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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