

insufficient material. Similarly, according to the FBI, the letter to the New York Post, which 

was initially analyzed on October 20, 2001, “was not suitable” for particle size testing.

49For additional information, see Jernigan et al., “Investigation of Bioterrorism-Related 

Anthrax, United States, 2001: Epidemiologic Findings,” Emerging Infectious Diseases, vol. 

8, No. 10 (October 2002).
Page 28 GAO-04-239 U.S. Postal Service

clothing or safety equipment. Likewise, the former plant manager indicated 

that, on October 20—one day before the first case of inhalation anthrax 

was confirmed—he toured the facility with a CDC doctor, who also wore 

no protective clothing or equipment. According to the former plant 

manager, the fact that the doctor did not wear protective clothing or 

equipment reassured him that the facility was safe. He emphasized that he 

would not have been in the building and would not have allowed other 

postal employees in the building if he had been aware that the facility was 

contaminated.

Communication 

Problems Raised 

Employees’ Concerns 

The Postal Service communicated information to affected postal 

employees about the health risks posed by, and the extent of, anthrax 

contamination at the five facilities in our review; but problems with 

accuracy, clarity, and timeliness led employees to question the information 

they received. The early health risk information provided to the Postal 

Service by public health officials understated the potential health risk to 

postal employees and information on the medical response to anthrax 

contamination was unclear to employees because it kept changing as 

knowledge evolved. Problems with accuracy and clarity were exacerbated 

by postal employees’ perceptions of unequal treatment and long-standing 

distrust of management. Although the Postal Service reported qualitative 

(positive or negative) results of environmental tests at its facilities within 2 

days, it delayed the release of quantitative data (spore counts) for one 

facility, Wallingford, even though OSHA requires such information to be 

provided if it is requested. The Postal Service has taken steps aimed at 

communicating more effectively. 

Communications to Postal 

Employees Understated 

Health Risks 

During the fall of 2001, before postal employees were confirmed with 

anthrax, the Postal Service transmitted extensive information from CDC 

about the health risks of anthrax to postal employees.50 CDC derived this 

information from the existing scientific literature, experts, and its own 

early epidemiological investigations of the anthrax incidents in Florida and 

50The Postal Service used a wide variety of methods to communicate information to 

employees, including briefings, newsletters, fact sheets, videos played on closed-circuit 

televisions in its facilities, and a toll-free information line. CDC and local public health 

officials attended some of the employee briefings. In addition, the Postal Service said it 

regularly updated its Web site and, after the facilities closed, it mailed information to its 

employees’ homes. 
Page 29 GAO-04-239 U.S. Postal Service

New York. The early health risk information, together with information that 

the envelopes were unopened and taped when they passed through the U.S. 

mail system, led CDC to conclude that the potential for leakage and 

aerosolization was too small to pose a risk of inhalation anthrax to postal 

employees. If postal employees contracted the disease, CDC believed they 

would contract cutaneous anthrax, the readily treatable form of the 

disease. The Postal Service disseminated information about this health risk 

to postal employees, including information needed to watch for signs of 

cutaneous anthrax and related information pertaining to the use of gloves 

and other protective equipment intended to prevent this form of the 

disease.51 The Postal Service also provided an October 12, 2001, CDC health 

advisory to postal employees that stated that to cause cutaneous anthrax, 

the organism must be rubbed into abraded skin. Further, the advisory 

indicated that anthrax spores would be very difficult to refine into particles 

that would be small enough to aerosolize. 

Relying on available information, the state epidemiologist for the New 

Jersey Department of Health and Senior Services told employees at 

Trenton on October 15 that the likelihood of contracting anthrax through 

an unopened envelope was “infinitesimal.” Likewise, in an October 18 press 

conference at the Brentwood facility, held in part to announce a large 

financial reward for the arrest and conviction of the individual or 

individuals responsible for the anthrax mailings, the Postmaster General—

accompanied by an FBI Deputy Director and the Chief Postal Inspector—

assured postal employees and others that they were not at risk of 

contracting inhalation anthrax. Just 3 days later, when the first Brentwood 

employee was confirmed with inhalation anthrax, CDC and the Postal 

Service realized that the information they supplied to postal employees had 

underestimated the risks to their health. 

51On numerous occasions, the Postal Service also provided employees with instructions on 

what to do if they observed a powder spill or found a suspicious package. 
Page 30 GAO-04-239 U.S. Postal Service

Medical Information Was 

Difficult to Communicate 

Accurately and Clearly, and 

Efforts Were Complicated 

by Perceptions of Unequal 

Treatment and LongStanding Postal LaborManagement Relations 

Issues 

Public health agencies and the Postal Service reported that they had 

difficulty communicating information about nasal swabs, antibacterial 

drugs, and the anthrax vaccine accurately and clearly to postal employees. 

In trying to communicate information about nasal swabs, for example, they 

had to contend first with the effects of an error and later with employees’ 

perceptions of unequal treatment. During the fall of 2001, nasal swabs were 

used to determine the location and extent of contamination at a facility, not 

to diagnose illness. However, a Postal Service bulletin issued on October 

11, 2001, incorrectly suggested that nasal swabs were useful in diagnosing 

anthrax.52 The media also incorrectly described nasal swabs as a “test” for 

anthrax. The Postal Service corrected the bulletin, but the media continued 

to refer to nasal swabs as a test for the illness, and many postal employees 

continued to believe the inaccurate information. When Capitol Hill 

employees began receiving nasal swabs to test for exposure to aerosolized 

anthrax spores after the letter to Senator Daschle was opened on October 

15, some Trenton and Brentwood employees believed that they too should 

receive nasal swabs once it was determined that the letter was processed in 

their facilities. However, public health authorities were reluctant to 

administer the swabs to postal employees, given their belief that too much 

time would have elapsed to detect anthrax on a swab.53 Some postal 

employees perceived this reluctance as evidence of unequal treatment. 

Public health officials told us that addressing employees’ perceptions of 

unequal treatment was particularly challenging. As a result, when 

requested, the public health officials said they often administered nasal 

swabs simply to allay the employees’ concerns. 

52In its technical comments on our draft report, CDC noted that, under the best conditions, 

nasal swabs serve primarily to identify persons who have been exposed to anthrax. 

According to CDC, this information along with other information about an employee’s job, 

work location, and tasks may be used to support hypotheses about potential pathways of 

exposure. Nevertheless, CDC noted that the reliability of nasal swabs for this purpose is 

unknown. 

53As discussed, such samples should be taken soon after exposure, before the spores are 

inhaled or washed out of a person’s nasal passages. 
Page 31 GAO-04-239 U.S. Postal Service

Public health agencies also reported that they had difficulty explaining the 

reasons for changes in (1) the medication recommended for individuals 

who might have been exposed to anthrax and (2) the length of the 

recommended treatment. Initially, CDC had recommended ciprofloxacin 

for a variety of reasons,54 but later it recommended doxycycline. Postal 

employees believed that they were receiving an inferior drug because 

ciprofloxacin—which had been initially provided to Capitol Hill staff—had 

been characterized as the drug of choice in media reports. Similarly, in 

December 2001, when postal employees and others were finishing the 60-

day drug regimen recommended in CDC’s initial guidance, postal 

employees questioned CDC’s advice about the need to consider taking the 

drugs for an additional 40 days. CDC officials acknowledged that CDC did 

not effectively communicate uncertainties related to the appropriate length 

of prophylaxis, even though there was significant disagreement on the 

issue within CDC at the time. Since the incidents, CDC officials have 

acknowledged the necessity of expressing uncertainty in terms the public 

can understand and appending appropriate caveats to the agency’s 

statements. In addition, CDC has changed its processes to release 

information more quickly, bring in other professionals to aid in 

disseminating information, and expand its communication capacity, a step 

that includes the development of an emergency plan to communicate more 

effectively. 

Finally, CDC officials reported difficulties in explaining information about 

the administration of the anthrax vaccine to interested postal employees. 

The Food and Drug Administration considers the vaccine safe but has 

approved its use only for individuals who have not been exposed to 

anthrax—not for those who may have been exposed. Consequently, CDC 

had to administer the vaccine using extensive protocols that the Food and

54CDC initially recommended ciprofloxacin for several reasons. First, absent information 

about the strain’s susceptibility to various drugs, CDC considered ciprofloxacin most likely 

to be effective against any naturally occurring strain of anthrax. Also, as the newest 

antibacterial available, CDC considered it less likely that someone would have had time to 

engineer a resistant strain of anthrax. Finally, the Food and Drug Administration had already 

approved ciprofloxacin for the postexposure prophylaxis for inhalation anthrax. After CDC 

determined that the anthrax was equally susceptible to doxycycline and other drugs and the 

Food and Drug Administration announced that doxycycline was approved for inhalation 

anthrax, CDC began recommending that individuals use doxycycline instead. At the time, 

the switch to doxycycline was considered desirable for a variety of reasons, including its (1) 

lower risk for side effects, (2) lower cost, and (3) greater availability. In its technical 

comments on a draft of this report, CDC noted that research conducted in the fall of 2001 

suggests that doxycycline and ciprofloxacin generally have equal rates of side effects. 
Page 32 GAO-04-239 U.S. Postal Service

Drug Administration requires for an “investigational new drug.”55 These 

protocols, which are standard for new drugs, required postal employees to 

complete more paperwork and undergo more monitoring than for 

approved drugs. According to some postal employees, the protocols made 

them feel like “guinea pigs.” CDC officials acknowledged that CDC did not 

explain the vaccine program clearly and concluded, in hindsight, that 

communication problems probably contributed to the misperceptions of 

postal employees and others potentially exposed to the disease. 

As we reported in October 2003,56 differences between the responses to 

anthrax contamination on Capitol Hill and Brentwood reflected differences 

in the circumstances at the two locations (a powder identified in a letter 

and positively tested as anthrax on Capitol Hill versus no observable 

evidence of contamination at postal facilities) and in the decision makers 

(the Attending Physician of the U.S. Capitol versus the Postal Service in 

consultation with CDC). However, it appears that these differences were 

less visible to postal employees and others than the differences between 

the actions taken on Capitol Hill—where the Hart Senate Office Building 

was closed within a day and nasal swabs and antibacterial medications 

were quickly administered to nearby employees and first responders—and 

at postal facilities—where operations continued and medical intervention 

was less immediate because contamination was not observed at the postal 

facilities. Some postal employees perceived these differences as evidence 

of unequal treatment. 

Long-standing labor relations issues also complicated efforts to 

communicate with postal employees. For example, while consistent with a 

CDC alert at the time, some Brentwood employees told us that they viewed 

instructions by Postal Service managers to pick up suspicious letters and 

packages and isolate them in sealed containers as evidence that the Postal

55Requirements for investigational new drugs apply to new, unapproved drugs as well as to 

drugs—such as the anthrax vaccine—that have been approved by the Food and Drug 

Administration for a different use or purpose.

56GAO-04-205T. 
Page 33 GAO-04-239 U.S. Postal Service

Service was not concerned about their safety.57 According to CDC, local 

public health officials, union representatives, and postal officials, postal 

employees were often suspicious of postal management’s motives and 

routinely scrutinized information they received for evidence of any ulterior 

motives. In fact, the Director of the Palm Beach County Health Department 

told us that postal employees in Florida expressed a greater degree of 

anger and mistrust toward management than she had ever observed. Such 

concerns appear consistent with the results of our past work, which has 

identified persistent workplace problems exacerbated by decades of 

adversarial labor-management problems. These problems were so serious, 

we reported in 2001, that long-standing and adversarial labor-management 

relations hampered efforts to address its management challenges.58 The 

President’s Commission on the United States Postal Service also identified 

a need to address this long-standing issue.59

Postal Service Did Not 

Provide Timely Quantitative 

Information on 

Contamination at One 

Facility When Requested 

The Postal Service provided employees with the qualitative results (i.e., 

negative or positive) of environmental tests conducted at the five facilities 

in our review within 2 days of receiving the results, but it did not promptly 

disclose available quantitative results (spore counts) for the Wallingford 

facility when requested. OSHA requires employers to disclose available test 

results in response to an employee’s request.60 Initially, the Postal Service 

obtained only qualitative results, but as testing methods evolved, it 

obtained quantitative results for three of the five facilities—Wallingford, 

which remained open, and Brentwood and Trenton, both of which closed.61

As we reported in April 2003, the Postal Service obtained quantitative test 

results for Wallingford on December 2, 2001, but it did not disclose these 

57This instruction was consistent with guidance the Postal Service issued on October 10, 

2001, and a health advisory from the CDC. The Postal Service revised its guidance on 

October 12, 2001. Instead of handling suspicious letters and packages, employees were told 

to isolate them and contact their supervisor.

