U.S. Postal Service: Issues Associated with Anthrax Testing at	 
the Wallingford Facility (19-MAY-03, GAO-03-787T).		 
                                                                 
The anthrax attacks of 2001 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). But none of the workers at the Wallingford facility	 
contracted the disease from the anthrax contamination. As a	 
result, GAO was asked to examine the adequacy of methods used to 
determine whether the Wallingford facility and other postal	 
facilities were contaminated. In this testimony, GAO presents its
preliminary findings concerning the test results for the	 
Wallingford facility: (1) the collection of samples to detect	 
anthrax, (2) the meaning of the test results, and (3) the	 
communication of the test results to workers.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-787T					        
    ACCNO:   A06938						        
  TITLE:     U.S. Postal Service: Issues Associated with Anthrax      
Testing at the Wallingford Facility				 
     DATE:   05/19/2003 
  SUBJECT:   Building inspection				 
	     Facility management				 
	     Government information				 
	     National preparedness				 
	     Government information dissemination		 
	     Hazardous substances				 
	     Health hazards					 
	     Infectious diseases				 
	     Occupational safety				 
	     Postal service					 
	     Postal service employees				 
	     Safety regulation					 
	     Testing						 
	     Wallingford (CT)					 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-03-787T

U. S. POSTAL SERVICE Issues Associated with Anthrax Testing at the
Wallingford Facility

Statement of Keith Rhodes, Chief Technologist Center for Technology and
Engineering, Applied Research and Methods

Bernard Ungar, Director Physical Infrastructure Issues

United States General Accounting Office

GAO Testimony Before the Subcommittee on National

Security, Emerging Threats, and International Relations, Committee on
Government Reform For Release on Delivery

Expected at 1: 00 p. m., EDT Monday, May 19, 2003 GAO- 03- 787T

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. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

At the Wallingford facility, it took four attempts before anthrax
contamination was eventually identified. The first two attempts by U. S.
Postal Service contractors collected samples at various places in the
facility, using dry swabs, the least effective method for sample
collection. The Postal Service nationwide sampling plan required that
contractors use dry swabs to collect anthrax samples at more than 280
facilities, including Wallingford. But the Centers for Disease Control and
Prevention (CDC), in commenting on the plan, had recommended that the
Postal Service use other sampling methods. Nevertheless,

the Postal Service did not revise its sampling plan, and, with a few
exceptions, has not retested the other facilities that had negative test
results. In the third attempt, CDC and the Agency for Toxic Substance and
Disease Registry also found no contamination using wet swabs, but in the
fourth attempt------ us i ng wet wi pes a nd HEPA v acuums t o c ol l ect
t he s ampl es ------ t hey f ound contamination in

samples from mail- sorting machines. Anthrax test results, whether
qualitative (positive or negative) or quantitative, cannot be interpreted
as a health risk, based on current scientific knowledge. Positive test
results establish the presence of contamination, but only in the

samples collected. Quantitative test results, although more definitive,
only indicate the extent of contamination in the samples collected, not
the amount present in the whole facility. Negative results, as the initial
tests at the Wallingford facility demonstrated, do not necessarily mean
that a facility is free from contamination. As EPA recently reported,
knowledge of the ** lethal dose** (the number of spores required to kill
50 percent of people exposed to airborne anthrax) is necessary for a
credible health risk assessment. Although previous es t i mat es of a l et
hal dos e------ 8, 000 t o 1 0, 000 s por es ------ ar e bei ng r econs i
der ed, there is still no agreement on the lethal dose. However, some
experts now agree that only a few spores could be harmful to a susceptible
individual. As CDC also concluded, even with numbers of spores as high as
those found in one sample from one mail- sorting machine at
Wallingford------ about 3 million spores------ CDC did not know how to
extrapolate the quantitative test results to an individual*s

risk for inhalation anthrax. In an April 2003 report, GAO found that the
Postal Service*s communication of test results to workers at the
Wallingford facility generally appears consistent with its guidelines. But
the decision not to release the first positive quantitative test results,
after a worker*s union requested them, was not consistent with OSHA*s
requirement to disclose requested results. The Postal Service said it did
not release the December 2001 quantitative results because it could not
validate

them, as required by its guidelines, which, however, do not define
validation or use it appropriately. The Postal Service communicated the
results to workers as ** trace** and ** a concentration of spores**------
t er ms t hat di d not pr ovi de wor ker s with useful information needed
to make health- related decisions. It has agreed to revise the guidelines
as GAO recommended. Further communications appear warranted based on GAO*s
ongoing work. The anthrax attacks of 2001 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). But none of
the workers at the Wallingford facility contracted the disease from the

anthrax contamination. As a result, GAO was asked to examine the adequacy
of methods used to determine whether the Wallingford facility and other
postal facilities were contaminated. In this testimony, GAO presents its

preliminary findings concerning the test results for the Wallingford
facility: (1) the collection of samples to detect anthrax, (2) the meaning
of the test results, and (3) the communication of the test results to
workers.

In addition to its April 2003 recommendations, for those facilities that
were deemed to be free of anthrax spores based solely on a single negative
result, GAO recommends that the Postmaster General work with CDC, EPA,
OSHA, and other relevant agencies,

and union representatives to (1) reassess the risk level associated with
contamination, (2) reconsider the advisability of retesting, and (3)

communicate any relevant healthrelated information to postal workers and
the public.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 787T. To view the full product,
including the scope and methodology, click on the link above. For more
information, contact Keith Rhodes, 202- 512- 6412, rhodesk@ gao. gov.
Highlights of GAO- 03- 787T, a testimony before the Subcommittee on
National Security, Emerging Threats, and international Relations, House
Committee

on Government Reform May 19, 2003

U. S. POSTAL SERVICE

Issues Associated with Anthrax Testing at the Wallingford Facility

1

May 19, 2003 Mr. Chairman and Members of the Subcommittee: We are pleased
to be here today to present our findings on anthrax testing conducted by
the U. S. Postal Service (USPS) and the Centers for Disease Control and
Prevention (CDC) at the Southern Connecticut Processing and Distribution
Center in Wallingford, Connecticut (the Wallingford facility). As you
know, in September and October 2001, four letters containing anthrax
spores were mailed to news media personnel and congressional officials. As
a result, the letters contaminated numerous postal facilities and exposed
several postal workers to anthrax. 1 Some of the workers became sick, and
two died of inhalation anthrax. Three others also died from inhalation
anthrax, including an elderly woman in Connect i cut ------ a post al cust
omer . A f t er c ont ami nat i on was f ound i n t he Wallingford
facility, a union official raised concerns regarding how postal

