    U.S. Postal Service: Better Guidance Is Needed to Improve
    Communication Should Anthrax Contamination Occur in the Future
    (07-APR-03, GAO-03-316).

    In 2001, letters contaminated with anthrax resulted in 23 cases
    of the disease, 5 deaths, and the contamination of numerous U.S.
    Postal Service facilities, including the Southern Connecticut
    Processing and Distribution Center in Wallingford, Connecticut
    (the Wallingford facility). GAO was asked to address, among other
    matters, whether (1) the Postal Service followed applicable
    guidelines and requirements for informing employees at the
    facility about the contamination and (2) lessons can be learned
    from the response to the facility's contamination.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-03-316
        ACCNO:   A06590
      TITLE:     U.S. Postal Service: Better Guidance Is Needed to Improve
    Communication Should Anthrax Contamination Occur in the Future
         DATE:   04/07/2003
      SUBJECT:   Chemical and biological agents
    	     Health hazards
    	     Investigations into federal agencies
    	     Postal facilities
    	     Postal service
    	     Postal service employees
    	     Occupational safety

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    GAO-03-316

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

    United States General Accounting Office

    GAO

    April 2003 U. S. POSTAL SERVICE

    Better Guidance Is Needed to Improve Communication Should Anthrax
    Contamination Occur in the Future

    GAO- 03- 316

    The Wallingford facility first tested positive for anthrax in early
    December 2001. The contamination was found in samples collected from four
    mailsorting machines in November. Analyses of the samples produced
    quantified results, including about 3 million anthrax colonies, or living
    anthrax cells, in

    one of the samples. While this was far more than the amount needed to
    cause death, none of the employees at the facility became sick from the
    anthrax contamination.

    The Postal Service*s decision not to inform workers about the number of
    anthrax colonies identified in December 2001 appears consistent with its
    guidelines because, according to the Service, it could not validate the
    results, as required. However, its subsequent decision not to release the
    results after an employee union requested all the facility*s test results
    in January and February 2002, was not consistent with OSHA*s requirement
    for disclosing test results that are requested. An OSHA investigation
    resulted in the Service*s release of the quantitative test results in
    September 2002* about 9 months after the results were first known.
    Although OSHA did not issue a regulatory citation, it expressed concern
    about communication deficiencies.

    In retrospect, the Service*s decision not to release the quantitative test
    results in December 2001 was understandable given the challenging
    circumstances that existed at the time, the advice it received from public
    health officials, an ongoing criminal investigation, and uncertainties
    about the sampling methods used. However, numerous lessons can be learned
    from the experience, such as the need for more complete and timely
    information to workers to maintain trust and credibility and to help
    ensure

    that workers have essential information for making informed health
    decisions. Federal guidelines developed in 2002 by GSA and the National
    Response Team suggest that more* rather than less* information should be
    disclosed. However, neither the Service*s guidelines nor the more recent
    federal guidelines fully address the communication- related issues that
    developed in Wallingford. For example, none of the guidelines specifically
    require the full disclosure of quantified test results. Likewise, OSHA*s
    regulations do not require employers to disclose test results to workers
    unless requested, which assumes that workers are aware of the test results
    and know about this requirement.

    Decontamination Efforts at the Wallingford, Connecticut, Facility

    Source: U. S. Postal Service. U. S. POSTAL SERVICE

    Better Guidance Is Needed to Improve Communication Should Anthrax
    Contamination Occur in the Future

    www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 316 To view the full report,
    including the scope and methodology, click on the link above. For more
    information, contact Bernard L. Ungar, (202) 512- 2834, ungarb@ gao. gov.
    Highlights of GAO- 03- 316, a report to the

    Ranking Minority Member, Committee on Governmental Affairs, U. S. Senate

    April 2003

    In 2001, letters contaminated with anthrax resulted in 23 cases of the
    disease, 5 deaths, and the contamination of numerous U. S. Postal Service
    facilities, including the Southern Connecticut Processing and Distribution
    Center in

    Wallingford, Connecticut (the Wallingford facility). GAO was asked to
    address, among other matters, whether (1) the Postal Service followed
    applicable guidelines and requirements for informing employees at the
    facility about the contamination and (2) lessons can be learned from the
    response to the

    facility*s contamination. To help prevent a reoccurrence of communication
    problems, GAO recommends that the Postal Service, OSHA, GSA, and the
    National Response Team* a group chaired by the Administrator of EPA and
    comprising 16 federal agencies with responsibilities for planning,
    preparing, and responding to activities related to the release of
    hazardous substances* work

    together to revise their existing guidelines or regulations to, among
    other things, require prompt communication of available test results,
    including quantitative

    results, to workers and others, as applicable. The Service, EPA, and GSA
    generally agreed with our recommendations, indicating that they would work
    together to revise their guidelines. OSHA did not

    comment on our recommendations.

    Page i GAO- 03- 316 U. S. Postal Service Letter 1 Results in Brief 3
    Background 6 Anthrax Contamination Was First Identified at Wallingford in

    December 2001 after an Extensive Multiagency Investigation 10 Quantitative
    Test Results Were Provided to Workers in April 2002* but Not in December
    2001 14 Disclosure of Anthrax Test Results 19 Lessons Learned at the
    Wallingford Facility Suggest the Need for

    More Complete and Timely Information to Workers 29 Conclusions 34
    Recommendations for Executive Action 35 Agency Comments and Our Evaluation
    36 Appendix I Objectives, Scope, and Methodology 45

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

    Appendix III Comments from the Environmental Protection Agency 51

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

    Appendix V Comments from the American Postal Workers Union 55

    Table

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

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

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

    This is a work of the U. S. Government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. It may contain
    copyrighted graphics, images or other materials. Permission from the
    copyright holder may be necessary should you wish to reproduce copyrighted
    materials separately from GAO*s product. Abbreviations

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

    April 7, 2003 The Honorable Joseph I. Lieberman Ranking Minority Member
    Committee on Governmental Affairs United States Senate

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

    In late November 2001, the death of a Connecticut woman* 1 of the 5 people
    who died* spurred an extensive investigation by a multiagency team to
    determine, among other things, how she had been exposed to

    anthrax. Believing that the woman may have died from exposure to mail that
    had been contaminated as it passed through the Wallingford facility,
    federal and state investigators conducted more extensive testing of the
    facility. Facility workers received antibiotics on November 21, 2001* the
    day that the elderly woman died. The antibiotics were provided as a
    precautionary measure, since the Postal Service*s earlier testing of the
    facility had not identified any contamination. At about the same time, the
    Postal Service also initiated a medical surveillance program to monitor
    the health of the facility*s employees. The investigative team sampled the
    facility on numerous occasions between November and December 2001 and, in
    early December, identified anthrax on four mail- sorting machines. Anthrax
    also was identified in areas above the mail- sorting machines in

    1 Technically, the term *anthrax* refers to the disease caused by Bacillus
    anthracis and not the bacterium or its spores. In this report, we use the
    term *anthrax* for ease of reading and to reflect terminology commonly
    used in the media and by the general public. United States General
    Accounting Office Washington, DC 20548

    Page 2 GAO- 03- 316 U. S. Postal Service

    April 2002. 2 On both occasions, the affected areas were decontaminated,
    while mail processing continued in other areas of the facility.

    Perhaps because the facility*s workers had been provided with antibiotics,
    none of the employees at the Wallingford facility became sick from
    anthrax. However, you requested that we review the Postal Service*s
    disclosure of anthrax test results to the facility*s workers. As agreed,
    in this report, we address (1) how and when contamination was identified
    at

    the Wallingford facility, (2) what and when information was communicated
    to facility workers, (3) whether the Postal Service followed applicable
    guidelines and requirements for informing facility workers about the
    contamination, and (4) whether lessons can be learned from the response to
    contamination at the facility. As agreed, our future work will compare the
    treatment of postal workers at the Wallingford facility with the treatment
    of employees at other postal facilities contaminated with anthrax in the
    fall of 2001.