58GAO, Major Management Challenges and Program Risks: U.S. Postal Service,

GAO-01-262 (Washington, D.C.: January 2001).

59Report of the President’s Commission on the United States Postal Service, Embracing the 

Future: Making the Tough Choices to Preserve Universal Mail Service, July 31, 2003.

60See 29 C.F.R. § 1910.1020 (e)(1)(i).

61The results were quantified to assist agencies in decontaminating the facilities.
Page 34 GAO-04-239 U.S. Postal Service

results until September 4, 2002.62 Although a union leader had requested the 

results in January and February 2002, the Postal Service did not initially 

provide them, it said, because, among other reasons, it was uncertain what 

the results meant for employees’ safety and public health, it could not 

validate the results as its guidelines require, and Connecticut’s Chief 

Epidemiologist had assured postal managers that the results did not 

indicate any additional health risk to employees at the facility.63 The Postal 

Service disclosed the quantitative results after the union leader filed a 

formal complaint with OSHA and OSHA investigated the complaint. The 

complaint alleged that the Postal Service’s failure to “properly and timely 

disclose” the level of contamination in the facility left employees without 

adequate information for making informed decisions about such issues as 

whether to continue taking antibacterial drugs and working in the facility.64

Although OSHA did not take regulatory action against the Postal Service,65

it stressed the importance of timely communication of test results and 

stated in a letter to the Postal Service that a “failure to effectively 

communicate issues” affecting employees’ health and safety “can lead to 

fear and mistrust.”66

62The results indicated that four mail-sorting machines were contaminated, including one 

that was highly contaminated. Analysis of a sample taken from the highly contaminated 

machine identified about 3 million colony-forming units (i.e., living cells) of anthrax. 

63The Chief Epidemiologist informed postal managers that there was no additional risk to 

employees for a variety of reasons—the contaminated machines had already been isolated 

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

the facility had already been offered antibacterial drugs; and, in the view of public health 

officials, the incubation period for the disease had already passed without illness.

64The union leader and other union representatives at Wallingford subsequently explained to 

us that, according to their discussions with employees at the facility, many of the employees 

either (1) did not take their antibacterial medication or (2) stopped taking their medicine 

prematurely based on the Postal Service’s use of the terms “trace” and “concentration” to 

characterize the extent of contamination in the facility.

65According to an OSHA Regional Administrator involved in the decision not to take 

regulatory action, OSHA’s decision was influenced by several factors, including the (1) 

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

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

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

spores that involved several federal agencies.

66In its technical comments on a draft of this report, CDC noted that there are several issues 

related to the December 2, 2001, test results at Wallingford. These issues are discussed in 

more detail in our prior report. See GAO-03-316. 
Page 35 GAO-04-239 U.S. Postal Service

According to documentation from CDC, the quantitative results for 

Brentwood, which were based on samples taken by CDC investigators and 

Postal Service contractors in October 2001, were made available to the 

Postal Service and national union representatives on November 1, 2001, 

and CDC published the results on December 21, 2001.67 According to the 

document, 27 of the 39 vacuum samples—69 percent—tested positive for 

anthrax, with concentrations up to 9.7 million colony-forming units per 

gram of material collected. The Postal Service notified former Brentwood 

employees about the quantitative results on January 25, 2002, and referred 

them to CDC’s Web site to obtain the actual results. CDC reported the 

quantitative results for tests taken in Trenton in February 2002 to the Postal 

Service and to representatives of the national postal unions on May 31, 

2002.68 This analysis indicated that 247 of the 362 samples—68 percent—

were positive for anthrax, with concentrations up to 800 million colonyforming units.69

The Postal Service Took 

Steps Aimed at 

Communicating More 

Effectively

Recognizing the need to improve its communication both internally and 

externally, the Postal Service took a number of steps aimed at 

communicating more effectively during the fall of 2001. First, on October 

16, 2001, it established a National Postal Operations Center to coordinate

information within the postal system. It also created a Mail Security Task 

Force composed of representatives from management associations and 

employee unions. Union leaders applauded the efforts of this task force, 

which met daily as the crisis unfolded, to involve them in decision making. 

Finally, to improve its communications with other agencies, on October 31, 

2001, the Postal Service established a Unified Incident Command Center 

with representatives from the agencies that respond to contamination in 

67U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, Morbidity and Mortality Weekly Report, “Evaluation of Bacillus anthracis

Contamination Inside the Brentwood Mail Processing and Distribution Center—District of 

Columbia, October 2001.” (Atlanta, GA: Dec. 21, 2001).

68CDC provided the qualitative test results to the Postal Service and its unions on March 4, 

2002. These samples were reanalyzed and quantified and CDC reported the results to the 

Postal Service and its unions on May 31. 

69The sample with a concentration of 800 million colony-forming units of anthrax was a 

composite wipe—a combination sample taken from four stacker bins on one of the facility’s 

contaminated mail-processing machines. Thus, according to CDC, the concentration would 

be more accurately reported as “800 million CFUs (colony-forming units) per 4 bin 

composite wipe.” 
Page 36 GAO-04-239 U.S. Postal Service

postal facilities. According to the Chief Operating Officer, the Postal 

Service had not previously needed such an infrastructure because, before 

September 11, its weather-related and other emergencies were relatively 

short-lived and could be dealt with locally.

The Postal Service also worked with the National Response Team—a group 

of 16 federal agencies responsible for planning, preparing, and responding 

to the release of hazardous substances—to revise existing guidelines for 

responding to anthrax. Consistent with recommendations in our April 7, 

2003, report on the response to anthrax at the Wallingford facility, the most 

recent version of the guidelines,70 dated November 3, 2003, suggests that 

agencies (1) disclose more—rather than less—information, particularly 

when the release of undisclosed information could damage an agency’s 

credibility; (2) consider the needs of different audiences (e.g., employees, 

reporters, local politicians) for different types of information; (3) anticipate 

what information people need and in what form; and (4) admit when you 

do not know the information. As we recommended, the Postal Service also 

revised its guidance to require that facility managers communicate future 

test results—including quantitative results—to employees and others as 

quickly as possible, along with information explaining any limitations or 

uncertainties associated with the results.71

While the Postal Service agreed to explain any limitations or uncertainties 

associated with future test results, it did not accurately characterize the 

extent of residual risk at Brentwood after the facility was decontaminated. 

As we previously testified, an October 2003 newsletter to former 

Brentwood employees incorrectly stated that the facility was “100 percent 

free of anthrax contamination” and that there was “no remaining health 

risk” associated with returning to work there. Although the facility has 

since been certified as safe, it is scientifically impossible to eliminate all 

risk or to guarantee that working at a previously contaminated facility is 

absolutely risk free. Postal managers agreed with this assessment and 

indicated that a misunderstanding within the Postal Service resulted in the 

distribution of incorrect information to employees before the document 

had been fully reviewed. The Postal Service mailed corrected information 

to Brentwood employees in December 2003.

70Technical Assistance for Anthrax Response, Interim-Final Draft Phase I Update, 

November 3, 2003.

71Interim Guidelines for Sampling, Analysis, Decontamination, and Disposal of Anthrax 

for U.S. Postal Service Facilities, December 2003.
Page 37 GAO-04-239 U.S. Postal Service

Several Lessons 

Emerged from the 

Response to Anthrax 

Contamination

The response to anthrax contamination afforded multiple lessons, two of 

which are key. First, it is important for agencies to err on the side of 

caution when dealing with uncertain and potentially life-threatening 

situations—meaning that agencies need to choose a course of action that 

poses the least risk of harm to individuals. Because public health agencies 

underestimated the health risks involved in the anthrax attacks, actions to 

protect postal employees were delayed. Public health agencies and the 

Postal Service have since adopted a more proactive approach and the 

Postal Service has twice revised its guidance. However, the most recently 

revised guidance—issued in December 2003—needs improvement in 

several areas. The second key lesson is that sharing information in a timely 

manner is critical to an effective response. While collocating liaisons from 

CDC and the Postal Inspection Service with FBI headquarters officials 

facilitated timely information sharing, agencies reported that information 

was not always shared within and among public health agencies and the 

Postal Service. Several factors may have hindered the prompt exchange of 

information, including unclear responsibilities for decision making. Two 

additional lessons, on the need for reliable methods to test for anthrax in 

the environment and on the need for an emergency medical plan, also 

emerged.

Erring on the Side of 

Caution Is Important When 

Human Life May Be at Risk

The uncertainty of health risk information—demonstrated by the gap 

between what public health agencies knew about anthrax and what they 

learned over time—points to a need for agencies to err on the side of 

caution when considering actions to protect people in uncertain and 

potentially life-threatening situations. For example, the Commander of the 

U.S. Army Medical Research Institute of Infectious Diseases noted in 

testimony before a subcommittee of the House Committee on Government 

Reform in May 2003, that there is “still much to be learned about the effects 

of this agent [anthrax] under conditions different from those encountered 

during natural outbreaks.” In particular, he said, the health effects of 

aerosolized anthrax spores on human populations are poorly understood, 

and there is no scientific consensus on the lethal dose for humans. Thus, 

any level of contamination could potentially harm some individuals. 

Consistent with what he described as the Army Institute’s long-standing 

approach, the Commander advised agencies to initially err on the side of 

caution “in the absence of surety” while taking full advantage of all 

available expertise to formulate a future long-term response. In addition, 

due to such factors as limitations in testing methods and the uncertainty of 

the anthrax dose necessary to cause infection, representatives from the 
Page 38 GAO-04-239 U.S. Postal Service

Environmental Protection Agency and the U.S. Army’s Dugway Proving 

Ground have also indicated the advisability of taking a cautious approach 

when dealing with anthrax.72

As discussed, the events of October 2001 soon demonstrated that the 

agencies’ inferences about the anthrax health risks to postal employees 

were wrong. For example, 3 days after the Postmaster General, in 

consultation with public health officials, assured postal employees that 

they were not at risk of contracting inhalation anthrax, CDC confirmed the 

first case of inhalation anthrax in a postal employee and within 5 days, CDC 

confirmed three more cases. These cases belied the views of public health 

agencies that postal employees were not at risk for contracting inhalation 

anthrax. Ultimately, even the participants in the press conference, who did 

not work at Brentwood, were advised to take antibacterial drugs because 

they might have been exposed to contamination at the facility. According to 

the former director of the D.C. Department of Public Health, once a postal 

employee developed inhalation anthrax, it became clear that CDC’s 

recommendations, while sound in terms of prior knowledge and science, 

“had left the Brentwood workers unprotected.”

The Palm Beach County Health Department initiated its epidemiological 

investigation on October 3, 2001, about 36 hours before it received 

confirmation that the first of two employees from American Media 

Incorporated had inhalation anthrax. Initially, the epidemiological 

investigation focused on, among other locations, office space within 

American Media Incorporated. As the investigation proceeded, 

investigators realized that the contamination might have come from a letter 

delivered by the Postal Service. On the basis of this possibility, the 

department began offering antibacterial medication to selected postal 

employees—those most likely to have handled mail to the media 

company—on October 12, the same day that environmental testing began 

at selected postal facilities and 3 days before anthrax contamination was 

confirmed at any of the facilities.73 The director of the Palm Beach County 

72The mission of the Dugway Proving Ground is to test U.S. and Allied biological and 

chemical defense systems; perform nuclear, biological, and chemical survivable testing of 

defense material; provide support to chemical and biological weapons conventions; and 

operate and maintain an installation to support its testing mission.

73At the other facilities in our review, antibacterial prophylaxis was provided after the 

facility tested positive or after CDC confirmed that a postal employee or customer had 

contracted anthrax. 
Page 39 GAO-04-239 U.S. Postal Service

Health Department acknowledged that the department’s sensitivity to risk 

had been heightened by the first case of inhalation anthrax at American 

Media Incorporated. The director emphasized the importance of 

intervening early when a delay in responding could threaten lives. In her 

view, the only risk in responding immediately is the possibility of being 

criticized for wasting public money. According to public health officials in 

Florida, the single most important lesson they learned from their 

experience with anthrax was the importance of taking precautions in the 

face of potentially life-threatening situations. 

An April 2002 report prepared for the Department of Defense74 noted that 

because neither the local health officials nor the private physicians 

involved in the Florida response waited for final CDC confirmation of 

anthrax disease before acting, the medical community in Florida had a 36-

hour head start on containing the crisis. The report also identified other 

proactive steps that Florida public health officials took to alert the medical 

community and the public to the risks of anthrax. For example, public 

health officials notified all hospitals of the anthrax threat, attempted to fax 

an informational letter to every licensed doctor in Florida, established a 

toll-free telephone number for people who might have been exposed, and 

set up an informational Web site staffed with doctors who were available to 

answer direct questions.75 According to the report, these steps heightened 

public awareness, increased medical surveillance throughout the system, 

and aided in discovering the second case of inhalation anthrax in Florida.

