oversight

U.S. Postal Service: Better Guidance Is Needed to Improve Communication Should Anthrax Contamination Occur in the Future

Published by the Government Accountability Office on 2003-04-07.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to the Ranking Minority Member
             Committee on Governmental Affairs
             U.S. Senate


April 2003
             U.S. POSTAL
             SERVICE
             Better Guidance Is
             Needed to Improve
             Communication
             Should Anthrax
             Contamination Occur
             in the Future




GAO-03-316
                                               April 2003


                                               U.S. POSTAL SERVICE

                                               Better Guidance Is Needed to Improve
Highlights of GAO-03-316, a report to the
Ranking Minority Member, Committee on
                                               Communication Should Anthrax
Governmental Affairs, U.S. Senate              Contamination Occur in the Future



In 2001, letters contaminated with             The Wallingford facility first tested positive for anthrax in early December
anthrax resulted in 23 cases of the            2001. The contamination was found in samples collected from four mail-
disease, 5 deaths, and the
                                               sorting machines in November. Analyses of the samples produced quantified
contamination of numerous U.S.
Postal Service facilities, including           results, including about 3 million anthrax colonies, or living anthrax cells, in
the Southern Connecticut Processing            one of the samples. While this was far more than the amount needed to
and Distribution Center in                     cause death, none of the employees at the facility became sick from the
Wallingford, Connecticut (the                  anthrax contamination.
Wallingford facility). GAO was asked
to address, among other matters,               The Postal Service’s decision not to inform workers about the number of
whether (1) the Postal Service                 anthrax colonies identified in December 2001 appears consistent with its
followed applicable guidelines and             guidelines because, according to the Service, it could not validate the results,
requirements for informing                     as required. However, its subsequent decision not to release the results after
employees at the facility about the            an employee union requested all the facility’s test results in January and
contamination and (2) lessons can be           February 2002, was not consistent with OSHA’s requirement for disclosing
learned from the response to the               test results that are requested. An OSHA investigation resulted in the
facility’s contamination.
                                               Service’s release of the quantitative test results in September 2002—about 9
                                               months after the results were first known. Although OSHA did not issue a
                                               regulatory citation, it expressed concern about communication deficiencies.

To help prevent a reoccurrence of              In retrospect, the Service’s decision not to release the quantitative test
communication problems, GAO                    results in December 2001 was understandable given the challenging
recommends that the Postal Service,            circumstances that existed at the time, the advice it received from public
OSHA, GSA, and the National                    health officials, an ongoing criminal investigation, and uncertainties about
Response Team—a group chaired by               the sampling methods used. However, numerous lessons can be learned
the Administrator of EPA and                   from the experience, such as the need for more complete and timely
comprising 16 federal agencies with            information to workers to maintain trust and credibility and to help ensure
responsibilities for planning,                 that workers have essential information for making informed health
preparing, and responding to
activities related to the release of
                                               decisions. Federal guidelines developed in 2002 by GSA and the National
hazardous substances—work                      Response Team suggest that more—rather than less—information should be
together to revise their existing              disclosed. However, neither the Service’s guidelines nor the more recent
guidelines or regulations to, among            federal guidelines fully address the communication-related issues that
other things, require prompt                   developed in Wallingford. For example, none of the guidelines specifically
communication of available test                require the full disclosure of quantified test results. Likewise, OSHA’s
results, including quantitative                regulations do not require employers to disclose test results to workers
results, to workers and others, as             unless requested, which assumes that workers are aware of the test results
applicable. The Service, EPA, and              and know about this requirement.
GSA generally agreed with our
recommendations, indicating that               Decontamination Efforts at the Wallingford, Connecticut, Facility
they would work together to revise
their guidelines. OSHA did not
comment on our recommendations.


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

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Bernard L.
Ungar, (202) 512-2834, ungarb@gao.gov.
                                               Source: U.S. Postal Service.
Contents


Letter                                                                                     1
               Results in Brief                                                            3
               Background                                                                  6
               Anthrax Contamination Was First Identified at Wallingford in
                 December 2001 after an Extensive Multiagency Investigation              10
               Quantitative Test Results Were Provided to Workers in April
                 2002—but Not in December 2001                                           14
               Disclosure of Anthrax Test Results                                        19
               Lessons Learned at the Wallingford Facility Suggest the Need for
                 More Complete and Timely Information to Workers                         29
               Conclusions                                                               34
               Recommendations for Executive Action                                      35
               Agency Comments and Our Evaluation                                        36

Appendix I     Objectives, Scope, and Methodology                                        45



Appendix II    Summary of Anthrax Testing at the Wallingford
               Facility between November 2001 and April 2002                             48



Appendix III   Comments from the Environmental Protection
               Agency                                                                    51



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



Appendix V     Comments from the American Postal Workers
               Union                                                                     55



Table
               Table 1: Summary of Sampling for Anthrax Contamination between
                        November 2001 and April 2002 and the Associated Test
                        Results                                                          10




               Page i                                         GAO-03-316 U.S. Postal Service
Abbreviations

CDC               Centers for Disease Control and Prevention
EPA               Environmental Protection Agency
FBI               Federal Bureau of Investigation
GSA               General Services Administration
HEPA              High Efficiency Particulate Air
HHS               Department of Health and Human Services
OSHA              Occupational Safety and Health Administration



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Page ii                                                   GAO-03-316 U.S. Postal Service
United States General Accounting Office
Washington, DC 20548



                                   April 7, 2003

                                   The Honorable Joseph I. Lieberman
                                   Ranking Minority Member
                                   Committee on Governmental Affairs
                                   United States Senate

                                   Dear Senator Lieberman:

                                   In September and October 2001, letters containing anthrax spores were
                                   mailed to news media personnel and congressional officials, leading to the
                                   first bioterrorism-related cases of anthrax in the United States.1 The
                                   contaminated letters caused 23 illnesses and resulted in 5 deaths from
                                   inhalation anthrax and the contamination of numerous postal facilities.
                                   The U.S. Postal Service initially responded to this crisis by collecting and
                                   testing samples from over 280 of its facilities, including the Southern
                                   Connecticut Processing and Distribution Center in Wallingford,
                                   Connecticut (the Wallingford facility). The facility was first tested on
                                   November 11, 2001, and no contamination was found.

                                   In late November 2001, the death of a Connecticut woman—1 of the 5
                                   people who died—spurred an extensive investigation by a multiagency
                                   team to determine, among other things, how she had been exposed to
                                   anthrax. Believing that the woman may have died from exposure to mail
                                   that had been contaminated as it passed through the Wallingford facility,
                                   federal and state investigators conducted more extensive testing of the
                                   facility. Facility workers received antibiotics on November 21, 2001—the
                                   day that the elderly woman died. The antibiotics were provided as a
                                   precautionary measure, since the Postal Service’s earlier testing of the
                                   facility had not identified any contamination. At about the same time, the
                                   Postal Service also initiated a medical surveillance program to monitor the
                                   health of the facility’s employees. The investigative team sampled the
                                   facility on numerous occasions between November and December 2001
                                   and, in early December, identified anthrax on four mail-sorting machines.
                                   Anthrax also was identified in areas above the mail-sorting machines in




                                   1
                                    Technically, the term “anthrax” refers to the disease caused by Bacillus anthracis and not
                                   the bacterium or its spores. In this report, we use the term “anthrax” for ease of reading
                                   and to reflect terminology commonly used in the media and by the general public.



                                   Page 1                                                    GAO-03-316 U.S. Postal Service
April 2002.2 On both occasions, the affected areas were decontaminated,
while mail processing continued in other areas of the facility.

Perhaps because the facility’s workers had been provided with antibiotics,
none of the employees at the Wallingford facility became sick from
anthrax. However, you requested that we review the Postal Service’s
disclosure of anthrax test results to the facility’s workers. As agreed, in
this report, we address (1) how and when contamination was identified at
the Wallingford facility, (2) what and when information was
communicated to facility workers, (3) whether the Postal Service followed
applicable guidelines and requirements for informing facility workers
about the contamination, and (4) whether lessons can be learned from the
response to contamination at the facility. As agreed, our future work will
compare the treatment of postal workers at the Wallingford facility with
the treatment of employees at other postal facilities contaminated with
anthrax in the fall of 2001.

To address our reporting objectives, we interviewed federal and state
officials involved in investigating and responding to anthrax
contamination at the Wallingford facility, including officials from the
Postal Service’s headquarters office, its Connecticut district, and the
Wallingford facility; the Connecticut Department of Public Health; and
numerous federal agencies. We also interviewed representatives of
employees at the facility, including the national American Postal Workers
Union and its Greater Connecticut Area Local Union. We discussed,
among other matters, the officials’ roles and involvement in responding to
the crisis and lessons that can be learned from the response. We obtained
and reviewed documentation related to the sampling and testing of the
facility, including laboratory test results; information about when and how
test results and associated health risks were communicated to facility
workers; the Postal Service’s guidelines for releasing and communicating
test results; the Occupational Safety and Health Administration’s (OSHA)
regulatory requirements for disclosing test results to workers; more recent
federal guidelines developed in 2002 by the General Services
Administration (GSA) and the National Response Team—a group chaired
by the Administrator of the Environmental Protection Agency (EPA) and
comprising 16 federal agencies with responsibility for planning, preparing,
and responding to activities related to the release of hazardous substance;



2
 The elevated areas of the facility—known as the “high bay”—include pipes, ducts, lights,
joists, beams, and overhead conveyors.




Page 2                                                    GAO-03-316 U.S. Postal Service
                   and other documents related to the facility’s contamination. Additional
                   information on our scope and methodology appears in appendix I.


                   Following a series of negative test results in November 2001, the
Results in Brief   Wallingford facility first tested positive for anthrax in early December. The
                   positive results were found in samples collected from four mail-sorting
                   machines on November 28, 2001. Subsequent analyses of the samples
                   identified two quantitative results, including about 3 million colony-
                   forming units of anthrax in a sample collected from one of the mail-sorting
                   machines.3 This finding was far more than the 8,000 to 10,000 spores
                   considered harmful, at that time, if inhaled in a fine powder form.
                   Although district postal managers said they received written confirmation
                   of the test results from the Chief Epidemiologist for the Connecticut
                   Department of Public Health (Chief Epidemiologist) on December 10,
                   2001, available documentation indicates that Postal Service headquarters
                   may have received the results 2 days earlier. In April 2002, after the mail-
                   sorting machines had been decontaminated and returned to operation,
                   anthrax was found in samples collected from areas above the machines.
                   Following both the December 2001 and April 2002 test results, the
                   contaminated areas were isolated and decontaminated and, thereafter,
                   returned to operation.

                   On December 2, 2001—when anthrax contamination was first identified in
                   the facility—Postal Service managers and a physician under contract with
                   the Postal Service met with workers to inform them that “trace” amounts
                   of anthrax had been found in samples collected on November 28. Knowing
                   that the laboratory initially identified a small number (1 or 2 colony-
                   forming units) of anthrax spores, the Chief Epidemiologist—who helped
                   lead the investigation—told district postal managers that it would be
                   accurate to use the term “trace” to describe the extent of contamination.
                   On December 2, postal managers also relayed the Chief Epidemiologist’s
                   health-related recommendations to the facility’s employees. For example,
                   although the Chief Epidemiologist viewed the health risk as “minimal,”
                   workers were advised, as a precautionary measure, to continue taking the
                   antibiotics they received on November 21, 2001—the day that the
                   Connecticut woman died from inhalation anthrax. On December 12,



                   3
                    The term “colony-forming units” refers to the number of living cells in a sample and is
                   typically reported per gram of material sampled for High Efficiency Particulate Air vacuum
                   samples and per square inch for samples collected using wipes.




                   Page 3                                                    GAO-03-316 U.S. Postal Service
2001—2 days after district postal managers said they received written
confirmation of the presence of about 3 million spores in a sample
collected on November 28 and, possibly, 4 days after headquarters postal
managers received the results—postal managers once again relayed the
Chief Epidemiologist’s views and health-related recommendations to
employees at the facility. Specifically, district postal managers told us that
they informed workers that, while trace amounts of anthrax existed on
three mail-sorting machines, a “concentration” of spores had been
identified in a sample collected from a fourth machine. Although the
extent of contamination was much greater than initially believed,
following the assurances of the Chief Epidemiologist, postal managers said
they informed workers that there was “no additional risk” to employees
because all of the steps needed to protect them had already been taken. In
April 2002, the Postal Service provided employees with the actual
quantitative test results (1 to 18 colony-forming units) from the samples
collected in April from areas above the previously contaminated mail-
sorting machines.