    To address our reporting objectives, we interviewed federal and state
    officials involved in investigating and responding to anthrax
    contamination at the Wallingford facility, including officials from the
    Postal Service*s headquarters office, its Connecticut district, and the
    Wallingford facility; the Connecticut Department of Public Health; and
    numerous federal agencies. We also interviewed representatives of
    employees at the facility, including the national American Postal Workers
    Union and its Greater Connecticut Area Local Union. We discussed, among
    other matters, the officials* roles and involvement in responding to the
    crisis and lessons that can be learned from the response. We obtained and
    reviewed documentation related to the sampling and testing of the

    facility, including laboratory test results; information about when and
    how test results and associated health risks were communicated to facility
    workers; the Postal Service*s guidelines for releasing and communicating
    test results; the Occupational Safety and Health Administration*s (OSHA)
    regulatory requirements for disclosing test results to workers; more
    recent federal guidelines developed in 2002 by the General Services
    Administration (GSA) and the National Response Team* a group chaired by
    the Administrator of the Environmental Protection Agency (EPA) and
    comprising 16 federal agencies with responsibility for planning,
    preparing, and responding to activities related to the release of
    hazardous substance;

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

    Page 3 GAO- 03- 316 U. S. Postal Service

    and other documents related to the facility*s contamination. Additional
    information on our scope and methodology appears in appendix I.

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

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

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

    Page 4 GAO- 03- 316 U. S. Postal Service

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

    quantitative test results (1 to 18 colony- forming units) from the samples
    collected in April from areas above the previously contaminated
    mailsorting machines.

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

    January 29, 2002, and February 6, 2002, was not consistent with OSHA*s
    regulations for disclosing test results that are requested by workers or

    Page 5 GAO- 03- 316 U. S. Postal Service

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

    results in December 2001 is understandable given all of the circumstances
    that existed at the time, the lessons learned from this experience suggest
    the need for more complete and timely information to workers to maintain
    trust and credibility. Officials from OSHA and members of the
    investigative team did not specifically fault the Postal Service for not
    releasing the quantified results when they were first known in December
    2001. However, they said full and timely disclosure of test results is the
    best method for communicating with employees and others. Two federal
    guidelines developed in 2002 by GSA and the National Response Team suggest
    that more* rather than less* information should be disclosed. For

    example, GSA*s guidelines emphasize the need for *timely, clear,
    consistent, and factual* information, including any limitations associated
    with the information, so that people can make informed decisions. The
    other set of guidelines, developed by the National Response Team, warns
    agencies not to withhold information because it could affect the agency*s
    credibility. However, neither the Postal Service*s guidance nor the more
    recent federal guidelines fully address the anthrax communication- related
    issues that developed at the Wallingford facility. For example, none of
    the

    guidelines specifically require the full disclosure of all test results,
    including quantitative test results. Likewise, OSHA*s regulations for
    communicating test results to workers do not address the need for full,
    immediate, and proactive disclosure. We are making several recommendations
    to minimize the likelihood that the communicationrelated problems at the
    Wallingford facility will reoccur elsewhere.

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

    Page 6 GAO- 03- 316 U. S. Postal Service

    agencies when events occur. However, the union said that our report did
    not adequately reflect the union*s perspective of the facts and that a
    number of our conclusions were not supported by the facts. We disagree. We
    believe that our conclusions are fully supported by the evidence

    presented in this report and that the report presents a fair, objective,
    and balanced depiction of the facts as best we could determine them.

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

    resulted from occupational exposure to infected animals or contaminated
    animal products, such as wool, hides, or hair. Infection can occur in
    three forms: (1) cutaneous, usually through a cut or an abrasion; 5 (2)
    gastrointestinal, by ingesting undercooked contaminated meat; and (3)
    inhalation, by breathing aerosolized anthrax spores into the lungs.
    Aerosolization occurs when anthrax spores become airborne, thus enabling a
    person to inhale the spores into the lungs. Symptoms depend on how the
    disease is contracted and, on the basis of experiences in the fall of
    2001, are now thought by medical experts to typically appear within 4 to 6

    days of exposure, although individuals have contracted the disease as long
    as 43 days after exposure. The disease can be treated with a variety of
    antibiotics and is not contagious. Persons who come in contact with
    anthrax spores are described as having been *exposed.* Depending on the
    extent of contamination and its form, a person can be exposed without
    developing the disease. Anthrax spores are dormant cells that can
    germinate and, if viable, replicate under suitable environmental
    conditions, such as in the human body. A person can die if the anthrax
    spores grow and the bacteria multiply and spread throughout the body.
    There is a range of laboratory tests for detecting anthrax in a

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

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

    person*s body and in the environment. Laboratories report anthrax test
    results either qualitatively (e. g., as *positive* or *negative*) or
    quantitatively (e. g., as a specific number of colony- forming units per
    gram or square inch of material sampled or in milligrams per microliter).

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

    understanding about the number of spores needed to cause the disease is
    still evolving. According to the contract physician responsible for
    providing medical advice to postal employees at the Wallingford facility
    in the fall of 2001, her literature search revealed that a person would
    need to inhale 8, 000 to 10,000 spores to contract the disease. 7 However,
    given that

    anthrax spores were never discovered in the Connecticut woman*s home or
    places that she frequented, 8 experts we consulted now believe that the
    number of spores needed to cause inhalation anthrax could be very small,
    depending on a person*s health status and the aerosolization capacity of

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

    6 The last cases of anthrax from this release occurred 43 days after the
    individuals* exposure. 7 According to CDC, the estimate of 8, 000 to 10,
    000 spores is from a Department of Defense, Defense Intelligence Agency
    publication entitled Soviet Biological Warfare Threat, DST161OF- 057- 86
    (Washington, D. C.: 1986).

    8 In commenting on our draft report, EPA noted that anthrax spores also
    were not found in the home or workplace of a female hospital worker who
    died from inhalation anthrax in October 2001 in New York City.

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

    operated by a facility manager and is under the jurisdiction of the
    District Manager in Hartford.

    On or about October 9, 2001, at least two letters containing anthrax
    spores entered the U. S. mail stream* one was addressed to Senator Thomas
    Daschle, the other to Senator Patrick Leahy. Before being sent to the
    Brentwood facility in Washington, D. C.* the facility that processed mail
    to the Senators* the letters were processed on high- speed mail- sorting
    machines at a postal facility in Hamilton, New Jersey. The Hamilton
    facility* also known as the Trenton postal facility* processed mail that
    was to be transported to Wallingford for further processing. 9 The
    Wallingford facility covers about 350,000 square feet and has over

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

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

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

    9 Two other contaminated letters were sent to a television news anchor and
    the editor of

    The New York Post in New York City on or around September 18, 2001.
    Although the letters were processed through the Hamilton/ Trenton
    facility, it is not known whether the letters contaminated the Wallingford
    facility.

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

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

    The Postal Service requested and the investigative team agreed that the
    Postal Service would be the sole party responsible for communicating test
    results and other information to the workers at the facility. In this
    regard, the physician under contract with the Postal Service informed the
    facility*s

    workers that, according to her research, inhalation of 8,000 to 10,000
    spores would likely be needed to cause inhalation anthrax.

