United States General Accounting Office 

GAO Report to the Honorable Bill Frist, 

Majority Leader, U.S. Senate 

October 2003 BIOTERRORISM 

Public Health 

Response to Anthrax 

Incidents of 2001 

GAO-04-152 

Highlights of GAO-04-152, a report to the 

Honorable Bill Frist, Majority Leader, U.S. 

Senate 

In the fall of 2001, letters 

containing anthrax spores were 

mailed to news media personnel 

and congressional officials, leading 

to the first cases of anthrax 

infection related to an intentional 

release of anthrax in the United 

States. Outbreaks of anthrax 

infection were concentrated in six 

locations, or epicenters, in the 

country. An examination of the 

public health response to the 

anthrax incidents provides an 

important opportunity to apply 

lessons learned from that 

experience to enhance the nation’s 

preparedness for bioterrorism. 

Because of your interest in 

bioterrorism preparedness, you 

asked GAO to review the public 

health response to the anthrax 

incidents. Specifically, GAO 

determined (1) what was learned 

from the experience that could 

help improve public health 

preparedness at the local and state 

levels and (2) what was learned 

that could help improve public 

health preparedness at the federal 

level and what steps have been 

taken to make those 

improvements. 

www.gao.gov/cgi-bin/getrpt?GAO-04-152. 

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

(202) 512-7119. 

October 2003 

BIOTERRORISM 

Public Health Response to Anthrax 

Incidents of 2001 

Local and state public health officials in the epicenters of the anthrax 

incidents identified strengths in their responses as well as areas for 

improvement. These officials said that although their preexisting planning 

efforts, exercises, and previous experience in responding to emergencies 

had helped promote a rapid and coordinated response, problems arose 

because they had not fully anticipated the extent of coordination needed 

among responders and they did not have all the necessary agreements in 

place to put the plans into operation rapidly. Officials also reported that 

communication among response agencies was generally effective but public 

health officials had difficulty reaching clinicians to provide them with 

guidance. In addition, local and state officials reported that the capacity of 

the public health workforce and clinical laboratories was strained and that 

their responses would have been difficult to sustain if the incidents had been 

more extensive. Officials identified three general lessons for public health 

preparedness: the benefits of planning and experience; the importance of 

effective communication, both among responders and with the general 

public; and the importance of a strong public health infrastructure to serve 

as the foundation for responses to bioterrorism or other public health 

emergencies. 

The experience of responding to the anthrax incidents showed aspects of 

federal preparedness that could be improved. The Centers for Disease 

Control and Prevention (CDC) was challenged to both meet heavy resource 

demands from local and state officials and coordinate the federal public 

health response in the face of the rapidly unfolding incidents. CDC has said 

that it was effective in its more traditional capacity of supporting local 

response efforts but was not fully prepared to manage the federal public 

health response. CDC experienced difficulty in managing the voluminous 

amount of information coming into the agency and in communicating with 

public health officials, the media, and the public. In addition to straining 

CDC’s resources, the anthrax incidents highlighted both shortcomings in the 

clinical tools available for responding to anthrax, such as vaccines and 

drugs, and a lack of training for clinicians in how to recognize and respond 

to anthrax. CDC has taken steps to implement some improvements. These 

include creating the Office of Terrorism Preparedness and Emergency 

Response within the Office of the Director, creating an emergency 

operations center, enhancing the agency’s communication infrastructure, 

and developing databases of information and expertise on the biological 

agents considered likely to be used in a terrorist attack. CDC has also been 

working with other federal agencies and private organizations to develop 

better clinical tools and increase training for medical care professionals. 

In commenting on a draft of this report, DOD stressed the critical role it 

played in the public health response, and HHS provided additional examples 

of actions taken to enhance national preparedness for bioterrorism and 

other public health emergencies. 
Contents 


Letter 


Results in Brief 


Background


Local and State Public Health Officials Identified Strengths in Their 


Responses as Well as Areas for Improvement 


Experience Showed Aspects of Federal Preparedness That Could 


Be Improved 


Concluding Observations 


Agency Comments 


1 

4 

5 

10 

21 

31 

32 

Appendix I 	 Timeline of Selected Key Events in the Anthrax 

Incidents 

Appendix II Comments from the Department of Defense 

Appendix III 	 Comments from the Department of Health and 

Human Services 

Appendix IV GAO Contact and Staff Acknowledgments 41 


GAO Contact 41


Acknowledgments 41


Related GAO Products 

Table 

Table 1: People with Anthrax Infections, Letters Containing 


Anthrax Spores, and Facilities Contaminated with Anthrax 


Spores in the Six Epicenters 10


Page i GAO-04-152 Public Health Response to Anthrax Incidents 

34 

37 

39 

42 
Abbreviations 

AHRQ Agency for Healthcare Research and Quality 


AMI American Media Inc. 


CDC Centers for Disease Control and Prevention 


DOD Department of Defense 


EIS Epidemic Intelligence Service 


EOC Emergency Operations Center 


EPA Environmental Protection Agency 


Epi-X Epidemic Information Exchange 


FBI Federal Bureau of Investigation 


FDA Food and Drug Administration 


FEMA Federal Emergency Management Agency 


HAN Health Alert Network 


HHS Department of Health and Human Services 


MMWR Morbidity and Mortality Weekly Report 

NIH National Institutes of Health 

USAMRIID United States Army Medical Research Institute of 

Infectious Diseases 

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reproduce this material separately. 

Page ii GAO-04-152 Public Health Response to Anthrax Incidents 
United States General Accounting Office 

Washington, DC 20548 

October 15, 2003 


The Honorable Bill Frist 


Majority Leader 


United States Senate 


Dear Senator Frist: 


In the fall of 2001, letters containing anthrax spores were mailed to news 


media personnel and congressional officials, leading to the first cases of 


anthrax infection related to an intentional release of anthrax in the United


States.1

 Outbreaks of the disease were concentrated in six locations, or 


epicenters, in the country—Florida; New York; New Jersey; Capitol Hill in 


Washington, D.C.;2

 the Washington, D.C., regional area, which includes 


Maryland and Virginia; and Connecticut—where individuals came into 


contact with spores from the contaminated letters. The anthrax incidents 


caused illness in 22 people, 11 with the cutaneous (skin) form of the 


disease and 11 with the inhalational (respiratory) form. Five people died, 


all from inhalational anthrax. The anthrax incidents and the illness and 


deaths they caused also had an impact on the country beyond the six 


epicenters. Across the nation, even in areas far removed from the 


epicenters, residents brought samples of suspicious powders to officials 


for testing and worried about the safety of their daily mail. 


The public health response to the anthrax incidents was complicated by


several factors. The incidents occurred in the turbulent period following 


the terrorist attacks of September 11, 2001, when the focus of the nation 


was centered on response to those events. In addition, the anthrax 


1

Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. 

A bacterium is a very small organism made up of one cell. A spore is a dormant bacterium 

cell that can be revived under certain conditions. 

2

In this report, we identify Capitol Hill, the complex of congressional office buildings 

centering on the U.S. Capitol, as an epicenter distinct from the Washington, D.C., regional 

area epicenter because Capitol Hill functions independently from the District of Columbia. 

The Office of the Attending Physician, U.S. Congress, which is an office of the U.S. Navy, 

serves as the local health department for Capitol Hill and is responsible for the health of 

about 30,000 public officials and staff, as well as tourists, on Capitol Hill. 

Page 1 GAO-04-152 Public Health Response to Anthrax Incidents 
incidents were unprecedented. The response was coordinated by the 

Department of Health and Human Services (HHS), primarily through its 

Centers for Disease Control and Prevention (CDC), and CDC had never 

responded simultaneously to multiple disease outbreaks caused by the 

intentional release of an infectious agent. Anthrax was virtually unknown 

in clinical practice, and many clinicians did not have a good understanding 

of how to diagnose and treat it. As a result, public health officials at the 

federal, state, and local levels were basing their actions and 

recommendations to government officials, other responders,3

 and the 

public on information that was changing rapidly. The response to the 

incidents has been characterized by several public officials, academics, 

and other commentators as problematic and an indication that the country 

was unprepared for a bioterrorist event. 

An examination of the response to the anthrax incidents provides an 

important opportunity to apply lessons learned from that experience to 

enhance the nation’s preparedness for bioterrorism and other public 

health emergencies. Because of your interest in bioterrorism 

preparedness, you asked us to review the public health response to the 

anthrax incidents. Specifically, you asked us to determine (1) what was 

learned from the experience that could help improve public health 

preparedness for bioterrorism at the local and state levels and (2) what 

was learned that could help improve public health preparedness for 

bioterrorism at the federal level and what steps have been taken to make 

those improvements. 

In studying the response of local and state public health departments, we 

interviewed officials from the six epicenters. For a previous report,4

 we 

had conducted interviews about bioterrorism preparedness with officials 

from seven cities and their respective state capitals. These interviews were 

conducted from December 2001 through March 2002, and we used 

information from these interviews to examine the public health response 

3

In this report, the term responder refers to any organization or individual that would 

respond to a bioterrorist incident. These include physicians, nurses, hospitals, laboratories, 

public health departments, emergency medical services, emergency management agencies, 

fire departments, and law enforcement agencies. 

4

U.S. General Accounting Office, Bioterrorism: Preparedness Varied across State and 

Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7, 2003). 

Page 2 GAO-04-152 Public Health Response to Anthrax Incidents 
to the anthrax incidents in localities that were not epicenters. To study 

federal public health efforts, we interviewed officials from the Department 

of Defense (DOD) and HHS. These officials included representatives from 

DOD’s Armed Forces Institute of Pathology, Chemical Biological Incident 

Response Force, Naval Medical Research Center, and U.S. Army Medical 

Research Institute of Infectious Diseases (USAMRIID), and from HHS’s 

Agency for Healthcare Research and Quality (AHRQ), CDC, Food and 

Drug Administration (FDA), National Institutes of Health (NIH), and Office 

of the Assistant Secretary for Public Health Emergency Preparedness. To 

determine the nature of the information provided by CDC during the 

incidents, we examined the materials that CDC disseminated during 

October 2001 through December 2001. For overall assessments of and 

information on the local, state, and federal public health response, we 

interviewed members of the academic community and officials of private 

organizations representing groups affected by the incidents or involved in 

the response, including the American Hospital Association, the American 

Medical Association, the American Nurses Association, the American 

Postal Workers Union, the American Public Health Association, and the 

District of Columbia Hospital Association. We also reviewed media reports 

of the incidents from television news services and newspapers, 

retrospective analyses of the response published after the incidents, 

relevant congressional hearings that were held between October 2001 and 

December 2001, and materials provided to us by local, state, and federal 

agencies and private organizations involved in responding to the attack. To 

understand the scientific community’s analysis of the anthrax incidents, 

we searched the scientific literature using the National Library of 

Medicine’s PubMed service and reviewed relevant articles. To determine 

what was learned from the experience that could help improve public 

health preparedness for bioterrorism, we analyzed these materials for 

common themes. We focused on what could be learned from the anthrax 

incidents that could help improve public health preparedness not 

specifically for anthrax or any particular locality but for bioterrorism in 

general. To determine what steps have been taken to make those 

improvements, we reviewed materials from relevant federal agencies 

through October 2003. Although efforts to decontaminate affected 

facilities are part of the public health response, they are outside the scope 

of this report, as is the criminal investigation associated with the 

Page 3 GAO-04-152 Public Health Response to Anthrax Incidents 
incidents.5

 We conducted our work from May 2003 through October 2003 

in accordance with generally accepted government auditing standards. 