managers communicated test results to workers. We have issued a report in
this regard. 2 Even though our analysis of the Wallingford incident is
only one part of our larger

study, it gives unique insight into the lessons that need to be learned
from the response of the federal government, state health departments, and
USPS to the anthrax attacks in the fall of 2001. All of these entities
served either as direct responders or as advisors, or both; and all were
creating or adapting guidelines as the crisis progressed. The situation
was further complicated by an ongoing

criminal investigation, coupled with a public health emergency. The
Wallingford facility was unique in that it did not directly handle the
anthrax letters. Rather, it was cross- contaminated by them, with the
largest number of

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

2

spores being found in a sample collected from a single machine. There was,
however, evidence that the spores had become airborne (re- aerosolized)
since small numbers of spores were found in elevated areas------ mor e t
han 20 f eet ------ above the previously contaminated machines. In
addition, while other facilities had workers and customers who suffered
from either cutaneous or inhalation anthrax, the death of a postal
customer served by the Wallingford facility underlines the insidious
nature of anthrax and the difficulty in determining a lethal dose, since
the elderly Connecticut woman died from anthrax when no evidence of
anthrax could be found in either her home or places she frequented. To
compound this, a single spore was found on a letter received by another
postal customer in the community, and yet no other illnesses or deaths
were reported. Further, the Wallingford facility was outside the
predictive analysis (a mapping of the facilities predicted most likely to
be contaminated) that USPS performed to determine the

impact of the contaminated letters processed through facilities in
Washington, D. C., and Trenton, New Jersey, on the rest of the postal
distribution network. The unpredictability of both the lethality of
anthrax and the route that contaminated mail might take, makes it
extremely difficult to establish the health risks associated with a
release of a biological agent inside a facility, such as anthrax, that
serves the public. This difficulty underscores the need for a standardized
and aggressive response, as well as forward planning, to protect facility
workers and the public should an anthrax attack occur again.

As you know, determining whether or not a facility is contaminated with
anthrax is critical. This is dependent upon the effectiveness of the
methods used to detect anthrax. As a result, at your request, we are
conducting a study to examine the

adequacy of the methods used by involved contractors and federal agencies
in determining whether postal facilities were contaminated. We will report
the final results of this study at a later date.

2 U. S. General Accounting Office, U. S. Postal Service: Better Guidance
Is Needed to Improve Communication Should Anthrax Contamination Occur in
the Future, GAO- 03- 316 (Washington, D. C.: April 7, 2003).

3

In our testimony today, at your request, our remarks will focus on our
preliminary findings regarding the test results for the Wallingford
facility. Specifically, we will address the issues that arose concerning
the following three areas: (1) the collection of environmental samples to
detect anthrax contamination, (2) the meaning of the test 3 results from
the samples (both qualitative and quantitative) with respect to the health
risk of the workers, and (3) the communication of the test results. Our
work thus far has involved interviews with officials from USPS, CDC, and
experts in this area, reviews of relevant documents and literature, and
review of the documents we were provided by USPS and CDC associated with
the sampling done at the Wallingford facility during November 2001 through
April 2002. We did not independently assess or verify any of the
laboratory test results, sampling plans, or sampling methods to determine
their adequacy or accuracy. Our work has been performed in accordance with
generally accepted government auditing standards. SUMMARY Three issues
emerged with regard to the collection of environmental samples at

the Wallingford facility: (1) the methods used for sampling 4 , (2) the
locations from which samples were collected, and (3) how many samples were
collected. USPS, in response to the anthrax attack of 2001, developed a
plan to test over 280 facilities nationwide, including the Wallingford
facility. This plan was precautionary and assumed that those facilities
were probably not contaminated

with anthrax. Further, this plan specified what sample collection methods
to use, where to sample, and the number of samples to be collected, among
other things. At the Wallingford facility, however, it took four attempts
before contamination was eventually identified. USPS used its own
contractors to collect a limited

3 The terms *test* or *testing* refer to the laboratory analysis of the
samples collected. 4 Technically, the term *sampling* refers to a strategy
to extract organisms that might be present in the environment. In this
testimony, however, sampling refers to the number of samples collected, as
well as other associated events, on a given day.

4

number of samples at various places in the facility. 5 In addition, USPS
collected the samples using the dry swab method, which is the least
effective method for collection of samples from surfaces. On November 9,
CDC officials recommended that USPS use moistened swabs; however, USPS did
not incorporate this recommendation into its sampling plan. 6 According to
USPS officials, in the beginning, they mirrored the methods used by CDC in
other postal facilities. USPS did not find contamination. However, after
the death of the elderly

Connecticut woman on November 21, 2001, CDC and the Agency for Toxic
Substance and Disease Registry (ATSDR) eventually used targeted sampling,
f ocusi ng o n t he mai l - sor t i ng machi nes, a nd di f f er ent s
ampl i ng met hods------ wet wipes and high efficiency particulate air
(HEPA) vacuum. CDC and ATSDR, using

a CDC- contracted laboratory, collected more than three times the number
of samples previously collected by USPS and found contamination in some of
the samples. Experts we consulted at the U. S. Army Medical Research
Institute for Infectious Disease told us that before October 2001, they
had found that dry swabs were ineffective at collecting spores and that
spores could not be recovered efficiently from dry swabs. Finally, even
though the contamination found at the Wallingford facility was unexpected,
according to a USPS official, the nationwide plan was not revised because
it was 60- days removed from the event, well past the perceived incubation
period as far as health risk was concerned. This approach did not take
into account the possibility that if spores are present in a facility, re-
aerosolization can occur at any time if the site of contamination is
disturbed. The USPS official also said that, with a few exceptions, he
believed, of

those facilities that had tested negative during the nationwide sampling,
none had been retested. Thus, the negative findings from the first three
sampling attempts at the Wallingford facility raise questions about the
reliability of a single negative sampling result, especially one based
upon the use of a method considered the least effective, as was the case
in Wallingford. 5 CDC officials told us that the number of samples
collected on a given day was, in part, governed by the capacity of the
state laboratories to process the samples.