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

    Page 10 GAO- 03- 316 U. S. Postal Service

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

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

    Sampling date Type (Number of samples) Result Agency that collected the
    samples a 11/ 11/ 01 Dry swabs (53) Negative Postal Service 11/ 21/ 01 Dry
    swabs (64) Negative Postal Service 11/ 25/ 01 Wet swabs (60) Negative CDC

    11/ 28/ 01 Wet wipes and HEPA vacuums (212) Positive CDC

    12/ 02/ 01 Wet wipes (200) Positive CDC 4/ 21/ 02 HEPA vacuums (101)
    Positive Postal Service Sources: GAO (summary) and Postal Service and CDC
    (data).

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

    Disease Registry.

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

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

    Contamination Was First Identified at Wallingford in December 2001 after
    an Extensive Multiagency Investigation

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

    state and federal investigative team targeted mail as one possible source
    of her exposure. Having found no contamination at the Wallingford facility
    or at the woman*s home and other places she frequented in the 2 months

    preceding her death, CDC and the Agency for Toxic Substances and Disease
    Registry resampled the facility on November 25, 2001, using wet swabs* not
    dry swabs. These 60 samples also tested negative. The laboratory informed
    the Chief Epidemiologist of the results, and he, in turn, called district
    postal managers to relay the results.

    Determined to ascertain the role that mail may have played in the woman*s
    exposure to anthrax, on November 28, 2001, CDC and the Agency for Toxic
    Substances and Disease Registry, with the full support of the Postal
    Service, performed what officials termed a *targeted* and *extensive*

    sampling of the facility. The team collected 212 samples, the majority of
    which were from machines that could have been used to process mail to the
    deceased woman*s home. The team also used different collection methods
    than had been used earlier* that is, the team collected samples using two
    methods: wet wipes and HEPA vacuums rather than dry swabs or wet swabs
    alone. 12 The use of these sampling methods resulted in the identification
    of anthrax on 4 of the facility*s 13 mail- sorting machines.

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

    sample of 0.55 grams of material (dust) collected from the heavily 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 12 GAO- 03- 316 U. S. Postal Service

    contaminated machine. 14 A second sample identified 370 colony- forming
    units per gram of material collected from another mail- sorting machine.
    The two samples were collected using HEPA vacuums. 15 The laboratory e-
    mailed the quantitative results to CDC officials and the

    Chief Epidemiologist on December 6. After subsequent discussions with the
    laboratory concerning the results as well as related discussions over the
    next few days with members of the investigative and response teams, the
    Chief Epidemiologist faxed the results on December 9 to the Postal
    Service*s district Human Resource Manager, who, according to the manager,
    received them on December 10. Precisely when Postal Service headquarters
    and district managers first became aware of the quantified test results is
    unclear. According to CDC officials and the Chief

    Epidemiologist, they began discussing the quantitative results with team
    members, which they believe included a district postal manager, on
    December 6, 2001. However, district postal managers said that they were
    not involved in discussions about the quantitative results until December
    9. District postal managers confirmed that the Chief Epidemiologist faxed
    the quantitative results to the district on December 9 (a Sunday) and that
    district postal managers received the fax on December 10. However, a
    chronology of the events prepared in January 2002 by Postal Service
    employees and shared with CDC indicates that postal managers at
    headquarters may have received the documented results on or about December
    8, 2001. We discussed the chronology with postal headquarters managers in
    March 2003 and they told us that, according to their recollections, there
    were errors in the chronology that were not corrected. They also said that
    they do not otherwise recall precisely when they received the documented
    quantitative results. Absent definitive documentation of when Postal
    Service headquarters received the test results and documentation of the
    discussions between public health and 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 13 GAO- 03- 316 U. S. Postal Service

    postal managers, we were unable to determine when Postal Service
    headquarters managers first learned of the quantitative test results.

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

    (3) 1 of 48 samples from each of the two other mail- sorting machines. A
    Postal Service contractor under the guidance of CDC and the Corps of
    Engineers decontaminated the four mail- sorting machines. To test the
    effectiveness of the decontamination, follow- up samples were collected
    between December 7 and December 18, 2001. The laboratory informed the
    Chief Epidemiologist of the negative results on December 20. The Chief
    Epidemiologist relayed the results to district postal managers who,
    shortly thereafter, returned the machines to operation. The facility
    remained open throughout the period in part because, according to public
    health officials, there was no evidence that the anthrax was airborne,
    workers had already

    received antibiotics, no one had contracted the disease, and action had
    already been taken to isolate the contaminated machines from workers on
    December 2, 2001* the day that anthrax contamination was first reported.
    16 On April 21, 2002, a Postal Service contractor, in consultation with
    CDC,

    OSHA, EPA, and the Connecticut Department of Public Health, sampled areas
    above the previously contaminated machines using HEPA vacuums. The
    sampling was performed because of a Postal Service requirement for testing
    prior to the routine cleaning of elevated areas in facilities that had
    previously tested positive for anthrax. The effort was undertaken to

    protect workers from the possibility of exposure to spores that may have
    blown into these areas as a result of the Postal Service*s prior use of
    compressed air to clean its facilities. The laboratory relayed the results

    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 14 GAO- 03- 316 U. S. Postal Service

    from the April 21 sampling effort to district postal managers on April 24.
    The results revealed from 1 to 18 colony- forming units in 3 of 101
    samples collected from the elevated areas. 17 The contaminated areas were

    subsequently encapsulated and decontaminated. A Postal Service contractor
    collected follow- up samples to test the effectiveness of the
    decontamination between May 1 and June 3, 2002. The laboratory reported
    negative results in all of the samples directly to district postal
    managers on June 6 and, on June 7, the facility was returned to full
    operation. 18 The Postal Service typically provided nonquantitative (i.
    e., *positive* or

    *negative*) results from samples collected between November 2001 and April
    2002 to employees on each of the facility*s three work shifts. The
    specific content of the information disclosed varied. The Postal Service
    began communicating the results of the first samples* which were collected
    on November 11, 2001* on November 15, the day after the Postal Service
    received the negative results. The Facility Manager informed

    supervisors and union officials of the results, and the supervisors, in
    turn, informed employees at the facility. According to a district manager,
    the test results also were posted on designated bulletin boards at the
    facility. The Postal Service began relaying the results of the November
    21, 2001, sampling effort, which were also negative, to employees in a
    briefing on November 23, the day that district postal managers were
    notified of the results. On November 27, the day that district managers
    received the results from the third sampling done on November 25, 2001,
    the Facility Manager once again began briefing employees about the
    negative results.

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

    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.
    Quantitative Test Results Were

    Provided to Workers in April 2002* but Not in December 2001

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

    managers told us that no documentation of the meeting exists; however,
    according to several of the individuals present, the Chief Epidemiologist
    described the extent of contamination as *trace* amounts on three
    mailsorting machines. 19 According to the Chief Epidemiologist, although
    the laboratory initially reported only a positive finding, his subsequent
    discussions with laboratory personnel indicated that the samples contained
    *one or two* colony- forming units of anthrax. Thus, he said, he used the
    term to denote a small amount of contamination. Also, he said,

    *trace* seemed appropriate given the number of sampling efforts undertaken
    before any contamination was found in the facility.

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

    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 16 GAO- 03- 316 U. S. Postal Service

    measure, the Chief Epidemiologist recommended that the Postal Service
    advise facility workers to continue taking antibiotics.