Since the anthrax incidents, public health agencies and the Postal Service 

have moved to a more proactive approach. On November 9, 2001, CDC 

revised its guidance, indicating that closing a facility may be warranted, 

among other conditions, (1) after a case of inhalation anthrax is detected 

and a probable site of exposure is identified, (2) when there is a known 

aerosolization of anthrax in the facility, or (3) where evidence strongly 

suggests that an aerosolization of anthrax has occurred. Furthermore, 

while CDC’s November 2001 guidance recommends minimizing the risk of 

inhalation anthrax and reducing opportunities for the spread of 

contamination, the guidance states that facility closures are not warranted 

74Center for Strategic and International Studies and the Defense Threat Reduction Agency, 

Lessons from the Anthrax Attacks: Implications for U.S. Bioterrorism Preparedness, April 

2002.

75In its technical comments on a draft of this report, CDC noted that many parts of the 

country, including Washington, D.C., New Jersey, and New York also took similar actions. 
Page 40 GAO-04-239 U.S. Postal Service

based solely on the identification of cutaneous anthrax cases or anthrax in 

samples from environmental surfaces. 

In May 2004, we discussed CDC’s November 9, 2001, guidance for 

responding to cases of cutaneous anthrax and positive environmental 

samples with several CDC officials, including the Acting Associate Director 

for Policy, Planning, and Evaluation, Office of Terrorism Preparedness and 

Emergency Response. The officials noted that CDC learned a great deal 

about the potential for aerosolization during the fall of 2001 but that its 

knowledge and current approach are not yet fully reflected in its guidance. 

While emphasizing that the decisions reached in any response are highly 

dependent on the circumstances at each site, the officials said that if a case 

of cutaneous anthrax or positive environmental samples were identified at 

a postal facility, CDC would immediately assemble a multidisciplinary team 

of experts to assess the situation. The team would, among other things, 

determine the extent of contamination, the likelihood of aerosolization, 

and the potential health risks to postal employees. In addition, CDC 

informed us that it may require closure or, depending upon the 

circumstances, recommend that other federal or state agencies close the 

facility. In fact, according to one of the officials, CDC would now likely 

recommend that a facility be closed unless CDC was otherwise convinced 

that the facility should remain open. Later this year, CDC expects to publish 

updated guidance on its current approach, including recommendations for 

planning for and responding to a case of cutaneous anthrax or positive 

environmental samples in postal facilities. 

The Postal Service has taken several proactive steps, including changing its 

cleaning procedures, increasing its use of technology, and revising its 

guidance. As discussed, it restricted its use of compressed air to clean 

(“blow-out”) its mail-processing machines on October 16, 2001, and 

eliminated the use of this procedure altogether on October 26, 2001. 

According to its existing guidance, Postal Service employees are now to 

vacuum the mail-processing machines and, instead of dry sweeping the 

floors, are to use wet or treated mops to clean floors. 

The Postal Service has also been shipping certain types of mail destined for 

federal agencies in Washington, D.C., to a facility in New Jersey, where the 

mail is irradiated to kill any organisms, such as anthrax. In addition, the 

Postal Service has pilot-tested a new detection system at 15 facilities and 

plans to install the system at 283 of its processing facilities by July 2006. 

This system collects and preliminarily analyzes samples from the
Page 41 GAO-04-239 U.S. Postal Service

environment and triggers an alarm if anthrax is detected.76 The Postal 

Service’s guidelines for implementing the new detection system call for 

taking immediate emergency actions, including evacuation, as soon as the 

system is triggered. Furthermore, according to these guidelines,77 a facility 

will reopen only if a follow-up analysis of the sample is negative for 

anthrax—a process that can take several days.78

If the detection system is triggered at a facility with the technology, the 

Postal Service also plans to follow CDC’s April 2004 guidance to employers 

and others using autonomous systems to detect anthrax,79 which not only 

recommends immediate evacuation, but also prescribes antibacterial 

treatment for employees “as soon as possible” after a qualified laboratory 

has initially confirmed a positive result. According to the guidance, such 

treatment should continue until the sample is cultured, which will likely 

take 3 to 5 days. If positive results are ultimately confirmed, CDC 

recommends a 60-day course of antibacterial drugs in combination with 

inoculation with the anthrax vaccine. Because the Postal Service issued 

guidance to reflect CDC’s recommended medical interventions on June 30, 

2004,80 we eliminated a proposed recommendation in our draft report that 

it do so. According to the Postal Service’s Manager, Safety Performance 

Management, the Postal Service has already implemented the CDC 

guidance through training, standard operating procedures, and emergency 

management plans at sites with the detection systems. 

The Postal Service revised its Interim Guidelines in December 2003 to 

reflect the need for more proactive measures when responding to anthrax.

76The technology is designed, ultimately, to detect multiple biological and chemical 

contaminants, but the Postal Service is currently using the system only to test for anthrax. 

77Biohazard Detection System Pre-production Concept of Operations, July 18, 2003. 

78This follow-up analysis involves culturing the sample that triggered the alarm. Spores 

collected by the detection system are cultured so that the resulting bacteria can be 

positively confirmed.

79U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, Morbidity and Mortality Weekly Report,“Responding to Detection of 

Aerosolized Bacillus anthracis by Autonomous Detection Systems in the Workplace,” 

(Atlanta, GA: Apr. 30, 2004).

80Biohazard Detection System Alert-Positive Test: Evacuation, personal decontamination, 

and postexposure prophylaxis, June 30, 2004.
Page 42 GAO-04-239 U.S. Postal Service

The guidelines are generally applicable to all postal facilities.81 For the first 

time, the guidance describes a “suspected release” of anthrax spores as an 

emergency and specifies that if the suspicion is “strong,” the building will 

be evacuated and secured. Furthermore, in accordance with CDC’s April 

2004 recommendations, the guidance specifies antibacterial prophylaxis 

for postal employees and others along the transit path of an envelope 

containing anthrax that may have been aerosolized. The revised 

guidance—which conforms to the guidelines developed by the National 

Response Team—also emphasizes the Postal Service’s commitment to 

continuously improve its responses and processes related to anthrax and 

other biohazards. This commitment includes updating its guidance as more 

information is gleaned, lessons are learned, and technologies advance. 

While the December 2003 guidance reflects some of the lessons learned 

since the fall of 2001, it does not define or provide examples of some key 

terms, including what would constitute either a “suspected release” or a 

“strong suspicion” of anthrax that would warrant evacuation from a facility. 

In addition, the December 2003 guidance references outdated guidance and 

could therefore cause confusion during an emergency response. 

Specifically, the guidance refers readers to the Postal Service’s October 

1999 guidance on responding to mail allegedly containing anthrax for a 

description of,82 among other topics, management roles and responsibilities 

and lines of responsibility for the response. Directing readers to this 

outdated information could cause confusion in the future because the 1999 

guidance is no longer in effect.83 The December 2003 guidance also does 

not fully address all of the circumstances that the Postal Service faced in 

2001 or could likely face in the future. For example, although the guidance 

calls for closure if sampling results indicate that anthrax has been 

aerosolized and transported throughout a facility, the Postal Service would 

not have any sampling results for facilities without detection systems 

unless (1) it routinely collected and tested samples from all of its facilities 

or (2) an observable event—such as the discovery of a suspicious letter or 

package—or a “strong suspicion” had triggered a decision to sample. The 

81As discussed, additional guidance exists for facilities with anthrax detection systems.

82Emergency Response to Mail Allegedly Containing Anthrax, October 4, 1999, 

Management Instruction EL-860-1999-3.

83In response to our inquiries, on June 24, 2004, the Postal Service published a bulletin 

indicating that roles and lines of responsibility identified in sections 4 to 7 of the December 

2003 guidance are obsolete. The December 2003 guidance, however, has not yet been 

updated to eliminate the obsolete information. 
Page 43 GAO-04-239 U.S. Postal Service

guidance also specifies closure if a diagnosis of inhalation anthrax is 

confirmed in a postal employee, but confirmation takes time, and the 

guidance does not indicate what measures would be taken in the interim. 

Although the Postal Service’s December 2003 guidance does not fully 

address all of the circumstances the agency faced in 2001, the Postal 

Service has since taken additional precautions in responding to threats. 

However, it has not yet finalized its guidance to reflect these precautions. 

According to the Manager, Safety Performance Management, the Postal 

Service has learned not to wait for others before taking action; now, if it 

learned that it had delivered an envelope containing anthrax, it would 

immediately determine the path of the recovered envelope through the mail 

system and immediately close the facilities that had processed it. 

Consistent with this proactive approach, on November 6, 2003, the Postal 

Service shut down 11 postal facilities in and around Washington, D.C., after 

a preliminary test—not a confirmed result—from a routine air sample 

taken by a U.S. Navy contractor on November 5 indicated that a Navy mailprocessing facility might be contaminated with anthrax. The Postal Service 

tracked the flow of mail through the facility and closed 11 postal facilities, 

most of which picked up mail from the Navy facility. The subsequent 

confirmatory tests were negative, and the postal facilities reopened on 

November 7 and 8. In addition, on February 2, 2004, the Postal Service shut 

down its “V Street” facility, which now processes mail for Capitol Hill and 

other federal offices in Washington, D.C, soon after preliminary tests 

indicated that a powder found on a mail machine in the Senate mailroom 

was ricin, a deadly toxin.84 No letter was ever found in this incident, and no 

ricin was detected at the V Street facility. Nevertheless, the Postal Service 

monitored the health of the facility’s employees and the facility remained 

closed for 2 days while 132 environmental samples were taken and 

analyzed. All of the samples were negative, and the facility reopened on 

February 4, 2004. 

According to Postal Service managers, the Postal Service is in the process 

of updating its guidance and intends to replace the December 2003 interim 

guidelines for anthrax with a more comprehensive “all hazards” emergency 

response plan for addressing future natural and man-made emergencies. 

According to the Manager, Safety Performance Management, the plan will 

84Ricin is a poison that can be made from the waste (mash) left over from processing castor 

beans. Ricin can be made in the form of a powder, a mist, or a pellet or it can be dissolved in 

water or weak acid.
Page 44 GAO-04-239 U.S. Postal Service

be completed by the fall of 2004 and will address the additional precautions 

that the Postal Service has taken since the fall of 2001, such as its 

November 2003 closure of postal facilities after receiving preliminary test 

results indicating the possibility of anthrax. 

Although the Postal Service has taken a more proactive approach to 

protect its employees since the anthrax attacks, it is also responsible for 

carrying out its mission to process and deliver the mail. False positive test 

results, such as the one obtained for the Navy mail-processing facility, are 

but one of the obstacles to efficient operations. Incidents involving 

suspicious packages or powder spills can also interrupt operations, cause 

fear, and divert resources, not only for the Postal Service but also for law 

enforcement and public health agencies at all levels of government. During 

the anthrax attacks, the frequency of suspicious powder incidents 

increased dramatically. According to the head of the Postal Inspection 

Service, over 7,000 anthrax hoaxes, threats, and suspicious letters and 

packages—an average of almost 600 per day—were reported to his agency 

in the weeks following the first anthrax attack, and nearly 300 postal 

facilities had to be evacuated because of these incidents. On October 30, 

2001, the head of the FBI’s Counterterrorism Division testified before the 

House Committee on Government Reform that the FBI and state and local 

authorities were overwhelmed by hoaxes in the wake of the anthrax 

incident, handling more than 2,000 in the first 2 weeks of October 2001, 

compared with about 250 a year previously. He cited both the 

“indeterminable” resources required to address them and “the terror they 

bring to the victims.” Additionally, according to CDC officials, large 

numbers of medical, public health, law enforcement, and emergency 

response personnel throughout the country and the world dealt with 

numerous hoaxes perpetrated in the weeks after the incidents. According 

to officials, while the frequency of incidents involving suspicious packages 

or powder spills has declined since 2001, they nevertheless remain a 

challenge to the Postal Service and other agencies. 