Results in Brief 
 Local and state public health officials identified strengths in their 

responses to the anthrax incidents of 2001 as well as areas for 

improvement. These officials said that their planning efforts had helped to 

promote a rapid and coordinated response, but they had not fully 

anticipated the extent of coordination that would be needed across both 

public and private entities involved in the response to the anthrax 

incidents. Even though many aspects of their existing response plans had 

been made operational, for example, by putting agreements into place, the 

aspects that had not been operationalized affected their ability to 

coordinate a rapid response to the anthrax incidents. Local and state 

officials said that their responses also benefited from previous 

experiences, whether gained through exercising their plans or by 

responding to emergencies of various kinds. These experiences had 

allowed them to build relationships and identify areas for improvement in 

their plans and thus to be better prepared to respond to the anthrax 

incidents. Local and state officials also stressed the importance of 

effective communication throughout the incidents. They reported that 

communication among response agencies was generally effective, but they 

had difficulty reaching clinicians to provide them with needed guidance. 

Local and state public health officials were concerned that the capacity of 

their workforce and clinical laboratories was strained and said that their 

responses would have been difficult to sustain if the incidents had been 

more extensive. 

The experience of responding to the anthrax incidents also showed 

aspects of federal preparedness that could be improved. CDC was 

challenged to both meet heavy resource demands from local and state 

officials and coordinate the federal public health response in the face of 

5

For information on aspects of the response to the anthrax incidents that are outside the 

scope of this report, see our reports on those topics: U.S. General Accounting Office, 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); U.S. 

General Accounting Office, Capitol Hill Anthrax Incident: EPA’s Cleanup Was Successful; 

Opportunities Exist to Enhance Contract Oversight, GAO-03-686 (Washington, D.C.: June 

4, 2003); and U.S. General Accounting Office, U.S. Postal Service: Issues Associated with 

Anthrax Testing at the Wallingford Facility, GAO-03-787T (Washington, D.C.: May 19, 

2003). For a list of our other work related to bioterrorism preparedness, see the list of 

related products at the end of this report. 

Page 4 GAO-04-152 Public Health Response to Anthrax Incidents 
rapidly unfolding anthrax incidents. CDC has acknowledged that although 

it was effective in its more traditional capacity of supporting local 

response efforts, it was not fully prepared to manage the federal public 

health response. CDC served as the focal point for communicating critical 

information during the response to the anthrax incidents and experienced 

difficulty in managing the voluminous amount of information coming into 

the agency and in communicating with public health officials, the media, 

and the public. In addition to straining CDC’s resources, the anthrax 

incidents highlighted both shortcomings in the clinical tools available for 

responding to anthrax, such as vaccines and drugs, and a lack of training 

for clinicians on how to recognize and respond to anthrax. 

CDC has reviewed its performance during the anthrax incidents, identified 

areas for improvement, and taken steps to implement those 

improvements. These include restructuring the Office of the Director, 

building and staffing an emergency operations center, enhancing the 

agency’s communication infrastructure, and developing and maintaining 

databases of information on and expertise in biological agents considered 

most likely to be used in a terrorist attack. CDC has also increased its 

collaborative efforts with others within and outside of HHS, for example, 

by creating a permanent position of CDC liaison to the Federal Bureau of 

Investigation (FBI). CDC has also been working with other federal 

agencies as well as private organizations to support the development of 

better clinical tools, including new vaccines and treatments for anthrax 

and other potential agents of bioterrorism, and increased training for 

medical care professionals. 

In commenting on a draft of this report, DOD stressed the critical role it 

played in the public health response, and HHS provided additional 

examples of actions it has taken to enhance national preparedness for 

bioterrorism and other public health emergencies. 

Background 


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

bacterium called Bacillus anthracis. The bacterium is commonly found in 

the soil, and its spores can remain dormant for many years. Although 

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

animals. Human anthrax infections have usually resulted from 

occupational exposure to infected animals or contaminated animal 

products, such as wool, hides, or hair. Both human and animal anthrax 

infections are rare in the United States. 

Page 5 GAO-04-152 Public Health Response to Anthrax Incidents 
Anthrax infection can take one of three forms: cutaneous, usually through 

a cut or an abrasion; gastrointestinal, usually by ingesting undercooked 

contaminated meat; or inhalational, by breathing airborne anthrax spores 

into the lungs. After the spores enter the body through any of these routes, 

they germinate into bacteria, which then multiply and secrete toxins that 

can produce local swelling and tissue death. The symptoms are different 

for each form and usually occur within 7 days of exposure. Depending on 

the extent of exposure and its form, a person can be exposed to Bacillus 

anthracis without developing an infection. There are several methods for 

detecting anthrax spores or the disease itself, for example, nasal swabs for 

exposure to spores, blood tests for infections, and wet swabs for 

environmental contamination. CDC does not recommend the use of the 

nasal swab test to determine whether an individual should be treated, 

primarily because a negative result (no spores detected) does not exclude 

the possibility of exposure. Confirmation of anthrax infection or the 

presence of anthrax spores can require more than one type of test. The 

disease can be treated with a variety of antimicrobial medications and is 

not contagious.6

 With proper treatment, fatalities are rare for cutaneous 

anthrax. For gastrointestinal anthrax, between 25 and 60 percent of cases 

have resulted in death. For inhalational anthrax, the fatality rate before the 

2001 incidents had been approximately 75 percent, even with appropriate 

antimicrobial medications. An anthrax vaccine is available, but it is 

indicated for use in individuals at high risk of exposure to anthrax spores, 

such as laboratory personnel who work with Bacillus anthracis. 

Because so few instances of inhalational anthrax have occurred, scientific 

understanding about the number of spores needed to cause infection is 

still evolving. Before the 2001 incidents, it was estimated that a person 

would need to inhale thousands of spores to develop an infection. 

However, based on some of the cases that occurred during the anthrax 

incidents, experts now believe that the number of spores needed to cause 

inhalational anthrax could be fewer than that, depending on a person’s 

health and the nature of the spores. 

6

An antimicrobial medication either kills or slows the growth of microbes. 

Page 6 GAO-04-152 Public Health Response to Anthrax Incidents 
Public Health Response to 

a Bioterrorist Attack 

In the existing model for response to a public health emergency of any 

type, including a bioterrorist attack, the initial response is generally a local 

responsibility. This local response can involve multiple jurisdictions in a 

region, with states providing additional support as needed. Having the 

necessary resources immediately available at the local level to respond to 

an emergency can minimize the magnitude of the event and the cost of 

remediation. In the case of a covert release of a biological agent such as 

anthrax, it can be days before exposed people start exhibiting signs and 

symptoms of the disease. The model anticipates that exposed individuals 

would seek out local clinicians, such as private physicians or medical staff 

in hospital emergency departments or public clinics. Clinicians would 

report any illness patterns or diagnostic clues that might indicate an 

unusual infectious disease outbreak to their state or local health 

departments. Local and state health departments would collect and 

monitor data, such as reports from clinicians, for disease trends and 

evidence of an outbreak. Environmental and clinical samples would be 

collected for laboratorians7

 to test for possible exposures and 

identification of illnesses. Epidemiologists8

 in the health departments 

would use the disease surveillance systems9

 to provide for the ongoing 

collection, analysis, and dissemination of data to identify unusual patterns 

of disease. Public health officials would provide needed information to the 

clinical community, other responders, and the public and would 

implement control measures to prevent additional cases from occurring. 

The federal government can also become involved, as requested, by 

providing assistance with testing of samples and epidemiologic 

investigations, providing advice on treatment protocols and other 

technical information, and coordinating a national response. 

7

A laboratorian is one who works in a laboratory; in the medical and allied health 

professions, a laboratorian examines or performs tests (or supervises such procedures) 

with various types of chemical and biologic materials, chiefly to aid in the diagnosis, 

treatment, and control of disease, or as a basis for health and sanitation practices. 

8

An epidemiologist is a specialist in the study of how disease is distributed in populations 

and the factors that influence or determine this distribution. 

9

Disease surveillance systems provide for the ongoing collection, analysis, and 

dissemination of health-related data to identify, prevent, and control disease. 

Page 7 GAO-04-152 Public Health Response to Anthrax Incidents 
CDC’s Bioterrorism 

Response Planning Efforts 

As early as 1998, CDC had begun its planning efforts to enhance its 

capacity to respond effectively to bioterrorism. CDC said it was 

responsible for providing national leadership in the public health and 

medical communities in a concerted effort to detect, diagnose, respond to, 

and prevent illnesses that occur as a result of bioterrorism. In its strategic 

preparedness and response plan, CDC anticipated that it would need to 

collaborate with local and state public health partners and other federal 

agencies in order to strengthen components of the public health 

infrastructure.10 As part of this collaboration, CDC initiated a cooperative 

agreement program in 1999 to enhance state and local bioterrorism 

preparedness. CDC’s planning efforts identified the importance of 

coordination with the Department of Justice, including the FBI and the 

National Domestic Preparedness Office. In addition, CDC said that there 

was ongoing coordination with the Office of Emergency Preparedness 

within HHS, FDA, NIH, DOD, the Federal Emergency Management Agency 

(FEMA), and many other partners, including academic institutions and 

professional organizations. At the time of the anthrax incidents, some of 

these collaborative efforts were in the planning stage, some were in the 

form of working groups, and others were limited in scope to areas such as 

laboratory preparedness, training, or new vaccine research. 

CDC was also working to make improvements in various aspects of 

preparedness and prevention, detection and surveillance, and 

communication and coordination. At the time of the anthrax incidents, 

CDC was working on creating diagnostic and epidemiologic performance 

standards for local and state health departments. In collaboration with 

NIH and DOD, CDC was encouraging research for the development of new 

vaccines, antitoxins, and innovative drugs. In addition, CDC had developed 

a repository of pharmaceuticals and other supplies through the Strategic 

National Stockpile.11 CDC was developing educational materials and 

providing terrorism-related training to epidemiologists, laboratory 

workers, emergency responders, emergency department personnel, and 

other front-line health care providers and health and safety personnel. 

10Public health infrastructure is the foundation that supports the planning, delivery, and 

evaluation of public health activities and is composed of a well-trained public health 

workforce, effective program and policy evaluation, sufficient epidemiology and 

surveillance capability to detect outbreaks and monitor incidence of diseases, appropriate 

response capacity for public health emergencies, effective laboratories, secure information 

systems, and advanced communication systems. 

11At the time of the anthrax incidents, the Strategic National Stockpile was known as the 

National Pharmaceutical Stockpile. 