    According to district postal managers, after their December 2, 2001,
    meeting with the Chief Epidemiologist; the physician and postal managers,
    including the Facility Manager, began briefing employees on each of the

    facility*s three shifts. The managers relayed the Chief Epidemiologist*s
    views that there was no additional health risk associated with the test
    results. According to the managers, they also informed workers about
    planned actions to remediate the contamination. 21 As previously
    discussed, district postal managers recall being notified of

    the quantitative test results on December 9, 2001, which is the date they
    told us that the Chief Epidemiologist first called them to relay the
    results of additional laboratory analyses that he and CDC had received on
    December 6, 2001. The results were from the two samples collected on
    November 28, 2001, including the sample involving 2.9 million
    colonyforming

    units per 0.55 grams of sample material (dust) collected from one of the
    four contaminated mail- sorting machines. The Chief Epidemiologist told us
    that he discussed the results with laboratory personnel and, after these
    discussions, concluded that the results revealed the presence of *about 3
    million spores.* According to district postal managers, the test results
    were discussed at length in teleconferences between them, the Chief
    Epidemiologist, and other members of the investigation team on December 9
    and 10. District postal managers said that they were concerned about the
    test results and asked whether the facility*s employees were at risk.
    Although we were told that no documentation exists about the advice the
    Postal Service received at the time, according to district postal
    managers, the Chief Epidemiologist informed them that there was *no
    additional risk* to employees for the same reasons

    previously cited* the contaminated machines had already been isolated and
    were being decontaminated; the anthrax was not believed to be airborne;
    employees at the facility had already been offered antibiotics; and, in
    the view of public health officials, the incubation period for the

    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 17 GAO- 03- 316 U. S. Postal Service

    disease had already passed without illness. Nevertheless, as a
    precautionary measure, the Chief Epidemiologist recommended that the
    Postal Service managers advise workers to continue taking their

    antibiotics. CDC concurred with the Chief Epidemiologist*s recommendation
    and assessment about the health risk.

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

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

    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 18 GAO- 03- 316 U. S. Postal Service

    officials we spoke to do not recall this meeting. However, district postal
    managers issued a press release on December 12 containing the terminology
    that the Chief Epidemiologist said he had used. Further, district postal
    managers told us that supervisors on each of the facility*s three work
    shifts began relaying the Chief Epidemiologist*s views and health- related
    recommendations directly to the facility*s employees on December 12. Union
    representatives told us that they did not recall any supervisory briefings
    on December 12. 23 Although no documentation of these briefings is
    available, postal headquarters officials said that the December 12 press
    release would have been made widely available per the Service*s standard
    operating procedures and that a local Connecticut newspaper reported the
    information contained in the press release on December 13.

    According to the district managers, during follow- up testing later that
    month, workers were routinely advised of the qualitative (e. g., negative/
    positive) test results when the Postal Service received them from the
    laboratory. Beginning on December 20, 2001, workers were briefed

    that all of the follow- up samples had tested negative for contamination.
    On December 21, the Postal Service issued a press release stating that the
    four mail- sorting machines had been completely decontaminated and
    returned

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

    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 19 GAO- 03- 316 U. S. Postal Service

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

    daily with union representatives to provide and discuss test results and
    the status of decontamination efforts. The Postal Service posted the final
    results on bulletin boards in the facility on June 7, informing employees
    that decontamination had been completed.

    Consistent with its guidelines, the Postal Service generally provided the
    facility*s test results to workers within 1 day of receiving the results.
    The one exception to this practice involved the December 2001 quantitative
    test results. In this case, there was a delay of at least 2 days between
    the

    date that the Postal Service received documentation of the quantified test
    results and the date that it notified its workers about the *concentration
    of spores* on one mail- sorting machine. It is not clear precisely when in

    December 2001 the Postal Service first received the documented test
    results. While the Postal Service informed workers of the results in a
    qualitative manner, it did not disclose the actual quantitative results to
    workers until September 2002. The Postal Service*s decision not to release
    the quantitative test results in December 2001 appears to have been
    consistent with its guidelines because the sampling methods used could not
    be validated, as required. However, its decision not to release the
    December 2001 quantitative test results in response to two requests by a
    local union leader in January 2002 and February 2002 was not consistent
    with OSHA*s regulations for disclosing test results that are requested by
    workers or their designated representatives. OSHA*s subsequent

    25 The Postal Service also issued a press release communicating similar
    information. Disclosure of Anthrax Test Results

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

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

    Following the anthrax contamination of several postal facilities, the
    Postal Service, in consultation with public health and other organizations
    that were members of the Postal Service*s Command Center, issued* in
    December 2001* policies and procedures for, among other things, releasing
    and communicating anthrax test results. 26 The guidelines specify, among
    other things, how and when test results will be communicated to employees
    and the public. The guidelines state that results cannot be

    released until confirmed data are received from CDC or a state public
    health laboratory. Also, all confirmed data have to be validated before
    being sent to the Command Center. 27 Once data are confirmed and
    validated, the guidelines state that the Manager of the Command Center is
    to release the data to affected district and facility managers, the
    affected

    state health department( s), and the CDC liaison at the Command Center.
    According to the guidelines, when a Facility Manager receives the results,
    he or she is to ensure that employees, union representatives, and other
    affected parties are notified *as soon as possible.* An earlier version of
    the guidelines, dated November 16, 2001, has identical requirements.

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

    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.* The Postal Service*s

    Release of the December 2001 Test Results Appears Consistent with Its
    Guidelines

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

    have occurred after the Postal Service received written confirmation of
    the results from the two quantified samples collected on November 28,
    2001. According to district postal managers, they began relaying the
    results to facility workers on December 12, 2001* 2 days after district
    postal managers said they first received written confirmation of the
    laboratory*s quantified results from the Chief Epidemiologist. District
    postal managers provided several reasons for their 2- day delay in
    notifying workers of the results. 28 First, they said they needed time to
    consult with public health officials from Connecticut*s Department of
    Public Health and CDC about (1) the meaning and implications of the
    quantitative results and (2) how to describe the results and associated
    health risks to employees at the facility. Second, the managers said that
    they needed additional time to obtain advice from Postal Service
    headquarters and to draft a press release. Although the district did not
    receive the quantitative results until December 10, as previously
    discussed, a chronology of events prepared in January 2002 by Postal
    Service employees and shared with CDC indicates

    that postal managers at headquarters may have received the documented
    results on or about December 8, 2001* 4 days before workers were informed
    of the test results. 29 The length of the delay in informing workers
    cannot be specifically determined because postal headquarters managers do
    not recall when they first obtained the written test results.

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

    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 22 GAO- 03- 316 U. S. Postal Service

    guidelines. More specifically, the Postal Service indicated that the
    results could not be validated, in part, because the team that collected
    the samples* individuals from the Agency for Toxic Substances and Disease
    Registry and CDC* did not always measure and record the extent of the
    surface area that they sampled. 30 Also, the team used various sampling
    methods, and there was no way to correlate the results from the various
    methods used. 31 The Postal Service also indicated that the laboratory
    that produced the results was not hired by or working directly for the
    Postal Service, as had been expected when the Postal Service developed its
    guidelines. 32 Aside from the requirements in its guidelines, district
    postal managers said two other factors influenced their decision not to
    disclose the quantified results in December 2001. First, district postal
    managers said that they

    were uncertain about whether they could release the results given the
    ongoing FBI criminal investigation related to the facility*s
    contamination. 33 Although acknowledging that they did not consult the FBI
    or others about

    releasing the quantitative results, district postal managers noted that
    the investigative team was subject to strict rules and had agreed not to
    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 23 GAO- 03- 316 U. S. Postal Service

    disclose information exchanged during its twice- daily conference calls.
    Second, they said that there was considerable uncertainty about what the
    results meant from the standpoint of worker safety and public health. The
    District Manager explained that in December 2001, interpretations about
    the meaning of the results were changing by the hour, depending on the
    views of individuals involved at the time. As a result, according to
    members of the investigative team, there was considerable daily discussion
    within the team about what the test results actually meant. 34 CDC pointed
    out that it *did not and still does not know how to interpret

    quantitative results such as the high spore count from a health risk
    standpoint.* Nevertheless, CDC noted that the actions taken by the Postal
    Service when the contamination was found were *very cautionary and
    prudent.*