5

Neither qualitative (positive or negative) nor quantitative test results
from a qualified laboratory can be used to establish a health risk.
Concerning qualitative results, positive results only show whether
contamination is present in the samples collected. However, negative
results do not necessarily mean that a facility is free from
contamination. Quantitative test results only show the extent of
contamination in the specific samples found to be positive------ not how
much anthrax is present in the facility. For example, in the Wallingford
facility, the level

of contamination found in a dust sample collected from a mail- sorting
machine was about 3- million spores (5.5 million per gram of dust).
However, with regard to the health risk to an individual, although this
number was significantly higher t han what was c onsi der ed h i st or i
cal l y t o b e a l et hal d ose f or a n i ndi vi dual ------ 8,000 to
10,000 spores------ CDC d i d not k now how t o ext r apol at e t he a
mount i n a s ampl e to a person*s risk for inhalation anthrax. 7 EPA
recently reported that in order to

perform credible risk assessments, it is essential to identify the minimum
number of spores needed to cause inhalation and cutaneous anthrax.
Nevertheless, there is now a consensus among the experts that a few spores
could be harmful to a susceptible individual, as may have been the case in
the death of the Connecticut woman.

Three major communication issues arose at the Wallingford facility: (1)
the timing of the release of the quantitative results; (2) reasons for
USPS withholding the quantitative results from the workers, such as a lack
of confirmation and validation of the test results; and (3) the
terminology used to describe the extent of contamination to the workers.
First, USPS did not communicate to the workers the quantitative test
results of the November 28, 2001, test until 9 months after it received
them, and it did not comply with the Occupational Safety and Health
Administration (OSHA) regulations, which require the release of test
results to workers after they are requested. But USPS generally
communicated to

6 USPS Draft Standard Sampling Plan dated November 9, 2001. USPS*s Draft
Interim Guidelines replaced this plan in late November 2001. 7 It is
important to note that the range of spores (8,000 to 10,000) for the human
lethal dose was extrapolated from animal studies. This range of spores
refers to a dose that will kill 50 percent of

6

the workers the qualitative test results (positive and negative) soon
after they became available. Second, USPS officials told us that USPS did
not release the quantitative test results because it could not validate
the confirmed results, as required by its draft guidelines. However, these
guidelines did not define either confirmation or validation. The use of
the terms ** confirmation** and ** validation** in this context has caused
confusion both about (1) the status of the

methodologies used to detect anthrax and (2) the communication of test
results to workers. The experts we consulted told us that, in their view,
the terms confirmation and validation were not used appropriately in USPS
guidelines, and CDC concurs with this view. The guidelines do not specify
the process and methods for confirming test results. Validation is not
done after a test or a procedure has already been performed, as would have
been the case with the quantitative test result. Thus, according to the
experts we consulted, validation, when used in this sense, should not have
prevented USPS from communicating the quantitative test results. According
to USPS officials, the term validation, as used in USPS guidance, was
intended to be used more for quality assurance purposes. Finally, the
terminology used by USPS after discussion with the chief epidemiologist of
the Connecticut Health Department was not helpful to workers

in assessing their risk. USPS communicated the quantitative results to
workers as

** trace** amounts and ** a concentration of spores. ** These terms did
not provide workers with useful information, when it was needed most,
which was when they were making decisions regarding their health risk.
Further, the lack of communication of the test results may have
contributed to workers* inability to make informed decisions, such as
whether to continue taking their medication or work at another facility.
As OSHA noted, ** Failure to effectively communicate issues, which can
have an effect on a worker*s health and safety, can lead to fear and
mistrust. ** Finally, USPS and the other federal agencies involved in the
communication

issues we raised responded positively to the recommendations we made in
our individuals exposed to airborne anthrax. However, the lethal dose for
a person could be a few spores, as

7

April 2003 report aimed at enhancing communication of test results.
However, our preliminary work on testing approaches revealed three other
issues that we believe need to be addressed. These are, for those
facilities that were deemed to be free of anthrax spores based solely on a
single negative sampling result, (1) the risk level for postal workers at
those facilities and the general public served by those facilities, (2)
the advisability of retesting those facilities------ empl oyi ng t he most
effective sampling methods and procedures, and (3) communication to postal
workers and the general public of relevant information that may be helpful

regarding their health. We are making recommendations to USPS to address
these issues.

BACKGROUND On or about October 9, 2001, at least two letters containing
anthrax spores ent er ed t he U. S. mai l ------ one was a ddr essed t o S
enat or Thomas Daschl e, t he o t her to Senator Patrick Leahy. Before
being sent to the Brentwood facility in Washi ngt on, D. C. ------ t he f
acility that processed mail to the two senators------ t he letters were
processed on high- speed mail- sorting machines at a postal facility in
Hamilton, New Jersey. The Hamilton facility------ al so known a s t he Tr
ent on post al facility------ pr ocessed mai l t hat was t o b e t r
anspor t ed t o t he Wal l i ngf or d f acility for further processing. 8
A study conducted in Canada in 2001 has shown that a contaminated
envelope, when opened, may cause a substantial primary aerosol event, that
is, particles become airborne. Also envelopes with the open corners not
specifically sealed could also pose a threat to individuals in the mail
handling system. 9 The letters to the senators contaminated the Brentwood
and Hamilton postal

facilities and, according to USPS, resulted in the cross- contamination of
some

may have been the case with the Connecticut woman. 8 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 these letters contaminated the
Wallingford facility.

8

mail as it moved between these and other facilities in the postal system.
10 Crosscontaminated mail is believed to have been processed through the
Wallingford facility on or around October 11, 2001. The possibility of
cross- contamination and associated potential exposure to anthrax spores,
contained in cross- contaminated mail that was processed at the
Wallingford facility, went unrecognized until after the death of the
Connecticut woman from inhalation anthrax on November 21, 2001. Airborne
transmission of anthrax spores at the Wallingford facility and other
facilities is believed to have been facilitated by the use of high- speed
sorters, as well as compressed air, for routine cleaning of the mail-
sorting machines. 11 As a result, USPS terminated the use of compressed
air at all postal facilities on October 23, 2001.