Page 8 GAO-04-152 Public Health Response to Anthrax Incidents 
Through cooperative agreements, CDC was also working to upgrade the 

surveillance systems of the local and state health departments and 

investing in the Health Alert Network (HAN)12 and Epidemic Information 

Exchange (Epi-X)13 communication systems. 

Fall 2001 Anthrax 

Incidents 

In October 2001, an employee of American Media Inc. (AMI) in Florida was 

diagnosed with inhalational anthrax, the first case in the United States in 

over two decades. By the end of November 2001, 21 more people had 

contracted the disease, and 5 people, including the original victim, had 

died as a result. Although the FBI confirmed the existence of only four 

letters containing anthrax spores, by December 2001 the Environmental 

Protection Agency (EPA) had confirmed that over 60 sites, about one third 

of which were U.S. postal facilities, had been contaminated with anthrax 

spores. 

The cases of inhalational anthrax in Florida, the first epicenter, were 

thought to have resulted from proximity to opened letters containing 

anthrax spores, which were never found. (See table 1.) The initial cases of 

anthrax detected in New York, the second epicenter, were all cutaneous 

and were also thought to have been associated with opened anthrax 

letters. The cases detected initially in New Jersey, the third epicenter, 

were cutaneous and were in postal workers who presumably had not been 

exposed to opened anthrax letters. Unlike the incidents at other 

epicenters, which began when cases of anthrax were detected, the 

incident on Capitol Hill, the fourth epicenter, began with the opening of a 

letter containing anthrax spores and resulting exposure. The discovery of 

inhalational anthrax in a postal worker in the Washington, D.C., regional 

area, the fifth epicenter, revealed that even individuals who had been 

exposed only to sealed anthrax letters could contract the inhalational form 

of the disease. Subsequent inhalational cases in Washington, D.C., New 

Jersey, New York, and Connecticut, the sixth epicenter, underscored that 

12HAN is a nationwide program designed to ensure communication capacity at all local and 

state health departments (including full Internet connectivity and training), ensure capacity 

to receive distance learning offerings from CDC and others, and ensure capacity to 

broadcast and receive health alerts at every level. 

13Epi-X is a secure, Web-based communication system to enhance bioterrorism 

preparedness efforts by facilitating the sharing of preliminary information about disease 

outbreaks and other health events among public health officials across jurisdictions and 

provide experience in the use of secure communications. 

Page 9 GAO-04-152 Public Health Response to Anthrax Incidents 
finding. (For a list of key events in the history of the anthrax incidents and 

the public health response to the incidents, see app. I.) 

Table 1: People with Anthrax Infections, Letters Containing Anthrax Spores, and 

Facilities Contaminated with Anthrax Spores in the Six Epicenters 

Number of infected people Letter 

recovered 

within 

Epicenters epicenter

Cutaneous 

anthrax 

Inhalational 

anthrax 

Contaminated 

facilities 

Florida 0 2 No Yes 

New York 7 1 Yes Yes 

New Jersey 4 2 Noa Yes 

Capitol Hill 0 0 Yes Yes 

Washington, D.C., 0 5 No a Yes 

regional area 

Connecticut 0 1 No Yes 

Source: CDC. 

a

Although no letters were recovered within the New Jersey and Washington, D.C., epicenters 

themselves, the letters found in the New York and Capitol Hill epicenters have been determined to be 

the source of the contamination in New Jersey and Washington, D.C. 

Although the anthrax incidents were limited to six epicenters on the East 

Coast, the incidents had national implications. Because mail processed at 

contaminated postal facilities could be cross-contaminated and end up 

anywhere in the country, the localized incidents generated concern about 

white powders found in locations beyond the epicenters and created a 

demand throughout the nation for public health resources at the local, 

state, and federal levels. 

Local and state public health officials across the epicenters emphasized 

the benefits of their planning efforts for promoting a rapid and 

coordinated response, stressed the importance of effective communication 

throughout the incidents, and reported that their response capacity was 

strained and the response would have been difficult to sustain if the 

incidents had been more extensive. 

Local and State Public 

Health Officials 

Identified Strengths in 

Their Responses as 

Well as Areas for 

Improvement 

Page 10 GAO-04-152 Public Health Response to Anthrax Incidents 
Local and State Public 

Health Officials Relied on 

Plans for Coordinating 

with a Wide Range of 

Entities and Identified 

Areas for Improvement 

Epicenters Had Engaged in 

Some Response Planning but 

Had Not Anticipated the Full 

Extent of Coordination That 

Would Be Needed 

Local and state public health officials were challenged to coordinate their 

responses to the anthrax incidents across a wide range of public and 

private entities, often across more than one local jurisdiction. Officials 

reported that anticipating local needs in emergency response plans, 

making those plans operational with formal contracts and agreements, and 

having experience with other public emergencies or large events improved 

their ability to mount a rapid and coordinated response. When pieces of 

this planning process were missing, had not been operationalized, or had 

not been tested by experience, coordination of the local response was 

often more difficult. 

Local and state public health officials reported that they had typically 

planned for coordination of their emergency response but had not fully 

anticipated the extent to which they would have to coordinate with a wide 

range of both public and private entities involved in the response to the 

anthrax incidents, both locally and in other jurisdictions. Among others, 

public health departments had to coordinate their responses with those of 

local and federal law enforcement, emergency responders, the postal 

community, environmental agencies, and clinicians. 

Most response plans anticipated the need for public health officials to 

coordinate with law enforcement and emergency response officials, both 

within their community and across jurisdictions. In one epicenter, for 

example, a regional organization of local governments had developed 

planning guidance that outlined collaborative networks between the 

public health and emergency response communities needed to strengthen 

the region’s response to an event such as the anthrax incidents. 

In contrast, the need to link the public health response with the responses 

of other public entities affected by the anthrax incidents, such as 

environmental agencies, military response teams, and the U.S. Postal 

Service, was less likely to have been anticipated in local response plans. 

During the response, standard practices for clinical and environmental 

testing and use of proper protective clothing and equipment needed to be 

coordinated among public health officials, postal officials, police, 

firefighters, environmental specialists, and teams from DOD. However, 

officials reported that in some cases personnel from environmental and 

military groups were meeting with public health officials for the first time 

as the response unfolded. When the need for consistency in testing 

procedures and standards for protective clothing and equipment had not 

been anticipated, officials sometimes had difficulty agreeing on which 

procedures and standards to follow. In addition, some plans had not 

anticipated the need to forge quick relationships between public health 

Page 11 GAO-04-152 Public Health Response to Anthrax Incidents 
Some Aspects of Response 

Plans Had Been Made 

Operational and Increased 

Officials’ Ability to Coordinate 

a Rapid Response 

departments and local groups affected by the incidents but not expressly 

mentioned in the plans. During the anthrax incidents, the absence of such 

a measure proved to be a particular problem for postal officials and postal 

union representatives. In part due to this absence of proactive plans, 

coordination between public health and postal officials on many of the 

details of the response was problematic, and there were difficulties 

communicating critical information, such as decisions on how and when 

to provide prophylactic, or preventive, treatment to postal workers. 

The need for coordination between public health and private groups 

affected by the emergency—such as the hospital community—was also 

not always fully anticipated in local response plans. Public health officials 

in several areas had to work with local hospitals and other facilities to set 

up screening and postexposure prophylaxis clinics rapidly, sometimes in 

less than 24 hours. In this time they had to identify an appropriate site 

location, design patient flow plans, outline staff needs and responsibilities 

(medical, pharmacy, counseling, administrative, and facilities operation 

components), and obtain medications (including dealing with the logistics 

of breaking down and repackaging bulk medications). Few locations had 

formally addressed all of these issues before the anthrax incidents, but 

those that had addressed at least some of them reported being able to 

respond more rapidly. 

Officials relied on a variety of formal agreements, such as memoranda of 

understanding and legal contracts, to address the needs identified in their 

planning documents. These needs included coordination across disciplines 

and jurisdictions, access to scientific information, and human resources 

support. Local officials reported that putting agreements and contracts 

into place to address these needs strengthened their preparedness both by 

solidifying links with their public and private partners and by helping them 

identify weaknesses that could be addressed prior to an emergency. When 

systems had not been put into place to support plans, coordination of 

response efforts was more difficult. 

Formal agreements had often been put into place to support coordination 

among officials within communities and across jurisdictions, but some 

aspects of plans that were important for coordinating the response had not 

yet been made operational. For example, one official reported having 

arranged to link surveillance and environmental health personnel with law 

enforcement officials during criminal investigations in the event of an 

anthrax attack. Another official had already established agreements with 

local counterparts to provide access to prophylaxis. Officials reported that 

when formal contacts between officials had not been established, 

Page 12 GAO-04-152 Public Health Response to Anthrax Incidents 
Experience with Drills and 

Responding to Emergencies 

Allowed Officials to Identify 

Areas for Improvement in Their 

Plans 

coordination with counterparts in their community and other jurisdictions 

during the incidents often relied on personal relationships. 

While some public health departments reported having systems in place to 

ensure ready access to the scientific information needed to make 

decisions and provide information to the media and the public, many 

reported that they did not. Officials reported that planning ahead and then 

taking the necessary steps to compile available scientific information— 

including what was known about anthrax, procedures for testing exposure 

to anthrax, treatment protocols, and standards for the types of protective 

clothing and equipment that are appropriate for first responders—were 

important for responding rapidly and reducing confusion across the 

parties involved in the response. 

Officials stated that during the response they relied on existing mutual aid 

agreements or contracts that gave them access to staff for screening and 

mass care clinics, allowed the state to pull local epidemiologists to support 

the state response, and addressed licensure issues for staff brought in 

from other states. However, these agreements were not always in place, or 

only partially covered the needs of the situation, and some officials had to 

spend time dealing with issues that could have been addressed before the 

event. For example, an official in one epicenter reported that because a 

state of emergency had not been declared in the jurisdiction, there was no 

system to pay for food for staff who were working 24-hour shifts in 

prophylaxis clinics. Several officials in other localities reported that 

systems had not been put into place to authorize payment for overtime 

work in both public health departments and laboratories. In addition, one 

health department received offers of volunteer help from many physicians, 

pharmacists, nurses, epidemiologists, and other concerned citizens. 

However, it could not use the volunteers because it did not have a 

volunteer management system to train providers and verify credentials. 

Experience with drills and responding to public health emergencies helped 

officials identify weaknesses in their plans. These officials stated that 

drills ranging from tabletop to full-scale exercises were useful for testing 

coordination and response capacities both locally and regionally. Public 

health officials also reported that their experience in dealing with hoax 

letters and false alarms proved useful, particularly in supporting 

coordination with the law enforcement community. In major metropolitan 

areas, experience with large events, such as political conventions, forced 

local public health departments to develop their emergency response 

plans and put the necessary agreements in place to support those plans. 

Experience with public health emergencies—including natural disasters 

Page 13 GAO-04-152 Public Health Response to Anthrax Incidents 
and outbreaks of infectious disease such as West Nile virus—also allowed 

officials to work on coordinating their responses across multiple sites, test 

their surveillance systems, and establish links with other public and 

private entities. 