    To help ensure that employees have safe and healthy work places, OSHA
    enforces a variety of standards that it developed to eliminate foreseeable
    and preventable hazards, such as worker exposure to asbestos, lead, and
    carbon monoxide. The risk of contamination from anthrax was not

    anticipated when these standards were developed. Thus, there is no
    specific OSHA standard governing the timing and disclosure of test results
    for anthrax and a host of other unanticipated substances that could harm
    workers. However, regardless of the contamination, OSHA regulations
    require employers to disclose exposure- related test results *whenever an
    employee or designated representative requests access to a record. . . .
    35 Employers are required to provide access to the records *in a
    reasonable

    time, place, and manner.* If access is not provided within 15 working
    days, employers must explain the delay and indicate when the record can be
    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.* The Postal Service*s Delay

    in Disclosing the December 2001 Quantitative Test Results Was Not
    Consistent with OSHA*s Disclosure Requirements

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

    made available. 36 OSHA has considerable discretion in enforcing this
    requirement and, depending upon the seriousness of the situation, can cite
    and even fine an employer for noncompliance. 37 The President of the
    Greater Connecticut Area Local American Postal

    Workers Union* a designated representative of many of the facility*s
    employees* triggered the OSHA requirement on January 29, 2002, when he
    requested postal facility managers to provide copies of all test results

    and all supporting and relevant documents for all anthrax testing
    conducted at the Wallingford facility in the fall of 2001. 38 The request
    was made pursuant to the union*s collective bargaining agreement with the
    Postal Service. The Postal Service responded on February 6, 2002, with a
    summary listing of tests performed at the Wallingford facility, including
    information about whether the test was positive or negative for anthrax.
    The Postal Service did not (1) provide any of the actual laboratory
    reports for the tests or (2) inform the union leader that it had not
    disclosed all of the relevant records. According to the Postal Service, it
    viewed the union leader*s request, like others it receives from the union,
    in the context of its

    collective bargaining agreement with the union, not within the context of
    OSHA*s disclosure requirement. As a result, the Postal Service did not
    provide him with the earliest date when the other records would be made
    available, as required by OSHA*s regulations.

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

    36 29 C. F. R. S: 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 25 GAO- 03- 316 U. S. Postal Service

    leader of the reason for the delay in disclosing all of the records or the
    earliest date when the records would be made available.

    According to the union leader, he believed that the Postal Service had
    provided him with all of the relevant information and did not pursue the
    matter further until April 2002* after he learned from a newspaper article
    that at least one of the facility*s test results had been quantified. 39
    According to the union leader and the Postal Service physician who had

    been responsible for providing medical advice to workers at the facility
    in December 2001, this was the first time that they were aware that any of
    the facility*s test results had been quantified.

    The union leader told us that the news article alarmed him; as a result,
    he initiated action to obtain the quantified test results under the
    Freedom of Information Act. Specifically, on April 23, 2002, the union
    leader requested OSHA, the Connecticut Department of Public Health, and
    CDC to supply

    *any and all documents regarding any and all investigations of hazardous
    conditions, or suspected hazardous conditions, including, but not limited
    to, all documents related to any and all investigations of contamination,
    or suspected contamination, of the anthrax virus at the [Wallingford
    facility] in 2001 and 2002.*

    OSHA responded to the request but indicated that it did not have the test
    results and, therefore, it could not release the information. Second,
    while the Commissioner of the Connecticut Department of Public Health had
    discussed the December 2001 quantified results with the union leader on

    April 22, 2002, and the Chief Epidemiologist had briefed the facility*s
    workers about the quantitative results on April 24, 2002, the department
    subsequently declined to release the actual results because of state
    prohibitions on releasing epidemiological investigative data. 40 Finally,
    although CDC had previously (1) released the quantitative test results for

    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 26 GAO- 03- 316 U. S. Postal Service

    the Wallingford facility at a March 2002 conference and (2) published some
    quantitative test results for the Brentwood facility in Washington, D. C.,
    41 it did not release the results to the union until March 28, 2003,
    because, according to a CDC official, the FBI had only recently notified
    CDC that it did not need to review CDC*s records before the release of
    *anthrax- related information.* 42 Unsuccessful in obtaining the
    facility*s test results, the union leader filed a

    formal complaint with OSHA. The May 29, 2002, complaint alleged that the
    Postal Service had *intentionally failed to properly and timely disclose
    to the employees working at [the facility] and to their union
    representatives

    the actual level of anthrax contamination found on four (4) automated
    processing machines back in December 2001.* The letter noted that the
    Postal Service was aware of the quantified test results *on or about

    December 12, 2001* yet did not inform the facility*s workers. Absent
    knowledge of the actual amount of contamination at the facility, the union
    leader charged that employees had inadequate information for making

    informed decisions, such as decisions about whether to continue (1) taking
    antibiotics and (2) working in the facility. The union leader and other
    union representatives subsequently explained to us that, according to
    their discussions with workers at the facility, many of the employees
    either (1) did not take their antibiotics or (2) stopped taking their
    medicine prematurely on the basis of the Postal Service*s use of *trace*
    and *concentration* to characterize the extent of contamination in the
    facility.

    The complaint resulted in an OSHA investigation and the Postal Service*s
    subsequent release of test results from samples collected in November and
    December 2001. This included the actual laboratory record for the sample
    that identified about 3 million spores in a sample collected from one
    mailsorting machine on November 28, 2001. The Postal Service provided the
    quantified results to union representatives and to members of the
    facility*s

    Safety and Health Committee on September 4, 2002, along with a letter 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. S: 568, which permits CDC to withhold
    information that would interfere with ongoing law enforcement proceedings.

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

    describing the Postal Service*s reasons for not releasing the results
    earlier. Specifically, the Postal Service indicated that the results could
    not be validated because *the laboratory that produced the results was not
    hired by or working directly for the Postal Service.* As a result, the
    letter cautioned recipients not to use the information to interpret the
    risk to employees who had been working in the facility in December 2001.

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

    According to OSHA officials, OSHA typically sends a letter of significant
    findings when the employer has disclosed information requested by an
    employee or his or her designated representative while the complaint is

    still open* as the Postal Service did on September 4, 2002, prior to the
    end of OSHA*s investigation. Although OSHA did not believe that a citation
    was warranted, OSHA officials stated that they used a letter of
    significant findings to establish a basis for a future violation if the
    problem reoccurs.

    Dissatisfied with OSHA*s decision not to take regulatory action, on
    October 17, 2002, the union leader requested that OSHA*s Regional
    Administrator in Boston, Massachusetts, review the matter. The request was
    based, in part, on the fact that the Postal Service did not release the
    quantified results until September 4, 2002* more than 3 months after the
    union filed its complaint with OSHA and more than 7 months after the union
    had first requested all test results directly from the Postal Service. The
    request also cited conflicting information that had been received by

    OSHA about whether postal managers were still in possession of the
    December 2001 quantified results in June 2002, when OSHA initiated its
    investigation, and thus whether the Postal Service could have supplied the

    Page 28 GAO- 03- 316 U. S. Postal Service

    information to the union earlier. 43 In his request, the union leader
    argued that a regulatory citation was needed because, otherwise, there
    would be no incentive for the Postal Service to prevent a similar
    situation from reoccurring. OSHA*s Regional Administrator reviewed the
    matter and, by a

    letter dated November 26, 2002, affirmed OSHA*s prior decision not to
    issue a regulatory citation.

