Bioterrorism: Public Health Response to Anthrax Incidents of 2001
Published: 2003-10-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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 its interest in bioterrorism preparedness, Congress 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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 the disease were concentrated in six locations, or  epicenters, in the country—Florida; New York; New Jersey; Capitol Hill in  Washington, D.C.; 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  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, 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, 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  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  incidents. We conducted our work from May 2003 through October 2003  in accordance with generally accepted government auditing standards.
subsections: section_title: Background
subsections: section_title: Anthrax
paragraphs: 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.
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. 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.
section_title: Public Health Response to a Bioterrorist Attack
paragraphs: 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 laboratorians to test for possible exposures and  identification of illnesses. Epidemiologists in the health departments  would use the disease surveillance systems 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.
section_title: CDC’s Bioterrorism Response Planning Efforts
paragraphs: 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. 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. 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.
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) and Epidemic Information  Exchange (Epi-X) communication systems.
section_title: Fall 2001 Anthrax Incidents
paragraphs: 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  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.)
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.
section_title: Local and State Public Health Officials Identified Strengths in Their Responses as Well as Areas for Improvement
paragraphs: 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.
subsections: section_title: Local and State Public Health Officials Relied on Plans for Coordinating with a Wide Range of Entities and Identified Areas for Improvement
paragraphs: 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.
subsections: section_title: Epicenters Had Engaged in Some Response Planning but Had Not Anticipated the Full Extent of Coordination That Would Be Needed
paragraphs: 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  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.
section_title: Some Aspects of Response Plans Had Been Made Operational and Increased Officials’ Ability to Coordinate a Rapid Response
paragraphs: 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,  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.
section_title: Experience with Drills and Responding to Emergencies Allowed Officials to Identify Areas for Improvement in Their Plans
paragraphs: 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  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.
section_title: Communicating Effectively during the Incidents Was Challenging
paragraphs: 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.
subsections: section_title: Communication among Response Agencies Was Generally Viewed as Effective
paragraphs: 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,  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.
section_title: Flow of Information to Clinicians Was Problematic
paragraphs: 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  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.
section_title: Criminal Investigation Sometimes Hindered Flow of Information to Officials and the Public
paragraphs: 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  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.
section_title: Supplying Information to Meet Needs of Media and Local Public Was Challenging
paragraphs: 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.
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.
section_title: Response Capacity Was Strained and Would Have Been Difficult to Sustain
paragraphs: 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.
subsections: section_title: Public Health Workers Were Overwhelmed with Work
paragraphs: 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  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.
section_title: Laboratories Handled Huge Volumes of Samples, and Some Were Underequipped to Do So
paragraphs: 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 Network 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.
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.
section_title: Experience Showed Aspects of Federal Preparedness That Could Be Improved
paragraphs: 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.
subsections: section_title: CDC Provided Support to Meet Heavy Resource Demands from Local and State Officials
paragraphs: 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  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.
section_title: CDC Reported It Was Not Fully Prepared to Coordinate the Federal Public Health Response
paragraphs: 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  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.
section_title: CDC Experienced Difficulty Serving as Focal Point for Communicating Critical Information during Response to Anthrax Incidents
paragraphs: 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.
subsections: section_title: CDC Had Difficulty Managing the Influx of Information to Produce and Disseminate Guidance Rapidly
paragraphs: 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.
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  information and associated internal communication problems were  complicated by its concurrent responsibility for coordinating the day-to- day 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  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 time- consuming. 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.
section_title: CDC Had Difficulty Conveying Information to Media and Public
paragraphs: 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  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.
section_title: Anthrax Incidents Strained Some Aspects of Federal Response Capacity
paragraphs: 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.
subsections: section_title: CDC’s Epidemiologic and Laboratory Resources Were Strained
paragraphs: 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.
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.
section_title: Available Clinical Tools Had Shortcomings
paragraphs: 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  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. 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.
section_title: Few Clinicians Had Been Trained to Recognize Anthrax
paragraphs: 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  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).
section_title: Concluding Observations
paragraphs: 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.
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.
section_title: Agency Comments
paragraphs: 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.
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.
section_title: Appendix I: Timeline of Selected Key Events in the Anthrax Incidents
paragraphs: Events Occurring on That Date  Events Determined Retrospectively to Have Occurred on That Date (in italics)
Terrorist attack on World Trade Center and Pentagon prompts heightened epidemiologic surveillance  activities in some areas.
In New York (NY), two NBC employees, a New York Post employee, and the child of an ABC employee  and in New Jersey (NJ), two U.S. Postal Service (USPS) employees, one from the West Trenton postal  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.
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.
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.
In Florida, an AMI employee becomes the first anthrax victim to die.
In Florida, the AMI building is closed after anthrax spores are found.
In Florida, prophylaxis of AMI employees begins.
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.
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.
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.
In the Washington, D.C., regional area (DC), 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.
Events Occurring on That Date  Events Determined Retrospectively to Have Occurred on That Date (in italics)
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.
In DC, a third USPS employee who works at the Brentwood postal facility is admitted to a hospital with a  respiratory condition.
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
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.
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.
In NY, USPS begins giving prophylaxis to employees at six New York City postal facilities where  contaminated letters may have been processed.
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.
In NY, NYCDOH announces the sixth case of cutaneous anthrax, in a second New York Post employee.
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.
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.
In NY, the hospital employee becomes the fourth anthrax victim to die.
Events Occurring on That Date  Events Determined Retrospectively to Have Occurred on That Date (in italics)
CDC broadcasts part two of the live satellite and Web broadcast on anthrax for clinicians.
In NY, NYCDOH announces the seventh case of cutaneous anthrax, in a third New York Post employee.
In Connecticut, an elderly woman, who was admitted to the hospital for dehydration on 11/16/01, becomes  the fifth anthrax victim to die.
The Connecticut Department of Public Health, in consultation with CDC, begins prophylaxis for USPS  employees working in the Seymour and Wallingford postal facilities.
CDC expands the options for those on prophylaxis to include extending the duration of drug therapy and  adding the anthrax vaccine.
As of September 30, 2003, the source of exposure had not been confirmed.
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Robert Copeland, Charles  Davenport, Donald Keller, Nkeruka Okonmah, and Roseanne Price made  key contributions to this report.
section_title: Related GAO Products
paragraphs: 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.
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.  Washington, D.C.: September 14, 1999.
Combating Terrorism: Observations on Biological Terrorism and Public  Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,  1999.