Timely Sharing of 

Information Is Critical to an 

Effective Response

A second key lesson learned during the anthrax response was the need for 

prompt information sharing. While efforts were made to facilitate effective, 

timely communication, information was not always shared within and 

among agencies. Several factors may have contributed to the problems 

with information sharing. 
Page 45 GAO-04-239 U.S. Postal Service

Collocating Liaisons at FBI 

Headquarters Facilitated Timely 

Information Sharing 

Historically, according to an April 2002 report prepared for the Department 

of Defense,85 the FBI has “been reluctant to share information it has 

collected in pursuit of a criminal investigation,” and the goals of law 

enforcement and of public health sometimes conflict. During the anthrax 

response, the FBI tried to mitigate these differences by collocating liaisons 

from CDC and the Postal Inspection Service with FBI headquarters 

officials. As the Section Chief of the FBI’s Counterterrorism Division 

testified on October 30, 2001, before the House Committee on Government 

Reform, the CDC liaison was “literally living in my space at FBI 

headquarters” and the Postal Inspection Service liaison was “also working 

in our space, in on every briefing, . . . so that he can coordinate postal 

efforts with the FBI efforts.” As a result, he said, “there’s no information 

that we have or the Postal Service has that doesn’t cross back and forth, so 

that we’re all totally informed of all aspects of the investigation.” 

The CDC and Postal Inspection Service liaisons we interviewed confirmed 

that they generally received timely information from the FBI. For example, 

the CDC liaison testified that he participated in an interagency 

teleconference on October 15, when the FBI first received information 

from the U.S. Army Medical Research Institute of Infectious Diseases 

describing the anthrax contamination in the letter to Senator Daschle. It 

was during this teleconference that a scientist for the Army Institute 

referred to the anthrax spores in the letter as “weaponized”—a term that 

was subsequently modified.86 The CDC liaison further testified that he 

hosted a conference call to relay the information to other CDC personnel in 

the early hours of October 16. The liaison for the Postal Inspection Service 

did not begin work at the FBI until October 17, 2001; consequently, he did 

not participate in the interagency teleconference on October 15. 

Nevertheless, the liaison told us that, to the best of his knowledge, the FBI 

shared all of the information it had, including the test results of the Daschle 

letter. He described his agency’s relationship with the FBI as cooperative, 

saying that if the Inspection Service asked for something, the FBI did its 

85Center for Strategic and International Studies and the Defense Threat Reduction Agency, 

Lessons from the Anthrax Attacks: Implications for U.S. Bioterrorism Preparedness, April 

2002.

86On October 16, the U.S. Army Medical Research Institute of Infectious Diseases revised its 

description, indicating in another teleconference that the spores were “professionally done” 

and “energetic.” According to an official from the Army Institute, these terms were 

considered more appropriate, since personnel at the Army Institute, he said, were not 

familiar with weaponized materials.
Page 46 GAO-04-239 U.S. Postal Service

best to provide what was needed; and if the FBI asked for something, the 

Inspection Service likewise did its best to supply it. 

While collocating liaisons from other agencies at FBI headquarters 

facilitated information sharing, it appears that there are still opportunities 

for improvement. For example, although CDC asked the FBI for 

information on the size of the spores in the Daschle letter and their 

potential to aerosolize on October 19, 2001, a discrepancy exists between 

CDC and the FBI about when the information was provided. We could not 

resolve the discrepancy. The CDC liaison told us that he received the 

information from the FBI on October 24, 2001—a day after the Secretary of 

Health and Human Services was briefed on the results. In contrast, FBI 

officials said that the information was provided to CDC’s liaison on October 

22—the same day that the U.S. Army Medical Research Institute of 

Infectious Diseases delivered its report to the FBI.87 Similarly, the liaison 

for the Postal Inspection Service and the Postal Service’s former Senior 

Vice President for Government Relations and Public Policy told us that 

they were unaware of the Army Institute’s results, including the results of 

its spore size analysis, until days after Brentwood’s closure.88 According to 

the testimony of the Commanding General of the U.S. Medical Research 

and Materiel Command before the Senate Committee on Governmental 

Affairs on October 31, 2001,89 the Army Institute’s analyses revealed 

particles ranging from single spores to aggregates of spores up to 100 

microns or more in diameter. Furthermore, the spores had a “propensity to 

pulverize.” 

87The Army Institute also faxed a report of the results of its analyses to the FBI on Sunday, 

October 21, 2001.

88Questions remain about why this information was not or may not have been 

communicated to CDC and the Postal Service earlier. An official from the U.S. Army Medical 

Research Institute of Infectious Diseases told us that under the terms of its agreement with 

the FBI, officials from the Army Institute could not discuss their test results without FBI 

approval. Thus, according to the Postal Service’s former Senior Vice President for 

Government Relations and Public Policy, an official from the Army Institute subsequently 

called to apologize for the delay. 

89The Army Institute is part of the U.S. Army Medical Research and Materiel Command.
Page 47 GAO-04-239 U.S. Postal Service

Problems with Sharing 

Information Were Reported 

within and among Agencies

Local public health officials identified problems with the timely sharing of 

information both within CDC and among state public health agencies. For 

example, the epidemiologist for New Jersey told us that based on his 

interactions with the CDC team that assisted in New Jersey, the 

information CDC learned from the response in Florida did not appear to 

have been shared. The epidemiologist also said that he did not acquire 

some information about the Florida response that could have influenced 

his decision making until a year after the anthrax incidents. Specifically, he 

learned from an October 2002 CDC publication90 that public health 

authorities in Florida had provided antibacterial drugs for some postal 

employees on October 12, 2001—the same day testing was initiated at 

selected postal facilities in Florida91—and that the Postal Service had some 

preliminary positive test results on October 13, 2001. The epidemiologist 

said that if this information had been shared at the time, New Jersey 

officials would very likely have begun testing the Trenton facility 

immediately and might have urged closing the facility and offering 

antibacterial medication to the employees deemed most likely to have been 

affected. The former director of the D.C. Department of Health also 

reported problems with information sharing. Specifically, he said that 

information about the characteristics of anthrax in the Daschle letter was 

not shared with departmental personnel and other local officials, including 

the D.C. mayor. As a result, he said he first read about the anthrax being 

“weaponized” in the newspaper. 

Within the Postal Service, managers found that some postal employees had 

not shared current and accurate information on how they could be 

contacted in an emergency. As a result, the managers said, they were 

greatly hampered in their efforts to relay important information to Trenton 

and Brentwood employees who were not at work when the facilities 

closed, including information on how to receive medical treatment and 

where to report to work. Postal managers said they had to rely on contact 

information supplied by union representatives, use postal inspectors and 

local law enforcement authorities to search for employees and, when

90Centers for Disease Control and Prevention, Department of Health and Human Services, 

Emerging Infectious Diseases, vol. 8, No. 10 (October 2002): 1033.

91While an established link to U.S. mail did not initially exist in Florida, investigators were 

beginning to explore that possibility.
Page 48 GAO-04-239 U.S. Postal Service

unsuccessful, wait for employees to report for duty after they learned 

about the facility closures through the media. 

Several Factors May Have 

Hindered Timely 

Information Sharing

The problems with timely information sharing may have occurred for a 

variety of reasons. First, according to the Postal Service’s Chief Operating 

Officer and other senior postal managers, information on who was 

responsible for managing the response within federal agencies was not 

always clear. Individuals involved in early discussions, the managers 

learned, were not always authorized to make decisions. As a result, 

decisions were sometimes delayed while decision makers familiarized 

themselves with the issues. A U.S. Army Medical Research Institute of 

Infectious Diseases official also observed that within CDC, and between 

CDC and affected locations, information was not shared well because, at 

the time, CDC did not have a command center. Changes in CDC staffing 

further complicated information sharing, according to Postal Service

managers, who cited difficulties in educating CDC officials who lacked 

knowledge of postal operations. 

Within the Postal Service, problems with sharing information appear to be 

linked to poor relations between labor and management. For example, 

union representatives and postal managers told us that postal employees 

often do not provide current and accurate contact information because 

they do not trust postal management. 

As recollections have faded over time and changes in agency personnel 

have occurred, it has become increasingly difficult to reconstruct events 

and determine what information was available to whom at what time. 

Documentation of who participated in key meetings, what information was 

communicated, and what decisions were reached is often unavailable or 

difficult to identify and obtain. In our earlier work on the anthrax 

contamination at Wallingford, for example, we could not determine when 

the Postal Service first learned of the quantitative test results for the facility 

because there was no definitive documentation. Similarly, during this 

review, we could not always reconcile seemingly conflicting recollections 

of what information was shared, with whom, and when, because 

participants often did not document their activities or decisions. Even 

during the response, postal managers said, it was very difficult to reconcile 

conflicting information from different parties. Nearly 3 years later, it is even 

more difficult. 
Page 49 GAO-04-239 U.S. Postal Service

Agencies Have Taken Steps 

to Improve Information 

Sharing and Documentation 

Organizational changes made since the anthrax incidents may facilitate 

information sharing at the federal level. While the Office of Homeland 

Security existed in the fall of 2001, it had just been created and played a 

limited role in the anthrax response. Now that there is a cabinet-level 

Department of Homeland Security, responsible for coordinating the 

homeland security activities of multiple federal agencies, opportunities 

exist for establishing clear lines of authority and designating positions with 

responsibility for making decisions in the event of a future bioterrorist 

attack. According to the Postal Service’s Chief Operating Officer and other 

senior postal managers, coordination at the federal level has been greatly 

improved with the creation of the Department of Homeland Security. Postal 

managers noted that when ricin was discovered in a South Carolina postal 

facility in October 2003, personnel from the new department immediately 

took the lead, sought advice from all the relevant agencies, and reached a 

quick consensus on how to proceed. However, when a ricin-contaminated 

letter addressed to the White House was intercepted at an off-site 

nonpostal mail-sorting facility in November 2003, the Secret Service waited 

2 days after the substance was positively identified to notify the FBI, the 

Postal Service, and other agencies about the discovery. According to postal 

managers, the following day, the Department of Homeland Security 

oversaw a series of conference calls to discuss the situation. A Postal 

Service manager said that the Postal Service would have liked to have 

known about the ricin letter earlier so that the Postal Service could have 

monitored the health of the employees, even though there is no drug or 

antidote for ricin poisoning.

The Postal Service has also improved its ability to share information. 

During the anthrax response, the Postal Service learned more about the 

roles and responsibilities of key federal agencies and personnel. Postal 

managers said they now interact regularly with federal agencies, including 

OSHA and the Environmental Protection Agency. In addition, postal 

managers meet periodically with representatives of the 16 federal agencies 

that make up the National Response Team. Such regular interaction has 

established a basis for better coordination with federal agencies than the 

Postal Service had prior to the anthrax incidents. 

Internally, the Postal Service has centralized responsibility for any future 

response. According to postal managers, the agency has created a new 

position, the Vice President for Emergency Preparedness, to identify a 

single decision maker and to ensure that one individual will be involved in 

all phases of planning for and responding to any future emergency. 

Additionally, according to officials from the Postal Inspection Service, the 
Page 50 GAO-04-239 U.S. Postal Service

Postal Service has established a 24-hour watch desk so that when an 

incident occurs, a call goes directly to the desk and the Inspection Service 

can transmit information nationwide. The agency can then see, track, and 

analyze patterns as they develop, they said, whereas in the past such 

information was not available until after a report on the incident had been 

prepared. They noted that having earlier information on the response also 

allows the Inspection Service to meet sooner with the Department of 

Homeland Security to discuss the issues. 

Finally, the Postal Service has established procedures for obtaining up-todate information for contacting employees. For example, when the 

Brentwood facility reopened, the Postal Service required employees to 

provide current information before their identification badges were issued. 

In addition, the Postal Service said the plant orientation brochure and 

orientation briefing would address the importance of keeping the 

information up to date. The Postal Service added that it would post 

periodic reminders and locate a kiosk within the workspace to make it 

easier for employees to update their contact information. 

Efforts have also been made to improve documentation during the 

response to a bioterrorist attack. In our April 2003 report on the events at 

Wallingford, we recommended that the Postal Service and the 

Environmental Protection Agency—as lead agency of the National 

Response Team—revise their guidance to require and maintain 

documentation of the basis for decisions made, including the health-related 

advice that they receive and the specific content of their communications 

to employees and others. This information is needed to establish a clear 

record of actions taken and to help reconcile differences in the 

recollections of participants. Both organizations have implemented this 

recommendation. Guidance developed by the National Response Team, for 

example, recommends that agencies “develop and maintain good records

documenting advice received from public health officials and others about 

the communication of health-related information of workers and the 

general public.” 

Two Other Lessons Also 

Emerged

In addition to the two key lessons that the Postal Service and other 

agencies learned about the importance of responding proactively in the 

face of uncertain health risks and of sharing information in a timely manner 

with all affected parties during an emergency, we identified two additional 

lessons during our review: the need for reliable methods to test for anthrax 
Page 51 GAO-04-239 U.S. Postal Service

in the environment and the need for a plan to provide emergency medical 

services to employees. 