Although the Postal Service’s communication of anthrax test results
appears consistent with its guidelines, its decision not to provide the
December 2001 quantified results (i.e., the number of colony-forming units
found in the positive samples)—after being requested to do so by an
employee union—did not satisfy OSHA’s disclosure requirements. The
Postal Service generally provided the facility’s test results to workers
within 1 day of receiving the test results. Such timely disclosure is
consistent with the Postal Service’s guidelines to notify workers “as soon
as possible.” However, for a period of 2 days, district managers delayed
informing the facility’s workers about the documented test results that the
district postal managers received on December 10, 2001. According to the
Postal Service, the additional time was needed to obtain advice from
public health officials about the meaning of the results, particularly the
result indicating the presence of about 3 million spores in a sample
collected from one mail-sorting machine. According to Postal Service
managers, the December 2001 decision not to release the quantitative
results—even after being requested to do so by a union leader—was also
consistent with the Postal Service’s guidelines because, according to the
managers, the Postal Service could not ensure that the sampling had been
done in accordance with procedures specified in its guidelines, and, thus,
it could not validate the results, as required by its guidelines. However, the
Postal Service’s decision not to release the December 2001 quantitative
test results after a union leader requested all of the facility’s test results on
January 29, 2002, and February 6, 2002, was not consistent with OSHA’s
regulations for disclosing test results that are requested by workers or


Page 4                                              GAO-03-316 U.S. Postal Service
their designated representatives. OSHA’s regulations require employers to
disclose test results within 15 working days of the request or explain the
delay and provide the requester with a time frame for releasing the results.
OSHA’s subsequent investigation into this matter resulted in the Postal
Service’s release of the December 2001 quantitative test results in
September 2002—more than 7 months after the union leader first
requested the results and about 9 months after the test results were known
by the Postal Service. OSHA did not cite the Postal Service for not
disclosing the quantitative test results earlier; however, in an October 7,
2002, letter to the Postal Service, OSHA noted that a “failure to effectively
communicate issues which can have an effect on a worker’s health and
safety, can lead to fear and mistrust.”

While the Postal Service’s decision not to release the quantitative test
results in December 2001 is understandable given all of the circumstances
that existed at the time, the lessons learned from this experience suggest
the need for more complete and timely information to workers to maintain
trust and credibility. Officials from OSHA and members of the
investigative team did not specifically fault the Postal Service for not
releasing the quantified results when they were first known in December
2001. However, they said full and timely disclosure of test results is the
best method for communicating with employees and others. Two federal
guidelines developed in 2002 by GSA and the National Response Team
suggest that more—rather than less—information should be disclosed. For
example, GSA’s guidelines emphasize the need for “timely, clear,
consistent, and factual” information, including any limitations associated
with the information, so that people can make informed decisions. The
other set of guidelines, developed by the National Response Team, warns
agencies not to withhold information because it could affect the agency’s
credibility. However, neither the Postal Service’s guidance nor the more
recent federal guidelines fully address the anthrax communication-related
issues that developed at the Wallingford facility. For example, none of the
guidelines specifically require the full disclosure of all test results,
including quantitative test results. Likewise, OSHA’s regulations for
communicating test results to workers do not address the need for full,
immediate, and proactive disclosure. We are making several
recommendations to minimize the likelihood that the communication-
related problems at the Wallingford facility will reoccur elsewhere.

The Postal Service, EPA, and GSA generally agreed with our findings and
recommendations and indicated that they would work together to revise
their respective guidelines. The union also agreed with our
recommendations to better coordinate communication between federal


Page 5                                           GAO-03-316 U.S. Postal Service
             agencies when events occur. However, the union said that our report did
             not adequately reflect the union’s perspective of the facts and that a
             number of our conclusions were not supported by the facts. We disagree.
             We believe that our conclusions are fully supported by the evidence
             presented in this report and that the report presents a fair, objective, and
             balanced depiction of the facts as best we could determine them.


             Anthrax is an acute infectious disease caused by the spore-forming
Background   bacterium called Bacillus anthracis. Anthrax is found in the soil in many
             parts of the world and forms spores (like seeds) that can remain dormant
             in the environment for many years. Anthrax can infect humans; however,
             the disease occurs most commonly in herbivores.4

             Human anthrax infections are rare in the United States and have normally
             resulted from occupational exposure to infected animals or contaminated
             animal products, such as wool, hides, or hair. Infection can occur in three
             forms: (1) cutaneous, usually through a cut or an abrasion; 5 (2)
             gastrointestinal, by ingesting undercooked contaminated meat; and (3)
             inhalation, by breathing aerosolized anthrax spores into the lungs.
             Aerosolization occurs when anthrax spores become airborne, thus
             enabling a person to inhale the spores into the lungs. Symptoms depend on
             how the disease is contracted and, on the basis of experiences in the fall of
             2001, are now thought by medical experts to typically appear within 4 to 6
             days of exposure, although individuals have contracted the disease as long
             as 43 days after exposure. The disease can be treated with a variety of
             antibiotics and is not contagious.

             Persons who come in contact with anthrax spores are described as having
             been “exposed.” Depending on the extent of contamination and its form, a
             person can be exposed without developing the disease. Anthrax spores are
             dormant cells that can germinate and, if viable, replicate under suitable
             environmental conditions, such as in the human body. A person can die if
             the anthrax spores grow and the bacteria multiply and spread throughout
             the body. There is a range of laboratory tests for detecting anthrax in a



             4
             Herbivores are animals that eat plants.
             5
              Cutaneous means of, relating to, or affecting the skin. Cutaneous anthrax is characterized
             by lesions on the skin.




             Page 6                                                     GAO-03-316 U.S. Postal Service
person’s body and in the environment. Laboratories report anthrax test
results either qualitatively (e.g., as “positive” or “negative”) or
quantitatively (e.g., as a specific number of colony-forming units per gram
or square inch of material sampled or in milligrams per microliter).

Before the fall of 2001, outbreaks of inhalation anthrax in the United
States had been linked mainly to occupational exposure. However,
according to the Centers for Disease Control and Prevention (CDC), there
was a release of anthrax in 1979 from a military bioweapons facility in
Sverdlovsk in the Former Soviet Union. The release of anthrax, which had
been prepared in a powder form, reportedly caused the death of 66 people
and demonstrated the lethal potential of aerosolized anthrax as a weapon.6

Because so few instances of inhalation anthrax have occurred, scientific
understanding about the number of spores needed to cause the disease is
still evolving. According to the contract physician responsible for
providing medical advice to postal employees at the Wallingford facility in
the fall of 2001, her literature search revealed that a person would need to
inhale 8,000 to 10,000 spores to contract the disease.7 However, given that
anthrax spores were never discovered in the Connecticut woman’s home
or places that she frequented,8 experts we consulted now believe that the
number of spores needed to cause inhalation anthrax could be very small,
depending on a person’s health status and the aerosolization capacity of
the anthrax spores.

The Postal Service’s infrastructure includes, in part, its headquarters office
in Washington, D.C.; 8 area offices; the Capital Metro Operations office;
approximately 350 mail processing and distribution centers, including the
Wallingford facility; and about 38,000 post offices, stations, and branches.
The area offices are further divided into 85 postal districts throughout the
United States, including the Connecticut district in Hartford, which
oversees operations at the Wallingford facility. The Wallingford facility is



6
 The last cases of anthrax from this release occurred 43 days after the individuals’
exposure.
7
 According to CDC, the estimate of 8,000 to 10,000 spores is from a Department of Defense,
Defense Intelligence Agency publication entitled Soviet Biological Warfare Threat, DST-
161OF-057-86 (Washington, D.C.: 1986).
8
 In commenting on our draft report, EPA noted that anthrax spores also were not found in
the home or workplace of a female hospital worker who died from inhalation anthrax in
October 2001 in New York City.




Page 7                                                      GAO-03-316 U.S. Postal Service
operated by a facility manager and is under the jurisdiction of the District
Manager in Hartford.

On or about October 9, 2001, at least two letters containing anthrax spores
entered the U.S. mail stream—one was addressed to Senator Thomas
Daschle, the other to Senator Patrick Leahy. Before being sent to the
Brentwood facility in Washington, D.C.—the facility that processed mail to
the Senators—the letters were processed on high-speed mail-sorting
machines at a postal facility in Hamilton, New Jersey. The Hamilton
facility—also known as the Trenton postal facility—processed mail that
was to be transported to Wallingford for further processing.9

The Wallingford facility covers about 350,000 square feet and has over
1,100 employees. The facility handles nearly 3 million pieces of mail per
day and operates 24 hours a day with employees who work one of three 8-
hour shifts. Two unions—the Greater Connecticut Area Local American
Postal Workers Union, in New Haven, Connecticut, and the Mail Handlers
Union in Boston, Massachusetts—represent workers at the facility.

In October 2001, the Postal Service established a Unified Incident
Command Center (the Command Center) in Washington, D.C., to, among
other things, manage the Postal Service’s response to anthrax
contamination in its facilities. The Command Center was staffed by Postal
Service employees and supported by several agencies, including EPA;
CDC; the U.S. Army Corps of Engineers; the U.S. Postal Inspection Service;
OSHA; and the Federal Bureau of Investigation (FBI).

On November 20, 2001, a team of representatives from state and federal
government agencies with responsibilities for law enforcement (the
Connecticut State Police and the FBI); environmental safety (the
Connecticut Department of Environmental Protection); public health (the
Connecticut Department of Public Health, local health departments, and
CDC); and the Postal Service was formed to investigate and formulate the
public health response to the case of the elderly woman who contracted
and subsequently died from inhalation anthrax. The Chief Epidemiologist




9
 Two other contaminated letters were sent to a television news anchor and the editor of
The New York Post in New York City on or around September 18, 2001. Although the letters
were processed through the Hamilton/Trenton facility, it is not known whether the letters
contaminated the Wallingford facility.




Page 8                                                   GAO-03-316 U.S. Postal Service
for the Connecticut Department of Public Health (Chief Epidemiologist),10
an on-site CDC team leader, and a CDC team leader in Atlanta, jointly led
the on-site investigation team. The team communicated with one another
largely through twice-daily confidential telephone conference calls during
which information was shared, possible actions were discussed, and
decisions were made. Once contamination was identified in the
Wallingford facility, a facility-specific response team was formed
consisting of the National Institute for Occupational Safety and Health, the
Agency for Toxic Substances and Disease Registry, and CDC—all within
the Department of Health and Human Services (HHS); the Corps of
Engineers; the Postal Service; EPA; and the Connecticut Department of
Public Health. The team was led by the Postal Service’s Command Center.
OSHA—an agency within the Department of Labor that enforces safety
and health standards in the workplace—was not part of the response
team.

The Postal Service requested and the investigative team agreed that the
Postal Service would be the sole party responsible for communicating test
results and other information to the workers at the facility. In this regard,
the physician under contract with the Postal Service informed the facility’s
workers that, according to her research, inhalation of 8,000 to 10,000
spores would likely be needed to cause inhalation anthrax.




10
 Epidemiology is a branch of medical science that investigates the incidence, distribution,
and control of disease in a population.




Page 9                                                     GAO-03-316 U.S. Postal Service
                      The Wallingford facility was tested on numerous occasions between
Anthrax               November 2001 and April 2002 (see table 1). The first sampling was
Contamination Was     performed by a Postal Service contractor on November 11, 2001, as part of
                      the Postal Service’s effort to identify facilities that may have been
First Identified at   contaminated with anthrax. The contractor collected 53 samples using dry
Wallingford in        swabs.11 The laboratory found no contamination and provided the negative
                      results to Postal Service managers on November 14. A second Postal
December 2001 after   Service contractor sampled the facility on November 21, 2001—the day the
an Extensive          Connecticut woman died. The 64 samples, collected using dry swabs,
Multiagency           tested negative, and the results were verbally provided to Postal Service
                      officials on November 23. (App. II summarizes additional information
Investigation         about sampling at the facility, including the dates of the samples, the
                      agencies involved in the sampling, the date and content of information
                      provided to workers. This appendix also provides information about
                      decontamination activities at the facility.)

                      Table 1: Summary of Sampling for Anthrax Contamination between November 2001
                      and April 2002 and the Associated Test Results

                                                                                             Agency that collected
                                                                                                          a
                          Sampling date          Type (Number of samples)         Result     the samples
                          11/11/01               Dry swabs (53)                   Negative   Postal Service
                          11/21/01               Dry swabs (64)                   Negative   Postal Service
                          11/25/01               Wet swabs (60)                   Negative   CDC
                                                 Wet wipes and HEPA
                          11/28/01               vacuums (212)                    Positive   CDC
                          12/02/01               Wet wipes (200)                  Positive   CDC
                          4/21/02                HEPA vacuums (101)               Positive   Postal Service
                      Sources: GAO (summary) and Postal Service and CDC (data).

                      Legend

                      CDC – Centers for Disease Control and Prevention
                      HEPA – High Efficiency Particulate Air
                      a
                      The Postal Service used a contractor; CDC was assisted by the Agency for Toxic Substances and
                      Disease Registry.


                      Following confirmation on November 20, 2001, that the elderly
                      Connecticut woman had contracted inhalation anthrax, the multiagency



                      11
                       Swabs can be either wet or dry and have small surface areas (similar to Q-tips®). Swabs
                      are typically used to sample small, nonporous surface areas (less than 100 sq. cm) that do
                      not have a large accumulation of dust. Depending upon the circumstances, wet swabs may
                      attract more particles of sample material than dry swabs.