Environmental testing and remediation for anthrax contamination in a
facility consists of several steps: sample collection, laboratory
identification, decontamination, and retesting. To collect samples, a
sampling plan should be

developed, which specifies, among other things, number of samples,
specific methods to collect the samples, areas in which to sample, and
instructions for submitting the samples to a qualified laboratory for
analysis. A variety of sample collection methods were used in the
Wallingford facility, including dry swabs, wet wi pes, a nd HEPA v acuums.
S wabs------ ei t her wet o r d r y------ have small surface areas
(similar to Q- tips (R) ). They are typically used to sample small,
nonporous surface areas (less than 100 sq. cm) that do not have a large
accumulation of dust. Wet wipes-- sterile gauze pads, approximately 3
inches square-- are typically used for sampling larger (more than 100 sq.
cm), nonporous surface areas. HEPA vacuum i s a s uct i on d evi ce wi t h
a n ozzl e------ i ncl udi ng a cone- shaped f i l t er i ng t r ap o r s
ock at t ached------ t o c ol l ect dust s ampl es f r om a s ur f ace or
the air. After samples have

been collected, they are to be transported to a qualified laboratory for
analyses.

9 B. Kournikakis, and others, Risk Assessment of Anthrax Threat Letters.
Suffield: DRES Technical Report TR 2001- 048, September 2001. 10 USPS
officials suspect that the source of the contamination that caused the
elderly woman to contract

anthrax was the October 9th set of letters processed at the Hamilton
facility in New Jersey. 11 Centers for Disease Control and Prevention,
*Evaluation of Bacillus anthracis Contamination Inside the Brentwood Mail
Processing and Distribution Center* District of Columbia; Mortality and
Morbidity Weekly Report (2001), vol. 50, pp. 1129- 1133.

9

A range of laboratory tests exists for detecting anthrax in a person*s
body and in the environment. However, analysis by the culture method is
considered to be the gold standard for identifying anthrax. Qualified
laboratories report anthrax test results either qualitatively (for
example, as ** positive** or ** negative** ) or quantitatively (for
example, as a specific number of colony- forming units (CFU)), 12 that is,
living cells per gram or square inch of material sampled or in milligrams
per micro liter. USPS* SAMPLING APPROACH DID NOT IDENTIFY ANTHRAX AT THE
WALLINGFORD FACILITY USPS*s initial sampling approach at the Wallingford
facility was ineffective in that

it did not detect contamination at the Wallingford facility as soon as was
practically possible. If additional testing had not been done to determine
the source of contamination for the death of the Connecticut woman from
inhalation anthrax, it is possible that the contamination would have gone
undetected. USPS guidelines specified the least effective method for
sample collection. Assuming that there was probably no anthrax
contamination, USPS, as part of its nationwide testing of over 280
facilities, initially used a precautionary approach to determine whether
those facilities, including the Wallingford facility, were contaminated.
13 Thi s a ppr oach i ncl uded a met hod------ dr y s wabs- - consi der ed
t o b e t he l east e f f ect i ve for sample collection, based on
comparative studies and the opinions of experts

we consulted. This approach did not find contamination (negative results)
in the Wallingford facility. On the other hand, CDC used an approach at
the Wallingford facility that included a combination of more effective
methods------ wet wi pes a nd HEPA v acuum------ with which contamination
was found. Further, USPS officials told us that based on their mail-
tracking system, they identified some postal

12 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
HEPA vacuum samples and per square inch for samples collected using wipes.
13 Facilities in Florida, New Jersey, New York, and Washington, D. C., had
already been tested and found contaminated.

10

facilities that they considered likely to have been contaminated by
anthrax letters processed through those facilities. 14 However,
Wallingford was not one of these. The negative test results for the
sampling at the Wallingford facility must, therefore, cast doubt about the
true extent of contamination in other facilities that tested ** negative.
** As part of its approach, USPS used its draft Standard Sampling Plan,
which

specified a minimum number of samples to be collected from various areas,
using the dry swab method. 15 USPS used four contractors to sample the
Wallingford facility. These contractors were previously contracted to
conduct routine environmental sampling for such substances as air and
water, rather than dealing with unusual and dangerous bacteria such as
anthrax. Before the Wallingford facility was tested, USPS and CDC had
learned that some of the mail- sorting machines in the facilities that
processed the letters containing the anthrax powder ------ f or exampl e,
t he Br ent wood a nd Tr ent on f acilities------ wer e f ound t o b e
heavily contaminated. This suggests that mail- sorting machines would be a
likely

starting point for sample collection. On November 11, 2001, using a
contractor, USPS collected 53 samples from various sites throughout the
facility using dry swabs. The test results were negative. Although USPS,
as part of its nationwide sampling, had only intended to test the facility
once, it retested the facility on November 21, the day that the

elderly Connecticut woman died, to determine the possible source of
contamination. On November 21, USPS attempted to identify the path the
contaminated letter would have taken. USPS collected 64 samples from
surfaces where mail was processed and from air- circulating units, using
dry swabs. Again the test results were negative. The November 25, 2001,
testing by CDC and the

14 According to USPS, to determine the condition of sites of possible
contamination and to evaluate specific downstream sites throughout the
country, USPS obtained test equipment, systems, and contract services.
When testing was completed in late November 2001, 284 facilities were
tested, with 23 positive and 261 negative results. 15 USPS contractors
used the USPS Draft Standard Sampling Plan, dated November 2 and 9, 2001.
The

draft USPS interim guidelines, dated November 16, 2001, replaced this
plan, and a subsequent version of the guidelines was issued December 4,
2001.

11

ATSDR, while using a di fferent method------ wet swab------ also collected
60 samples, of which 8 were from mail- sorting machines. Again, the
results were negative. Of the 177 samples collected during the November
11, 21, and 25 samplings, 15 samples were collected from the facility*s 13
mail- sorting machines. The Connecticut Public Health Laboratory analyzed
all of these samples. In addition, according to CDC officials, the numbers
of samples collected on the above dates were, in part,

influenced by the capacity of the Connecticut Public Health Laboratory.
(See table 1 for sampling details.)