Where previous experience had not allowed officials to identify and 

address shortcomings of their plans, the anthrax incidents tended to 

uncover weaknesses. For example, one local public health official 

reported that although the agency had planned how to set up a 

prophylaxis clinic it had not actually exercised getting people through the 

testing and prophylaxis process. During the anthrax response, it took 

significantly longer than the agency had anticipated to obtain test results 

from overwhelmed laboratories. This official said that if the agency had 

known how long it was going to take to get laboratory results, it would 

have provided the first doses of prophylaxis for a longer duration to take 

into account the additional time required to obtain test results. Another 

official reported that the agency’s experience with setting up a prophylaxis 

clinic during the anthrax response taught the agency how to select more 

appropriate sites for mass vaccination or prophylaxis clinics in emergency 

situations. Experience also revealed shortcomings in regional 

coordination. Several officials noted that although some plans for 

coordination across jurisdictions were in place, they had not been 

exercised, and so the relationships to support coordination had not been 

formed or tested. 

Communicating Effectively 

during the Incidents Was 

Challenging 

Communication among 

Response Agencies Was 

Generally Viewed as Effective 

Local officials identified communication among responders and with the 

public during the anthrax incidents as a challenge, both in terms of having 

the necessary communication channels and in terms of making the 

necessary information available for distribution. Good communication can 

minimize an emergency, improve response, and reassure the public. 

Officials reported that although communication among local responders 

was generally effective, there were problems in communicating with some 

hospitals and physicians. They also reported that dealing with the media 

and communicating messages to the public were also challenging. 

Communication among local and state response agencies was generally 

perceived to be effective and helped keep agency officials informed and 

the public health response coordinated. Channels of communication 

between public health agencies and other responders—including law 

enforcement and emergency management agencies, hazardous material 

units, and neighboring state public health agencies—were already in 

existence at the time of the anthrax incidents. Regular conference calls, 

Page 14 GAO-04-152 Public Health Response to Anthrax Incidents 
Flow of Information to 

Clinicians Was Problematic 

which were initiated during the incidents, were used to distribute 

information, raise issues, and answer questions. 

In addition to telephone calls, local and state public health offices relied 

on fax machines and the Internet to send and receive information during 

the incidents. Most local health departments, however, noted that they did 

not have backup communication systems that could be used in case 

everyday systems became unavailable. In addition, public health workers 

did not generally have cell phones, pagers, or laptop computers, which 

could provide the means to keep working if it became necessary to vacate 

a building during a crisis. In one epicenter, when an agency had to 

evacuate its quarters during the incidents and workers could not be at 

their desks, many of its communication systems (in addition to the 

information stored in the office in electronic formats) became unavailable. 

Several local agencies that did not have backup systems available at the 

time of the anthrax incidents told us they have concluded that it is 

important to invest in such systems to be prepared for any future public 

health emergencies. 

Local response agencies generally got the information they requested from 

other local agencies. For example, in one epicenter, police and fire 

departments were given specific protocols for handling suspicious 

samples and triaging them for the laboratory. However, there were 

instances in which they did not get needed information. For example, a 

local emergency response official stated that the local fire department did 

not know what protective equipment (such as masks and gloves) 

firefighters should wear when responding to a suspected anthrax incident. 

The fire department turned to the local health department for answers, but 

the health department took weeks to release the protocol. 

State and local officials reported difficulty providing needed information 

to some hospitals and physicians in a timely way, and members of the 

medical community expressed concern about the timeliness of the 

information they received. Physicians recognized that they lacked 

experience with anthrax and were particularly concerned about missing a 

diagnosis because of its high fatality rate. They expected to be given rapid 

and specific instructions from public health officials about how to 

recognize and treat people who had been exposed. They wanted 

guidelines, for example, on how to diagnose inhalational anthrax and how 

to advise individuals who worked in post offices. Hospitals in one 

epicenter reported receiving daily influxes of people with flulike 

symptoms. Because these hospitals were seeking guidance on how to 

distinguish between influenza and anthrax symptoms, the hospital 

Page 15 GAO-04-152 Public Health Response to Anthrax Incidents 
Criminal Investigation 

Sometimes Hindered Flow of 

Information to Officials and the 

Public 

association in the area initiated daily conference calls with concerned 

clinicians. The purpose of these calls was to collect questions to ask other 

organizations, such as CDC, to coordinate consistent answers to questions 

from the public, and to share information about clinical approaches. 

Some of the ways in which local public health agencies tried to 

communicate with hospitals and physicians were regarded as relatively 

effective by the agencies, but no method worked well for all targeted 

recipients. Health departments used various means to make relevant 

materials available to hospitals and physicians, including sending faxes or 

e-mail messages, posting relevant information on their Web sites, 

distributing CD-ROMs, and setting up hotlines. In one state, which had no 

confirmed anthrax infections but numerous false alarms, the state public 

health department faxed critical information to hospitals throughout the 

state. Officials in the department reported that while this system was 

useful in disseminating information it was insufficient because it did not 

provide a means of receiving information from the hospitals. E-mail 

worked well for institutions, but it was an ineffective way of 

communicating with physicians, especially those who did not have a 

hospital-based practice. Several local public health officials told us that 

many private physicians did not have e-mail or Web access. Because 

electronic messages were not a feasible way of communicating with many 

clinicians, there was no way to get timely information about anthrax to 

them. Some primary care physicians were difficult to reach by any mass 

communication method or even individually because public health 

officials sometimes did not have up-to-date rosters of their telephone 

numbers. Officials in one state said they realized during the incidents that 

they did not have a way to send information directly to dermatologists, a 

group of specialists who were especially important for detecting the 

cutaneous form of anthrax infection. Because localities were unable to 

reach all physicians directly, government agencies relied on physicians 

and associations who did receive the information to serve as conduits. 

However, government and association officials agreed that this method did 

not provide complete coverage of all physicians. 

Local officials reported that the criminal investigation of the anthrax 

incidents sometimes hindered their ability to obtain information they 

needed to conduct their public health response. For example, public 

health officials in one epicenter said that they were unable to get certain 

information from the FBI because the local public health officials lacked 

security clearances. They said that if they had received more detailed 

information earlier about the nature of the anthrax spores in the 

envelopes, it might have affected how their agencies were responding. In 

Page 16 GAO-04-152 Public Health Response to Anthrax Incidents 
Supplying Information to Meet 

Needs of Media and Local 

Public Was Challenging 

addition, a laboratory director in one of the epicenters reported that the 

criminal investigation led to constraints on his ability to communicate 

laboratory results to clinicians. 

Just as information was not provided to government agencies because of 

law enforcement considerations, officials stated that criminal aspects of 

the incidents complicated the distribution of information to the public. 

Officials expressed concern about the necessity of withholding some 

information from the public. One official reported that communication 

with the public was constrained when the situation became a criminal 

investigation. She was concerned that information the public needed to 

understand its risk was no longer being provided. Officials in one 

epicenter told us that they were concerned that constraints on the ability 

of local public health departments to communicate could lead to a loss of 

credibility. More generally, officials reported that fear in the community 

could have been reduced if they had been able to release more information 

to the media and the public. 

Local and state officials reported that although they were generally 

successful in persuading people to seek treatment, they encountered 

difficulties in providing needed information to the media and local public 

during the anthrax incidents. Because the incidents were taking place in 

many locations, local communications were complicated by the public’s 

exposure to information about other localities and from the national 

media. 

Local and state officials realized that they needed to use the media to 

disseminate information to the public and that they needed to be 

responsive to the media so that the information the media were providing 

was accurate. Public health and other government officials in the 

epicenters held regular press conferences to keep the public informed 

about local developments, made officials available to respond to media 

requests, and developed informational materials so that the media and the 

public could be better informed. Several officials stated that the media 

helped in publicizing sources of information such as hotlines and specific 

information such as details about who should seek treatment and where to 

go for it. However, media analysts have also noted that the media were 

sometimes responsible for providing incorrect information. For example, 

one official said that when the media reported that nasal swabbing was the 

test for anthrax, individuals sought unnecessary nasal swab testing from 

emergency rooms, physicians, and the health department, and thereby 

diverted medical and laboratory resources from medical care that was 

required elsewhere. 

Page 17 GAO-04-152 Public Health Response to Anthrax Incidents 
Communication with the public was further complicated by the evolving 

nature of the incidents and the local public’s exposure to information from 

other localities and the national media. Comparisons of actions taken by 

officials at different points in time and in different areas caused the public 

to question the consistency and fairness of actions taken in their locale. 

For example, the affected public in some epicenters wondered why they 

were being given doxycycline for prophylaxis instead of ciprofloxacin, 

which had been heralded in the media as the drug of choice for the 

prevention of inhalational anthrax and used earlier in other epicenters. 

CDC’s initial recommendation for ciprofloxacin was made because 

ciprofloxacin was judged to be most likely to be effective against any 

naturally occurring strain of anthrax and had already been approved by 

FDA for use in postexposure prophylaxis for inhalational anthrax. 

However, when it was determined that doxycycline was equally effective 

against the strain of anthrax in the letters and following FDA’s 

announcement that doxycycline was approved for inhalational anthrax, 

the recommendation was changed. This change was made because of 

doxycycline’s lower risk for side effects and lower cost and because of 

concerns that strains of bacteria resistant to ciprofloxacin could emerge if 

tens of thousands of people were taking it. In epicenters where 

prophylaxis was initiated after the recommendation had changed, officials 

followed the new recommendation and gave doxycycline to affected 

people. Local officials were challenged to explain the switch and address 

concerns raised by affected groups about apparently differential 

treatment. One local official described the importance of explaining that 

the switch was also taking place even in locations that had started with 

ciprofloxacin. 

Response Capacity Was 

Strained and Would Have 

Been Difficult to Sustain 

Elements of the local and state public health response systems—including 

the public health department and laboratory workforce as well as 

laboratories—were strained by the anthrax incidents to an extent that 

many local and state officials told us that they might not have been able to 

manage if the crisis had lasted longer. The anthrax incidents required 

extended hours for many public health workers investigating the 

incidents, as well as the assignment of new tasks, including the staffing of 

hotlines, to some workers. Aside from problems of workforce capacity, 

some clinical laboratories were not prepared in terms of equipment, 

supplies, or available laboratory protocols to test for anthrax, and most of 

them were unprepared for and overwhelmed by the large number of 

environmental samples they received for testing. The systems experienced 

these stresses in spite of assistance from CDC and DOD, and temporary 

transfers of local, and in some cases regional, resources. 

Page 18 GAO-04-152 Public Health Response to Anthrax Incidents 
Public Health Workers Were 

Overwhelmed with Work 

During the anthrax incidents, the workload increased greatly at local and 

state health departments and laboratories and across the country. The 

departments heightened their disease surveillance, investigated false 

alarms and hoaxes as well as potential threats, tested large numbers of 

samples, and performed other duties such as answering calls on telephone 

hotlines that were set up to respond to questions from the public. Health 

departments across the nation received thousands of such calls. For 

example, officials at one location told us that they received 25,000 calls 

over a 2-week period during the crisis. Nine states—Colorado, 

Connecticut, Louisiana, Maryland, Montana, North Dakota, Tennessee, 

Wisconsin, and Wyoming—reported to CDC that during the week of 

October 21 to 27, 2001, they received a total of 2,817 bioterrorism-related 

calls. These nine states also reported that during that week they conducted 

approximately 25 investigations per state and had from 8 to 30 state 

personnel engaged full-time in the responses in each state. 