                      Page 10                                                         GAO-03-316 U.S. Postal Service
state and federal investigative team targeted mail as one possible source of
her exposure. Having found no contamination at the Wallingford facility or
at the woman’s home and other places she frequented in the 2 months
preceding her death, CDC and the Agency for Toxic Substances and
Disease Registry resampled the facility on November 25, 2001, using wet
swabs—not dry swabs. These 60 samples also tested negative. The
laboratory informed the Chief Epidemiologist of the results, and he, in
turn, called district postal managers to relay the results.

Determined to ascertain the role that mail may have played in the woman’s
exposure to anthrax, on November 28, 2001, CDC and the Agency for
Toxic Substances and Disease Registry, with the full support of the Postal
Service, performed what officials termed a “targeted” and “extensive”
sampling of the facility. The team collected 212 samples, the majority of
which were from machines that could have been used to process mail to
the deceased woman’s home. The team also used different collection
methods than had been used earlier—that is, the team collected samples
using two methods: wet wipes and HEPA vacuums rather than dry swabs
or wet swabs alone.12 The use of these sampling methods resulted in the
identification of anthrax on 4 of the facility’s 13 mail-sorting machines.

The Chief Epidemiologist first knew the results of the November 28, 2001,
sampling effort on December 2, when samples collected from three of the
mail-sorting machines tested “positive” for anthrax. Shortly thereafter, a
fourth machine—which also had been sampled on November 28, 2001—
also tested positive for anthrax.13 The laboratory analyzed the November
28, 2001, samples and provided two quantified results. The results
indicated that although all four of the machines were contaminated, one of
the machines was heavily contaminated. Specifically, on the basis of the
laboratory’s quantified results, the Chief Epidemiologist identified 2.9
million colony-forming units of anthrax—about 3 million spores—in a
sample of 0.55 grams of material (dust) collected from the heavily




12
 Wet wipes are sterile gauze pads, approximately 3 inches square. Wet wipes are typically
used for sampling larger (more than 100 sq. cm), nonporous surface areas.
13
 This machine was suspected of being positive for anthrax on December 2, but that
suspicion was not confirmed until later.




Page 11                                                   GAO-03-316 U.S. Postal Service
contaminated machine.14 A second sample identified 370 colony-forming
units per gram of material collected from another mail-sorting machine.
The two samples were collected using HEPA vacuums.15

The laboratory e-mailed the quantitative results to CDC officials and the
Chief Epidemiologist on December 6. After subsequent discussions with
the laboratory concerning the results as well as related discussions over
the next few days with members of the investigative and response teams,
the Chief Epidemiologist faxed the results on December 9 to the Postal
Service’s district Human Resource Manager, who, according to the
manager, received them on December 10. Precisely when Postal Service
headquarters and district managers first became aware of the quantified
test results is unclear. According to CDC officials and the Chief
Epidemiologist, they began discussing the quantitative results with team
members, which they believe included a district postal manager, on
December 6, 2001. However, district postal managers said that they were
not involved in discussions about the quantitative results until December
9. District postal managers confirmed that the Chief Epidemiologist faxed
the quantitative results to the district on December 9 (a Sunday) and that
district postal managers received the fax on December 10. However, a
chronology of the events prepared in January 2002 by Postal Service
employees and shared with CDC indicates that postal managers at
headquarters may have received the documented results on or about
December 8, 2001. We discussed the chronology with postal headquarters
managers in March 2003 and they told us that, according to their
recollections, there were errors in the chronology that were not corrected.
They also said that they do not otherwise recall precisely when they
received the documented quantitative results. Absent definitive
documentation of when Postal Service headquarters received the test
results and documentation of the discussions between public health and



14
  The sample collected 0.55 grams of material (dust) from the heavily contaminated
machine. The laboratory adjusted its analyses to reflect a full gram of sample and reported
the presence of 5.5 million colony-forming units per gram of material sampled. The Chief
Epidemiologist subsequently determined, through extrapolation, that the 0.55 grams of
material sampled contained approximately 2.9 million colony-forming units of anthrax.
According to the Chief Epidemiologist, this finding was equivalent to about 3 million
spores. In this report, we refer to the 2.9 million colony-forming units for the 0.55 grams of
material actually sampled.
15
 The number of colony-forming units was not provided for any of the other positive
samples. The other samples were collected using wet wipes, which, according to the Chief
Epidemiologist, did not allow for measuring the amount of dust collected.




Page 12                                                      GAO-03-316 U.S. Postal Service
postal managers, we were unable to determine when Postal Service
headquarters managers first learned of the quantitative test results.

On December 9, 2001, the Chief Epidemiologist also relayed the results of
other samples collected at the facility. The samples were collected on
December 2—hours before the four contaminated mail-sorting machines
were to be enclosed and decontaminated—by CDC and the Agency for
Toxic Substances and Disease Registry. The 200 samples were collected
using wet wipes to establish the extent of contamination on the machines.
The results identified unspecified amounts of contamination (i.e.,
“positives”) on (1) 30 of 52 samples collected from the heavily
contaminated machine, (2) 3 of 52 samples from a second machine, and
(3) 1 of 48 samples from each of the two other mail-sorting machines.

A Postal Service contractor under the guidance of CDC and the Corps of
Engineers decontaminated the four mail-sorting machines. To test the
effectiveness of the decontamination, follow-up samples were collected
between December 7 and December 18, 2001. The laboratory informed the
Chief Epidemiologist of the negative results on December 20. The Chief
Epidemiologist relayed the results to district postal managers who, shortly
thereafter, returned the machines to operation. The facility remained open
throughout the period in part because, according to public health officials,
there was no evidence that the anthrax was airborne, workers had already
received antibiotics, no one had contracted the disease, and action had
already been taken to isolate the contaminated machines from workers on
December 2, 2001—the day that anthrax contamination was first
reported.16

On April 21, 2002, a Postal Service contractor, in consultation with CDC,
OSHA, EPA, and the Connecticut Department of Public Health, sampled
areas above the previously contaminated machines using HEPA vacuums.
The sampling was performed because of a Postal Service requirement for
testing prior to the routine cleaning of elevated areas in facilities that had
previously tested positive for anthrax. The effort was undertaken to
protect workers from the possibility of exposure to spores that may have
blown into these areas as a result of the Postal Service’s prior use of
compressed air to clean its facilities. The laboratory relayed the results


16
 According to the contractor’s report on the decontamination, the mail-sorting machines
were enclosed in “6-mil polyethylene sheeting” supported by wood frames. Further,
according to the report, air filtration devices, with exhausts to the outside, were installed to
maintain negative air pressure inside each of the four enclosures.




Page 13                                                      GAO-03-316 U.S. Postal Service
                        from the April 21 sampling effort to district postal managers on April 24.
                        The results revealed from 1 to 18 colony-forming units in 3 of 101 samples
                        collected from the elevated areas.17 The contaminated areas were
                        subsequently encapsulated and decontaminated. A Postal Service
                        contractor collected follow-up samples to test the effectiveness of the
                        decontamination between May 1 and June 3, 2002. The laboratory reported
                        negative results in all of the samples directly to district postal managers on
                        June 6 and, on June 7, the facility was returned to full operation.18


                        The Postal Service typically provided nonquantitative (i.e., “positive” or
Quantitative Test       “negative”) results from samples collected between November 2001 and
Results Were            April 2002 to employees on each of the facility’s three work shifts. The
                        specific content of the information disclosed varied. The Postal Service
Provided to Workers     began communicating the results of the first samples—which were
in April 2002—but Not   collected on November 11, 2001—on November 15, the day after the Postal
                        Service received the negative results. The Facility Manager informed
in December 2001        supervisors and union officials of the results, and the supervisors, in turn,
                        informed employees at the facility. According to a district manager, the
                        test results also were posted on designated bulletin boards at the facility.
                        The Postal Service began relaying the results of the November 21, 2001,
                        sampling effort, which were also negative, to employees in a briefing on
                        November 23, the day that district postal managers were notified of the
                        results. On November 27, the day that district managers received the
                        results from the third sampling done on November 25, 2001, the Facility
                        Manager once again began briefing employees about the negative results.

                        According to district postal managers, they began informing employees
                        about contamination at the facility on December 2, 2001, the same day
                        they learned that the facility was contaminated. The positive results were
                        identified from samples collected on November 28, 2001, and were relayed
                        to district postal managers in a telephone call from the Chief
                        Epidemiologist. The Chief Epidemiologist met with district postal facility
                        managers, union representatives, and a physician under contract with the
                        Postal Service on December 2, 2001, to discuss the results. District postal



                        17
                         Specifically, the test results indicated (1) 1 colony from 7.50 grams of material sampled,
                        (2) 10 colonies and 11 colonies from 7.69 grams of material sampled, and (3) 13 colonies
                        and 18 colonies from 5.67 grams of material sampled.
                        18
                         During the period of decontamination, many of the facility’s mail processing operations
                        were transferred to other postal facilities.




                        Page 14                                                     GAO-03-316 U.S. Postal Service
managers told us that no documentation of the meeting exists; however,
according to several of the individuals present, the Chief Epidemiologist
described the extent of contamination as “trace” amounts on three mail-
sorting machines.19 According to the Chief Epidemiologist, although the
laboratory initially reported only a positive finding, his subsequent
discussions with laboratory personnel indicated that the samples
contained “one or two” colony-forming units of anthrax. Thus, he said, he
used the term to denote a small amount of contamination. Also, he said,
“trace” seemed appropriate given the number of sampling efforts
undertaken before any contamination was found in the facility.

According to officials present at the December 2, 2001, meeting, they
pressed the Chief Epidemiologist about any possible risk to workers at the
facility and were assured that for a variety of reasons, there was no
additional health risk. First, as a precautionary measure, workers had been
provided antibiotics on November 21, the day the Connecticut woman died
from inhalation anthrax. Second, even if workers had not chosen to take
the antibiotics, the results of the Postal Service’s medical surveillance
program indicated that none of the facility’s workers had contracted the
disease. Further, in the view of the Chief Epidemiologist and CDC
officials, workers were not expected to contract the illness because the
contamination was found weeks after what public health officials
considered the likely incubation period for the disease.20 Third, the
contaminated machines were being isolated and decontamination was
scheduled to begin the next day. Fourth, there was no evidence that the
anthrax was airborne because no spores had been found in the facility’s
heating, ventilating, and air conditioning systems. Finally, related to this
last issue, the Chief Epidemiologist told us that the likelihood of spores
being blown within the facility (becoming airborne) had been greatly
reduced by the Postal Service’s decision on October 23, 2001, to stop using
compressed air to clean its facilities. Nevertheless, as a precautionary



19
 As previously discussed, a fourth machine also tested positive for anthrax on the basis of
samples collected on November 28, 2001. However, the positive results were not confirmed
until after December 2, 2001.
20
  Although individuals have contracted inhalation anthrax 43 days after their exposure to
the disease, according to the Chief Epidemiologist and CDC literature, individuals exposed
in the 2001 anthrax incidents typically contracted inhalation anthrax within 4 to 6 days. In
the view of public health officials, the letters to Senators Daschle and Leahy entered the
mail stream on or about October 9, 2001—weeks before contamination was identified at
the facility and, thus, well after the period they viewed as the likely period of maximum
risk of exposure to the disease.




Page 15                                                    GAO-03-316 U.S. Postal Service
measure, the Chief Epidemiologist recommended that the Postal Service
advise facility workers to continue taking antibiotics.

According to district postal managers, after their December 2, 2001,
meeting with the Chief Epidemiologist; the physician and postal managers,
including the Facility Manager, began briefing employees on each of the
facility’s three shifts. The managers relayed the Chief Epidemiologist’s
views that there was no additional health risk associated with the test
results. According to the managers, they also informed workers about
planned actions to remediate the contamination.21

As previously discussed, district postal managers recall being notified of
the quantitative test results on December 9, 2001, which is the date they
told us that the Chief Epidemiologist first called them to relay the results
of additional laboratory analyses that he and CDC had received on
December 6, 2001. The results were from the two samples collected on
November 28, 2001, including the sample involving 2.9 million colony-
forming units per 0.55 grams of sample material (dust) collected from one
of the four contaminated mail-sorting machines. The Chief Epidemiologist
told us that he discussed the results with laboratory personnel and, after
these discussions, concluded that the results revealed the presence of
“about 3 million spores.” According to district postal managers, the test
results were discussed at length in teleconferences between them, the
Chief Epidemiologist, and other members of the investigation team on
December 9 and 10. District postal managers said that they were
concerned about the test results and asked whether the facility’s
employees were at risk. Although we were told that no documentation
exists about the advice the Postal Service received at the time, according
to district postal managers, the Chief Epidemiologist informed them that
there was “no additional risk” to employees for the same reasons
previously cited—the contaminated machines had already been isolated
and were being decontaminated; the anthrax was not believed to be
airborne; employees at the facility had already been offered antibiotics;
and, in the view of public health officials, the incubation period for the



21
  The Postal Service also issued a statement to the news media on December 2, 2001.
Referring to the November 28 sampling, the press release stated that “trace amounts” of
anthrax had been identified on three mail-sorting machines in the facility. The press release
quoted the Connecticut Commissioner of Public Health as saying that, “This is a very small
amount of anthrax.” The press release further indicated that, according to public health
officials, the contamination posed “no health risk” to postal employees or their customers,
in part because the machines had already been isolated and were to be decontaminated.