Table 1: Summary of Sampling for Anthrax Contamination between November
2001 and April 2002 and the Associated Test Results for the Wallingford
Facility Test results Sampling date Method

used No. of samples

(Samples collected from mail- sorting machines)

Qualitative (No. positive) Quantitative Agency

collecting samples a Five tests performed during initial period of
contamination

11/ 11/ 01 Dry swabs 53 (1) Negative N/ A USPS 11/ 21/ 01 Dry swabs 64 (6)
Negative N/ A USPS 11/ 25/ 01 Wet swabs 60 (8) Negative N/ A CDC 11/ 28/
91 Wet wipes

and HEPA vacuums

212 (130) Positive (6) 3 million CFU/ 0. 55 gram b 370 CFU/ gram CDC 12/
2/ 01 Wet wipes 200 (200) Positive (35) N/ A CDC

Test (precautionary) performed in high- bay areas c 4/ 21/ 02 HEPA vacuums

101 (N/ A) Positive (3) 1 colony from 7.50 gram sample material 10/ 11
colonies from 7.69 gram sample material 13/ 18 colonies from 5.67 gm
sample material USPS Source: GAO (summary), USPS, and CDC (data). a The
USPS used a contractor; CDC was assisted by the Agency for Toxic
Substances and Disease

Registry. b The sample collected contained 0.55 gram of material (dust)
from the heavily contaminated machine. The laboratory adjusted its
analyses to reflect a full gram of sample material and reported the
presence of 5.5 million CFUs per gram, which the chief epidemiologist
subsequently determined, through extrapolation, to be 2.9 million CFUs* or
about 3 million spores* in the sample. In this testimony, we refer to the
2.9 CFU for

the 0.55 grams of sample material actually collected. c * High- bay* areas
refer to elevated areas in the facility such as pipes, ducts, joists,
beams, and overhead conveyors. Precautionary testing was performed to
ensure no anthrax was present during annual cleaning. Note: N/ A =
Quantitative data either not applicable (no anthrax present) or not
provided.

12

On November 28, CDC and ATSDR performed what they termed ** targeted**
testing, based upon new information concerning which mail- sorting
machines were likely to have processed the woman*s mail. CDC and ATSDR
collected 212 samples using a combination of methods: wet wipes and HEPA
vacuums, rather than the wet swabs CDC had previously used. This time, CDC
and ATSDR collected 130 samples from the mail- sorting machines as opposed
to the 15 samples collected during the three prior sampling efforts. A
CDC- contracted laboratory analyzed the samples and found 6 that were
positive for anthrax, 2 of which had been collected by HEPA vacuum and
four by wet wipes. For the November 28 samples, the laboratory also
provided two quantitative results, one of which, according to the
Connecticut chief epidemiologist, was about 3 million CFUs of anthrax
(that is, 5.5 million CFUs per gram of dust) in a sample collected

from a heavily contaminated mail- sorting machine. Finally, on December 2,
while the contaminated machines were isolated and the process of
decontamination was beginning, CDC and ATSDR used wet wipes alone to
collect 200 follow- up samples from the machines to determine the extent
of contamination on the machines and found 35 additional positive samples.
On April 21, 2002, a USPS contractor, in consultation with CDC, OSHA, EPA,
and the

Connect i cut Depar t ment o f Publ i c Heal t h------ usi ng HEPA
vacuums------ t est ed elevated, or high bay, areas above the previously
contaminated machines. The sampling was performed because of a USPS
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 USPS*s

prior use of compressed air to clean its facilities. The results revealed
from 1 to 18 CFUs in 3 of 101 samples collected from the elevated areas.
16 This finding indicates that spores had been airborne at some period in
the facility.

16 Specifically, the test results indicated (1) 1 CFU from 7.50 grams of
material sampled, (2) 10 CFU and 11 CFU from 7.69 grams of material
sampled, and (3) 13 CFU and 18 CFU from 5.67 grams of material sampled.

13

Based on the testing done at the Wallingford facility by USPS and by CDC
and ATSDR, neither dry nor wet swabs alone identified anthrax
contamination in the samples collected. Wet wipes and HEPA vacuums did
identify anthrax in some samples. Experts we consulted at the U. S. Army
Medical Research Institute for Infectious Disease told us that before
October 2001, they had found that dry swabs were ineffective at collecting
spores. CDC, on November 9, 2001, in commenting on USPS draft guidelines,
recommended that USPS use sterile swab samples for environmental sampling
and that these swabs be moistened with sterile water. In addition, CDC
informed USPS that CDC*s own draft procedures, that is, ** Procedures for
Collecting Environmental Sampling for Culturing Bacillus anthracis, **
continued to address bulk and vacuum samples. CDC draft guidelines did
not, however, address the use of wet wipes. CDC also stated that, ** some
of the

state labs may be less familiar with the methods needed to perform
analyses for vacuum and bulk samples. ** Finally, CDC stated that it
understood that USPS* sole use of the swab method was related to an
accommodation reached with the

Association of Public Health Laboratories to more effectively use state
health department laboratories to assist with sample analysis. USPS also
acknowledged in a subsequent draft of its guidelines that, ** the
Association of Public Health Laboratories does not recognize air, bulk, or
HEPA vacuum for purposes for Bacillus anthracis identification. ** USPS
officials we interviewed said that in the beginning, USPS mirrored the

methods used by CDC in the Brentwood and Trenton facilities. The officials
noted that, at one point, ** one method was recommended, and later,
another method was recommended. ** USPS officials also told us that in the
absence of any other

guidance, they were attempting to use pre- existing guidance and
extrapolate it to a bio- terrorist attack. In December 2001, a study
carried out by CDC, ATSDR, and USPS clearly showed that sampling methods
differed significantly in their ability