Reliable Methods Are Needed to 

Test for Anthrax in the 

Environment

The lesson on needing reliable methods to test for anthrax contamination 

in the environment emerged when two initial quick tests at Brentwood—

performed by a local hazardous materials response team on October 18, 

2001—produced negative results that misled the Postal Service and public 

health agencies. As a result, the facility remained open and CDC did not 

recommend antibacterial drugs for employees until after it confirmed a 

case of inhalation anthrax in a Brentwood employee on October 21. In 

total, four Brentwood employees contracted inhalation anthrax, two of 

whom died, and later tests showed that the facility was heavily 

contaminated. At Wallingford, four rounds of tests were also conducted 

before anthrax was identified in the facility.

During an anthrax investigation, taking environmental samples is critical to 

identify the likely source of infection and the extent of environmental 

contamination and to support decisions about the need for antibacterial 

medication or decontamination and determine when employees and others 

can reenter a facility. However, at the time of the 2001 investigations, there 

were no validated methods of sampling the environment to test for anthrax.

The quick tests that were used at Brentwood are designed to detect living 

organisms, but are not specific to anthrax and are known to produce a high 

rate of false positive results. A false positive occurs when organisms are 

detected in a sample, but follow-up laboratory testing proves that they are 

not anthrax. Laboratory testing traditionally involves culturing bacterial 

spores taken from the sample so that they can grow into cells whose 

identity can be confirmed through a variety of additional tests. According 

to CDC, obtaining confirmation can take 3 to 5 days. 

Quick tests may also produce false negative results if the environment is 

contaminated but the sample does not contain a sufficient number of 

spores for the test to detect any living organisms. While positive results 

may have provided early warning of contamination at Brentwood, even 

though more time would have been needed to identify the contaminant as 

anthrax, the negative results appear to have promoted a false sense of
Page 52 GAO-04-239 U.S. Postal Service

security. Results from other tests, conducted the same day, took much 

longer to obtain but revealed that the facility was contaminated.92

The environmental testing at Wallingford, conducted in November and 

December 2001, helped to demonstrate the relative sensitivity of different 

sampling methods.93 Various methods were used there, including dry and 

wet swabs, wet wipes, and a high efficiency particulate air (HEPA) 

vacuum.94 For the first two rounds of tests, contractors hired by the Postal 

Service used dry swabs, and for the third round, a CDC investigation team 

used wet swabs. CDC found no contamination in the samples collected by 

these methods. For the fourth round, the CDC investigative team used a 

combination of these methods, and found contamination in the samples 

collected from mail-sorting machines. On the basis of research on and 

experience from sampling efforts in the fall of 2001, CDC eventually 

recommended the use of wet wipes and vacuums for future investigations 

of large facilities. 

In 2001, CDC reported that it lacked data on the relative effectiveness of 

the methods used to collect samples from surfaces typically found in an 

indoor environment. Since then, various studies have addressed this issue. 

In a report published in 2002,95 for example, side-by-side samples were 

collected from surfaces at Brentwood before it was decontaminated, using 

swabs, wipes, and a HEPA vacuum. Wet wipes and the vacuum were found 

to be more effective than surface swabs, particularly dry swabs. While 

various sampling and analytical methods have been evaluated for the 

detection of anthrax, none of those that were used in postal facilities 

92It is unclear whether the two quick tests produced false negatives because, with only two 

samples available, investigators may have inadvertently sampled uncontaminated areas. 

93For additional information about the sensitivity and effectiveness of various sampling 

methods, see E.H. Teshale, J. Painter, G.A. Burr, P. Mead, S.V. Wright, L.F. Cseh et al., 

“Environmental Sampling for Spores of Bacillus anthracis,” Emerging Infectious Diseases, 

vol. 8, No. 10 (October 2002): 1083.

94Swabs—either wet or dry—have small surface areas (similar to Q-tips® cotton swabs) and 

are typically used to collect samples from small, nonporous surface areas that do not have a 

large accumulation of dust. Wet wipes—sterile gauze pads—are typically used to collect 

samples from larger, nonporous surface areas. A HEPA vacuum is a suction device with a 

nozzle that has a filter attached to it for collecting dust samples from a surface or from the 

air. 

95W.T. Sanderson, M.J. Hein, L. Taylor, B.D. Curwin, G.M. Kinnes, T.A. Seitz, et al., “Surface 

Sampling Methods for Bacillus anthracis Spore Contamination,” Emerging Infectious 

Diseases, vol. 8, No. 10 (October 2002): 1145.
Page 53 GAO-04-239 U.S. Postal Service

during the fall of 2001 had been scientifically validated. GAO is currently 

completing a review of, among other matters, (1) the activities performed 

by federal agencies in the fall of 2001 to detect anthrax contamination in 

postal facilities, (2) the results of these activities, and (3) the process of 

validation and its significance. The results of this review, including 

recommendations for improving sampling methods, are expected before 

the end of 2004. 

Policies and Procedures for 

Obtaining Emergency Medical 

Services

The lesson about the need for an emergency medical plan detailing, among 

other matters, where postal employees would go for medical services and 

who would pay arose when the lack of such a plan resulted in some 

confusion in New Jersey. Medical treatment was not immediately provided 

to postal employees after Trenton closed on October 18.96 The following 

day, New Jersey public health officials recommended that postal 

employees consult with their personal physicians about getting 

antibacterial medication.97 They made this recommendation late on a 

Friday afternoon, when there was little opportunity for postal employees to 

contact their personal physicians. The local mayor disagreed with the 

recommendation and arranged instead for a local hospital, which had an 

existing contract to provide treatment for job-related injuries to postal 

employees, to begin treating postal employees immediately. However, 

specific arrangements for paying for the anthrax-related treatment were 

not made at that time; consequently, it was unclear who was financially 

responsible for the treatment—the Postal Service, the Office of Homeland 

Security using funds for emergencies, or the state. Payment of the bill, 

which was submitted to the Postal Service in March 2002, was delayed for 

about 3 months for a number of reasons. Specifically, the Postal Service’s 

existing agreement with the hospital for providing services to postal 

employees did not cover all of the types of services needed to deal with 

anthrax exposure; the Postal Service did not specifically authorize the 

services in advance, as required; and initially, the hospital did not provide 

96Public health officials told us the facility was closed for testing to determine the extent of 

the contamination and that they initially did not believe that immediate antibacterial 

treatment was appropriate because a case of cutaneous, rather than inhalation, anthrax had 

been identified. 

97According to the New Jersey epidemiologist, the recommendation was based on several 

factors: (1) the relatively high mean age of the postal employees suggested that added 

medications should be supervised by their personal physicians, (2) the lack of state and 

local public health resources to provide direct medical services to the employees, and (3) 

the lack of clear state authority to designate a specific nongovernmental facility to provide 

these services. 
Page 54 GAO-04-239 U.S. Postal Service

any supporting documentation with its bill. Nevertheless, after resolving 

these issues, the Postal Service reached agreement with the hospital on the 

amount to be reimbursed and, in June 2002, paid the hospital $618,000. 

Subsequently, the Postal Service worked with the New Jersey Department 

of Health and Senior Services to develop response guidelines to deal with 

possible future anthrax exposure events. The guidelines, which were still in 

draft as of mid-June 2004, included arrangements for getting emergency 

medical services for postal employees but did not address policies and 

procedures for payments. In commenting on a draft of this report, the 

Postal Service noted that it is working with the Department of Homeland 

Security and other entities responsible for dealing with terrorist activity to 

formulate policies and procedures for dealing with terrorist events, 

including how to pay providers of emergency medical services. While we 

agree that the Postal Service’s policies and procedures eventually should be 

consistent with those adopted by others, it is not clear when the broader 

policies and procedures will be available. Thus, consistent with our 

recommendation, we continue to believe that the Postal Service should 

establish a time frame by which it will develop interim policies and 

procedures for paying emergency service providers. 

Conclusions Since the anthrax incidents, the Postal Service has twice revised its Interim 

Guidelines to incorporate the lessons it has learned from the response to 

anthrax in its facilities. While the revised guidance addresses many of the 

circumstances that the Postal Service faced in 2001 and could face in the 

future, the specific concerns that we identified—including the use of 

undefined terms, such as “suspected release” and “strong suspicion,” and 

the references to outdated guidance—could be confusing for decision 

makers. Without definitions of such terms, for example, it would not be 

clear what events should trigger an evacuation or closure or what evidence 

should indicate a need for medical intervention, particularly for facilities 

without anthrax detection devices. Furthermore, the revised guidance does 

not reflect precautions that the Postal Service has taken since 2001, such as 

closing facilities after receiving preliminary test results indicating possible 

contamination with anthrax and ricin. The Postal Service acknowledges 

limitations in its existing guidance and has committed to updating its 

guidance as more information is gleaned and more lessons are learned. 

Like the Postal Service, CDC has not yet published its updated guidance to 

reflect its current knowledge about anthrax or its current approach for 

responding to evidence of anthrax contamination. Consequently, for cases 
Page 55 GAO-04-239 U.S. Postal Service

of cutaneous anthrax or positive environmental samples, CDC’s published 

guidance does not call for a facility to be closed, even though CDC 

informed us that it may now require or recommend other agencies to close 

facilities in these circumstances. Given the many uncertainties revealed 

during the anthrax incidents—including (1) the possibility that cases of 

cutaneous anthrax may indicate a risk of inhalation anthrax and (2) the 

potential for very low levels of environmental exposure to cause inhalation 

anthrax in some persons, especially those with preexisting health 

conditions—we believe it is important for CDC to publish its revised 

guidance to reflect its current approach. Because CDC is currently revising 

its guidance to reflect the cautious approach it described and plans to have 

this guidance completed by the end of 2004, we are not making a specific 

recommendation that it do so at this time. 

The Postal Service and New Jersey have drafted an agreement for 

providing emergency medical services to postal employees in New Jersey 

but have not yet developed policies and procedures for paying for these 

services. The Postal Service is also working with the Department of 

Homeland Security and others responsible for dealing with terrorist events, 

among other things, to formulate governmentwide policies and procedures 

for paying for emergency medical services. However, it is not known when 

these policies and procedures will be available. As a result, if another 

emergency arises in the interim, confusion could again cause delays in 

payments to providers and/or disputes over payments. Given that nearly 3 

years have elapsed since the Trenton postal employees were exposed to 

anthrax and reimbursement issues arose, we believe that, at a minimum, 

the Postal Service should set and meet a definitive time frame for 

developing interim policies and procedures for paying for emergency 

services. These policies and procedures should address the documentation 

needed by the Postal Service to support bills submitted to it and any other 

steps the Postal Service believes are necessary to provide for sound 

financial management. 

Recommendations for 

Executive Action

To help ensure that the Postal Service has accurate, clear, comprehensive, 

and up-to-date guidance for responding to an emergency, we recommend 

that the Postmaster General, working with other agency officials as 

appropriate, implement the following two recommendations. First, the 

Postal Service should revise its December 2003 Interim Guidelines to

• define key terms, such as “suspected release” and “strong suspicion” of 

contamination;
Page 56 GAO-04-239 U.S. Postal Service

• ensure that any references to earlier guidance are still applicable; and 

• clarify the actions that the Postal Service would take under various 

scenarios, such as when (1) the Postal Service receives preliminary 

evidence of anthrax contamination or (2) a postal employee is 

diagnosed with either inhalation or cutaneous anthrax.

Second, to help ensure (1) the availability of timely and appropriate 

emergency medical treatment and (2) that medical providers receive timely 

payment for emergency medical services provided to postal employees 

exposed to anthrax or other threatening substances, the Postal Service 

should establish and meet a definitive time frame for developing interim 

policies and procedures on paying for such services. 

Agency Comments and 

Our Evaluation

We requested comments on a draft of this report from the Postal Service, 

CDC, the FBI, the U.S. Army Medical Research Institute of Infectious 

Diseases, and representatives of three postal unions (the American Postal 

Workers Union, the National Postal Mailhandlers Union, and the National 

Association of Letter Carriers). Most of these organizations provided 

technical comments, which we incorporated as appropriate.98 The Postal 

Service’s written response to our draft report agreed with the thrust of our 

recommendations. CDC provided detailed written comments to clarify 

portions of our draft report. The agencies’ comments are summarized 

below. 

The Postal Service acknowledged that it would have made different 

decisions had the present state of medical and scientific knowledge been 

available in 2001. However, the Postal Service said it was pleased that we 

recognized that the health and safety of its employees and customers were 

its first priority and that its decisions were based on the advice and 

guidance it received from the scientific and medical community. Regarding 

our draft recommendations, the Postal Service said that it either (1) had 

revised or (2) would revise and clarify its guidance. For example, the Postal 

Service noted that it had recently published a new management instruction 

that establishes the procedures to be followed if a biohazard detection 

system generates a positive test alert, including the procedures set forth in 

CDC’s April 2004 guidance for evacuating a facility and administering 

98We also provided local public health officials with relevant excerpts of our draft report. 