Page 16                                                    GAO-03-316 U.S. Postal Service
disease had already passed without illness. Nevertheless, as a
precautionary measure, the Chief Epidemiologist recommended that the
Postal Service managers advise workers to continue taking their
antibiotics. CDC concurred with the Chief Epidemiologist’s
recommendation and assessment about the health risk.

According to participants in the teleconferences, they also discussed how
to communicate the quantitative test results to workers at the facility. As a
result of these conversations, we were told, the participants agreed that
using the term “trace”—after the finding of about 3 million spores in a
sample from one of the four mail-sorting machines—was no longer
appropriate in describing the extent of contamination at the facility. As a
result, district managers asked the Chief Epidemiologist how the results
could be communicated to employees and others. According to district
postal managers, the Chief Epidemiologist advised them that it would be
accurate to characterize the contamination as a “concentration of spores”
on one mail-sorting machine and “trace” amounts on three others. The
Chief Epidemiologist agreed that he used the terms “trace” and
“concentration” to describe contamination at the facility. However, he
subsequently informed us that he did not provide a single description of
the extent of contamination in the facility but, instead, told postal
managers that this was one way to discuss the extent of contamination to
facility workers. According to the Chief Epidemiologist, it was up to the
Postal Service to determine how to communicate the test results. A district
postal manager told us that he relayed information about the
concentration of spores in the facility—one of the interpretations provided
by the Chief Epidemiologist—to the Facility Manager, without any
information about the actual quantitative results. The Chief Epidemiologist
and district postal managers agree that they never discussed whether the
Postal Service should disclose the quantified test results to employees.

According to the Chief Epidemiologist, at the invitation of district postal
managers, he met with facility managers and union leaders on December
12 to discuss the test results and to answer questions about his health
recommendations.22 The terms “concentration of spores” and “heavily
contaminated machine” were used, he said, but no quantitative results
were presented or discussed. Union representatives and Postal Service


22
 In commenting on our draft report, postal headquarters officials also indicated that, on
December 12, 2001, the District Manager and the Inspector in Charge for the Northeast
Area met with the Chief Epidemiologist, the Commissioner of the Connecticut Department
of Public Health, and the Connecticut Governor and his staff.




Page 17                                                  GAO-03-316 U.S. Postal Service
officials we spoke to do not recall this meeting. However, district postal
managers issued a press release on December 12 containing the
terminology that the Chief Epidemiologist said he had used. Further,
district postal managers told us that supervisors on each of the facility’s
three work shifts began relaying the Chief Epidemiologist’s views and
health-related recommendations directly to the facility’s employees on
December 12. Union representatives told us that they did not recall any
supervisory briefings on December 12.23 Although no documentation of
these briefings is available, postal headquarters officials said that the
December 12 press release would have been made widely available per the
Service’s standard operating procedures and that a local Connecticut
newspaper reported the information contained in the press release on
December 13.

According to the district managers, during follow-up testing later that
month, workers were routinely advised of the qualitative (e.g.,
negative/positive) test results when the Postal Service received them from
the laboratory. Beginning on December 20, 2001, workers were briefed
that all of the follow-up samples had tested negative for contamination. On
December 21, the Postal Service issued a press release stating that the four
mail-sorting machines had been completely decontaminated and returned
to service.

In contrast to its actions in December 2001, the Postal Service fully
released all test results related to its April 21, 2002, sampling of the
facility’s elevated areas. An OSHA official involved in sampling the
facility’s elevated areas—OSHA was not involved in December 2001—
recommended immediate disclosure of all of the results. The results,
which included the finding of from 1 to 18 colony-forming units in several
samples, were provided to union representatives in a meeting on April 24,
the same day that postal managers were notified of the results. Later that
day, facility managers and the Chief Epidemiologist began briefing
employees about the results, indicating that 3 of 101 samples collected
from 71 locations were contaminated.24 According to the President of the


23
  The President of the Greater Connecticut Area Local American Postal Workers Union
indicated that there is no record or evidence indicating that the union leadership or
workers were ever advised about the change in the level of contamination from “trace
amounts” to a “concentration of spores” on one of the mail-sorting machines.
24
  According to the Chief Epidemiologist and district postal managers, the Chief
Epidemiologist also informed workers about the December 2001 quantified results,
including the finding of about 3 million spores on one mail-sorting machine.




Page 18                                                  GAO-03-316 U.S. Postal Service
                        Greater Connecticut Area Local American Postal Workers Union, the
                        quantitative results were also posted on bulletin boards in the facility.
                        There is little documentation of these briefings or the advice that the
                        Postal Service received from public health officials. However, we were
                        told that postal managers relayed the views and recommendations of the
                        Connecticut Department of Public Health officials, who had advised them
                        that there was no immediate health risk to workers and, therefore, that the
                        employees would not need to take antibiotics. This decision was based, in
                        part, on the view that the contaminated areas had already been isolated
                        and, in consultation with CDC, OSHA, and EPA, were to be
                        decontaminated. The managers also assured workers that testing would be
                        performed to ensure that no contamination was present before the areas
                        were returned to operation.25 The elevated areas were resampled in a
                        series of tests and, on June 6, 2002, the final laboratory report indicated
                        that all samples were negative for anthrax. Postal Service managers met
                        daily with union representatives to provide and discuss test results and the
                        status of decontamination efforts. The Postal Service posted the final
                        results on bulletin boards in the facility on June 7, informing employees
                        that decontamination had been completed.


                        Consistent with its guidelines, the Postal Service generally provided the
Disclosure of Anthrax   facility’s test results to workers within 1 day of receiving the results. The
Test Results            one exception to this practice involved the December 2001 quantitative
                        test results. In this case, there was a delay of at least 2 days between the
                        date that the Postal Service received documentation of the quantified test
                        results and the date that it notified its workers about the “concentration of
                        spores” on one mail-sorting machine. It is not clear precisely when in
                        December 2001 the Postal Service first received the documented test
                        results. While the Postal Service informed workers of the results in a
                        qualitative manner, it did not disclose the actual quantitative results to
                        workers until September 2002. The Postal Service’s decision not to release
                        the quantitative test results in December 2001 appears to have been
                        consistent with its guidelines because the sampling methods used could
                        not be validated, as required. However, its decision not to release the
                        December 2001 quantitative test results in response to two requests by a
                        local union leader in January 2002 and February 2002 was not consistent
                        with OSHA’s regulations for disclosing test results that are requested by
                        workers or their designated representatives. OSHA’s subsequent


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




                        Page 19                                                  GAO-03-316 U.S. Postal Service
                            investigation into this matter resulted in the Postal Service’s release of the
                            December 2001 quantitative test results in September 2002—more than 7
                            months after the union leader first requested the results and about 9
                            months after the results were first known by the Postal Service. OSHA did
                            not cite the Postal Service for its decision not to disclose the results
                            earlier; however, in a October 7, 2002, letter to the Postal Service, OSHA
                            noted that a “failure to effectively communicate issues which can have an
                            effect on a worker’s health and safety, can lead to fear and mistrust.”


The Postal Service’s        Following the anthrax contamination of several postal facilities, the Postal
Release of the December     Service, in consultation with public health and other organizations that
2001 Test Results Appears   were members of the Postal Service’s Command Center, issued—in
                            December 2001—policies and procedures for, among other things,
Consistent with Its         releasing and communicating anthrax test results.26 The guidelines specify,
Guidelines                  among other things, how and when test results will be communicated to
                            employees and the public. The guidelines state that results cannot be
                            released until confirmed data are received from CDC or a state public
                            health laboratory. Also, all confirmed data have to be validated before
                            being sent to the Command Center.27 Once data are confirmed and
                            validated, the guidelines state that the Manager of the Command Center is
                            to release the data to affected district and facility managers, the affected
                            state health department(s), and the CDC liaison at the Command Center.
                            According to the guidelines, when a Facility Manager receives the results,
                            he or she is to ensure that employees, union representatives, and other
                            affected parties are notified “as soon as possible.” An earlier version of the
                            guidelines, dated November 16, 2001, has identical requirements.

                            The Postal Service, with one exception, began disclosing the laboratory
                            test results for samples collected from the facility within 1 day of receiving
                            the qualitative results. Such prompt disclosure is consistent with the
                            Postal Service’s guidelines, which require facility managers to notify
                            workers of sample results “as soon as possible” if the results are
                            confirmed and validated. The one exception to this practice appears to



                            26
                             U.S. Postal Service, Interim Guidelines for Sampling, Analysis, Decontamination, and
                            Disposal of Anthrax for U.S. Postal Service Facilities (Dec. 4, 2001). The guidelines were
                            developed as the anthrax crisis unfolded with input and guidance from several federal
                            agencies, including CDC and OSHA, and the national unions that represent postal workers.
                            27
                             The Postal Service’s guidelines do not define the meaning of the terms “confirmed” and
                            “validated.”




                            Page 20                                                   GAO-03-316 U.S. Postal Service
have occurred after the Postal Service received written confirmation of the
results from the two quantified samples collected on November 28, 2001.
According to district postal managers, they began relaying the results to
facility workers on December 12, 2001—2 days after district postal
managers said they first received written confirmation of the laboratory’s
quantified results from the Chief Epidemiologist. District postal managers
provided several reasons for their 2-day delay in notifying workers of the
results.28 First, they said they needed time to consult with public health
officials from Connecticut’s Department of Public Health and CDC about
(1) the meaning and implications of the quantitative results and (2) how to
describe the results and associated health risks to employees at the
facility. Second, the managers said that they needed additional time to
obtain advice from Postal Service headquarters and to draft a press
release. Although the district did not receive the quantitative results until
December 10, as previously discussed, a chronology of events prepared in
January 2002 by Postal Service employees and shared with CDC indicates
that postal managers at headquarters may have received the documented
results on or about December 8, 2001—4 days before workers were
informed of the test results.29 The length of the delay in informing workers
cannot be specifically determined because postal headquarters managers
do not recall when they first obtained the written test results.

According to Postal Service managers, the decision to withhold the actual
quantified results from facility workers also was consistent with the
guidelines because the Postal Service could not ensure that the
contractor’s sampling procedures were consistent with the procedures
and protocols specified in the guidelines. As a result, according to the
Postal Service, it was unable to validate the results as required by its



28
  Although the Postal Service began relaying information about the concentration of spores
on one machine on December 12, we were unable to determine whether the Postal Service
also relayed the specific results of samples collected on December 2. As discussed in
appendix II, the Postal Service received these results on or around December 9. The results
identified unspecified amounts of contamination (i.e., “positives”) on (1) 30 of 52 samples
collected from the heavily contaminated machine, (2) 3 of 52 samples from a second
machine, and (3) 1 of 48 samples from each of the two other mail-sorting machines.
29
 As previously discussed, in March 2003, postal headquarters managers told us that there
were errors in this chronology that they believe were not corrected and that they do not
recall precisely when they received the documented results. Absent definitive
documentation of when Postal Service headquarters received the test results and
documentation of the discussions between public health and postal managers, we were
unable to determine when Postal Service headquarters managers first learned of the
quantitative test results.




Page 21                                                   GAO-03-316 U.S. Postal Service
guidelines. More specifically, the Postal Service indicated that the results
could not be validated, in part, because the team that collected the
samples—individuals from the Agency for Toxic Substances and Disease
Registry and CDC—did not always measure and record the extent of the
surface area that they sampled.30 Also, the team used various sampling
methods, and there was no way to correlate the results from the various
methods used.31 The Postal Service also indicated that the laboratory that
produced the results was not hired by or working directly for the Postal
Service, as had been expected when the Postal Service developed its
guidelines.32

Aside from the requirements in its guidelines, district postal managers said
two other factors influenced their decision not to disclose the quantified
results in December 2001. First, district postal managers said that they
were uncertain about whether they could release the results given the
ongoing FBI criminal investigation related to the facility’s contamination.33
Although acknowledging that they did not consult the FBI or others about
releasing the quantitative results, district postal managers noted that the
investigative team was subject to strict rules and had agreed not to


30
  In its technical comments on our draft report, CDC noted that the HEPA vacuum sample,
which identified 2.9 million colony-forming units of anthrax, had been taken on the feeder
mechanism of a mail-sorting machine. While the precise surface area of the feeder
mechanism would be difficult to measure, CDC noted that the mechanism is an important
part of the mail’s pathway through the machine. Thus, even though there are limitations in
the ability to measure such areas, CDC pointed out that there is value in sampling these
types of complex mail processing surfaces.
31
 For additional information about the rationale for the sampling methods used at
Wallingford as well as information about related validation issues, see CDC,
Environmental Sampling for Spores of Bacillus anthracis. Emerging Infectious
Diseases. Vol 8. No. 10. (October 2002).
32
  Unlike its actions in December 2001, the Postal Service immediately provided all of the
test results, including the quantified results of from 1 to 18 colony-forming units, to
employees at the facility in April 2002. Full and immediate disclosure of the April 2002 test
results had been recommended by an OSHA official to avoid miscommunication,
confusion, and workers’ concern about how the data may have been interpreted. The
decision to release the results also appears consistent with the Postal Service’s guidelines
because, according to the Postal Service, the sampling and analyses were performed by a
Service contractor in accordance with the Service’s procedures and protocols for sampling.
According to the Manager of the Command Center, this allowed the Postal Service to
validate the results.
33
 In addition to its participation on the investigation team at Wallingford, the FBI also was
conducting a separate criminal investigation related to the facility’s contamination. The
U.S. Postal Inspectors, the U.S. Attorney’s Office, the Connecticut Department of Public
Health, and CDC were also members of the criminal investigation team.