14

to detect spores, even in a heavily contaminated facility. 17 According to
the study, dry swabs failed to detect spores more than 86 percent of the
time, wet swabs more than 46 percent, HEPA more than 20 percent, and wipes
more than 13 percent. Based on the study, CDC concluded that dry swabs
should not be used to sample for anthrax. Finally, a report by the EPA,
dated February 2003, on environmental sampling for anthrax spores at USPS
Morgan Postal and Processing facility stated that wipe samples should be
used for sampling large surface areas, and wet techniques are more
effective than dry techniques. The report stated that epidemiological
approaches for different scenarios of environmental sampling should be
developed. 18 These issues raise questions about the reliability of a
single ** negative** sampling result, especially based on the least

ef f ect i ve met hod------ dr y swabs------ as was t he c ase i ni t i al
l y i n Wal l i ngf or d. 19 TEST RESULTS CANNOT BE USED TO DETERMINE
HEALTH RISK FOR WORKERS Neither qualitative (negative or positive) nor
quantitative tests results can be used to definitively establish the risk
to an individual*s health. Interpreting positive test results from a
sample as a health risk would require a real understanding of the physical
behavior of airborne anthrax spores as well as factors that may influence
their behavior. Thus, while both qualitative and quantitative test results
from a qualified laboratory can show that a facility is contaminated, they
do not show the actual extent of contamination in the facility or the
health risk for workers. In particular, qualitative test results show if a
facility is contaminated or not. Further, while quantitative test results
show the number of CFUs in a sample, such results can be difficult to
interpret and, possibly misleading, depending upon the relative
distribution of surface dust versus spores and the effectiveness of the

17 See CDC, *Surface Sampling Methods for Bacillus anthracis Spore
Contamination,* Emerging Infectious Diseases Journal, Vol. 8, No. 10
(October 2002). 18 U. S. Environmental Protection Agency: Summary Report:
Peer Review Workshop on Environmental Sampling for Anthrax Spores at
Morgan Postal Processing and Distribution Center, May 30, 2002, New York
City, New York. (EPA 500- R- 03- 001, Washington, D. C., February 2003).
19 USPS officials told us that they are in the process of revising their
interim guidelines, however, we have not yet reviewed these revised
guidelines.

15

sampling methods. Nevertheless, because of factors affecting how well a
sample method picks up anthrax and limitations affecting the amount of
anthrax that can be extracted from that sample, experts agree that there
would be more anthrax in the facility than can be picked up by a sample.
However, according to officials

from the U. S. Army Medical Research Institute for Infectious Disease,
what is most important is not the number of spores in a sample but whether
or not any spores exist. On the other hand, EPA recently reported that in
order to perform credible risk assessments, it is essential to identify
the minimum number of

spores needed to cause inhalation and cutaneous anthrax. Negative test
results, as shown at the Wallingford facility, do not necessarily mean
that a facility is free from contamination. Test results at a contaminated
facility could be negative if (1) the sampling method used was not
sufficiently effective; (2) samples were not collected from places where
contamination was actually present; and (3) an insufficient number of
samples were collected. Concerning the sampling methods used in the
Wallingford facility, for example, the samplings conducted on 3 different
days, which involved collecting a limited number of

samples from various places in the facility, using either dry or wet
swabs, came out negative, while a subsequent sampling------ whi ch used (
1) a c ombi nat i on o f sampling methods, (2) a different sampling
approach, and (3) an increased

number o f s ampl es------ came o ut p osi t i ve. It is, therefore,
essential to have a sound sampling plan that includes effective methods
and do repeat testing if it is considered necessary.

Once contamination is confirmed, actions must be taken to protect the
workers and decontaminate the facility. Interpretation of the positive
test results requires a real understanding of the physical processes
involved in generating airborne particles, such as anthrax; the behavior
of such particles; and the factors that influence their behavior.
Evaluation of the health risks involves the assessment of components that
govern the particle- size profile, stability, and biological impact. The
greatest risk to a worker*s health in the Wallingford facility appears to
have

16

come from the particles that became airborne as mail that had been
crosscontaminated passed through the sorting machines. In the case of the
Wallingford facility, postal officials suspect that contamination of the
facility may have occurred a few days after October 9, when the second set
of letters, those addressed to the two senators, passed through the
Trenton facility. It is likely that this high- risk period would have been
no more than a few hours, while spores were still airborne. Nevertheless,
once spores have settled, a risk can arise if spores again become
airborne, thus making it possible for workers to inhale them.

Investigations of anthrax contamination in the U. S. Senate Office
building found that simulated day- to- day office activities (that is,
paper handling, foot traffic, mail sorting, trash container movement,
patting chairs) resulted in spores again becoming airborne. Eighty percent
of these airborne particles were in the size range 0.9 to 3.5 microns and,
thus, would be capable of causing inhalation anthrax. 20 It was noted that
even minimal movement caused viable spores to become airborne. It is
therefore very likely that compressed air, used for machine cleaning,
could provide sufficient energy to cause particles to become airborne,
particularly from areas where there are high local concentrations of
spores, as was the case in Wallingford. Similarly, the processing of a
cross- contaminated letter through a sorting machine may also provide
sufficient energy to cause spores to again become airborne. Based on these
findings, it is important to recognize that in a mail- processing facility
that has tested positive for anthrax, there is a risk to the health of
workers because spores may become airborne again after the primary
event------ t he p assage of the contaminated letters------ has o ccur r
ed. In addition, these spores could then create a risk of cross-
contamination of mail.

USPS asked CDC whether it should conduct additional testing of postal
facilities to assure workers safety. On February 25, 2002, in its
response, CDC stated that additional testing was not warranted at that
time. CDC noted several reasons for not retesting those facilities
including, (1) qualitative or quantitative testing for

17

anthrax does not accurately correlate with exposure threshold or
predictors of disease at these work sites; (2) since the initial
contamination, there has been no report indicating increased risk for
disease among the workers at these sites; and

(3) there is a good reason to believe that the risk for workers has
decreased since the initial attack as a result of USPS*s newly adopted
prevention and control measures, such as repetitive machine
decontamination, medical monitoring, and revised operating and maintenance
procedures.

According to the experts, the level of contamination found at the
Wallingford facility was significantly higher than the level------ 8,000
to 10,000 spores----- historically considered likely to cause disease in
the individual when inhaled in a fine powder form. However, there is now a
consensus among the experts that even a few spores could be harmful to a
susceptible individual, as may have been the case in the death of the
Connecticut woman. According to officials from the U. S. Army Medical
Research Institute of Infectious Disease, what is most important is not
the number of spores in a facility but whether or not any spores are
found.

In an attempt to lessen the risk that spores might become airborne, USPS
stopped the use of compressed air for cleaning mail- sorting machines and
also revised its cleaning methods to include those less likely to cause
spores to be blown about the facility, for example, wet mopping instead of
dry brushing.