Some local and state health departments had to borrow workers from 

other parts of their agencies or from outside of their agencies, such as 

from CDC and DOD, to meet the greater demands for surveillance, 

investigation, laboratory testing, and other duties related to the incidents. 

Several agencies realized that they lacked staff in particular specialties, 

such as environmental epidemiology. Some state public health 

departments did not have enough epidemiologists to investigate the 

suspected cases in their localities and had to borrow staff from other 

programs. Health workers were pulled from other jobs to work in the field 

or to staff the telephone hotlines. Staff borrowed from other parts of the 

agency were sometimes unable to fulfill their traditional public health 

duties, such as working on prevention of sexually transmitted diseases, 

and some routine work was delayed. In spite of the borrowing, staff at 

some agencies worked long hours over a number of weeks. In some cases, 

state laboratories had to borrow staff from various parts of their health 

department because laboratory workers were overwhelmed and the 

laboratories required staffing for 24 hours a day, 7 days a week. In some 

locations, CDC provided epidemiologists and laboratorians to help fill 

gaps in staff. 

Some borrowed workers had to be trained for their new duties while the 

incidents were ongoing. Some workers had to be trained or cross-trained 

in two fields, requiring additional time from other staff and resources from 

the department. Some borrowed staff had to be trained for the specific 

tasks required by the incidents. Finding sufficient numbers of people who 

were appropriately trained or could be efficiently trained to staff the 

telephone hotlines effectively was also a challenge. Local officials 

Page 19 GAO-04-152 Public Health Response to Anthrax Incidents 
Laboratories Handled Huge 

Volumes of Samples, and Some 

Were Underequipped to Do So 

reported that even if sufficient staff were found, calls were not always 

handled effectively, especially when the caller needed mental health 

services. 

Many officials we interviewed were concerned about their ability to deal 

with demand on staff in future crises. Since the anthrax incidents, some 

states have sent members of their staff for additional training. Some 

officials emphasized that surge capacity should be flexible to ensure 

preparedness for various types of future bioterrorism incidents. 

In addition to overwhelming the laboratory workforce, the large influx of 

samples strained the physical capacity of the laboratories. Public health 

laboratories around the country tested thousands of white powders and 

other environmental samples as well as clinical samples. According to 

CDC, during the anthrax incidents, laboratories within the Laboratory 

Response Network14 tested more than 120,000 samples, the bulk of which 

were environmental samples. Officials from one state told us that its 

laboratories did not have the capacity to handle the volume of work they 

received. Some local and state public health laboratories could not analyze 

anthrax samples because of limitations of equipment, supplies, or 

laboratory protocols. For example, in some states there were a limited 

number of biological safety cabinets, which were needed to prevent 

inhalation of anthrax spores by laboratory workers during the testing of 

samples. Some laboratories did not have the chemicals needed to conduct 

the appropriate tests. In some states, none of the state laboratories could 

conduct an essential diagnostic test for anthrax, the polymerase chain 

reaction test. In another state, only one of three state laboratories could 

perform this test. Some state and local laboratories were not prepared to 

take the safety precautions required to test samples for anthrax. Local 

laboratories were even less capable of doing anthrax testing. Samples for 

confirmatory testing were sent to CDC or to DOD’s USAMRIID. In addition 

to performing confirmatory testing, DOD also provided other laboratory 

support to state and local officials. For example, the samples from one 

epicenter were sent to DOD, and the department sent mobile laboratories 

to two other epicenters to assist with testing samples. 

14The Laboratory Response Network was established in 1999 by CDC, DOD, and the 

Association of Public Health Laboratories to maintain state-of-the-art capabilities for 

biological agent identification and characterization. The network is a multilevel system 

designed to link local and state public health laboratories with advanced capacity clinical, 

military, veterinary, agricultural, water, and food-testing laboratories. About 100 

laboratories participate in the network, with at least one network laboratory in each state. 

Page 20 GAO-04-152 Public Health Response to Anthrax Incidents 
Experience Showed 

Aspects of Federal 

Preparedness That 

Could Be Improved 

Moreover, although some laboratories were relatively well prepared to test 

clinical samples, they were not expecting the hundreds of environmental 

samples they received and did not have protocols prepared for testing 

them. It was the volume of these environmental samples, rather than the 

volume of the clinical samples, that overwhelmed the laboratories. Among 

the environmental samples, there were white powder samples that arrived 

without any assessment by law enforcement as to the level of threat they 

posed. At least one state laboratory developed protocols so that law 

enforcement personnel could triage samples, thereby increasing the 

likelihood that only those samples with a relatively high threat level would 

be forwarded to the laboratory for further testing. Even where protocols 

for testing these samples were available, it was a time-consuming and 

unfamiliar task for the laboratory to label them, track their progress, and 

ensure that their results were reported to the appropriate authority. 

CDC led the federal public health response to the anthrax incidents, and 

the experience showed aspects of federal preparedness that could be 

improved. During the anthrax incidents, CDC was designated to act on 

behalf of HHS in providing national leadership in the public health and 

medical communities. As the lead agency in the federal public health 

response, CDC had to not only provide public health expertise but also 

manage the public health response efforts across epicenters and among 

other federal agencies. While local and state officials reported that CDC’s 

support of their responses to the rapidly unfolding anthrax incidents at the 

local and state levels was generally effective, CDC acknowledged that it 

was not fully prepared for the challenge of coordinating the public health 

response across the federal agencies. CDC experienced difficulty serving 

as the focal point for communicating critical information during the 

response. In addition to straining CDC’s resources, the anthrax incidents 

highlighted shortcomings in the clinical tools available for responding to 

anthrax, such as vaccines and drugs, and a lack of training for clinicians 

on how to recognize and respond to anthrax. 

CDC Provided Support to 

Meet Heavy Resource 

Demands from Local and 

State Officials 

CDC effectively responded to heavy resource demands from state and 

local officials to support the local responses. CDC reported that its 

support activities included surveillance; clinical, epidemiologic, and 

environmental investigation; laboratory work; communications; 

coordination with law enforcement; medical management; administration 

of prophylaxis; monitoring of adverse events; and decontamination. As 

new epicenters became involved, CDC dispersed additional agency staff to 

assist local and state health departments and other groups playing a role in 

the response efforts, eventually deploying more than 350 employees to the 

Page 21 GAO-04-152 Public Health Response to Anthrax Incidents 
six epicenters. In addition, because even the perception of danger required 

a public health response, CDC also provided assistance as requested in 

localities beyond the epicenters. From October 8 to 31, 2001, CDC’s 

emergency response center received 8,860 telephone inquiries from all 50 

states, the District of Columbia, Puerto Rico, Guam, and 22 foreign 

countries. CDC’s callers included health care workers, local and state 

health departments, the public, and police, fire, and emergency 

departments and included requests for information about anthrax 

vaccines, bioterrorism prevention, and the use of personal protective 

equipment. Thus CDC not only provided resources to the epicenters but 

also had to coordinate local efforts nationwide. 

Local public health offices required varying levels of assistance from CDC. 

For example, in one epicenter local officials looked to CDC to lead the 

epidemiologic investigation and relied primarily on CDC staff. In contrast, 

local officials in another epicenter led the local disease outbreak 

investigation and control effort and CDC staff supplemented a large local 

team. In most of the epicenters, the team sent by CDC included Epidemic 

Intelligence Service (EIS) officers, who are specially trained 

epidemiologists, to help with the investigation. The team’s epidemiologic 

investigation used the traditional two-pronged approach in which it 

completely investigated either the case or the circumstance of a confirmed 

exposure and conducted intensive surveillance to identify any other 

anthrax cases or exposures. Laboratory testing proved to be an important 

tool in the epidemiologic investigation, and the CDC team also included 

laboratorians, who assisted with laboratory testing. In one epicenter, CDC 

also sent one of its anthrax experts to provide guidance and assist the 

local and state officials. 

CDC Reported It Was Not 

Fully Prepared to 

Coordinate the Federal 

Public Health Response 

In addition to playing its traditional role of supporting local and state 

public health departments, CDC also was confronted with the challenge of 

coordinating the public health activities of multiple federal agencies 

involved in the response, a task for which it acknowledged it was not 

wholly prepared. CDC described having to create an ad hoc emergency 

response center in an auditorium from which to manage the federal public 

health response, which involved numerous agencies. These included FDA, 

which, among other activities, provided guidance on treatment and 

addressed drug and blood safety issues. In addition, NIH provided 

scientific expertise on anthrax. CDC also coordinated with federal 

agencies working on the environmental and law enforcement aspects of 

the response efforts. DOD was responsible for testing all of the anthrax 

letters that were recovered and was involved in the transportation and 

Page 22 GAO-04-152 Public Health Response to Anthrax Incidents 
testing of environmental samples as well as the cleanup of contaminated 

buildings. EPA was in charge of the cleanup of contaminated sites. FEMA 

assisted the President’s Office of Homeland Security in establishing and 

supporting an emergency support team. The FBI led the criminal 

investigation. 

Although CDC’s planning efforts prior to the anthrax incidents had 

identified the importance of coordination with other federal agencies for 

an effective response to bioterrorism, and CDC had developed some 

working groups among federal agencies, CDC sometimes had to adjust its 

response as events unfolded to facilitate coordination of more practical 

issues such as conducting simultaneous investigations in the field. For 

example, CDC told us that in one epicenter both CDC and the FBI, which 

needed to collect samples for the forensic investigation, identified the 

need to gain a better understanding of one another’s work. During the 

incidents, CDC provided a liaison to the FBI, and the agencies worked 

together to collect laboratory samples. Since the anthrax incidents, CDC 

has held joint training with the FBI to discuss what they learned from their 

experience that could facilitate working together in the future. 

CDC has made several efforts to improve coordination since the anthrax 

incidents, including major structural changes within the agency, creation 

of a permanent emergency operations center (EOC), and increased 

collaborative efforts with others within and outside of HHS. Officials point 

to the creation of the Office of Terrorism Preparedness and Emergency 

Response, which is part of the Office of the Director, as a major change. 

The primary services of this office are to provide strategic direction for 

CDC to support terrorism preparedness and response efforts, secure and 

position resources to support activities, and ensure that systems are in 

place to monitor performance and manage accountability. The office 

manages the cooperative agreement program to enhance local and state 

preparedness and jointly manages the Strategic National Stockpile with 

the Department of Homeland Security. The office also manages the EOC, 

which was created to promote quicker and better-coordinated responses 

to public health emergencies across the country and around the globe. The 

EOC is staffed 24 hours a day, 7 days a week, and the staff includes 

officials from FEMA, DOD, and other agencies. CDC also created a 

permanent position of CDC liaison to the FBI to increase collaboration 

with that agency. 