Page 22                                                     GAO-03-316 U.S. Postal Service
                             disclose information exchanged during its twice-daily conference calls.
                             Second, they said that there was considerable uncertainty about what the
                             results meant from the standpoint of worker safety and public health. The
                             District Manager explained that in December 2001, interpretations about
                             the meaning of the results were changing by the hour, depending on the
                             views of individuals involved at the time. As a result, according to
                             members of the investigative team, there was considerable daily
                             discussion within the team about what the test results actually meant.34
                             CDC pointed out that it “did not and still does not know how to interpret
                             quantitative results such as the high spore count from a health risk
                             standpoint.” Nevertheless, CDC noted that the actions taken by the Postal
                             Service when the contamination was found were “very cautionary and
                             prudent.”


The Postal Service’s Delay   To help ensure that employees have safe and healthy work places, OSHA
in Disclosing the            enforces a variety of standards that it developed to eliminate foreseeable
December 2001                and preventable hazards, such as worker exposure to asbestos, lead, and
                             carbon monoxide. The risk of contamination from anthrax was not
Quantitative Test Results    anticipated when these standards were developed. Thus, there is no
Was Not Consistent with      specific OSHA standard governing the timing and disclosure of test results
OSHA’s Disclosure            for anthrax and a host of other unanticipated substances that could harm
Requirements                 workers. However, regardless of the contamination, OSHA regulations
                             require employers to disclose exposure-related test results “whenever an
                             employee or designated representative requests access to a record. . . .35
                             Employers are required to provide access to the records “in a reasonable
                             time, place, and manner.” If access is not provided within 15 working days,
                             employers must explain the delay and indicate when the record can be




                             34
                              Since the amount of surface area collected for the sample containing about 3 million
                             spores was not recorded, investigators could not determine whether the spores had been
                             spread over the sample area or clumped together in one spot. Also, according to a team
                             member, it was not clear how to extrapolate the result from the surface sample into its
                             potential for existing in the air. (Additional information on the interpretation of surface
                             sampling results is contained in CDC’s MMWR Weekly, December 21, 2001, and in its fact
                             sheet entitled Comprehensive Procedures for Collecting Environmental Samples for
                             Culturing Bacillus anthracis (revised April 2002).
                             35
                               Within the context of the regulation, “records” include exposure and medical records.
                             More specifically, records include “environmental workplace monitoring or measuring of a
                             toxic substance or harmful physical agent, including personal, area, grab, wipe, or other
                             form of sampling, as well as related collection and analytical methodologies, calculations,
                             and other background data relevant to interpretation of the results obtained.”




                             Page 23                                                     GAO-03-316 U.S. Postal Service
made available.36 OSHA has considerable discretion in enforcing this
requirement and, depending upon the seriousness of the situation, can cite
and even fine an employer for noncompliance.37

The President of the Greater Connecticut Area Local American Postal
Workers Union—a designated representative of many of the facility’s
employees—triggered the OSHA requirement on January 29, 2002, when
he requested postal facility managers to provide copies of all test results
and all supporting and relevant documents for all anthrax testing
conducted at the Wallingford facility in the fall of 2001.38 The request was
made pursuant to the union’s collective bargaining agreement with the
Postal Service. The Postal Service responded on February 6, 2002, with a
summary listing of tests performed at the Wallingford facility, including
information about whether the test was positive or negative for anthrax.
The Postal Service did not (1) provide any of the actual laboratory reports
for the tests or (2) inform the union leader that it had not disclosed all of
the relevant records. According to the Postal Service, it viewed the union
leader’s request, like others it receives from the union, in the context of its
collective bargaining agreement with the union, not within the context of
OSHA’s disclosure requirement. As a result, the Postal Service did not
provide him with the earliest date when the other records would be made
available, as required by OSHA’s regulations.

Noting that the Postal Service had not provided him with certain test
results, including results related to the decontamination of the four mail-
sorting machines in December 2001, the union leader submitted an
identical request for all of the records to the Postal Service on February
28, 2002—again under the collective bargaining agreement. The Postal
Service provided the results of tests performed on November 11, 2001, as
well as the results of the December 2001 decontamination efforts.
However, once again, according to the headquarters’ manager responsible
for establishing and overseeing the Command Center, the Postal Service
did not view the request within the context of the OSHA disclosure
requirement. As a result, the Postal Service did not apprise the union



36
 29 C.F.R. § 1910.1020 (e)(1)(i).
37
 OSHA may cite the following violations with or without a fine: “Other than Serious,”
“Serious,” “Repeated,” “Failure to Abate,” and “Willful.”
38
 The union leader also requested test results from the post office in Seymour,
Connecticut—the post office that delivered mail to the deceased woman’s home.




Page 24                                                   GAO-03-316 U.S. Postal Service
leader of the reason for the delay in disclosing all of the records or the
earliest date when the records would be made available.

According to the union leader, he believed that the Postal Service had
provided him with all of the relevant information and did not pursue the
matter further until April 2002—after he learned from a newspaper article
that at least one of the facility’s test results had been quantified.39
According to the union leader and the Postal Service physician who had
been responsible for providing medical advice to workers at the facility in
December 2001, this was the first time that they were aware that any of the
facility’s test results had been quantified.

The union leader told us that the news article alarmed him; as a result, he
initiated action to obtain the quantified test results under the Freedom of
Information Act. Specifically, on April 23, 2002, the union leader requested
OSHA, the Connecticut Department of Public Health, and CDC to supply
“any and all documents regarding any and all investigations of hazardous
conditions, or suspected hazardous conditions, including, but not limited
to, all documents related to any and all investigations of contamination, or
suspected contamination, of the anthrax virus at the [Wallingford facility]
in 2001 and 2002.”

OSHA responded to the request but indicated that it did not have the test
results and, therefore, it could not release the information. Second, while
the Commissioner of the Connecticut Department of Public Health had
discussed the December 2001 quantified results with the union leader on
April 22, 2002, and the Chief Epidemiologist had briefed the facility’s
workers about the quantitative results on April 24, 2002, the department
subsequently declined to release the actual results because of state
prohibitions on releasing epidemiological investigative data.40 Finally,
although CDC had previously (1) released the quantitative test results for


39
  A March 26, 2002, article in The New York Times discussed a presentation by the Chief
Epidemiologist about contamination at the facility, including the finding of “about 3 million
spores” from a sample collected in November 2001. The Chief Epidemiologist told us that
he presented this information at an international conference on emerging infectious
diseases because he wanted to emphasize the importance of maintaining the Postal
Service’s restriction on the use of compressed air to clean its facilities to ensure that any
residual spores at Wallingford and other postal facilities are not blown elsewhere in the
facilities.
40
  The Commissioner told us that he was not aware that his department had not provided
the requested test results. We did not evaluate state laws related to the release of
epidemiological data because doing so was outside the scope of our work.




Page 25                                                     GAO-03-316 U.S. Postal Service
the Wallingford facility at a March 2002 conference and (2) published
some quantitative test results for the Brentwood facility in Washington,
D.C.,41 it did not release the results to the union until March 28, 2003,
because, according to a CDC official, the FBI had only recently notified
CDC that it did not need to review CDC’s records before the release of
“anthrax-related information.”42

Unsuccessful in obtaining the facility’s test results, the union leader filed a
formal complaint with OSHA. The May 29, 2002, complaint alleged that the
Postal Service had “intentionally failed to properly and timely disclose to
the employees working at [the facility] and to their union representatives
the actual level of anthrax contamination found on four (4) automated
processing machines back in December 2001.” The letter noted that the
Postal Service was aware of the quantified test results “on or about
December 12, 2001” yet did not inform the facility’s workers. Absent
knowledge of the actual amount of contamination at the facility, the union
leader charged that employees had inadequate information for making
informed decisions, such as decisions about whether to continue (1)
taking antibiotics and (2) working in the facility. The union leader and
other union representatives subsequently explained to us that, according
to their discussions with workers at the facility, many of the employees
either (1) did not take their antibiotics or (2) stopped taking their
medicine prematurely on the basis of the Postal Service’s use of “trace”
and “concentration” to characterize the extent of contamination in the
facility.

The complaint resulted in an OSHA investigation and the Postal Service’s
subsequent release of test results from samples collected in November and
December 2001. This included the actual laboratory record for the sample
that identified about 3 million spores in a sample collected from one mail-
sorting machine on November 28, 2001. The Postal Service provided the
quantified results to union representatives and to members of the facility’s
Safety and Health Committee on September 4, 2002, along with a letter


41
 Sampling performed by CDC investigators and Postal Service contractors at the
Brentwood facility in October 2001 identified from 8,700 to 2 million colony-forming units
per gram of material collected from high-speed mail-sorting machines and areas near the
machines. CDC published the results in December 2001. See MMWR Weekly, December 21,
2001/50(50); 1129-1133.
42
 According to CDC, it consulted with the FBI to determine whether the request was
subject to 45 C.F.R. § 568, which permits CDC to withhold information that would interfere
with ongoing law enforcement proceedings.




Page 26                                                   GAO-03-316 U.S. Postal Service
describing the Postal Service’s reasons for not releasing the results earlier.
Specifically, the Postal Service indicated that the results could not be
validated because “the laboratory that produced the results was not hired
by or working directly for the Postal Service.” As a result, the letter
cautioned recipients not to use the information to interpret the risk to
employees who had been working in the facility in December 2001.

At the conclusion of the inspection, OSHA’s area office in Bridgeport,
Connecticut, reported that its inspection had “revealed conditions of
significant findings,” which—while not warranting a citation for a
regulatory violation—were of “sufficient importance to require [the
Facility Manager’s] attention.” OSHA’s October 7, 2002, letter to the Postal
Service also stressed the importance of timely communication of test
results and stated that a “failure to effectively communicate issues which
can have an effect on a worker’s health and safety, can lead to fear and
mistrust.” Furthermore, the letter informed the Postal Service that
“effective and forthright communication of any and all information relating
to exposure records, both quantitative and qualitative, to toxic substances
and harmful physical agents should take place in a timely manner.”

According to OSHA officials, OSHA typically sends a letter of significant
findings when the employer has disclosed information requested by an
employee or his or her designated representative while the complaint is
still open—as the Postal Service did on September 4, 2002, prior to the end
of OSHA’s investigation. Although OSHA did not believe that a citation
was warranted, OSHA officials stated that they used a letter of significant
findings to establish a basis for a future violation if the problem reoccurs.

Dissatisfied with OSHA’s decision not to take regulatory action, on
October 17, 2002, the union leader requested that OSHA’s Regional
Administrator in Boston, Massachusetts, review the matter. The request
was based, in part, on the fact that the Postal Service did not release the
quantified results until September 4, 2002—more than 3 months after the
union filed its complaint with OSHA and more than 7 months after the
union had first requested all test results directly from the Postal Service.
The request also cited conflicting information that had been received by
OSHA about whether postal managers were still in possession of the
December 2001 quantified results in June 2002, when OSHA initiated its
investigation, and thus whether the Postal Service could have supplied the




Page 27                                           GAO-03-316 U.S. Postal Service
information to the union earlier.43 In his request, the union leader argued
that a regulatory citation was needed because, otherwise, there would be
no incentive for the Postal Service to prevent a similar situation from
reoccurring. OSHA’s Regional Administrator reviewed the matter and, by a
letter dated November 26, 2002, affirmed OSHA’s prior decision not to
issue a regulatory citation.

We discussed OSHA’s findings with officials responsible for the inspection.
They noted that OSHA was not involved at the facility until April 2002—
well past the December 2001 period in question. Nevertheless, they cited
the emergency situation that had existed at that time and indicated that,
on the basis of their subsequent knowledge of the events that had
transpired, they believed the Postal Service had taken “reasonable and
prudent” actions to protect its employees throughout the period of the
facility’s contamination. As a result, any hazard associated with the Postal
Service’s nondisclosure of the quantitative test results had been eliminated
in December 2001—about 6 months before OSHA’s investigation began.
Also, the OSHA officials noted that because the Postal Service had
subsequently released the requested data, in their view, it would not be
appropriate to issue a regulatory citation.