    We discussed OSHA*s findings with officials responsible for the
    inspection. They noted that OSHA was not involved at the facility until
    April 2002* well past the December 2001 period in question. Nevertheless,
    they cited the emergency situation that had existed at that time and
    indicated that, on the basis of their subsequent knowledge of the events
    that had transpired, they believed the Postal Service had taken
    *reasonable and prudent* actions to protect its employees throughout the
    period of the facility*s contamination. As a result, any hazard associated
    with the Postal Service*s nondisclosure of the quantitative test results
    had been eliminated

    in December 2001* about 6 months before OSHA*s investigation began. Also,
    the OSHA officials noted that because the Postal Service had subsequently
    released the requested data, in their view, it would not be appropriate to
    issue a regulatory citation.

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

    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 29 GAO- 03- 316 U. S. Postal Service

    source of the anthrax spores that involved several federal agencies. 44
    Nevertheless, she emphasized the need for better communication by the
    Postal Service and reaffirmed OSHA*s concern about the *failure of
    communication and openness* exhibited by the Postal Service in this case.

    Although OSHA and members of the investigative team in December 2001 were
    not critical of the Postal Service*s decision not to release the December
    2001 quantified results when they were first known, in hindsight and
    within the context of lessons learned, they said there was no reason why
    the results and any limitations associated with the results could not have
    been disclosed at that time. They explained that from their perspectives,
    full and timely disclosure of laboratory results is the best method for
    communicating test results. For example, the Chief Epidemiologist from the
    Connecticut Department of Public Health emphasized that it is important to
    *put the information out there frankly and then discuss it.* Similarly,
    CDC officials stated that the principle is to get all of the information
    out to employees regarding their health risks.

    Finally, although not a member of the investigative team, an OSHA official
    who was involved in the facility*s decontamination in April 2002 told us
    that he advised the Postal Service to provide employees with the *raw data
    sheets* of test results to avoid miscommunication, confusion, and concern

    about how the data may have been interpreted. Two recent guidelines
    developed by GSA and the National Response Team stress the importance of
    complete and timely information. The guidelines are intended to
    disseminate information learned from the response to anthrax contamination
    at postal and nonpostal facilities in the fall of 2001, including lessons
    relating to the communication of test results. GSA released its guidelines
    in July 2002. 45 The guidelines are written in the form of a policy
    advisory* not as regulations or explicit directives* and

    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.

    Lessons Learned at the Wallingford Facility Suggest the Need for More
    Complete and Timely Information to Workers

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

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

    The National Response Team developed the other guidelines, which are still
    in draft. The most recent version of the guidelines is dated September 30,
    2002, and is entitled Technical Assistance for Anthrax Response. 46
    Although not a member of the National Response Team, the Postal Service

    assisted in the development of the guidelines. The guidelines (1) suggest
    that more* rather than less* information should be disclosed and (2)
    provide a number of recommendations about communicating information during
    emergency situations. For example, the guidelines advise agencies to
    consider that *different audiences (e. g., employees, reporters, local
    politicians) may need different types of information* and to *anticipate
    what information people need and in what form.* Further, although the
    guidelines caution against passing on *everything you know,* it points out
    the consequences of not fully disclosing information. Specifically, the
    guidelines warn, *. . . do not withhold information . . . it is very
    likely that the withheld information will be found out, which will cripple
    your credibility. . . .* Finally, the guidelines advise agencies to *admit
    when you have made a mistake or do not know the information.*

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

    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 31 GAO- 03- 316 U. S. Postal Service

    explicitly address all of the communication issues that arose at the
    Wallingford facility. 47 None of these guidelines

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

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

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

    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 32 GAO- 03- 316 U. S. Postal Service

    accepted microbiological technique for determining the amount of bacteria
    in a given sample, including anthrax. The results show how many spores
    have replicated to form colonies, which can be seen by the naked

    eye. Thus, regardless of the sampling issues at Wallingford, none of the
    agencies involved provided any evidence indicating that the number of
    colony- forming units identified by the laboratory was incorrect.
    Accordingly, although the sampling issues may have hindered the
    interpretation of the test results, 49 according to these experts, the use
    of the term *concentration* to convey the finding of about 3 million
    spores in one sample may have been misleading because it did not
    adequately convey the health risk associated with the sample. According to
    the experts with whom we talked, providing information about the actual
    test results to workers would have given them better information for
    making

    informed medical decisions. In this case, according to the experts we
    consulted, an appropriate way to communicate the results to workers would
    have been to indicate that 2.9 million colony- forming units (from 0.55
    grams of dust) were found in a

    sample from one machine, along with appropriate limitations regarding the
    sampling procedures used. Although a precise interpretation of the health
    risks associated with the quantitative test results was problematic,
    providing the quantitative results would have given workers a framework
    for evaluating the information they were previously given regarding the
    8,000 to 10, 000 spores believed* at that time* to be needed to cause
    inhalation anthrax and would have provided some indication of the
    magnitude of the anthrax present in the facility. According to CDC,
    although the number of anthrax colonies can be counted, it is not possible
    to count the exact amount of anthrax in the environment because of
    uncertainties about how well a sample picks up anthrax. In other words,
    there could be more anthrax in the environment than can be picked up by a
    sample.

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

    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 33 GAO- 03- 316 U. S. Postal Service

    agencies should maintain, including the advice agencies receive from
    public health officials or others about the communication of test results
    to workers; or (3) discuss the actions that should be taken if test data
    are requested by an employee or a designated representative. As previously
    discussed, OSHA representatives were not involved in the December 2001
    discussions about what to communicate to workers. This deprived the Postal
    Service of the insights and suggestions that OSHA could have offered.
    Furthermore, although the Postal Service representatives cited

    uncertainty over what information could be released given the ongoing
    criminal investigation, the Postal Service did not consult with the FBI on
    this issue. According to FBI officials we interviewed in Connecticut, the
    test results were of no value to their investigation and, had they been
    consulted, they said that they would have allowed the results to be
    released.

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

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

    Page 34 GAO- 03- 316 U. S. Postal Service

    current regulatory agenda do not include any planned modifications to its
    requirements, including any changes to require the immediate and proactive
    disclosure of records related to an employee*s exposure to unforeseen
    hazards, such as anthrax, regardless of whether the records are requested
    by workers or their designated representatives. In retrospect, the Postal
    Service*s decision not to release the quantitative test results in
    December 2001 was understandable given (1) the

    circumstances that existed at that time, (2) the advice it received from
    public health officials, (3) an ongoing criminal investigation, and (4)
    uncertainties surrounding the validation of the sampling methods used and
    the meaning of the test results. However, the decision deprived facility
    employees of information that may have been useful in making informed
    decisions about whether to take or continue taking antibiotics and whether
    to continue working in the facility. Furthermore, in hindsight, it is
    clear that not fully disclosing quantified test results can affect an
    agency*s credibility and lead to worker distrust. It is also apparent now
    that not consulting relevant agencies* in this case, OSHA and the FBI*
    regarding its December 2001 decision about what to disclose to employees
    deprived the Postal Service of information that could have been useful in
    deciding what to communicate to its workers. Finally, the Postal Service*s
    failure to document the discussions that it had with other agency
    personnel on

    communication issues makes it difficult to resolve discrepancies in
    recollections that arose. As demonstrated at Wallingford, documentation of
    the advice and recommendations received from others, either at the time
    they are received or shortly thereafter for emergencies, could help
    resolve questions that may arise later about what was done and why.