Page 23 GAO-04-152 Public Health Response to Anthrax Incidents 
CDC Experienced 

Difficulty Serving as Focal 

Point for Communicating 

Critical Information during 

Response to Anthrax 

Incidents 

CDC Had Difficulty Managing 

the Influx of Information to 

Produce and Disseminate 

Guidance Rapidly 

CDC served as the focal point for information flow during the anthrax 

incidents, but experienced some difficulty in fulfilling that role. In addition 

to the varied responsibilities involved in leading the public health 

response, the agency concurrently had to collect and analyze the large 

amount of incoming information on the anthrax incidents, assemble and 

analyze the available scientific information on anthrax, and produce 

guidance and other information based on its analyses for dissemination to 

officials, other responders, the media, and the public. CDC officials 

reported that the agency had difficulty producing and disseminating this 

guidance rapidly as well as difficulty conveying information to the media 

and the public. 

CDC officials acknowledged that the agency was not always able to 

produce guidance as quickly as it would have liked. When the incidents 

began, it did not have a nationwide list of outside experts on anthrax, and 

it had not compiled all of the relevant scientific literature on anthrax. 

Consequently, CDC had to do time-consuming research to gather 

background information to inform its decisions, which slowed the 

development of its guidance. CDC has since compiled background 

information and lists of experts not only for anthrax but also for the other 

biological agents identified as having the greatest potential for adverse 

public health impact with mass casualties in a terrorist attack, and it has 

made the background information available on its Web site.15 

CDC officials reported that CDC also had difficulty compiling the 

information it received during the incidents. Although CDC’s role as focal 

point for information was a familiar one, the magnitude of information it 

received was unusual. CDC received a tremendous amount of information 

via e-mail, phone, fax, and news media reports from such sources as the 

agencies and organizations in the epicenters of the incidents, public health 

departments not in the epicenters, other federal agencies, and 

international public health organizations. CDC also received information 

from its staff in the field, but encountered some problems in those 

communications. Agency officials have said there were communication 

problems between epidemiologic staff in the field and at headquarters, 

which CDC attempted to address by holding “mission briefings” through 

its emergency response center; however, these briefings were not 

conducted regularly. CDC’s efforts to manage all of this incoming 

15These agents, which are labeled Category A agents, are anthrax, botulism, plague, 

smallpox, tularemia, and viral hemorrhagic fevers. 

Page 24 GAO-04-152 Public Health Response to Anthrax Incidents 
information and associated internal communication problems were 

complicated by its concurrent responsibility for coordinating the day-today activities involved in the federal public health response to the 

unfolding incidents. 

According to CDC, both clinical and environmental guidance was 

developed during the incidents by using working groups of six to eight 

employees who were subject matter experts. Keeping up with the influx of 

new information that was being acquired daily proved to be a challenge for 

these working groups. CDC officials told us that no group at CDC was 

responsible for collecting and analyzing all of the data that were coming in 

and that few people at CDC had time to read their e-mail messages during 

the incidents. Since the incidents, CDC has established teams of scientists 

from inside and outside CDC whose only role is to review and analyze 

information during a crisis; CDC does not intend for these teams to be 

involved in day-to-day response operations. 

As the working groups incorporated new information into their analyses, 

the guidance they were producing changed accordingly. For example, as 

the epidemiologic investigation expanded, CDC had to revise its 

assessment of the risk of developing inhalational anthrax from letters 

containing anthrax spores. Early on, CDC was acting on the theory that 

there was little risk of contracting inhalational anthrax from sealed letters. 

The incidents in the Washington, D.C., regional area, the fifth epicenter, 

represented a turning point in the epidemiologic investigation. The 

discovery of inhalational anthrax in a postal worker who presumably had 

been in contact only with sealed anthrax letters required CDC to revise its 

assessment. From this point on, CDC presumed that any exposure would 

put an individual at risk and changed its recommendation regarding who 

should get prophylaxis accordingly. CDC began to recommend 

prophylaxis for all individuals who had been in contact with sealed as well 

as unsealed anthrax letters, whereas earlier the agency had not been 

recommending such treatment unless an individual had been exposed to 

an opened letter. 

Initially, CDC relied on the HAN communication system and its Morbidity 

and Mortality Weekly Report (MMWR) publication to disseminate its 

guidance and other information; however, during the incidents there were 

difficulties with both of these methods. At the time of the incidents, all 

state health departments were connected to the HAN system. However, 

only 13 states were connected to all of their local health jurisdictions, and 

therefore HAN messages could not reach many local areas. Some states 

were satisfied with the information they received via HAN, but others 

Page 25 GAO-04-152 Public Health Response to Anthrax Incidents 
CDC Had Difficulty Conveying 

Information to Media and 

Public 

claimed they did not get much information from HAN and what they did 

get was incomplete. During the incidents, CDC expanded its list of HAN 

recipients to include additional organizations, including medical 

associations. MMWR is issued on a weekly basis, and so the information in 

the latest issue was not always completely up-to-date for incidents that 

were unfolding by the hour. For example, information published in MMWR 

on October 26, 2001, contained the notice that the information was current 

as of October 24, 2001. In addition to these structural barriers to getting 

information out quickly to those who needed it, CDC’s internal process of 

clearing information before issuance through HAN or MMWR was timeconsuming. CDC has since changed its clearing process so that 

information can get out faster. The agency also made a number of other 

changes during the incidents to address some of the difficulties it 

encountered in providing information to the public health departments 

and clinicians. These included bringing in professionals from other 

communication departments in CDC to help get information out quickly, 

issuing press releases twice a day, and holding telebriefings. Since the 

incidents, CDC has taken actions to expand its communication capacity, 

including developing an emergency communication plan, increasing the 

number of health experts on staff, and establishing a pressroom, in which 

the Director of CDC gives press briefings on public health efforts. In 

addition, it has developed, and posted to its Web site, information to assist 

local and state health officials in detecting and treating individuals 

infected with agents considered likely to be used in a bioterrorist attack. 

During the anthrax incidents, the media and the public looked to CDC as 

the source for health-related information, but CDC was not always able to 

successfully convey the information that it had. Media analysts and other 

commentators have asserted that although CDC officials were the most 

authoritative spokespersons they were not initially the most visible. In an 

October 2001 nationwide poll, respondents indicated that they considered 

the Director of CDC and the U.S. Surgeon General to be better sources of 

reliable information about the outbreak of disease caused by bioterrorism 

than other federal officials mentioned in the survey. 

Another problem CDC encountered in its efforts to communicate 

messages to the public was difficulty in conveying the uncertainty 

associated with the messages, that is, the caveat that although the 

messages were based on the best available information, they were subject 

to change when new facts became known. As a bioterrorist event unfolds 

and new information is learned, recommendations about who is at risk 

and how people should be treated may change, and the public needs to be 

prepared that changes may occur. Local officials and academics have 

Page 26 GAO-04-152 Public Health Response to Anthrax Incidents 
criticized CDC’s communication of uncertainty during the anthrax 

incidents. CDC officials have acknowledged that they were unsuccessful 

in clearly communicating their degree of uncertainty as knowledge was 

evolving during the incidents. For example, although there were internal 

disagreements at CDC over the appropriate length of prophylaxis, this 

uncertainty was not effectively conveyed to the public. Consequently, in 

December 2001, when many people were finishing the 60-day 

antimicrobial regimen called for in CDC’s guidance, the public questioned 

CDC’s announcement that patients might want to consider an additional 

40 days of antimicrobials. 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. 

Anthrax Incidents Strained 

Some Aspects of Federal 

Response Capacity 

CDC’s Epidemiologic and 

Laboratory Resources Were 

Strained 

The anthrax incidents highlighted some of the strengths of the federal 

public health response capacity, while also reflecting some of its 

limitations. CDC’s experience with epidemiologic investigations was 

drawn on extensively and effectively, and the Laboratory Response 

Network played an important role. Not all the clinical tools that were 

needed to identify, treat, and prevent anthrax infection were available, and 

those that were available had shortcomings. Although CDC’s bioterrorism 

preparedness training program for clinicians had begun at the time of the 

incidents, most clinicians had not yet been trained to recognize and report 

anthrax infection. 

CDC’s skills in disease investigation were heavily relied on during the 

anthrax incidents. CDC teams worked with local and state public health 

departments and law enforcement to determine what happened with each 

case. CDC’s EIS was an important component of the agency’s response. 

The availability of trained epidemiologists enabled CDC to send numbers 

of them to each epicenter to provide temporary staff to help investigate 

the nature and extent of the local incident. CDC reported that because of 

the number of epicenters and calls for assistance from other localities, its 

staff, both at headquarters and in the field, were spread thin. The level of 

assistance provided by CDC depended on the needs of the local public 

health departments and therefore varied considerably by location. For 

example, while CDC epidemiologists augmented the staff of some local 

and state health departments who would have been severely overtaxed 

without CDC’s help, the agency characterized its role in one epicenter as 

supplementary to that epicenter’s team of epidemiologists. 

Page 27 GAO-04-152 Public Health Response to Anthrax Incidents 
The Laboratory Response Network proved to be an asset, and some state 

and local officials told us they were satisfied with the laboratory response 

during the anthrax incidents. At that time, CDC laboratories, like many of 

the laboratories in the network, were inundated with samples and 

operated 24 hours a day to help epidemiologists determine exposure and 

risk by testing samples to confirm cases. From October 2001 to December 

2001, the network laboratories processed more than 120,000 samples for 

Bacillus anthracis. Public health laboratories other than those at CDC 

tested 69 percent of these samples, DOD laboratories tested 25 percent, 

and CDC laboratories tested 6 percent. In addition to testing samples at its 

laboratories, DOD also assisted the epicenters by providing personnel for 

laboratories in the epicenters and at CDC and operating portable 

laboratories to support local investigations. In addition to testing samples, 

CDC laboratories distributed chemicals needed for testing samples to 

network laboratories and developed a new testing method that permitted 

better diagnostics from biopsy samples. CDC used the network to send 

information to state bioterrorism response coordinators in local and state 

laboratories. State laboratories also communicated with each other and 

with CDC by using the network. 

However, there were signs of strain in the Laboratory Response Network. 

USAMRIID officials told us that USAMRIID, as well as other military and 

civilian laboratories, is set up to process clinical samples and was 

unprepared to process the volume and types of environmental samples 

that it received. They noted that many of the procedures for obtaining 

environmental samples from objects, such as keyboards and telephones, 

had never been standardized. Officials reported that they spent a great 

deal of time developing and validating these procedures as the incidents 

unfolded. In addition, DOD laboratory officials told us that they had to 

process overflow samples from overwhelmed laboratories at CDC and in 

the epicenters. DOD officials expressed concern about dependence on 

DOD laboratory resources for civilian emergencies, noting that in wartime 

DOD’s laboratories are needed to support military operations. 