In a February 2003 letter to the union leader, OSHA’s Regional
Administrator reaffirmed OSHA’s decision not to cite the Postal Service.
According to the Regional Administrator, the agency’s decision was
influenced by several factors, including the (1) national panic about the
anthrax threat in the fall of 2001; (2) lack of information about the
significance, in terms of employee exposure, of anthrax spores found in
the facility; and (3) existence of an ongoing criminal investigation into the




43
  According to a November 26, 2002, OSHA letter to the union leader, the Postal Service did
not have a copy of the December 2001 quantified results until August 13, 2002. Our work
showed that the Postal Service headquarters may have received documentation of the
quantified test results on or about December 8, 2001, and that the district had the written
results on December 10. Further, both of the offices maintained copies of the results
throughout the period in question. Postal Service officials told us they did not know why
OSHA was unaware that they had the results. Although OSHA provided us with
documentation associated with its investigation, the source of misinformation about the
Postal Service’s possession of the quantitative test results could not be discerned from the
material provided. Furthermore, our discussions with postal and OSHA officials did not
enable us to resolve this issue.




Page 28                                                    GAO-03-316 U.S. Postal Service
                       source of the anthrax spores that involved several federal agencies.44
                       Nevertheless, she emphasized the need for better communication by the
                       Postal Service and reaffirmed OSHA’s concern about the “failure of
                       communication and openness” exhibited by the Postal Service in this case.


                       Although OSHA and members of the investigative team in December 2001
Lessons Learned at     were not critical of the Postal Service’s decision not to release the
the Wallingford        December 2001 quantified results when they were first known, in hindsight
                       and within the context of lessons learned, they said there was no reason
Facility Suggest the   why the results and any limitations associated with the results could not
Need for More          have been disclosed at that time. They explained that from their
                       perspectives, full and timely disclosure of laboratory results is the best
Complete and Timely    method for communicating test results. For example, the Chief
Information to         Epidemiologist from the Connecticut Department of Public Health
Workers                emphasized that it is important to “put the information out there frankly
                       and then discuss it.” Similarly, CDC officials stated that the principle is to
                       get all of the information out to employees regarding their health risks.
                       Finally, although not a member of the investigative team, an OSHA official
                       who was involved in the facility’s decontamination in April 2002 told us
                       that he advised the Postal Service to provide employees with the “raw data
                       sheets” of test results to avoid miscommunication, confusion, and concern
                       about how the data may have been interpreted.

                       Two recent guidelines developed by GSA and the National Response Team
                       stress the importance of complete and timely information. The guidelines
                       are intended to disseminate information learned from the response to
                       anthrax contamination at postal and nonpostal facilities in the fall of 2001,
                       including lessons relating to the communication of test results. GSA
                       released its guidelines in July 2002.45 The guidelines are written in the form
                       of a policy advisory—not as regulations or explicit directives—and



                       44
                         According to the Postal Service, district postal managers—through the U.S. Postal
                       Inspection Service—contacted the FBI before releasing the December 2001 quantified test
                       results in September 2002. According to the Postal Service, the FBI told a member of the
                       Inspection Service that the quantified data could be released since the information already
                       had been discussed at a CDC conference and reported in the newspapers.
                       45
                        GSA is responsible for providing workspace and security for many federal agencies. The
                       agency also offers guidance and policies for various government functions, including mail
                       management. These guidelines are entitled GSA Policy Advisory: Guidelines for Federal
                       Mail Centers in the Washington, DC Metropolitan Area for Managing Possible Anthrax
                       Contamination.




                       Page 29                                                    GAO-03-316 U.S. Postal Service
primarily apply to the operation of mail centers located in federal agencies
in the Washington, D.C., area. While not requirements, GSA’s
recommendations for communicating test results to workers, in our view,
are relevant to the Postal Service and others. The guidelines emphasize the
importance of the integrity of the information communicated to workers
and stress the need for “timely, clear, consistent, and factual” information
about risk levels and any limitations associated with the information. The
guidelines conclude that people need “solid” information to have the
“confidence to make informed choices.”

The National Response Team developed the other guidelines, which are
still in draft. The most recent version of the guidelines is dated September
30, 2002, and is entitled Technical Assistance for Anthrax Response.46
Although not a member of the National Response Team, the Postal Service
assisted in the development of the guidelines. The guidelines (1) suggest
that more—rather than less—information should be disclosed and (2)
provide a number of recommendations about communicating information
during emergency situations. For example, the guidelines advise agencies
to consider that “different audiences (e.g., employees, reporters, local
politicians) may need different types of information” and to “anticipate
what information people need and in what form.” Further, although the
guidelines caution against passing on “everything you know,” it points out
the consequences of not fully disclosing information. Specifically, the
guidelines warn, “. . . do not withhold information . . . it is very likely that
the withheld information will be found out, which will cripple your
credibility. . . .” Finally, the guidelines advise agencies to “admit when you
have made a mistake or do not know the information.”

Although helpful in ensuring the integrity of information to be released,
neither of the two recent guidelines nor the Postal Service’s guidelines




46
  GSA emphasized that the guidelines developed by the National Response Team should be
the primary source of advice for anyone managing a credible threat situation. GSA
explained that its guidelines deal primarily with actions that managers of federal mail
centers in the Washington, D.C., area should take to prepare for possible anthrax threats
and to determine whether an anthrax threat is credible. As a result, once a credible threat
has been identified, responsibility for managing the situation passes from the manager of
the mail center to law enforcement, public health, and other authorities.




Page 30                                                    GAO-03-316 U.S. Postal Service
    explicitly address all of the communication issues that arose at the
    Wallingford facility.47 None of these guidelines

•   explicitly require disclosure of quantitative test results, when available, or
    specify the terminology (e.g., number of colony-forming units per gram or
    square inch of material sampled) that should be used to communicate the
    results to workers or others, along with any limitations associated with the
    results, or
•   specify the actions that should be taken if test results cannot be validated,
    including a strategy for communicating unvalidated test results to
    workers.

    Furthermore, the Postal Service’s guidelines do not define the meaning of
    “validation” or specify the steps that must be taken to validate test results.
    The Postal Service headquarters’s manager who was responsible for
    establishing and overseeing the Command Center told us that the term
    was intended to describe a method for ensuring that work had been done
    in accordance with the Postal Service’s sampling and testing procedures
    and, therefore, for coordinating the release of validated results. However,
    the guidelines do not specify who is to do the validation or how it is to be
    done, particularly when the testing is not done or sponsored by the Postal
    Service.

    The experts whom we consulted (1) told us that the sampling method
    (HEPA vacuums) used to collect the samples that were quantified was
    appropriate and (2) agreed that the lack of documentation about the
    extent of surface area sampled, especially given the complexity of the
    facility’s mail-sorting machines, could have made interpretations about the
    results difficult.48 Nevertheless, they noted that the method of counting
    colony-forming units is a long-standing, definitive, and universally



    47
      GSA and EPA—as the Chair for the National Response Team—explained that, by design,
    their guidelines were not intended to prescribe specific actions because knowledge about
    how to respond to anthrax is evolving rapidly, and each situation is unique. Instead, the
    agencies indicated that their guidelines provide background information and viable options
    for individuals who, in the case of GSA’s guidelines, operate and manage federal mail
    centers or, in the case of guidelines developed by the National Response Team, respond to
    anthrax attacks.
    48
      We consulted with numerous experts in the field of microbiology, including Dr. Jack
    Melling, former Director and Chief Executive Officer of the British Center for Applied
    Microbiology Research; Dr. Paul Keim, Professor in Microbiology, Northern Arizona
    University; Col. Eric Henchal, Department of the Army; and Dr. Barbara Johnson, former
    Safety Officer at the Dugway Proving Grounds, Department of the Army.




    Page 31                                                   GAO-03-316 U.S. Postal Service
accepted microbiological technique for determining the amount of
bacteria in a given sample, including anthrax. The results show how many
spores have replicated to form colonies, which can be seen by the naked
eye. Thus, regardless of the sampling issues at Wallingford, none of the
agencies involved provided any evidence indicating that the number of
colony-forming units identified by the laboratory was incorrect.
Accordingly, although the sampling issues may have hindered the
interpretation of the test results,49 according to these experts, the use of
the term “concentration” to convey the finding of about 3 million spores in
one sample may have been misleading because it did not adequately
convey the health risk associated with the sample. According to the
experts with whom we talked, providing information about the actual test
results to workers would have given them better information for making
informed medical decisions.

In this case, according to the experts we consulted, an appropriate way to
communicate the results to workers would have been to indicate that 2.9
million colony-forming units (from 0.55 grams of dust) were found in a
sample from one machine, along with appropriate limitations regarding
the sampling procedures used. Although a precise interpretation of the
health risks associated with the quantitative test results was problematic,
providing the quantitative results would have given workers a framework
for evaluating the information they were previously given regarding the
8,000 to 10,000 spores believed—at that time—to be needed to cause
inhalation anthrax and would have provided some indication of the
magnitude of the anthrax present in the facility. According to CDC,
although the number of anthrax colonies can be counted, it is not possible
to count the exact amount of anthrax in the environment because of
uncertainties about how well a sample picks up anthrax. In other words,
there could be more anthrax in the environment than can be picked up by
a sample.

An additional problem relating to the existing guidelines is that none of
them (1) specify who should be involved in deciding what to communicate
to workers and others, as appropriate; (2) describe the documentation



49
  The National Response Team’s September 2002 draft guidelines agree that methods have
not been validated for a variety of sampling techniques. Accordingly, the guidelines
recommend that agencies use “a multi-disciplinary team” to help them interpret anthrax
test results. Relating to this, according to CDC, it is important to scrutinize new sampling
techniques, such as the HEPA vacuum, to understand the strengths and limitations of the
methods so that the methods can be subsequently validated.




Page 32                                                     GAO-03-316 U.S. Postal Service
agencies should maintain, including the advice agencies receive from
public health officials or others about the communication of test results to
workers; or (3) discuss the actions that should be taken if test data are
requested by an employee or a designated representative. As previously
discussed, OSHA representatives were not involved in the December 2001
discussions about what to communicate to workers. This deprived the
Postal Service of the insights and suggestions that OSHA could have
offered. Furthermore, although the Postal Service representatives cited
uncertainty over what information could be released given the ongoing
criminal investigation, the Postal Service did not consult with the FBI on
this issue. According to FBI officials we interviewed in Connecticut, the
test results were of no value to their investigation and, had they been
consulted, they said that they would have allowed the results to be
released.

As previously discussed, another issue that arose in the Wallingford case
involved differing recollections among the various parties regarding who
participated in certain discussions and about what advice was given. For
example, in contrast to the recollections of officials from CDC and the
Connecticut Department of Public Health, postal managers told us that
they did not participate in a December 6, 2001, telephone conversation in
which the quantitative test results were first discussed. Further, postal
managers have different recollections about the advice they received from
the Chief Epidemiologist than the information that he recalls. Also, in the
Wallingford case, the Postal Service said that it did not associate the union
leader’s request for the test results with OSHA’s regulatory requirement
and, therefore, did not realize that it was obligated to either provide the
results within 15 days or provide the reasons for the delay along with a
time frame for providing the results. Related to this, OSHA’s disclosure
requirements do not fully address the emergency situation that arose at
Wallingford, where workers were exposed to an unanticipated and
externally introduced hazard capable of causing serious health problems,
including death. The regulations are not applicable until an employee or a
designated representative requests test results and, even then, the
employer has up to 15 days to provide the information or explain why it is
not providing the information. The 15-day time frame is far more than the
number of days needed to contract inhalation anthrax.

We discussed OSHA’s regulatory requirements with OSHA’s Director of
Enforcement Programs. The Director told us that OSHA’s standards were
written for airborne exposure to chemical and physical agents in the
workplace, and, at the time they were drafted, OSHA did not envision
biological hazards, such as anthrax. According to the Director, OSHA’s


Page 33                                          GAO-03-316 U.S. Postal Service
              current regulatory agenda do not include any planned modifications to its
              requirements, including any changes to require the immediate and
              proactive disclosure of records related to an employee’s exposure to
              unforeseen hazards, such as anthrax, regardless of whether the records
              are requested by workers or their designated representatives.


              In retrospect, the Postal Service’s decision not to release the quantitative
Conclusions   test results in December 2001 was understandable given (1) the
              circumstances that existed at that time, (2) the advice it received from
              public health officials, (3) an ongoing criminal investigation, and (4)
              uncertainties surrounding the validation of the sampling methods used and
              the meaning of the test results. However, the decision deprived facility
              employees of information that may have been useful in making informed
              decisions about whether to take or continue taking antibiotics and
              whether to continue working in the facility. Furthermore, in hindsight, it is
              clear that not fully disclosing quantified test results can affect an agency’s
              credibility and lead to worker distrust. It is also apparent now that not
              consulting relevant agencies—in this case, OSHA and the FBI—regarding
              its December 2001 decision about what to disclose to employees deprived
              the Postal Service of information that could have been useful in deciding
              what to communicate to its workers. Finally, the Postal Service’s failure to
              document the discussions that it had with other agency personnel on
              communication issues makes it difficult to resolve discrepancies in
              recollections that arose. As demonstrated at Wallingford, documentation
              of the advice and recommendations received from others, either at the
              time they are received or shortly thereafter for emergencies, could help
              resolve questions that may arise later about what was done and why.