USPS*S FAILURE TO RELEASE QUANTITATIVE RESULTS CAUSED COMMUNICATION
PROBLEMS AT THE WALLINGFORD FACILITY USPS generally provided the
Wallingford facility*s test results to workers at the facility within 1
day of receiving the results, consistent with USPS guidelines requiring
that workers be notified ** as soon as possible. ** However, USPS did not
inform the workers as promptly after contamination was identified in the
facility

20 C. P. Weiss and others, *Secondary Aerosolization of Viable Bacillus
anthracis Spores in a Contaminated

18

in December 2001, and it also did not promptly provide information to
workers on the quantitative test results after a union official requested
them. On December 2, 2001------ when a nt hr ax c ont ami nat i on was f i
r st i dent i f i ed i n t he facility------ USPS met wi t h wor ker s t o
i nf or m t hem t hat ** trace** amounts of anthrax had been found in
samples collected on November 28. Knowing that the laboratory initially
identified a small number (one or two CFUs) of anthrax spor es, t he c hi
ef e pi demi ol ogi st f or Connect i cut ------ who h el ped l ead t he i
nvest i gat i on------ t ol d di st r i ct p ost al managers that it would
be accurate to use the

term ** trace** to describe the extent of contamination. On December 12,
2001------ 2 days after district postal managers said they received
written confirmation of the presence of about 3 million spores in one of
the samples collected on November 28 and, possibly, 4 days after
headquarters postal managers received the results----- district postal
managers told us that they informed workers of the following: 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. But it was not until 9 months after USPS had
received the quantitative results of the November 28, 2001, testing that
it provided the information to the workers.

According to USPS, it did not release the quantitative test results to
workers because it could not validate the confirmed results, as required
by its guidelines, which state that results cannot be released until
confirmed data are received from CDC or a state public health laboratory.
However, the guidelines do not define

the meaning of either ** confirmation** or ** validation, ** nor do they
specify the steps that must be taken to validate test results. According
to USPS managers, USPS could not ensure that the sampling had been done in
accordance with procedures specified in the guidelines and, thus, could
not validate the results, as required by

the guidelines. 21 A USPS headquarters* manager told us that the term
validation U. S. Senate Office,* Journal of American Medical Association,
vol. 288 (2002), pp. 2853- 2858. 21 U. S. Postal Service, Interim
Guidelines for Sampling, Analysis, Decontamination, and Disposal of
Anthrax for U. S. Postal Service Facilities (Dec. 4, 2001). These
guidelines were developed as the anthrax

19

was intended to describe a method for ensuring that work had been done in
accordance with USPS* sampling and testing procedures and for coordinating
the release of validated results. A USPS official also told us that the
term validation, as used in USPS guidance, was intended to be used more
for quality assurance purposes. 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 USPS. Thus, the use of the terms confirmation and
validation in the context of USPS guidelines has caused confusion about
(1) the status of the methods used to detect anthrax (e. g., were the
methods appropriately used) and (2) whether and when test results were to
be communicated to workers.

The experts we consulted told us that, in their view, the terms
confirmation and validation were not used appropriately in USPS
guidelines. Confirmation is a process in which a qualified laboratory,
using specific tests, determines the presence of anthrax in a sample.
Normally, validation is a process that is carried out before a test or
procedure is used for a specific purpose to ensure that such a test or
procedure is effective. Thus, according to these experts, validation is
not usually done after a test or a procedure has already been performed,
as would have been the case had the results been validated in the manner
described by USPS officials. Thus, according to the experts we consulted,
validation, when done appropriately, should not have prevented USPS from
communicating the

quantitative test result. These experts also (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 of the results
difficult . 22 They explained that the method of

crisis unfolded, with input and guidance from several federal agencies,
including CDC and OSHA, and the national unions that represent postal
workers. 22 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, Porton Down; Dr. Paul Keim, Professor in
Microbiology, Northern Arizona University; Col. Eric Henchal,

20

counting CFUs is a long- standing, definitive, and universally 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 then 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 CFUs
identified by the laboratory was incorrect.

USPS communicated the quantitative results to workers as ** trace**
amounts and ** a concentration of spores, ** based on discussions with the
chief epidemiologist of the Connecticut Health Department. However,
according to the experts we

consulted, use of the terms trace amounts or concentration of spores did
not provide workers with useful information, when it was needed most,
which was when they were making decisions regarding their health risk.

According to experts we consulted, 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 potential health
risk associated with the sample, along with any limitation associated with
the results. The experts also said that 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 CFUs (from 0.55 grams
of dust) were found in a sample from one machine, along with appropriate
limitations regarding the sampling procedures used. Following a request
for test results by a union leader and an investigation by

OSHA, USPS eventually released the quantitative results 9 months later.
The delay was not consistent with OSHA regulations. OSHA did not cite USPS
for failure to disclose the quantitative test results within 15 working
days of the union leader*s Department of the Army; and Dr. Barbara
Johnson, former Safety Officer at the Dugway Proving Grounds,

21

January and February 2002 requests; however, in an October 7, 2002, letter
to USPS, 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. ** In addition, two federal guidelines, developed in 2002 by
GSA and the National

Response Team, suggest that more------ r at her t han l ess------ i nf or
mat i on s hould 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 USPS*s guidance
nor the more recent federal guidelines fully address the communication-
related issues concerning anthrax 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 regulations for communicating test results to workers do
not address the need for full, immediate, and proactive disclosure. Thus,
we made several recommendations to minimize the likelihood that the
communication- related problems at the Wallingford facility will recur
elsewhere (see appendix I). USPS, EPA, and GSA generally agreed with our
recommendations affecting them, but OSHA did not comment on our
recommendation to it.

Our work to date on this study has revealed three other issues that we
believe need to be addressed. These are, for those facilities that were
deemed to free of anthrax spores based solely on a single negative
sampling result, (1) reassessing the risk level for postal workers at
those facilities and the general public served by those facilities, (2)
reconsidering the advisability of retesting those facilities-----
employing the most effective sampling methods and procedures, and (3)
communicating to the postal workers and the general public the results of
the reassessment of health risk, the advisability of retesting, the
rationale for these

Department of the Army.