The Strategic National Stockpile was also an asset in CDC’s response 

efforts. The anthrax incidents underscored the benefits of having a system 

in place to transport antimicrobials and vaccines quickly to areas that 

need them during emergencies. The Strategic National Stockpile program 

delivered antimicrobial medications for postexposure prophylaxis and 

provided for the transportation of anthrax vaccine, clinical and 

environmental samples, and CDC personnel, including epidemiologists, 

laboratory scientists, pathologists, and special teams of researchers. 

Page 28 GAO-04-152 Public Health Response to Anthrax Incidents 
Available Clinical Tools Had 

Shortcomings 

Not all of the clinical tools that physicians needed to identify, treat, and 

prevent anthrax infection were available, and those that were had 

shortcomings. Clinicians did not suspect and had difficulty promptly 

diagnosing anthrax because of their inexperience with the disease and 

because of the nonspecific nature of its presenting symptoms. Cutaneous 

anthrax can be confused with cellulitis or a spider bite. Inhalational 

anthrax is difficult to distinguish from other respiratory illnesses, such as 

pneumonia or influenza. Routine laboratory and radiological testing did 

not always clearly signal anthrax infection, and, even after physicians did 

suspect it, the laboratory tests needed to confirm it were time-consuming, 

laborious, and required that samples be sent to specialized laboratories. 

Diagnostic tests that are more accurate and can yield results more quickly 

are in development. 

Treatment for anthrax infection was available, but it was not effective in 

almost half of the inhalational cases. Both inhalational and cutaneous 

anthrax, once diagnosed, were treated with a combination of intravenous 

antimicrobial medications. All of the patients with cutaneous anthrax 

recovered, but 5 of the 11 patients with inhalational anthrax did not. The 

drugs worked by killing the bacteria that develop from anthrax spores 

following germination of those spores in the body. However, anthrax 

bacteria produce toxins, and no treatments were available that could 

destroy these toxins. For this reason, the antimicrobial drugs used to treat 

inhalational anthrax were ineffective in those patients in whom the 

bacteria had already produced too much toxin by the time treatment was 

initiated. CDC is working with other agencies within HHS, such as NIH, 

and other federal agencies, including DOD, to support the development of 

new treatments for anthrax and other potential agents of bioterrorism. 

Methods of prophylaxis for people exposed to anthrax spores were 

available and apparently effective, but there were several difficulties with 

these methods. There was uncertainty about how to assess exposure to 

determine who should be given prophylaxis; initially only one drug had 

been approved for prophylaxis, and it was approved only for prophylaxis 

of inhalational anthrax; the optimal length of prophylaxis for those 

thought to have been exposed to anthrax spores was unknown; 

prophylactic drugs had to be taken for months and had side effects; and 

the anthrax vaccine requires more than one dose, had not been approved 

for postexposure prophylaxis, and was in short supply. Nasal swabs and 

blood tests were used early in the investigation to assess exposure, but 

these were not reliable methods. When there was uncertainty about who 

was exposed or how great their risk from exposure was, prophylaxis was 

sometimes recommended for all workers in a facility with some 

Page 29 GAO-04-152 Public Health Response to Anthrax Incidents 
Few Clinicians Had Been 

Trained to Recognize Anthrax 

contamination, regardless of how close to the contamination the workers 

had been. This prophylaxis often started with an initial supply of 

medication while test results were awaited. For example, some people 

were given a 10-day supply of drugs and asked to return within 10 days to 

learn whether they needed to continue taking the drugs. Initially, CDC, 

with advice from NIH, recommended prophylaxis for 60 days.16 The drugs 

had side effects, and the rate of compliance with the regimen was typically 

about 40 percent. Since the incidents, federal agencies have been 

developing and evaluating tools for detecting anthrax spores. Such tests 

could enable field workers to make better initial assessments of exposure 

at particular locations to determine who should get prophylaxis. CDC is 

working with other federal agencies to support the development of new 

methods of prophylaxis for anthrax and other potential agents of 

bioterrorism. 

HHS reported that at the time of the anthrax incidents no system or data 

collection instruments existed for monitoring the nearly 10,000 people 

who were receiving prophylaxis and thus it did not have a way to collect 

information on the compliance with, adverse events from, or effectiveness 

of prophylaxis. CDC attempted to collect this information retrospectively, 

but acknowledged that this method is not optimal. To improve 

preparedness for future incidents, CDC and FDA have created a post-event 

surveillance working group that is responsible for developing a system 

capable of collecting this kind of data. 

During the anthrax incidents, it became apparent that few clinicians had 

been trained to recognize anthrax infections. In November 2000, CDC had 

created a national training plan for bioterrorism preparedness and 

response. The plan outlined training required to implement the agency’s 

Bioterrorism Event Response Operational Plan and strategies for training 

public health and medical professionals in collaboration with partners 

(chiefly public health organizations and professional groups such as the 

American Medical Association). At the time of the anthrax incidents, CDC 

had been implementing the plan for less than a year, and relatively few 

people had been trained: CDC reports that by October 2001 about 12,000 

physicians, nurses, and other medical professionals had completed the 

programs. However, CDC estimated that during the incidents more than 

16Later, CDC recommended expanding prophylaxis for those already on it to include an 

additional 40 days of antimicrobial drugs, with or without three doses of the anthrax 

vaccine. 

Page 30 GAO-04-152 Public Health Response to Anthrax Incidents 
Concluding 

Observations 

one million medical professionals participated in its anthrax-related 

training programs via satellite, Web, video, and phone. In addition to 

CDC’s training programs, which continue to be available, CDC 

collaborates with professional organizations, such as the American 

Medical Association and the American Nurses Association, to provide 

training for their members, and other federal agencies present training 

programs on bioterrorism (for example, AHRQ) or fund training programs 

on bioterrorism (for example, the Health Resources and Services 

Administration). 

The anthrax incidents of 2001 required an unprecedented public health 

response. The specific nature of the incidents and the nature of the 

response varied across the epicenters and other localities across the 

country. In each epicenter, local officials had to coordinate responses that 

were a combination of local, state, and federal efforts. In addition, local 

public health officials in the epicenters were challenged to mount an 

intensive response that included identifying and treating people already 

infected with anthrax as well as people who had been exposed and could 

become infected, identifying contaminated areas and preventing additional 

people from being exposed, processing thousands of samples suspected of 

containing anthrax, and responding to thousands of calls from concerned 

members of their communities. 

The public health response to the anthrax incidents both demonstrated the 

benefit of public health preparedness measures already in place or under 

way at the local, state, and federal levels and emphasized the need to 

reinforce or expand on those measures. The specific strengths and 

weaknesses of the public health response identified by local and state 

public health officials varied. Nonetheless, public health officials from all 

locations identified general lessons learned for public health 

preparedness. The lessons identified fall into three general categories: the 

benefits of planning and experience; the importance of effective 

communication, both among those involved in the response efforts and 

with the general public; and the critical importance of a strong public 

health infrastructure to serve as the foundation from which response 

efforts can be mounted for bioterrorism or other public health 

emergencies. 

Page 31 GAO-04-152 Public Health Response to Anthrax Incidents 
Agency Comments 

CDC was instrumental in supporting local and state efforts throughout the 

anthrax incidents, for example, by sending epidemic investigators into the 

field and providing laboratory expertise. DOD resources and expertise 

were also required to support several epicenters. CDC was challenged 

with the unfamiliar task of coordinating the extensive federal public health 

response efforts. Before the incidents began, CDC officials had recognized 

that the agency was not fully prepared to coordinate a major public health 

response effort and indeed had identified areas that needed improvement 

in testimony before Congress on the day before it confirmed the first case 

of inhalational anthrax in Florida. CDC officials have acknowledged that 

the agency did not perform as well as it would have liked during the 

incidents. The agency has taken steps to improve future performance, 

including creating the Office of Terrorism Preparedness and Emergency 

Response within the Office of the Director, building and staffing an 

emergency operations center, enhancing the agency’s communication 

infrastructure, and developing and maintaining databases of information 

and expertise on the biological agents the federal government considers 

most likely to be used in a terrorist attack. 

We obtained comments on our draft report from DOD and HHS. (See apps. 

II and III.) DOD highlighted that lessons learned from its support of the 

public health response could aid in the development of expanded 

capabilities within the civilian sector to improve the nation’s public health 

preparedness. DOD emphasized its capabilities that were vital to the 

success of the public health response, including environmental 

assessment, transportation of contaminated articles, laboratory testing, 

and cleanup of contaminated locations. The environmental cleanup was 

beyond the scope of this report. 

HHS found the report to be informative and provided additional examples 

of actions taken to enhance national preparedness for bioterrorism and 

other public health emergencies. These examples included the 

establishment of the Office of Public Health Emergency Preparedness; the 

accelerated acquisition of antimicrobial drugs for the Strategic National 

Stockpile; and the expansion of basic and targeted research and upgrading 

of research facilities focused on the pathogens most likely to be used as 

bioterrorism agents. 

DOD and HHS also made technical comments, which we incorporated 

where appropriate. 

Page 32 GAO-04-152 Public Health Response to Anthrax Incidents 
We are sending copies of this report to the Secretary of DOD, the 


Secretary of HHS, and other interested officials. We will also provide 


copies to others upon request. In addition, the report will be available at 


no charge on GAO’s Web site at http://www.gao.gov. 


If you or your staff have any questions about this report, please call me at 


(202) 512-7119. Another contact and key contributors are listed in 


appendix IV.


Sincerely yours, 


Janet Heinrich 


Director, Health Care—Public Health Issues 


Page 33 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix I: Timeline of Selected Key Events 

in the Anthrax Incidents 

Events Occurring on That Date 

Date Events Determined Retrospectively to Have Occurred on That Date (in italics) 

Tuesday, 9/11/01 • 	 Terrorist attack on World Trade Center and Pentagon prompts heightened epidemiologic surveillance 

activities in some areas. 

Wednesday, 9/26/01 • In New York (NY), two NBC employees, a New York Post employee, and the child of an ABC employee 

through and in New Jersey (NJ), two U.S. Postal Service (USPS) employees, one from the West Trenton postal 

Monday, 10/01/01 facility and one from Hamilton postal facility, seek medical attention for skin conditions. 

• In Florida, an American Media Inc. (AMI) employee is admitted to the hospital with a respiratory condition. 

Tuesday, 10/02/01 • 	 The Centers for Disease Control and Prevention (CDC) issues a Health Alert Network (HAN) alert 

regarding preparedness for bioterrorism, acknowledging the public’s concern about smallpox and anthrax 

and providing information about preventive measures. 

• In Florida, a second AMI employee is admitted to the hospital, with a diagnosis of meningitis. 

Thursday, 10/04/01 • 	 CDC and the Florida Department of Health announce confirmation of a case of inhalational anthrax. The 

infected person is an AMI employee, and the cause of the infection is unknown. 

Friday, 10/05/01 • In Florida, an AMI employee becomes the first anthrax victim to die. 

Sunday, 10/07/01 • In Florida, the AMI building is closed after anthrax spores are found. 

Monday, 10/08/01 • In Florida, prophylaxis of AMI employees begins. 