              The agencies involved in the investigation and response to anthrax at
              Wallingford have learned a number of lessons from their experiences,
              including the need for more effective sampling methods and more explicit
              and consistent guidance concerning the communication of test results for
              hazardous substances, such as anthrax. However, the guidelines
              developed by the Postal Service, GSA, and the National Response Team
              are still too general to prevent problems like those that occurred at the
              Wallingford facility. Specifically, the current guidelines do not (1) require
              the prompt disclosure of all available test results, using specified
              terminology; (2) define how test results should be validated or the actions
              that should be taken when results cannot be validated; (3) specify which
              agencies should be involved in deciding what to communicate to workers
              and others; or (4) require documentation of the advice and
              recommendations from other organizations involved in deciding the


              Page 34                                           GAO-03-316 U.S. Postal Service
                      actions to be taken during a crisis. Moreover, since employees and their
                      designated representatives may not know that test results are available or
                      that they can be requested, it appears incumbent upon employers to, in
                      emergency situations, immediately disclose test results without waiting for
                      an employee or representative to request them. Because current OSHA
                      regulations require the disclosure of test results only when an employee or
                      representative requests them, such as occurred in the Wallingford case,
                      organizations can still decide to withhold essential information. Lastly,
                      agency officials dealing with an anthrax situation or similar emergency
                      may not be aware of, or associate an employee’s request for test data with,
                      OSHA’s regulations, which can result in penalties for noncompliance.


                      To help prevent the reoccurrence of the communications problems that
Recommendations for   occurred at the Wallingford facility, we recommend that the Postmaster
Executive Action      General; the Administrator of GSA; and the Administrator of EPA, as
                      Chairperson of the National Response Team, work together to, where
                      applicable, revise guidelines to

                  •   require prompt communication of test results, including quantified results
                      when available, to workers and others;
                  •   specify the terminology that should be used to communicate quantitative
                      test results to employees and others (e.g., the number of colony-forming
                      units per gram or square inch of material sampled) and any limitations
                      associated with the test results;
                  •   define what is meant by the validation of test results and explain the steps
                      that must be taken to validate sampling or testing methods that are
                      undertaken by the agency itself or by another organization;
                  •   specify the actions that should be taken if test results cannot be validated,
                      including a strategy for communicating unvalidated results;
                  •   specify the agencies that should be involved in deciding what to
                      communicate to workers and others, as appropriate;
                  •   require documentation of the basis for decisions made, including the (1)
                      advice the organization receives from public health officials and others
                      about the communication of health-related information to workers and
                      others, as appropriate, and (2) specific content of what the organizations
                      communicate to workers and others; and
                  •   reflect OSHA’s regulations for disclosing test results requested by workers
                      or their designated representatives.

                      In light of new concerns about the possibility and impact of future
                      terrorist actions using unforeseen hazardous substances, we also
                      recommend that the Assistant Secretary for Occupational Safety and



                      Page 35                                          GAO-03-316 U.S. Postal Service
                     Health consider whether OSHA regulations should require—in emergency
                     situations—full and immediate disclosure of test results to workers,
                     regardless of whether the information is requested by an employee or his
                     or her designated representative.


                     We requested comments on a draft of this report from the Postmaster
Agency Comments      General; the Commissioner of the Connecticut Department of Public
and Our Evaluation   Health; the Secretaries of HHS, Labor, and Homeland Security; the
                     Attorney General—for the FBI; the Administrators of EPA and GSA; and
                     the President of the American Postal Workers Union. EPA, the Postal
                     Service, GSA, the union, and the FBI provided comments on our
                     conclusions and/or recommendations. Their comments are summarized
                     below.

                     EPA’s Assistant Administrator provided comments on March 21, 2003, in
                     EPA’s capacity as the Chair for the National Response Team. According to
                     the EPA Assistant Administrator, OSHA, GSA, HHS (specifically the
                     National Institute of Occupational Safety and Health), and the Postal
                     Service were consulted in preparing the response. EPA indicated that the
                     members of the National Response Team believe that our draft report
                     provided a balanced presentation of anthrax testing and communications
                     with employees at the Wallingford postal facility. While stating that the
                     National Response Team agrees with our references and
                     recommendations regarding the content of its guidelines—Technical
                     Assistance for Anthrax Response—EPA stated that the guidelines had
                     been carefully written as a technical resource document, as opposed to a
                     directive or guidance, and that knowledge on anthrax is evolving rapidly.
                     Thus, EPA noted that each response situation is unique. As a result, EPA
                     stated that the guidelines were intended to provide scientific background
                     and viable options for responders to consider in addressing specific
                     circumstances. Nevertheless, EPA indicated that “certain improvements”
                     could be made to the guidelines that would be responsive to our
                     recommendations. The letter did not specify the nature of the planned
                     improvements. EPA also provided technical comments, which we
                     included, as appropriate. EPA’s letter is reproduced in appendix III.

                     In his March 31, 2003, comments on our draft report, the Postal Service’s
                     Chief Operating Officer and Executive Vice President stressed that the
                     safety and security of its employees and its customers were then and now
                     of the utmost importance. The Postal Service also emphasized that, when
                     the anthrax crisis unfolded in the fall of 2001, there were no guidelines and
                     no designated regulatory agency for dealing with the crisis. While stating


                     Page 36                                          GAO-03-316 U.S. Postal Service
that the Postal Service acted quickly and prudently to communicate
pertinent information to its employees, the Postal Service acknowledged
that there are always opportunities to improve communications regarding
anthrax and other biohazards. In this regard, the Postal Service stated that
it is committed to working with the National Response Team to revise the
team’s technical assistance guidelines for anthrax and, when completed,
that it planned to ensure that its guidelines are consistent with the team’s
updated guidelines. The Postal Service also noted that it agreed with many
of our specific recommendations. For example, the Postal Service agreed
that test results, including quantified results, should be released to
employees and others as quickly as possible. The Postal Service also
agreed that any limitations associated with the results should be
explained. Further, the Postal Service recognized the importance of
developing and maintaining sufficient records concerning its
communication of health-related information to employees and others.
Finally, the Postal Service indicated that it is aware of its obligation to
release testing information to employees and their unions, when requested
to do so. The Postal Service’s letter, which is reproduced in appendix IV,
did not comment on our other recommendations. The Postal Service also
provided technical comments, which we included, as appropriate.

The Postal Service’s commitment to work with the National Response
Team in revising the team’s anthrax-related guidelines and, thereafter, to
ensure that its guidelines are consistent with the revisions made to the
team’s Technical Assistance for Anthrax Response, should go a long way
in ensuring that the Postal Service’s employees have all of the information
they need to make informed decisions about their health and safety in a
timely manner. However, because the National Response Team did not
specify the nature of its planned revisions to its technical assistance, we
believe that the Postal Service should also revise its guidelines to address
any recommendations that are not eventually included in the National
Response Team’s revised technical assistance, particularly with respect to
issues related to the meaning of “validation,” the steps that must be taken
to verify sampling methods or test results, and the release of test results
that cannot be validated.

On March 31, 2003, GSA’s Associate Administrator provided oral
comments on our draft report. GSA said that it had consulted with the
National Response Team and with key members of an Interagency
Working Group that had participated in the development of GSA’s anthrax-
related guidelines. According to GSA, the other members of the working
group had similar comments. Overall, GSA said that our draft report
provided a balanced presentation of anthrax testing and communications


Page 37                                          GAO-03-316 U.S. Postal Service
with employees at the Wallingford facility and that it generally agrees with
our references to, and recommendations regarding, its guidelines. Like the
comments we received on behalf of the National Response Team, GSA
also emphasized that its guidelines were written as a policy advisory and
that they were not intended to prescribe specific actions that should be
taken in every case. Instead, GSA indicated that its guidelines are intended
to provide background information and viable options for managers who
operate federal mail centers in the Washington, D.C., area. GSA also
explained that its guidelines deal primarily with the actions that these
managers should take to prepare for possible anthrax threats and to
determine whether an anthrax threat is credible. Once a credible threat
has been identified, responsibility for managing the situation passes from
the manager of the mail center to law enforcement, public health, and
other authorities. As a result, GSA emphasized that the guidelines
developed by the National Response Team should be the primary source
of advice for anyone managing a credible threat.

GSA noted that it needs to consult with the entire Interagency Working
Group before implementing specific changes to its guidelines. However,
GSA informed us that it agreed with three of our recommendations and
indicated that it would work with other members to revise its guidelines
related to (1) the prompt disclosure of all test results, including any
available quantified results; (2) the need for adequate documentation of
the advice an agency receives from public health officials and others and
its related communications with employees and others; and (3) OSHA’s
regulations for disclosing test results requested by workers or their
designated representatives.

GSA also said that it would address the issues covered in three of our
other recommendations somewhat differently than in the manner that we
suggested. Nevertheless, GSA indicated that it would work with the
Interagency Working Group to address the concerns raised in our report.
The three recommendations in question relate to the need for (1) common
terminology in communicating quantitative test results, (2) understanding
what is meant by the “validation” of sampling methods and test results,
and (3) specifying the actions to be taken if test results cannot be
validated. Specifically, while GSA commented that it agrees that all test
results should be conveyed to workers promptly, it said that it does not
believe that quantitative test results should be used in all cases. GSA
explained that appropriate testing methods vary according to site-specific
circumstances and the ability to quantify results depends on the testing
methods used. GSA also noted that the term validation has various
meanings. Rather than promote confusion or add unnecessary detail to


Page 38                                          GAO-03-316 U.S. Postal Service
distinguish the different types of validation, GSA said that it would address
our recommendations by adding a statement in its guidelines that
recommends sharing all available test results; specifying the testing
methods used; and explaining the limitations, if any, of the results and the
testing methods.

We appreciate GSA’s commitment to address the concerns raised in our
report. From GSA’s comments, it appears that further clarification of our
view may be warranted. We did not mean to imply that quantitative results
should be used in all cases. As indicated in our report, quantitative results
are not always available, depending on the sampling methods used. In fact,
in the case of the Wallingford facility, quantified results were rarely
available. However, when quantitative results are available, like GSA, we
continue to believe that it is important to disclose them to all affected
parties. We clarified our recommendation to avoid any misunderstandings
in this area.

Regarding our final recommendation, GSA indicated that parties involved
in responding to anthrax may change over time and, as a result, it believes
that its guidelines—in a general fashion—adequately identify the types of
parties that should be involved in deciding what to communicate to
workers and others. Nevertheless, GSA said that, in consultation with the
Interagency Working Group, it would look for ways to enhance this part of
its guidelines.

The President of the American Postal Worker’s Union commented on our
draft report in a letter dated March 25, 2003. The union said that it agreed
with our recommendations to better coordinate communication between
federal agencies when events occur. However, the union said that our
report did not adequately reflect the union’s perspective of the facts and
that a number of our conclusions were not supported by the facts. We
disagree. We believe that our conclusions are fully supported by the
evidence presented in this report and that the report presents a fair,
objective, and balanced depiction of the facts as best we could determine
them. We also disagree that the report does not adequately reflect the
union’s perspective. Our report clearly concludes that the Postal Service’s
December 2001 decision not to disclose the quantitative results deprived
workers of essential information for making informed decisions related to
their health and safety. In addition, the report lays out a number of lessons
that can be learned to avoid similar problems in the future. Furthermore,
the report contains several recommendations for improving
communication with postal and other workers in the future if another
bioterrorist attack occurs. The union’s letter is reproduced in appendix V.


Page 39                                          GAO-03-316 U.S. Postal Service
The union disagreed with a number of our conclusions. First, the union
disagreed that the Postal Service’s decision not to release the quantitative
results to workers in December 2001 appeared consistent with its
guidelines. The union reiterated the requirements in the Postal Service’s
guidelines which, as discussed in this report, specify that confirmed test
results must be validated before being sent to the Postal Service’s
Command Center and, once the data are confirmed and validated, the
guidelines state that the Manager of the Command Center is to release the
data to, among other parties, affected postal managers and state health
departments. Thus, in the union’s view, the test results are considered to
be validated when they are reported by the Manager of the Command
Center. However, this is not what happened in Wallingford. In the
Wallingford case, the laboratory reported the quantitative results directly
to the Connecticut Department of Public Health and CDC—not to the
Postal Service’s Command Center—and the Chief Epidemiologist provided
the test results directly to the Postal Service’s district office. Thus, the
results were not reported by the Command Center as anticipated by the
guidelines. According to the Postal Service, the December 2001
quantitative results could not be validated, within the context of the Postal
Service’s guidelines, because the party that collected the samples did not
work for the Postal Service and the Postal Service could not ensure that
the samples had been collected in accordance with procedures set forth in
its guidelines. While we believe that the Postal Service’s decision not to
release the quantitative test results in December 2001 appears consistent
with its guidelines on the basis of its interpretation of the validation
requirement, we also believe that the use of the term “validation” in the
context of anthrax testing can be problematic. Therefore, our report
contains a recommendation to define what is meant by validation and
explain the steps that must be taken to validate test results.