22

decisions, and other relevant information that may be helpful regarding
the health of the postal workers and the general public. CONCLUSIONS The
Wallingford incident gives unique insight into the lessons that need to be

learned from the response of the federal government, state health
departments, and USPS to the anthrax attacks in the fall of 2001. The
unpredictability of the lethality of anthrax; the broad spectrum of the
population at risk of exposure, including postal workers, postal customers
and others; and the inability to determine the route that contaminated
mail might take as well as the extent of cross- contamination, are all
factors that make it extremely difficult to establish the health risks
associated with a release of a biological agent, such as anthrax, inside a
facility that serves the public. This difficulty underscores the need for
a standardized and aggressive response as well as forward planning to
protect both the workers and the public should this happen again.

When considering the testing approach taken, and the methods used, to
detect anthrax in postal facilities in the fall of 2001, it is important
to recognize that the knowledge and experience of public health officials
and others in this area were continually evolving. Experts we consulted
and studies we reviewed indicated that the use of dry swabs alone were the
least effective method of detecting anthrax. In addition, CDC recommended
that dry swabs should not be used for anthrax detection. Initial sampling
of the Wallingford facility, using USPS nationwide sampling guidelines
(which provided for the use of dry swabs), did not find contamination.
Also, use of the same guidelines to conduct nationwide

testing may not have identified anthrax contamination that could have
existed in some of those facilities that tested negative using dry swabs
alone.

23

In February 2002, CDC advised USPS, that to ensure worker safety, there
was no need to retest postal facilities for a variety of reasons.
Accordingly, USPS followed CDC*s advice and did not retest any of those
facilities. However, in our discussion with CDC officials, they agreed
that there are many uncertainties associated with anthrax risk assessment.
For example, we do not know the lethal dose for an individual, how to
extrapolate contamination in a facility to a health risk for an
individual, and whether postal facilities still contain spores, and the
reliability of the methods used to rule out anthrax contamination. CDC
also agreed that there could still be spores in some facilities.
Consequently, there

remains a risk, albeit probably low, of further infection. While CDC
judges the risk to be low, we believe that it is important that this
judgment of the risk be communicated to workers and the general public so
that they are in a position to make informed decisions about their health
and safety.

Public health response is most effective and efficient when it is
proactive, when it focuses on prevention, rather than on consequent
management. Thus, the Wallingford incident illustrates the challenges
facing the federal government, the state health departments, the network
of diagnostic laboratories and those companies that serve the general
public, including USPS. The challenge can be summed up in one question,
"Is it safe?" This is what everyone asked during the fall of 2001, and
this is what everyone is trying to answer to this day. Unfortunately, the
best answer anyone can give is, "It is probably safe." Once a building has
been contaminated, one can never say there is no risk, but there can be a
low risk. What all those who are trying to protect the public health must
realize is that they are defining the risk level for others: in this case,
the postal workers as well as the general public. RECOMMENDATIONS

24

The impact of additional anthrax cases could result in illness or loss of
life as well as loss of confidence in the nation*s postal system. Further,
even though the health risk is probably low, it is uncertain; we therefore
recommend that the Postmaster General, in consultation with CDC, EPA,
OSHA, as well as any other relevant agencies and postal unions, for those
facilities that were deemed to free of anthrax spores based solely on a
single negative sampling result, (1) reassess the risk level for postal
workers at those facilities and the general public served by those
facilities, (2) reconsider the advisability of retesting those facilities
and employing the most effective sampling methods and procedures, and (3)
communicate to the postal workers and the general public the results of
the reassessment of health risk, the advisability of retesting, the
rationale for these decisions, and other relevant information that may be
helpful regarding the health of the postal workers and the general public.
Mr. Chairman, this concludes our statement. We will be happy to answer any

questions you or members of the Subcommittee may have. CONTACTS AND
ACKNOWLEDGMENTS Should you or your offices have any questions concerning
this report, please

contact me at (202) 512- 6412 or Bernie Ungar at (202) 512- 2834. We can
also be reached by e- mail at rhodesk@ gao. gov and ungarb@ gao. gov.
Individuals making key contributors to this testimony were Don Allison,
Hazel Bailey, Latesha Love, Laurel Rabin, Cady Summers, and Kathleen
Turner. Drs. Jack Melling and Sushil Sharma provided technical expertise.

25

Appendix I RECOMMENDATIONS CONTAINED IN OUR APRIL 2003 REPORT ON THE
WALLINGFORD FACILITY To help prevent the recurrence of the communication
problems that occurred at the Wallingford facility, we recommended that
the Postmaster General; the Administrator of the General Services
Administration; and the Administrator of the Environmental Protection
Agency, 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 workers 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 agencies and
other organizations communicate to workers and others; and

reflect the Occupational Safety and Health Administration*s regulations
for disclosing test results requested by workers or their designated

26

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 Health
consider whether the Occupational and Health Administration regulations
should require------ i n emer gency s i t uat i ons------ f ul l and i
mmedi at e di scl osur e o f t est r esul t s t o wor ker s, regardless of
whether the information is requested by a worker or his or her

designated representative. (460533)

GAO*s Mission The General Accounting Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO*s
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost
is through the Internet. GAO*s Web site (www. gao. gov) contains abstracts
and fulltext files of current reports and testimony and an expanding
archive of older products. The Web site features a search engine to help
you locate documents using key words and phrases. You can print these
documents in their entirety, including charts and other graphics.

Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as *Today*s Reports,* on its
Web site daily. The list contains links to the full- text document files.
To have GAO e- mail

this list to you every afternoon, go to www. gao. gov and select
*Subscribe to daily E- mail alert for newly released products* under the
GAO Reports heading.

The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to: U. S. General Accounting Office 441 G Street NW, Room LM
Washington, D. C. 20548 To order by Phone: Voice: (202) 512- 6000

TDD: (202) 512- 2537 Fax: (202) 512- 6061

Contact: Web site: www. gao. gov/ fraudnet/ fraudnet. htm E- mail:
fraudnet@ gao. gov Automated answering system: (800) 424- 5454 or (202)
512- 7470 Jeff Nelligan, Managing Director, NelliganJ@ gao. gov (202) 512-
4800

U. S. General Accounting Office, 441 G Street NW, Room 7149 Washington, D.
C. 20548 Obtaining Copies of GAO Reports and

Testimony Order by Mail or Phone

To Report Fraud, Waste, and Abuse in Federal Programs Public Affairs
*** End of document. ***