    The agencies involved in the investigation and response to anthrax at
    Wallingford have learned a number of lessons from their experiences,
    including the need for more effective sampling methods and more explicit
    and consistent guidance concerning the communication of test results for
    hazardous substances, such as anthrax. However, the guidelines developed
    by the Postal Service, GSA, and the National Response Team are still too
    general to prevent problems like those that occurred at the

    Wallingford facility. Specifically, the current guidelines do not (1)
    require the prompt disclosure of all available test results, using
    specified terminology; (2) define how test results should be validated or
    the actions that should be taken when results cannot be validated; (3)
    specify which agencies should be involved in deciding what to communicate
    to workers and others; or (4) require documentation of the advice and
    recommendations from other organizations involved in deciding the
    Conclusions

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

    actions to be taken during a crisis. Moreover, since employees and their
    designated representatives may not know that test results are available or
    that they can be requested, it appears incumbent upon employers to, in
    emergency situations, immediately disclose test results without waiting
    for an employee or representative to request them. Because current OSHA
    regulations require the disclosure of test results only when an employee
    or representative requests them, such as occurred in the Wallingford case,

    organizations can still decide to withhold essential information. Lastly,
    agency officials dealing with an anthrax situation or similar emergency
    may not be aware of, or associate an employee*s request for test data
    with, OSHA*s regulations, which can result in penalties for noncompliance.

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

     require prompt communication of test results, including quantified
    results when available, to workers and others;  specify the terminology
    that should be used to communicate quantitative

    test results to employees and others (e. g., the number of colony- forming
    units per gram or square inch of material sampled) and any limitations
    associated with the test results;  define what is meant by the validation
    of test results and explain the steps

    that must be taken to validate sampling or testing methods that are
    undertaken by the agency itself or by another organization;  specify the
    actions that should be taken if test results cannot be validated,
    including a strategy for communicating unvalidated results;

     specify the agencies that should be involved in deciding what to
    communicate to workers and others, as appropriate;  require documentation
    of the basis for decisions made, including the (1)

    advice the organization receives from public health officials and others
    about the communication of health- related information to workers and
    others, as appropriate, and (2) specific content of what the organizations
    communicate to workers and others; and  reflect OSHA*s regulations for
    disclosing test results requested by workers

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

    Executive Action

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

    Health consider whether OSHA regulations should require* in emergency
    situations* full and immediate disclosure of test results to workers,
    regardless of whether the information is requested by an employee or his
    or her designated representative.

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

    EPA*s Assistant Administrator provided comments on March 21, 2003, in
    EPA*s capacity as the Chair for the National Response Team. According to
    the EPA Assistant Administrator, OSHA, GSA, HHS (specifically the National
    Institute of Occupational Safety and Health), and the Postal Service were
    consulted in preparing the response. EPA indicated that the members of the
    National Response Team believe that our draft report provided a balanced
    presentation of anthrax testing and communications with employees at the
    Wallingford postal facility. While stating that the National Response Team
    agrees with our references and recommendations regarding the content of
    its guidelines* Technical Assistance for Anthrax Response* EPA stated that
    the guidelines had been carefully written as a technical resource
    document, as opposed to a directive or guidance, and that knowledge on
    anthrax is evolving rapidly. Thus, EPA noted that each response situation
    is unique. As a result, EPA

    stated that the guidelines were intended to provide scientific background
    and viable options for responders to consider in addressing specific
    circumstances. Nevertheless, EPA indicated that *certain improvements*
    could be made to the guidelines that would be responsive to our
    recommendations. The letter did not specify the nature of the planned
    improvements. EPA also provided technical comments, which we included, as
    appropriate. EPA*s letter is reproduced in appendix III.

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

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

    and Our Evaluation

    Page 37 GAO- 03- 316 U. S. Postal Service

    that the Postal Service acted quickly and prudently to communicate
    pertinent information to its employees, the Postal Service acknowledged
    that there are always opportunities to improve communications regarding
    anthrax and other biohazards. In this regard, the Postal Service stated
    that it is committed to working with the National Response Team to revise
    the

    team*s technical assistance guidelines for anthrax and, when completed,
    that it planned to ensure that its guidelines are consistent with the
    team*s updated guidelines. The Postal Service also noted that it agreed
    with many of our specific recommendations. For example, the Postal Service
    agreed that test results, including quantified results, should be released
    to

    employees and others as quickly as possible. The Postal Service also
    agreed that any limitations associated with the results should be
    explained. Further, the Postal Service recognized the importance of
    developing and maintaining sufficient records concerning its communication
    of health- related information to employees and others. Finally, the
    Postal Service indicated that it is aware of its obligation to release
    testing information to employees and their unions, when requested to do
    so. The Postal Service*s letter, which is reproduced in appendix IV, did
    not comment on our other recommendations. The Postal Service also provided
    technical comments, which we included, as appropriate.

    The Postal Service*s commitment to work with the National Response Team in
    revising the team*s anthrax- related guidelines and, thereafter, to ensure
    that its guidelines are consistent with the revisions made to the

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

    that cannot be validated. On March 31, 2003, GSA*s Associate Administrator
    provided oral comments on our draft report. GSA said that it had consulted
    with the National Response Team and with key members of an Interagency
    Working Group that had participated in the development of GSA*s
    anthraxrelated guidelines. According to GSA, the other members of the
    working group had similar comments. Overall, GSA said that our draft
    report provided a balanced presentation of anthrax testing and
    communications

    Page 38 GAO- 03- 316 U. S. Postal Service

    with employees at the Wallingford facility and that it generally agrees
    with our references to, and recommendations regarding, its guidelines.
    Like the comments we received on behalf of the National Response Team, GSA

    also emphasized that its guidelines were written as a policy advisory and
    that they were not intended to prescribe specific actions that should be
    taken in every case. Instead, GSA indicated that its guidelines are
    intended to provide background information and viable options for managers
    who operate federal mail centers in the Washington, D. C., area. GSA also
    explained that its guidelines deal primarily with the actions that these
    managers should take to prepare for possible anthrax threats and to
    determine whether an anthrax threat is credible. Once a credible threat
    has been identified, responsibility for managing the situation passes from
    the manager of the mail center to law enforcement, public health, and
    other authorities. As a result, GSA emphasized that the guidelines
    developed by the National Response Team should be the primary source of
    advice for anyone managing a credible threat.

    GSA noted that it needs to consult with the entire Interagency Working
    Group before implementing specific changes to its guidelines. However, GSA
    informed us that it agreed with three of our recommendations and indicated
    that it would work with other members to revise its guidelines related to
    (1) the prompt disclosure of all test results, including any

    available quantified results; (2) the need for adequate documentation of
    the advice an agency receives from public health officials and others and
    its related communications with employees and others; and (3) OSHA*s
    regulations for disclosing test results requested by workers or their
    designated representatives.

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

    Page 39 GAO- 03- 316 U. S. Postal Service

    distinguish the different types of validation, GSA said that it would
    address our recommendations by adding a statement in its guidelines that
    recommends sharing all available test results; specifying the testing
    methods used; and explaining the limitations, if any, of the results and
    the testing methods.

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

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

    The President of the American Postal Worker*s Union commented on our draft
    report in a letter dated March 25, 2003. The union said that it agreed
    with our recommendations to better coordinate communication between

    federal agencies when events occur. However, the union said that our
    report did not adequately reflect the union*s perspective of the facts and
    that a number of our conclusions were not supported by the facts. We

    disagree. We believe that our conclusions are fully supported by the
    evidence presented in this report and that the report presents a fair,
    objective, and balanced depiction of the facts as best we could determine
    them. We also disagree that the report does not adequately reflect the
    union*s perspective. Our report clearly concludes that the Postal
    Service*s December 2001 decision not to disclose the quantitative results
    deprived workers of essential information for making informed decisions
    related to their health and safety. In addition, the report lays out a
    number of lessons

    that can be learned to avoid similar problems in the future. Furthermore,
    the report contains several recommendations for improving communication
    with postal and other workers in the future if another bioterrorist attack
    occurs. The union*s letter is reproduced in appendix V.