However, none of the officials provided comments.
Page 57 GAO-04-239 U.S. Postal Service

postexposure antibacterial drugs. We deleted our proposed 

recommendation in this area to reflect the Postal Service’s action. The 

Postal Service also said that it would work with the Department of 

Homeland Security and other relevant entities to develop appropriate 

policies and procedures for paying for emergency medical service; 

however, it is unclear when these policies and procedures will be available. 

Finally, although the Postal Service said that we concluded that its 

decisions in 2001 were appropriate under the circumstances, we did not 

draw conclusions on this issue. As stated in our report, our first objective 

was to describe the factors considered in deciding whether to close the five 

postal facilities and the actions taken to protect postal employees—not to 

assess the appropriateness of the Postal Service’s actions and decisions. 

The Postal Service’s comment letter is reproduced in appendix IV.

In its general comments, CDC agreed that communication challenges 

occurred during the anthrax incidents, but maintained that the draft report 

did not adequately emphasize (1) the nation’s limited experience with 

anthrax or (2) the lack of assigned federal leadership responsibility for 

coordinating a response to it. CDC also objected to our use of the term 

“assumptions” in our draft report to describe how it arrived at its public 

health recommendations. CDC emphasized that its decisions and 

recommendations were based on available science—not assumptions 

about health risk. Specifically, CDC indicated that its decisions “were based 

on inferences from previous experience and [its] epidemiological 

observations in Florida and New York, where no disease occurred among 

postal workers.” While we believe our draft report clearly described the 

limitations of available knowledge and experience in the fall of 2001 and 

how these limitations led to the development of incorrect inferences and 

working assumptions about health risk to postal employees, we revised the 

report to further clarify these and other points. CDC’s general comments 

are reproduced in appendix V. We addressed CDC’s technical comments, as 

appropriate, in the body of the report. 

We are sending copies of this report to the Postmaster General; the 

Chairman of the Senate Committee on Governmental Affairs; the Chairman 

and Ranking Minority Member of the House Committee on Government 

Reform; the CDC; OSHA; the U.S. Army Medical Research Institute of 

Infectious Diseases, and the FBI, as well as to postal unions, local public 

health departments, and other interested parties. We will provide copies to 

others on request. In addition, the report will be available at no charge on 

the GAO Web site at http://www.gao.gov.
Page 58 GAO-04-239 U.S. Postal Service

If you have any questions about this report, please contact me on 

(202) 512-2834 or at goldsteinm@gao.gov. Key contributors to this 

assignment were Don Allison, Jeannie Bryant, Derrick Collins, Elizabeth 

Eisenstadt, Bert Japikse, José Matos, Kathleen Turner, and Bernard Ungar.

Mark L. Goldstein

Director, Physical Infrastructure Issues
Page 59 GAO-04-239 U.S. Postal Service

Appendix I

Comparison of Medical Services and Apendxies

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities ApendxiI

Employees at the five facilities in our review received similar medical 

services, but the timing of the services varied depending on events at each 

location. Likewise, employees at the two facilities that were closed—

Trenton and Brentwood—received similar reassignment benefits; however, 

the duration of the benefits differed. Available information on reassignment 

benefits received at facilities that the Postal Service said were closed for 

other emergencies was neither complete nor comparable, hampering 

efforts to compare benefits across facilities. This information is incomplete 

because the Postal Service does not centrally maintain information on its 

facility closures. Furthermore, of the 22 closures for other emergencies 

that the Postal Service identified during the 5-year period between January 

1, 1998, and December 31, 2002, none lasted nearly as long as the closures 

of Trenton and Brentwood. 

Similar Medical 

Services Were 

Provided to Employees 

at the Five Facilities, 

but the Timing of the 

Services Varied 

Public health authorities provided similar medical services to employees at 

the five facilities in our review, including educational briefings on anthrax, 

literature to help employees make informed health decisions, medical 

screening, and antibacterial drugs; however, the timing of the services 

varied with the circumstances at each location. For example, in Florida, the 

local public health officials offered antibacterial drugs to employees at the 

West Palm Beach facility as soon as testing began at the facility and before 

any positive results were known. As discussed in the body of this report, 

the officials took this action because they believed it was important to 

respond proactively to the suspicion of contamination. In contrast, at the 

other facilities in our review, antibiotic prophylaxis was provided after the 

facility tested positive or after the Centers for Disease Control and 

Prevention (CDC) confirmed that a postal employee or customer had 

contracted anthrax. Table 3 identifies key events and indicates when 

medical screening began and antibacterial medication was offered to 

employees at the five facilities.
Appendix I

Comparison of Medical Services and 

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities

Page 60 GAO-04-239 U.S. Postal Service

Table 3: Key Events and Selected Medical Services Provided to Employees at the Five Postal Facilities

Sources: GAO presentation of Postal Service, CDC, and state health department information.

Postal facility

Primary medical service 

provider Date of key events and selected medical services provided

Trenton Local hospital 10/18/01: CDC confirmed that a postal employee had cutaneous anthrax. The 

facility was closed.

10/19/01: Medical screening and distribution of antibacterial drugs were 

initiated.

Brentwood D.C. Department of Health AM 10/21/01: CDC confirmed that a postal employee had inhalation anthrax. 

The mail-processing area of the facility was closed.

PM 10/21/01: Medical screening and distribution of antibacterial drugs were 

initiated.

Morgan CDC 10/24/01: Medical screening and distribution of antibacterial drugs were 

initiated.

West Palm Beach Palm Beach County Health 

Department

10/27/01: Initiation of environmental tests at the facility.

10/27/01: Antibacterial drugs were offered to postal employees at the facility. 

10/29/01: The facility tested positive for anthrax. 

Wallingford Connecticut Department of 

Public Health

11/21/01: CDC confirmed that an elderly woman (a postal customer in 

Connecticut) had inhalation anthrax. 

11/21/01: Medical screening and distribution of antibacterial drugs were 

initiated.
Appendix I

Comparison of Medical Services and 

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities

Page 61 GAO-04-239 U.S. Postal Service

Employees at the Two 

Closed Facilities 

Received Various 

Reassignment Benefits 

That Lasted for 

Different Periods of 

Time

Employees at the Trenton and Brentwood facilities received various 

benefits related to their reassignment to other facilities; however, the 

duration of the benefits differed at the two facilities.1

 The reassignment 

benefits to Trenton and Brentwood employees included administrative 

leave, free bus transportation and payment for time spent on the bus, and 

reimbursement for any additional commuting expenses.2

 The Postal 

Service provided the administrative leave first—from 1 to 3 days of time 

off—while it made alternative work arrangements for the employees. In 

addition, the Postal Service allowed employees to use administrative leave 

for any work time spent obtaining medical treatment. 

Second, the Postal Service provided Trenton and Brentwood employees 

with free bus transportation to their new work locations and compensated 

them for their time spent commuting on the bus. However, the length of 

time that the transportation was offered and the period of compensation 

for the commute differed at the two locations. At Trenton—where most 

employees were initially reassigned to one of two facilities3

—interested 

employees were bused from the parking lot of the Trenton facility to the 

alternative facilities beginning on Monday, October 22, 2001, and 

continuing until a new interim facility was opened in November 2002. The 

round-trip commute took about 2 hours per day and, for about the first 

month, the employees were paid for the time they spent commuting on the 

bus. However, as of November 19, 2001, the Postal Service stopped paying 

1

The Postal Service allowed employees at the three other facilities to take leave or to work 

temporarily at other locations while their facilities were being tested and decontaminated. 

However, few employees took advantage of these opportunities. At Wallingford, for 

example, only 3 of the over 1,100 employees asked to work elsewhere during the facility’s 

testing, while 180 employees took leave during the facility’s decontamination. At Morgan, 

the Postal Service allowed employees to work on other floors of the facility or at the postal 

facility across the street from Morgan during the facility’s testing and decontamination, but 

few people asked to do so. Similarly, at West Palm Beach, although some employees took 

leave during the facility’s decontamination, none requested to be reassigned to other postal 

facilities, according to the facility manager.

2

The benefits provided to employees following a postal facility’s closure are specified in the 

Postal Service’s Employee and Labor Relations Manual and in its collective bargaining 

agreements with unions. 

3

Not all Trenton employees were eligible for reassignment benefits. For example, carrier 

operations, which include sorting the mail, preparing it for letter carriers to deliver, and 

retail operations, continued in the parking lot of the facility, and therefore reassignment 

benefits were not paid to the employees performing these functions. Carrier operations 

continued in the Trenton parking lot for a few months, until they were relocated to a new 

building within a few miles of the Trenton facility.
Appendix I

Comparison of Medical Services and 

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities

Page 62 GAO-04-239 U.S. Postal Service

employees for their commuting time on the bus, indicating that it was 

inconsistent with postal policy because the alternative locations were 

within the local commuting area.4

 Although the Postal Service stopped 

paying for the time spent commuting on the bus, free bus transportation 

was provided until November 2002, when an interim facility was 

established. Similarly, the Postal Service assigned Brentwood employees to 

several facilities around Washington, D.C., and bused interested 

employees, free of charge, from the parking lot of the facility to one of the 

new work locations in Maryland beginning on Monday, October 22, 2001. At 

Brentwood, as at Trenton, the employees were initially paid for their 

commuting time, but Brentwood employees received this benefit for about 

3 months—2 months longer than the Trenton employees. According to a 

former manager of the Brentwood facility, the time spent commuting was 

reimbursed for a longer period at Brentwood out of consideration for the 

trauma arising from the deaths of employees there. The Postal Service 

terminated the benefit to Brentwood employees in January 2002, indicating 

that the payments were costly and inconsistent with postal policy. 

However, it continued to provide bus service to an alternate work location 

in Maryland until January 2003. 

At both locations, the Postal Service reimbursed employees for any 

additional commuting expenses they incurred while traveling 

independently to their new work locations, such as extra mileage driven in 

their vehicles or additional fares paid for public transportation. At Trenton, 

employees were reimbursed about $1.5 million in fiscal year 2002 and 

about $1.4 million in fiscal year 2003 for their additional commuting costs. 

Brentwood employees were reimbursed more than $540,000 in fiscal year 

2002 and more than $1.1 million in fiscal year 2003, according to the Postal 

Service.5

 

4

Trenton employees filed grievances over the decision not to compensate them for their 

commuting time. The grievances were not resolved and Trenton employees filed a lawsuit to 

force the Postal Service into arbitration on this issue. See Trenton Metropolitan Area Local 

v. the United States Postal Service, No. 04-1628(6EB) (DC NJ filed April 6, 2004). 

5

Although Trenton had fewer employees than Brentwood, it incurred higher costs because 

of greater distances traveled. In many cases, Trenton employees traveled more than 20 miles 

per round trip to alternate facilities and in some cases in excess of 60 miles. The Postal 

Service reported that its costs increased at Brentwood between fiscal years 2002 and 2003, 

in part because of a procedural change that allowed Brentwood employees to begin 

claiming reimbursement for the use of their private vehicles for transportation to work.
Appendix I

Comparison of Medical Services and 

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities

Page 63 GAO-04-239 U.S. Postal Service

Information on Benefits 

Paid to Employees at 

Facilities Closed for Other 

Emergencies Is Neither 

Complete nor Comparable, 

Hampering Comparisons 

across Facilities 

Available information on reassignment benefits received at facilities closed 

for other emergencies was neither complete nor comparable, hampering 

efforts to compare benefits across facilities. First, the Postal Service does 

not centrally maintain information on its facility closures. Thus, it was able 

to provide only general information on a portion of its facilities—the 22 

facilities with 10 or more employees that, it says, were closed for more than 

3 days between January 1, 1998, and December 31, 2002. Moreover, the 

circumstances associated with these closures (e.g., facility size, number of 

employees, length of closure) are not comparable to the closures of the 

Trenton and Brentwood facilities.6

 For example, as shown in table 4, only 1 

of the 22 closed facilities—the Houston Processing and Distribution 

Center—is comparable in size and function to the Trenton and Brentwood 

facilities. However, unlike Trenton and Brentwood, the Houston facility 

was closed for less than a month because of damage from tropical storm 

Allison in June 2001. The facility’s operations and 1,560 employees were 

moved temporarily to another facility. 