Wednesday, 10/10/01 • 	 Because the source of the AMI employee’s anthrax exposure is believed to have been a letter, USPS 

begins nationwide employee education on signs of anthrax exposure and procedures for handling mail to 

avoid anthrax infection. 

Friday, 10/12/01 • 	 In NY, the New York City Department of Health (NYCDOH) announces the confirmation of a case of 

cutaneous anthrax in an NBC employee. 

• USPS says that it will offer gloves and masks to all employees who handle mail. 

Monday, 10/15/01 • 	 On Capitol Hill, an employee opens a letter addressed to Senator Daschle thought to contain anthrax 

spores. People thought to be in the vicinity of the letter when it was opened are treated with ciprofloxacin, 

at the time the only drug approved for postexposure prophylaxis for anthrax. 

• In Florida, CDC confirms a second case of inhalational anthrax in an AMI employee. 

• In NY, NYCDOH announces a second case of cutaneous anthrax, in a child of an ABC employee. 

Thursday, 10/18/01 • 	 In the Washington, D.C., regional area (DC),a

 USPS reports that although it believes that the Daschle 

letter, which was processed at the Brentwood postal facility, was extremely well sealed and that there was 

a minute chance that anthrax spores escaped into the facility, it is testing the facility for anthrax 

contamination; quick tests are negative, other tests are sent to the laboratory. 

• 	 In NJ, laboratory testing confirms cutaneous anthrax in two USPS employees, one from the West Trenton 

postal facility and one from the Hamilton postal facility. 

• In NY, NYCDOH announces a third case of cutaneous anthrax, in a CBS employee. 

• In Florida, USPS closes two postal facilities contaminated with anthrax spores for cleaning. 

• 	 In a telebriefing, the Director of CDC provides information about anthrax, including risk of exposure, 

availability of vaccines and antimicrobial medications, screening tests, symptoms, and what to do with 

suspicious mail and also explains CDC’s role in the investigation. 

• CDC broadcasts part one of a live satellite and Web broadcast on anthrax for clinicians. 

• FDA announces that it has approved doxycycline for postexposure prophylaxis for anthrax. 

• In DC, a USPS employee who works at the Brentwood postal facility seeks medical attention. 

Page 34 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix I: Timeline of Selected Key Events 

in the Anthrax Incidents 

Events Occurring on That Date 


Date Events Determined Retrospectively to Have Occurred on That Date (in italics)


Friday, 10/19/01 • 	 In DC, a USPS employee who works at both the Brentwood postal facility and a Maryland postal facility is 

admitted to a hospital with suspected inhalational anthrax. 

• 	 In NJ, the Hamilton and West Trenton postal facilities are closed, and the New Jersey Department of 

Health and Senior Services recommends that all USPS employees from both facilities receive prophylaxis. 

• 	 In NJ, laboratory testing confirms cutaneous anthrax in a second USPS employee who works at the 

Hamilton postal facility. 

• In NY, NYCDOH announces a fourth case of cutaneous anthrax, in a New York Post employee. 

Saturday, 10/20/01 • 	 In DC, a third USPS employee who works at the Brentwood postal facility is admitted to a hospital with a 

respiratory condition. 

Sunday, 10/21/01 • 	 In DC, the USPS employee who worked at the Brentwood and Maryland postal facilities and was admitted 

to the hospital on 10/19/01 is confirmed to have inhalational anthrax. 

• 	 In DC, the Brentwood and Maryland postal facilities, are closed. Evaluation and prophylaxis of employees 

begin. 

• 	 In DC, a USPS employee who worked at the Brentwood postal facility and who initially sought medical 

attention on 10/18/01 is admitted to a hospital with suspected inhalational anthrax and becomes the 

second anthrax victim to die. 

• 	 In DC, a fourth USPS employee who worked at the Brentwood postal facility seeks medical attention at a 

hospital. His chest X-ray is initially determined to be normal, and he is discharged. 

Monday, 10/22/01 • 	 In DC, the USPS employee who worked at the Brentwood postal facility and who sought medical attention 

on 10/21/01 and was discharged is admitted to the hospital with suspected inhalational anthrax, and 

becomes the third anthrax victim to die. 

• 	 In DC, the USPS employee who was admitted to the hospital on 10/20/01 is confirmed to have 

inhalational anthrax. 

• 	 In DC, prophylaxis is expanded to include all employees and visitors to nonpublic areas at the Brentwood 

postal facility. 

• CDC rebroadcasts part one of the live satellite and Web broadcast on anthrax for clinicians. 

Wednesday, 10/24/01 • 	 In NY, USPS begins giving prophylaxis to employees at six New York City postal facilities where 

contaminated letters may have been processed. 

Thursday, 10/25/01 • 	 In DC, a State Department mail facility employee is called back to the hospital for admission; test taken 

the previous day is positive for inhalational anthrax. 

• In NY, NYCDOH announces a fifth case of cutaneous anthrax, in a second NBC employee. 

• CDC initiates daily telebriefings to provide updates on the anthrax incidents. 

Saturday, 10/27/01 • In NY, NYCDOH announces the sixth case of cutaneous anthrax, in a second New York Post employee. 

Sunday, 10/28/01 • 	 In NJ, laboratory testing confirms inhalational anthrax in a USPS Hamilton employee who was admitted to 

a hospital with suspected inhalational anthrax on 10/19/01. 

Monday, 10/29/01 • 	 In NY, preliminary tests indicate anthrax in a hospital employee who was admitted with suspected 

inhalational anthrax on 10/28/01. The hospital where she works is temporarily closed, and NYCDOH 

recommends prophylaxis for hospital employees and visitors. 

• 	 In NJ, laboratory testing confirms cutaneous anthrax in a woman who receives mail directly from the 

Hamilton 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 NJ, laboratory testing confirms a second case of inhalational anthrax, in a USPS Hamilton 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 NY, the hospital employee becomes the fourth anthrax victim to die.b 

Page 35 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix I: Timeline of Selected Key Events 

in the Anthrax Incidents 

Events Occurring on That Date 

Date Events Determined Retrospectively to Have Occurred on That Date (in italics) 

Thursday, 11/01/01 • CDC broadcasts part two of the live satellite and Web broadcast on anthrax for clinicians. 

Friday, 11/2/01 • In NY, NYCDOH announces the seventh case of cutaneous anthrax, in a third New York Post employee. 

Wednesday, 11/21/01 • 	 In Connecticut, an elderly woman, who was admitted to the hospital for dehydration on 11/16/01, becomes 

the fifth anthrax victim to die.b 

• 	 The Connecticut Department of Public Health, in consultation with CDC, begins prophylaxis for USPS 

employees working in the Seymour and Wallingford postal facilities. 

Friday, 12/21/01 • 	 CDC expands the options for those on prophylaxis to include extending the duration of drug therapy and 

adding the anthrax vaccine. 

Source: CDC, Connecticut Department of Public Health, District of Columbia Department of Health, FDA, Florida Department of Health, New Jersey Department of Health and Senior Services, NYCDOH, 

Office of the Attending Physician of the U.S. Congress, and USPS. 

a

The Washington, D.C., regional area includes Washington, D.C., Maryland, and Virginia. 

b

As of September 30, 2003, the source of exposure had not been confirmed. 

Page 36 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix II: Comments from the Department 

of Defense 

Page 37 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix II: Comments from the Department 

of Defense 

Page 38 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix III: Comments from the 

Department of Health and Human Services 

Page 39 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix III: Comments from the Department 

of Health and Human Services 

Page 40 GAO-04-152 Public Health Response to Anthrax Incidents 
Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact Michele Orza, (202) 512-6970 

Acknowledgments 	 In addition to the contact named above, Robert Copeland, Charles 

Davenport, Donald Keller, Nkeruka Okonmah, and Roseanne Price made 

key contributions to this report. 

Page 41 GAO-04-152 Public Health Response to Anthrax Incidents 
Related GAO Products 


Infectious Diseases: Gaps Remain in Surveillance Capabilities of State 

and Local Agencies. GAO-03-1176T. Washington, D.C.: September 24, 2003. 

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans 

but Lack Certain Capacities for Bioterrorism Response. GAO-03-924. 

Washington, D.C.: August 6, 2003. 

Severe Acute Respiratory Syndrome: Established Infectious Disease 

Control Measures Helped Contain Spread, but a Large-Scale Resurgence 

May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003. 

Capitol Hill Anthrax Incident: EPA’s Cleanup Was Successful; 

Opportunities Exist to Enhance Contract Oversight. GAO-03-686. 

Washington, D.C.: June 4, 2003. 

Bioterrorism: Information Technology Strategy Could Strengthen 

Federal Agencies’ Abilities to Respond to Public Health Emergencies. 

GAO-03-139. Washington, D.C.: May 30, 2003. 

U.S. Postal Service: Issues Associated with Anthrax Testing at the 

Wallingford Facility. GAO-03-787T. Washington, D.C.: May 19, 2003. 

SARS Outbreak: Improvements to Public Health Capacity Are Needed for 

Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-

769T. Washington, D.C.: May 7, 2003. 

Smallpox Vaccination: Implementation of National Program Faces 

Challenges. GAO-03-578. Washington, D.C.: April 30, 2003. 

Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have 

Improved Public Health Response Capacity, but Gaps Remain. GAO-03-

654T. Washington, D.C.: April 9, 2003. 

Bioterrorism: Preparedness Varied across State and Local Jurisdictions. 

GAO-03-373. Washington, D.C.: April 7, 2003. 

U.S. Postal Service: Better Guidance Is Needed to Improve 

Communication Should Anthrax Contamination Occur in the Future. 

GAO-03-316. Washington, D.C.: April 7, 2003. 

Hospital Emergency Departments: Crowded Conditions Vary among 

Hospitals and Communities. GAO-03-460. Washington, D.C.: March 14, 

2003. 

Page 42 GAO-04-152 Public Health Response to Anthrax Incidents 
Related GAO Products 

Homeland Security: New Department Could Improve Coordination, but 

Transferring Control of Certain Public Health Programs Raises 

Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002. 

Homeland Security: New Department Could Improve Biomedical R&D 

Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 

Washington, D.C.: July 9, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 

28, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Public Health Priority Setting. GAO-02-883T. 

Washington, D.C.: June 25, 2002. 

Bioterrorism: The Centers for Disease Control and Prevention’s Role in 

Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 

2001. 

Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-

149T. Washington, D.C.: October 10, 2001. 

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 

Washington, D.C.: October 9, 2001. 

Bioterrorism: Coordination and Preparedness. GAO-02-129T. 

Washington, D.C.: October 5, 2001. 

Bioterrorism: Federal Research and Preparedness Activities. GAO-01-

915. Washington, D.C.: September 28, 2001. 

West Nile Virus Outbreak: Lessons for Public Health Preparedness. 

GAO/HEHS-00-180. Washington, D.C.: September 11, 2000. 

Combating Terrorism: Need for Comprehensive Threat and Risk 

Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163. 

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Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 

1999. 

(290288) Page 43 GAO-04-152 Public Health Response to Anthrax Incidents 
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