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

    The union disagreed with a number of our conclusions. First, the union
    disagreed that the Postal Service*s decision not to release the
    quantitative results to workers in December 2001 appeared consistent with
    its

    guidelines. The union reiterated the requirements in the Postal Service*s
    guidelines which, as discussed in this report, specify that confirmed test
    results must be validated before being sent to the Postal Service*s
    Command Center and, once the data are confirmed and validated, the
    guidelines state that the Manager of the Command Center is to release the
    data to, among other parties, affected postal managers and state health

    departments. Thus, in the union*s view, the test results are considered to
    be validated when they are reported by the Manager of the Command Center.
    However, this is not what happened in Wallingford. In the Wallingford
    case, the laboratory reported the quantitative results directly to the
    Connecticut Department of Public Health and CDC* not to the Postal
    Service*s Command Center* and the Chief Epidemiologist provided the test
    results directly to the Postal Service*s district office. Thus, the
    results were not reported by the Command Center as anticipated by the
    guidelines. According to the Postal Service, the December 2001
    quantitative results could not be validated, within the context of the
    Postal Service*s guidelines, because the party that collected the samples
    did not work for the Postal Service and the Postal Service could not
    ensure that the samples had been collected in accordance with procedures
    set forth in its guidelines. While we believe that the Postal Service*s
    decision not to release the quantitative test results in December 2001
    appears consistent with its guidelines on the basis of its interpretation
    of the validation requirement, we also believe that the use of the term
    *validation* in the context of anthrax testing can be problematic.
    Therefore, our report contains a recommendation to define what is meant by
    validation and explain the steps that must be taken to validate test
    results.

    Second, the union stated that, in its view, it is unacceptable to withhold
    exposure information under any circumstances. While we agree in principle,
    our conclusion that the Postal Service*s decision not to release the
    quantified test results in December 2001 was understandable is based on
    the particularly challenging and difficult circumstances that existed at
    that specific point in time. As discussed in this report, these
    circumstances

    included an ongoing investigation of the bioterrorist attack; the advice
    that the Postal Service received from public health officials;
    uncertainties surrounding the validation of the sampling methods used and
    the meaning of the test results. In addition, while the Postal Service*s
    existing guidelines do not address all of the conditions that existed at
    the Wallingford facility, the decision not to disclose the quantified
    results in December 2001 appears consistent with the existing guidelines.

    Page 41 GAO- 03- 316 U. S. Postal Service

    Furthermore, neither OSHA nor the members of the investigative team,
    including CDC, the Connecticut Department of Public Health, the FBI, and
    EPA, specifically faulted the Postal Service for not releasing the
    quantitative results at that time. Nevertheless, our report clearly states
    that, in hindsight, not disclosing test results can be problematic and
    that the decision not to disclose the December 2001 quantified results
    deprived workers of important information. Consequently, we are making
    several

    recommendations to improve future communication of test results, including
    the prompt disclosure of available qualitative and quantitative results,
    and any limitations associated with the sampling methods or test

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

    Finally, the union said that the report concluded that the Postal Service
    followed its guidelines *with one exception,* without explaining that the
    exception involved the sample containing about 3 million spores on one
    heavily contaminated mail- sorting machine. According to the union, this
    exception placed employees at considerable risk. As discussed in this

    report, we agree that the Postal Service*s decision not to release the
    quantitative results in December 2001 deprived the facility employees of
    information that may have been useful to them in making informed decisions
    about whether to take or continue taking antibiotics and whether to
    continue working in the facility. However, we disagree that we have not
    adequately explained the circumstances associated with this situation.
    Throughout the report we discuss the results in question as well as the
    fact that the quantitative test results were not communicated to workers.
    Furthermore, the report clearly discusses the actual finding of

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

    about *3 million spores,* the *concentration* of spores that was
    communicated to workers, as well as the fact that exposure to 3 million
    spores is far more than the amount considered necessary to contract the
    disease.

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

    While we agree that the prompt disclosure of qualitative test results is
    important, we continue to believe that available guidelines need to be
    revised to ensure that any quantitative test results are properly
    disclosed.

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

    regulations and, therefore, subject to penalties for noncompliance.

    Page 43 GAO- 03- 316 U. S. Postal Service

    OSHA and two HHS components* CDC and the Agency for Toxic Substances and
    Disease Registry* provided technical comments via Email, which we
    incorporated, as appropriate. OSHA did not comment on our recommendation
    that the Assistant Secretary for Occupational Safety and Health consider
    whether OSHA regulations should require* in

    emergency situations* full and immediate disclosure of test results to
    workers, regardless of whether the information is requested by an employee
    or his or her designated representative. We also received technical
    comments from the Chief Epidemiologist of the Connecticut Department of
    Public Health in which he stated that, overall, the report accurately
    portrays his role as well as the role of the Connecticut Department of
    Public Health as it relates to the situation at the Wallingford facility.
    He suggested a number of revisions to clarify this report, which we
    incorporated. In a March 31, 2003, letter, HHS*s Acting Principal Deputy
    Inspector General said that the department had no comments aside from the
    technical comments provided by two of its components. Finally, we
    requested comments from the Secretary of Homeland Security, but we did not
    receive any.

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

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

    Page 44 GAO- 03- 316 U. S. Postal Service

    Don Allison, Hazel Bailey, Bert Japikse, Latesha Love, Cady Summers, and
    Kathleen Turner. Jack Melling and Sushil K. Sharma provided technical
    expertise.

    Sincerely yours, Bernard L. Ungar Director, Physical Infrastructure Issues

    Appendix I: Objectives, Scope, and Methodology

    Page 45 GAO- 03- 316 U. S. Postal Service

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

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

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

    Methodology

    Appendix I: Objectives, Scope, and Methodology

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

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

    Appendix I: Objectives, Scope, and Methodology

    Page 47 GAO- 03- 316 U. S. Postal Service

    [This page is intentionally left blank]

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

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

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

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

    Page 49 GAO- 03- 316 U. S. Postal Service

    a A fourth machine was suspected of being positive for anthrax on December
    2 but was not confirmed to be positive until later. b Precisely when
    Postal Service headquarters and district managers first became aware of
    the

    quantified test results is unclear. According to CDC officials and the
    Chief Epidemiologist, they began discussing the quantitative results with
    investigative team members, which they believe included a district postal
    manager, on December 6, 2001. However, district postal managers said that
    they were not involved in discussions about the quantitative results until
    December 9. Absent documentation,

    we were unable to reconcile these views.

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

    Page 50 GAO- 03- 316 U. S. Postal Service

    c According to CDC, although the number of anthrax colonies can be
    counted, it is not possible to count the exact amount of anthrax in the
    environment because of uncertainties about how well a sample picks up
    anthrax. In other words, there could be more anthrax in the environment
    than can be picked up by a sample. d District postal managers confirmed
    that the Chief Epidemiologist faxed the quantitative results to the

    district office on December 9 (a Sunday), and that district managers
    received the fax on December 10. However, other documentation suggests
    that postal managers at headquarters may have received the documented
    results on or about December 8. Postal headquarters managers said that
    they do not recall precisely when they received the documented results,
    and absent definitive documentation, we were unable to determine when they
    first knew about the quantitative test results.

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

    Appendix III: Comments from the Environmental Protection Agency

    Appendix III: Comments from the Environmental Protection Agency Page 52
    GAO- 03- 316 U. S. Postal Service

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

    Page 53 GAO- 03- 316 U. S. Postal Service

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

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

    Page 54 GAO- 03- 316 U. S. Postal Service

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

    Appendix V: Comments from the American Postal Workers Union

    Appendix V: Comments from the American Postal Workers Union Page 56 GAO-
    03- 316 U. S. Postal Service (543037)

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