Of the remaining 21 facilities, 12 closed for damage from natural disasters 

(fires, floods, or other weather-related reasons), 5 closed for safety reasons 

(such as renovation), and 4 closed for damage from the September 11, 

2001, terrorist attacks on the World Trade Center. The number of 

employees at these facilities ranged from 10 to 338—far fewer than the 

numbers of employees at Trenton and Brentwood. Operations for 14 of the 

21 facilities were temporarily transferred to other facilities, and the 

facilities have since reopened; 3 of the 21 facilities were closed for such a 

short time that the Postal Service granted the employees administrative 

leave and did not have to transfer operations to other facilities. Operations 

at 3 of the 4 facilities that were closed for damage from the terrorist attacks 

were moved temporarily to new facilities close to the original facilities. The 

fourth facility, the Church Street station in New York City, remained closed 

as of June 30, 2004. Table 4 provides information about the postal facilities 

closed for other emergencies during the 5 years between January 1, 1998, 

and December 31, 2002. 

6

When Trenton and Brentwood closed in October 2001, they had about 960 and 2,490 

employees, respectively. Trenton is not expected to reopen until February 2005, which 

would be more than 3 years after its closure. Brentwood reopened and was fully operational 

on December 22, 2003—about 26 months after it closed.
Appendix I

Comparison of Medical Services and 

Reassignment Benefits Provided to Postal 

Employees at Selected Facilities

Page 64 GAO-04-239 U.S. Postal Service

Table 4: Postal Facilities Closed for Other Emergencies, January 1, 1998, through December 31, 2002

Source: GAO presentation of Postal Service data as of June 30, 2004. 

Note: Reasons for closure: 

S = building safety. 

N = natural disaster or other emergency.

WTC = closed as a result of the attacks on the World Trade Center.

a

The Postal Service reported that it granted employees administrative leave.

b

According to the Postal Service, employees were assigned to other facilities during the closure.

c

The functions of this facility were transferred. 

Approximate date

Facility location

Reason for 

closure

Number of 

employees Closed Reopened

Brooklyn, N.Y., New Lots Station S 66b 3/1998 4/1998

Phoenix, Ariz., McDowell Station S 65b 5/1998 8/1998

Loudonville, Ohio, Main Post Office N 10b 1/1999 4/1999

Bound Brook, N.J., Main Post Office N 30b 9/1999 5/2000

Los Alamos, N. Mex., Main Post Office N 44a 5/2000 5/2000

Davenport, Iowa, Main Post Office N 101b 4/2001 5/2001

Houston, Tex., Computerized Forwarding System N 65b 6/2001 6/2001

Houston, Tex., Processing and Distribution Center N 1,560b 6/2001 6/2001

New York City, 3 stations (3) WTC 338b 9/2001 9/2001

La Plata, Md., Main Post Office N 11b 4/2002 4/2002

Archbald, Pa., Main Post Office N 14b 4/2002 6/2002

Roseau, Minn., Main Post Office N 11b 6/2002 7/2002

Brooklyn, N.Y., Brevoort Station S 58b 8/2002 8/2002

Abbeville, La., Main Post Office N 31a 11/2002 11/2002

Kaplan, La., Main Post Office N 15a 11/2002 11/2002

Cold Spring, N.Y., Main Post Office N 12b 2/2002 1/2003

Dallas, Tex., Downtown Station S 124b 4/2001 6/2003

Balch Springs, Tex., Station S 16b 11/2000 6/2003

New York City, Church St. Station WTC 202b 9/2001 Not reopenedc

Tampa, Fla., Ybor City Station N 60b 5/2001 Not reopenedc

Total facilities closed 22

Facilities not reopened 2
Page 65 GAO-04-239 U.S. Postal Service

Appendix II

Objectives, Scope, and Methodology ApendxiI

As requested, we reviewed the response to anthrax contamination at five 

postal processing and distribution centers—the Trenton Processing and 

Distribution Center in Hamilton, New Jersey; the Brentwood Processing 

and Distribution Center in Washington, D.C.; the Southern Connecticut 

Processing and Distribution Center in Wallingford, Connecticut; the West 

Palm Beach Processing and Distribution Center in West Palm Beach, 

Florida; and the Morgan Processing and Distribution Center in New York 

City.1

Specifically, our objectives were to describe (1) the factors considered in 

deciding whether to close the five processing and distribution centers; (2) 

the information communicated to affected postal employees about the 

health risks posed by, and the extent of, contamination in these facilities; 

and (3) how lessons learned from the response to the contamination could 

be used in future situations. Additionally, as requested, we determined 

what, if any, medical services and reassignment benefits were provided to 

employees at the five processing and distribution centers and how these 

benefits compared to those provided to employees at facilities closed for 

other emergencies during the 5-year period ending December 31, 2002. 

To address our overall reporting objectives, we interviewed federal and 

local officials involved in investigating and responding to anthrax 

contamination at the five postal processing and distribution centers in our 

review. We discussed, among other matters, the roles, responsibilities, 

activities, and lessons of the U.S. Postal Service; the Federal Bureau of 

Investigation (FBI); CDC and its National Institute for Occupational Safety 

and Health within the Department of Health and Human Services; the 

Environmental Protection Agency; the Occupational Safety and Health 

Administration within the Department of Labor; and the U.S. Army Medical 

Research Institute of Infectious Diseases within the Department of 

Defense. We also interviewed officials from the New Jersey Department of 

Health and Senior Services, the D.C. Department of Health, the Florida 

Department of Health, the Palm Beach County Department of Health in 

Florida, the New York City Department of Health and Mental Hygiene, and 

the Connecticut Department of Health. We also spoke to postal managers 

and union representatives from each of the facilities, including 

1

Each of the five facilities was apparently contaminated as (1) envelopes containing anthrax 

or (2) cross-contaminated envelopes passed through high-speed mail-sorting machines in 

the facilities. Two other processing and distribution centers, one in Raleigh, North Carolina, 

and the other in Bellmawr, New Jersey, also tested positive for anthrax, but they are not 

believed to have processed contaminated mail. 
Appendix II

Objectives, Scope, and Methodology

Page 66 GAO-04-239 U.S. Postal Service

representatives from the American Postal Workers Union, the National 

Association of Letter Carriers, and the National Postal Mail Handlers 

Union, and we met with representatives of an employee group who had 

worked at the Brentwood facility. Our work related to the Wallingford 

facility in Connecticut was principally derived from previous work we 

conducted between September 2002 and March 2003.2

 We updated this 

information, obtained additional supporting information, and incorporated 

the information, as appropriate, in this report to address our reporting 

objectives at the five facilities. 

To understand the context in which the response to anthrax contamination 

occurred, we reviewed and analyzed, among other things, published 

literature; including technical reports on anthrax, studies and analyses of 

the anthrax incidents, prior reports by GAO and the Postal Service’s Office 

of Inspector General, and newspaper articles from the period October 1, 

2001, through December 31, 2001, in communities near the five postal 

facilities. To obtain information on anthrax, the treatment of the disease, 

and the response to the 2001 contamination, we also reviewed reports 

prepared by CDC (including its Mortality and Morbidity Weekly reports 

and its monthly Emerging Infectious Diseases journals), as well other 

medical publications, such as the Journal of the American Medical 

Association. We reviewed testimony delivered before numerous 

congressional committees on the response to the anthrax contamination in 

the fall of 2001; we also reviewed videotapes of national and local 

television coverage of the events as they were unfolding. 

Specifically, to determine the factors considered in deciding whether to 

close postal facilities, we interviewed headquarters’ postal officials as well 

as managers at each of the five facilities to identify the person or persons 

responsible for deciding whether to close the facility and to understand 

their roles in the decisions that were made. We also interviewed local 

public health officials, including state officials who participated in making 

closure decisions; reviewed agency documentation related to the factors 

considered in deciding whether to close facilities; and reviewed results of 

environmental testing for anthrax at the facilities. We interviewed a former 

official from the D.C. Department of Health who provided advice to the 

Postal Service in the days prior to the closure of the Brentwood facility. To 

understand the policies and guidance related to closure decisions, we 

reviewed the Postal Service’s anthrax-related guidance available at that 

2

GAO-03-316.
Appendix II

Objectives, Scope, and Methodology

Page 67 GAO-04-239 U.S. Postal Service

time, specifically its October 1999 Emergency Response to Mail Allegedly 

Containing Anthrax; its October 19, 2001, guidance for responding to 

anthrax; and its Interim Guidelines for Sampling, Analysis, 

Decontamination, and Disposal of Anthrax for U.S. Postal Facilities

initially dated November 16, 2001. We also reviewed CDC’s guidance for 

closing facilities and the Postal Service’s plans for responding to other 

hazardous incidents in the fall of 2001, including its plans for controlling 

exposure to blood-borne diseases, evacuating facilities, and responding to 

releases of hazardous materials. Finally, we reviewed available emergency 

response plans at the Trenton and Brentwood facilities. 

To obtain information on what was communicated to employees about 

health risks posed by anthrax and the extent of contamination in facilities, 

we interviewed a wide range of postal and public health officials who 

provided information to employees during the crisis, including the 

epidemiologists for New Jersey and Connecticut, the CDC doctor who 

assisted in the response at Morgan, the occupational nurse for the Postal 

Service who assisted in providing medical services at the Robert Wood 

Johnson University Hospital in Hamilton, New Jersey, and the public health 

doctors who provided care to postal employees, as well as staff from the 

National Institute for Occupational Safety and Health who participated in 

testing and analyzing facility samples. To obtain employee views about the 

response to anthrax and what was communicated to them, we interviewed 

union representatives from each of the five facilities and met with 

representatives of an employee group who had worked at the Brentwood 

facility. In addition, we reviewed letters, flyers, and newsletters sent to 

employees, as well as videotapes of news programs and meetings between 

the Postal Service and affected parties, including employees. We also 

reviewed the Occupational Safety and Health Administration’s regulations 

for disclosing test results to employees, as well as documentation of 

briefings, health advisories, and various news bulletins provided to 

employees. To determine what was communicated to employees about the 

contamination at each facility, including the results of testing, we 

interviewed officials from the Postal Service, CDC, local public health 

authorities, the National Institute for Occupational Safety and Health, the 

FBI, the U.S. Army Medical Research Institute of Infectious Diseases, and 

the Occupational Safety and Health Administration. We also obtained 

environmental tests results for the facilities and reports and other 

documentation prepared by government and contractor personnel. We did 

not independently assess or verify any of these data, including the 

adequacy or reliability of the testing methods. Because the Postal Service 

and others did not document all of the advice that they received or 
Appendix II

Objectives, Scope, and Methodology

Page 68 GAO-04-239 U.S. Postal Service

provided, and did not, in all cases, document the precise information 

communicated to employees during various talks at the facilities, we 

sometimes relied on the recollections of Postal Service, public health, and 

other officials to reconstruct the events in this report. To the extent 

possible, we corroborated the information with other sources.

To determine how lessons learned from the response to the contamination 

could be used in future situations, we reviewed testimony and relevant 

reports to identify actions taken to prepare for future bioterrorism 

incidents, including those related to the creation of the new Department of 

Homeland Security. We also interviewed involved parties, including CDC 

and local public health authorities, about the lessons that have been or 

should be learned from the response to anthrax. We identified and 

documented actions taken, including actions taken to respond to our April 

7, 2003, report about the response to anthrax at the Wallingford facility in 

Connecticut. For example, we reviewed guidelines revised by the National 

Response Team for responding to anthrax contamination. Finally we 

reviewed the Postal Service’s December 2003 updated guidance, entitled 

Interim Guidelines for Sampling, Analysis, Decontamination, and 

Disposal of Anthrax for U.S. Postal Facilities, for, among other things, the 

Postal Service’s most recent guidance on closing facilities and 

communicating test results to workers. We also obtained and reviewed the 

Postal Service’s guidance for responding to anthrax at facilities with 

detection systems. 

Fourth, to determine what, if any, medical services and reassignment 

benefits were provided to employees, we interviewed officials from CDC, 

local public health officials, and Postal Service managers who helped 

coordinate the medical services at the five facilities in our review, including 

managers from the D.C. Department of Health who assisted in organizing 

the provision of medical services to Brentwood employees. We also 

interviewed officials at the Robert Wood Johnson University Hospital to 

obtain information about the medical services provided to Trenton postal 

employees and to discuss issues related to the hospital’s payment for the 

services. In addition, we discussed these issues with postal accounting staff 

at headquarters. We did not attempt to determine whether appropriate 

medications and guidance were provided to employees or whether 

appropriate medical protocols were followed at the five locations. To 

determine what, if any, reassignment benefits were paid to employees we 

interviewed Postal Service managers at the five facilities, including the 

human resource managers and representatives from the local unions. We 

also reviewed the Postal Service’s Employee and Labor Relations Manual
Appendix II

Objectives, Scope, and Methodology

Page 69 GAO-04-239 U.S. Postal Service

and the national collective bargaining agreements for three unions 

representing postal employees and the Postal Service’s memoranda 

terminating the reassignment benefits at Trenton and Brentwood. We did 

not attempt to determine whether appropriate benefits were provided to 

employees. Finally, to compare benefits received at the five facilities with 

those received by employees at facilities closed for emergencies, we 

requested and reviewed summary information on benefits received at 

facilities closed between January 1, 1998, and December 31, 2002, for 

emergencies unrelated to anthrax. Because the Postal Service specifically 

stated the limitations of the data, we did not attempt to independently 

assess or verify any of these data.