Second, the union stated that, in its view, it is unacceptable to withhold
exposure information under any circumstances. While we agree in
principle, our conclusion that the Postal Service’s decision not to release
the quantified test results in December 2001 was understandable is based
on the particularly challenging and difficult circumstances that existed at
that specific point in time. As discussed in this report, these circumstances
included an ongoing investigation of the bioterrorist attack; the advice that
the Postal Service received from public health officials; uncertainties
surrounding the validation of the sampling methods used and the meaning
of the test results. In addition, while the Postal Service’s existing
guidelines do not address all of the conditions that existed at the
Wallingford facility, the decision not to disclose the quantified results in
December 2001 appears consistent with the existing guidelines.


Page 40                                          GAO-03-316 U.S. Postal Service
Furthermore, neither OSHA nor the members of the investigative team,
including CDC, the Connecticut Department of Public Health, the FBI, and
EPA, specifically faulted the Postal Service for not releasing the
quantitative results at that time. Nevertheless, our report clearly states
that, in hindsight, not disclosing test results can be problematic and that
the decision not to disclose the December 2001 quantified results deprived
workers of important information. Consequently, we are making several
recommendations to improve future communication of test results,
including the prompt disclosure of available qualitative and quantitative
results, and any limitations associated with the sampling methods or test
results.

Third, the union stated that our report concluded that it was
understandable and acceptable that the Postal Service failed to follow
OSHA’s regulatory disclosure requirements and, as a result, that it was
acceptable to withhold the quantitative results for 9 months. We disagree
with the union’s characterization of our conclusion. Our report clearly
states that the Postal Service’s decision not to release the test results in
response to two union requests in January and February 2002 was not
consistent with OSHA’s regulations. To help ensure that similar situations
do not occur in the future, we are recommending that EPA, the Postal
Service, and GSA revise their guidelines to reflect OSHA’s regulations for
disclosing test results requested by workers. Related to this, we are also
recommending that OSHA consider strengthening its regulatory
requirements to require—in emergency situations—full and immediate
disclosure of test results to workers, regardless of whether the
information is requested by an employee or his or her designated
representative.

Finally, the union said that the report concluded that the Postal Service
followed its guidelines “with one exception,” without explaining that the
exception involved the sample containing about 3 million spores on one
heavily contaminated mail-sorting machine. According to the union, this
exception placed employees at considerable risk. As discussed in this
report, we agree that the Postal Service’s decision not to release the
quantitative results in December 2001 deprived the facility employees of
information that may have been useful to them in making informed
decisions about whether to take or continue taking antibiotics and
whether to continue working in the facility. However, we disagree that we
have not adequately explained the circumstances associated with this
situation. Throughout the report we discuss the results in question as well
as the fact that the quantitative test results were not communicated to
workers. Furthermore, the report clearly discusses the actual finding of


Page 41                                          GAO-03-316 U.S. Postal Service
about “3 million spores,” the “concentration” of spores that was
communicated to workers, as well as the fact that exposure to 3 million
spores is far more than the amount considered necessary to contract the
disease.

On March 27, 2003, we received technical comments from an FBI unit
chief responsible for dealing with threats from weapons of mass
destruction. The FBI noted conditions that existed in the fall of 2001 that it
believes might have contributed to some of the problems that we
identified at the Wallingford facility. These conditions included
uncertainties about anthrax testing and the interpretation of test results
and conflicting information about (1) what constituted a lethal dose of
anthrax and (2) the amount of spores needed to contract inhalation
anthrax. The FBI also commented on our recommendation that agency
guidelines specify the terminology that should be used to communicate
quantitative test results. Specifically, the FBI noted that it believes that
quantitative test results are not as helpful to employees as qualitative
information. The FBI also said that, in its view, quantitative data are less
applicable to the health and safety of employees than qualitative
information. As a result, the FBI suggested that we revise our
recommendation to specify that qualitative—rather than quantitative—test
results should be disclosed to workers.

While we agree that the prompt disclosure of qualitative test results is
important, we continue to believe that available guidelines need to be
revised to ensure that any quantitative test results are properly disclosed.
Thus, we have not revised our recommendation in this area. Experts that
we interviewed believe that, when available, quantitative test result data
can be helpful to employees. Further, CDC, the Connecticut Public Health
Department, and OSHA officials told us that the full disclosure of test
results is appropriate and that full disclosure can help avoid
misunderstandings, miscommunication, confusion, and mistrust. Similarly,
the experts we consulted—including the former Director and Chief
Executive Officer of the British Center for Applied Microbiology
Research—said that if the actual results had been provided to postal
employees, they would have had better information for making informed
medical decisions, particularly since the amount of anthrax in the facility
was much higher than the 8,000 to 10,000 spores that postal employees had
been advised would likely be needed to contract inhalation anthrax. A
final reason for not revising our recommendation is that by not providing
quantitative test results when requested by employees or their designated
representatives, an agency could be found in violation of OSHA
regulations and, therefore, subject to penalties for noncompliance.


Page 42                                           GAO-03-316 U.S. Postal Service
OSHA and two HHS components—CDC and the Agency for Toxic
Substances and Disease Registry—provided technical comments via E-
mail, which we incorporated, as appropriate. OSHA did not comment on
our recommendation that the Assistant Secretary for Occupational Safety
and Health consider whether OSHA regulations should require—in
emergency situations—full and immediate disclosure of test results to
workers, regardless of whether the information is requested by an
employee or his or her designated representative. We also received
technical comments from the Chief Epidemiologist of the Connecticut
Department of Public Health in which he stated that, overall, the report
accurately portrays his role as well as the role of the Connecticut
Department of Public Health as it relates to the situation at the Wallingford
facility. He suggested a number of revisions to clarify this report, which we
incorporated. In a March 31, 2003, letter, HHS’s Acting Principal Deputy
Inspector General said that the department had no comments aside from
the technical comments provided by two of its components. Finally, we
requested comments from the Secretary of Homeland Security, but we did
not receive any.


As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after the
date of this letter. At that time, we will send copies to the Chairman of the
Senate Committee on Governmental Affairs; the Chairman and Ranking
Minority Member of the House Committee on Government Reform; the
Postmaster General; the Secretaries of HHS, Labor, and Homeland
Security; the Administrators of EPA and GSA; the Assistant Secretary for
Occupational Safety and Health; the Attorney General; the Connecticut
Department of Public Health; CDC; the Agency for Toxic Substances and
Disease Registry; the national American Postal Workers Union; and other
interested parties. Copies will be made available to others on request and
are also available at no charge on our Web site at http://www.gao.gov.

If you have any questions about this report, please contact me on (202)
512-2834 or at ungarb@gao.gov. Key contributors to this assignment were




Page 43                                            GAO-03-316 U.S. Postal Service
Don Allison, Hazel Bailey, Bert Japikse, Latesha Love, Cady Summers, and
Kathleen Turner. Jack Melling and Sushil K. Sharma provided technical
expertise.

Sincerely yours,




Bernard L. Ungar
Director, Physical Infrastructure Issues




Page 44                                       GAO-03-316 U.S. Postal Service
              Appendix I: Objectives, Scope, and
Appendix I: Objectives, Scope, and
              Methodology



Methodology

              Our objectives for this report were to determine (1) how and when
              contamination was identified at the U.S. Postal Service’s Southern
              Connecticut Processing and Distribution Center in Wallingford,
              Connecticut (Wallingford facility); (2) what and when information about
              contamination was communicated to facility workers; (3) whether the
              Postal Service followed applicable guidelines and requirements for
              informing facility workers about the contamination; and (4) whether
              lessons can be learned from the response to contamination at the facility.

              To address these objectives, we identified and, with Postal Service
              headquarters, district, and facility managers, discussed the roles of the
              agencies involved in investigating and responding to anthrax at the
              Wallingford facility. We met with officials from the Postal Service, the
              Connecticut Department of Public Health, the Centers for Disease Control
              and Prevention (CDC), the Agency for Toxic Substances and Disease
              Registry, the Occupational Safety and Health Administration (OSHA), the
              Environmental Protection Agency, the Federal Bureau of Investigation, the
              national American Postal Workers Union, and its Greater Connecticut
              Area Local Union. We also requested and reviewed agency documentation
              related to the testing of the facility and the subsequent finding of anthrax
              contamination as well as documentation about how, when, and what
              information the Postal Service communicated to workers about the extent
              of contamination at the facility. The information documented, among
              other things, the various roles of the agencies involved, the laboratories’
              test results, sampling plans and testing protocols, press releases,
              information about the content of employee briefings, the Postal Service’s
              guidelines for testing and communicating anthrax test results, OSHA
              requirements for disclosing records related to employee health risks, and
              more recent anthrax guidelines developed by the General Services
              Administration and the National Response Team.

              We also interviewed officials from involved agencies to determine their
              views and the extent of their involvement in the response to the facility’s
              contamination between November 2001 and June 2002. Specifically, (1)
              what information was provided to employees at the facility and when, and
              by whom, it was provided and (2) what lessons can be learned about the
              response to contamination at the facility. Finally, we reviewed published
              literature, including technical reports on anthrax, and consulted several
              experts. We did not independently assess or verify any of the laboratory
              test results, sampling plans, or testing protocols to determine their
              accuracy or adequacy. Moreover, because the Postal Service did not
              document all of the advice that it received from public health officials or
              the precise information it communicated to workers at the facility, we


              Page 45                                         GAO-03-316 U.S. Postal Service
Appendix I: Objectives, Scope, and
Methodology




largely relied on the recollections of Postal Service, public health, and
other officials to reconstruct these events. We conducted our review from
September 2002 through March 2003 in Hartford, North Haven, New
Haven, and Bridgeport, Connecticut; Washington, D.C.; and Atlanta,
Georgia, in accordance with generally accepted government auditing
standards.




Page 46                                        GAO-03-316 U.S. Postal Service
Appendix I: Objectives, Scope, and
Methodology




[This page is intentionally left blank]




Page 47                                   GAO-03-316 U.S. Postal Service
              Appendix II: Summary of Anthrax Testing at
Appendix II: Summary of Anthrax Testing at
              the Wallingford Facility between November
              2001 and April 2002


the Wallingford Facility between November
2001 and April 2002




              Page 48                                      GAO-03-316 U.S. Postal Service
Appendix II: Summary of Anthrax Testing at
the Wallingford Facility between November
2001 and April 2002




a
 A fourth machine was suspected of being positive for anthrax on December 2 but was not confirmed
to be positive until later.
b
 Precisely when Postal Service headquarters and district managers first became aware of the
quantified test results is unclear. According to CDC officials and the Chief Epidemiologist, they began
discussing the quantitative results with investigative team members, which they believe included a
district postal manager, on December 6, 2001. However, district postal managers said that they were
not involved in discussions about the quantitative results until December 9. Absent documentation,
we were unable to reconcile these views.




Page 49                                                           GAO-03-316 U.S. Postal Service
Appendix II: Summary of Anthrax Testing at
the Wallingford Facility between November
2001 and April 2002




c
 According to CDC, although the number of anthrax colonies can be counted, it is not possible to
count the exact amount of anthrax in the environment because of uncertainties about how well a
sample picks up anthrax. In other words, there could be more anthrax in the environment than can be
picked up by a sample.
d
 District postal managers confirmed that the Chief Epidemiologist faxed the quantitative results to the
district office on December 9 (a Sunday), and that district managers received the fax on December
10. However, other documentation suggests that postal managers at headquarters may have
received the documented results on or about December 8. Postal headquarters managers said that
they do not recall precisely when they received the documented results, and absent definitive
documentation, we were unable to determine when they first knew about the quantitative test results.




Page 50                                                           GAO-03-316 U.S. Postal Service
             Appendix III: Comments from the Environmental Protection Agency
Appendix III: Comments from the
Environmental Protection Agency




             Page 51                                                GAO-03-316 U.S. Postal Service
Appendix III: Comments from the Environmental Protection Agency




Page 52                                                GAO-03-316 U.S. Postal Service
              Appendix IV: Comments from the U.S. Postal
Appendix IV: Comments from the U.S. Postal
              Service



Service




              Page 53                                      GAO-03-316 U.S. Postal Service
Appendix IV: Comments from the U.S. Postal
Service




Page 54                                      GAO-03-316 U.S. Postal Service
             Appendix V: Comments from the American
Appendix V: Comments from the American
             Postal Workers Union



Postal Workers Union




             Page 55                                  GAO-03-316 U.S. Postal Service
           Appendix V: Comments from the American
           Postal Workers Union




(543037)   Page 56                                  GAO-03-316 U.S. Postal Service
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