We did not examine issues related to the other 18 postal facilities that 

tested positive for anthrax or matters that are being litigated.3

 Likewise, we 

did not assess the response to the anthrax contamination at the Hart Senate 

Office building in Washington, D.C.; however, a previous GAO report 

provided information on this topic,4

 which we incorporated as appropriate.

3

See, for example, Briscoe v. Potter, No. 1:03cv2084 (DC DC. filed Sept. 15, 2003); Hubbard 

v. Potter, No. 1:03cv1062 (DC DC filed Feb. 13, 2004).

4

GAO-04-152.
Page 70 GAO-04-239 U.S. Postal Service

Appendix III

Time Line of Key Events, Fall 2001 ApendxiI

Date Events 

Tuesday,

9/11/01

• Terrorist attacks on the World Trade Center and the Pentagon heighten concerns about possible bioterrorism. 

Monday,

9/18/01

• Letters containing anthrax spores are mailed to the National Broadcasting Company (NBC) and the New York Post

from Trenton, N.J.

Wednesday, 

9/26/01-

Monday, 

10/01/01

• Two NBC employees, a New York Post employee, and the baby of an American Broadcasting Company (ABC) 

employee in New York City, and two postal employees in N.J. seek medical treatment for skin conditions.

• In Fla., an American Media Incorporated employee is admitted to the hospital with a respiratory condition.

Tuesday,

10/02/01

• In Fla., a second American Media Incorporated employee is admitted to the hospital with a diagnosis of meningitis.

• CDC issues an alert about bioterrorism, which provides information about preventive measures for anthrax.

Thursday,

10/04/01

• CDC and the Fla. Department of Health announce that an American Media Incorporated employee has inhalation 

anthrax. 

Friday,

10/05/01

• In Fla., an American Media Incorporated employee becomes the first person to die from anthrax.

Monday,

10/08/01

• In Washington, D.C., the Postmaster General announces that the Postal Inspection Service is working with other law 

enforcement agencies on the incident in Fla.

Tuesday,

10/09/01

• Letters containing anthrax spores are mailed to Senator Daschle and Senator Leahy from Trenton, N.J.

Wednesday, 

10/10/01

• The Postal Service begins to educate employees nationwide on signs of cutaneous anthrax exposure and procedures 

for handling mail to avoid anthrax infection. 

Friday,

10/12/01

• In N.Y., the New York City Department of Health announces that an NBC employee has a confirmed case of 

cutaneous anthrax. 

• The FBI recovers the letter sent to NBC and, later that day, a public health laboratory in New York City confirms that 

the letter contained anthrax. However, there was insufficient sample remaining to determine the size of the anthrax 

particles. 

• The Postal Service says that it will offer gloves and disposable masks to all employees who handle mail.

• Senator Daschle’s letter passes through the Brentwood processing and distribution center.

• The Boca Raton post office in Fla., which handled mail for American Media Incorporated, is tested for anthrax, and the 

Palm Beach County Department of Health administers nasal swabs and offers a 15-day supply of ciprofloxacin to 

postal employees considered most likely to have handled the mail to American Media Incorporated. 

Monday,

10/15/01 

• On Capitol Hill, an employee opens an envelope that is addressed to Senator Daschle containing anthrax. Staffs in 

that office, an adjacent office, and first responders are given nasal swabs and a 3-day supply of antibacterial drugs. 

• In N.J., the State Department of Health and Senior Services assures Trenton employees that they have a low risk of 

contracting anthrax.

• In Fla., the presence of anthrax spores is confirmed at the Boca Raton post office.

• In Fla., CDC confirms that a second American Media Incorporated employee has inhalation anthrax.

• U.S. Army Medical Research Institute of Infectious Diseases personnel communicate the initial results of the agency’s 

analyses of the substance in the letter to Senator Daschle to the FBI and the CDC.
Appendix III

Time Line of Key Events, Fall 2001

Page 71 GAO-04-239 U.S. Postal Service

Tuesday, 

10/16/01-

Wednesday,

10/17/01

• In Washington, D.C., part of the Hart Senate Office Building is closed in the morning, and the remainder of the building 

is closed in the evening. Over the next 3 days, employees located in the Hart building and other Capitol Hill employees 

who request them are given nasal swabs and a 3-day supply of antibacterial drugs. 

• U.S. Army Medical Research Institute of Infectious Diseases personnel conduct additional analyses of the substance 

in the Daschle letter and communicate their generalized findings to representatives of the FBI, CDC, and selected 

other agencies. Representatives from the Postal Service were not present.

Thursday,

10/18/01

• In Washington, D.C., a local hazardous materials response team conducts two “quick tests” at Brentwood. The tests 

are negative for anthrax. A contractor begins taking additional samples for laboratory testing in the evening.

• In Washington, D.C., the Postmaster General holds a press conference at Brentwood, in part to reassure postal 

employees that they are at low risk for contracting anthrax. 

• In N.J., CDC confirms cutaneous anthrax in a N.J. postal employee, and a second suspected case is identified. The 

Trenton facility is closed for environmental testing, and employees are sent home. 

• In N.Y., the New York City Department of Health announces another case of cutaneous anthrax in a Columbia 

Broadcasting System employee.

• In Fla., the Postal Service arranges with the Environmental Protection Agency to clean two post offices contaminated 

with anthrax spores.

• CDC distributes a press release announcing that the Food and Drug Administration has approved doxycycline for 

postexposure prophylaxis for anthrax, and begins recommending its use instead of ciprofloxacin. 

• In Washington, D.C., a Brentwood postal employee seeks medical attention.

• U.S. Army Medical Research Institute of Infectious Diseases personnel continue their analyses of the anthrax in the 

letter sent to Senator Daschle. 

Friday, 

10/19/01

• In N.J., the Department of Health and Senior Services refers postal employees to their private physicians for medical 

treatment. The mayor makes alternative arrangements and employees begin seeking treatment at a local hospital. 

CDC confirms that another N.J. postal employee has cutaneous anthrax.

• In Washington, D.C., a hospital notifies CDC that it has admitted a Brentwood employee with a possible case of 

inhalation anthrax.

• U.S. Army Medical Research Institute of Infectious Diseases personnel brief FBI personnel on, among other things, 

their observations about the size of the anthrax particles in Senator Daschle’s letter. Staff from CDC and the Postal 

Service were not present. 

• The FBI recovers the contaminated letter to the New York Post. The letter was recovered unopened from mail that had 

been set aside as suspicious by the media company.

Saturday,

10/20/01

• In Washington, D.C., another Brentwood employee is admitted to a hospital with a respiratory condition. 

• CDC arrives at the Brentwood facility to meet with Postal Service managers and monitor the employee admitted to the 

hospital on 10/19. According to Postal Service officials, CDC informed them that there was no reason to close 

Brentwood unless and until an employee is confirmed to have inhalation anthrax.

• Analyses by the U.S. Army Medical Research Institute of Infectious Diseases determine that the letter to the New York 

Post, recovered on 10/19, contains anthrax. According to the FBI, the sample was not suitable for testing the size of 

the anthrax particles. 

Sunday,

10/21/01

• In Washington, D.C., the Brentwood employee who was admitted to the hospital on 10/19/01 is confirmed to have 

inhalation anthrax. The mail-processing area on the first floor of Brentwood is closed and evaluation and prophylaxis 

of Brentwood employees begins. 

• In Washington, D.C., the Brentwood employee who initially sought medical attention on 10/18/01 is admitted to a 

hospital with a possible case of inhalation anthrax and becomes the first postal employee (and second person) to die. 

• In Washington, D.C., another Brentwood employee seeks medical attention at a hospital. His chest X-ray is initially 

determined to be normal, and he is discharged.

Date Events 
Appendix III

Time Line of Key Events, Fall 2001

Page 72 GAO-04-239 U.S. Postal Service

Source: GAO based on information provided by the U.S. Postal Service, the CDC, the Connecticut Department of Public Health, the D.C. 

Department of Health, the FBI, the Florida Department of Health, the New Jersey Department of Health and Senior Services, and the 

New York City Department of Health and Mental Hygiene.

Monday,

10/22/01

• In Washington, D.C., the Brentwood postal employee who sought medical attention on 10/21/01 and was discharged 

is readmitted to the hospital. This time, he is diagnosed with inhalation anthrax and subsequently dies, becoming the 

second postal employee (and third person) to die from anthrax. 

• In Washington, D.C., distribution of antibacterial drugs is expanded to include all employees and visitors to nonpublic 

areas at the Brentwood facility. 

• The Postal Service learns that environmental tests of Brentwood are positive for anthrax.

• U.S. Army Medical Research Institute of Infectious Diseases personnel hand-delivered a report, dated 10/21/01, 

describing the results of their various analyses of the substance in Senator Daschle’s letter to the FBI. The report had 

been previously faxed to the FBI on 10/21/01. 

• According to FBI officials, the CDC liaison is briefed on the results of the 10/21/01 report prepared by the U.S. Army 

Medical Research Institute of Infectious Diseases on its analyses of Senator Daschle’s letter, but CDC’s liaison said 

he was not briefed until later. 

Wednesday,

10/23/01

• In N.Y., environmental test results from the Morgan facility, which processed the anthrax-contaminated letters 

delivered to media personnel in N.Y., are positive for anthrax.

• In Washington, D.C., the Secretary of Health and Human Services is briefed on the results of the U.S. Army Medical 

Research Institute of Infectious Diseases’ analyses. 

• The Postal Service participates in discussions with U.S. Army Medical Research Institute of Infectious Diseases about 

test results from Senator Daschle’s letter. 

• The FBI learns that an envelope similar to the ones used in the anthrax mailings had pores up to 50 microns in size. 

Thursday,

10/24/01

• According to the CDC liaison, he was informed about the results of U.S. Army Medical Research Institute of Infectious 

Diseases’ 10/21/01 analyses of Senator Daschle’s letter. 

Sunday,

10/28/01

• In N.J., CDC confirms that a Trenton postal employee has inhalation anthrax.

Monday,

10/29/01

• In N.Y., preliminary tests indicate that a N.Y. resident who was admitted to the hospital on 10/28 has inhalation 

anthrax.

• In N.J., laboratory testing confirms cutaneous anthrax in a woman who received mail from the Trenton facility, but had 

not visited the facility. The woman originally sought medical attention on 10/18/01 and was admitted to the hospital on 

10/22/01 for a skin condition.

• In N.J., laboratory testing confirms a second case of inhalation anthrax in a Trenton postal employee who initially 

sought medical attention on 10/16/01 and was admitted to the hospital on 10/18/01 with a respiratory condition.

Wednesday, 

10/31/01

• In N.Y., the person hospitalized on 10/29/01 becomes the fourth person to die from inhalation anthrax.

Friday,

11/2/01

• In N.Y., public health officials announce another case of cutaneous anthrax, in a New York Post employee. 

Friday, 

11/16/01

• In Washington, D.C., a letter addressed to Senator Leahy is recovered in mail that was impounded before delivery to 

Capitol Hill by the FBI on 10/17/01. The letter, which was also mailed in Trenton, N.J., and processed through both the 

Trenton and Brentwood postal facilities, was subsequently found to contain anthrax. A total of four letters containing 

anthrax have now been recovered, all mailed from Trenton, N.J.

Wednesday, 

11/21/01

• In Connecticut, an elderly woman who was admitted to the hospital for dehydration on 11/16/01 becomes the fifth 

person to die from inhalation anthrax.

• The Connecticut Department of Public Health, in consultation with CDC, begins prophylaxis for postal employees 

working at the Wallingford postal facility, which processed mail to the fifth victim’s home.

Friday,

12/27/01

• CDC offers the anthrax vaccine to postal employees. 

Date Events 
Page 73 GAO-04-239 U.S. Postal Service

Appendix IV

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

Comments from the U.S. Postal Service

Page 74 GAO-04-239 U.S. Postal Service
Page 75 GAO-04-239 U.S. Postal Service

Appendix V

Comments from the Centers for Disease 

Control and Prevention ApendxiV
Appendix V

Comments from the Centers for Disease 

Control and Prevention

Page 76 GAO-04-239 U.S. Postal Service
Appendix V

Comments from the Centers for Disease 

Control and Prevention

(543046) Page 77 GAO-04-239 U.S. Postal Service
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