Bioterrorism: Public Health Response to Anthrax Incidents of 2001
(15-OCT-03, GAO-04-152).					 
                                                                 
In the fall of 2001, letters containing anthrax spores were	 
mailed to news media personnel and congressional officials,	 
leading to the first cases of anthrax infection related to an	 
intentional release of anthrax in the United States. Outbreaks of
anthrax infection were concentrated in six locations, or	 
epicenters, in the country. An examination of the public health  
response to the anthrax incidents provides an important 	 
opportunity to apply lessons learned from that experience to	 
enhance the nation's preparedness for bioterrorism. Because of	 
its interest in bioterrorism preparedness, Congress asked GAO to 
review the public health response to the anthrax incidents.	 
Specifically, GAO determined (1) what was learned from the	 
experience that could help improve public health preparedness at 
the local and state levels and (2) what was learned that could	 
help improve public health preparedness at the federal level and 
what steps have been taken to make those improvements.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-152 					        
    ACCNO:   A08726						        
  TITLE:     Bioterrorism: Public Health Response to Anthrax Incidents
of 2001 							 
     DATE:   10/15/2003 
  SUBJECT:   Chemical and biological agents			 
	     Emergency medical services 			 
	     Emergency preparedness				 
	     Health hazards					 
	     National preparedness				 
	     Homeland security					 

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GAO-04-152

United States General Accounting Office

GAO

Report to the Honorable Bill Frist,

                          Majority Leader, U.S. Senate

October 2003

BIOTERRORISM

              Public Health Response to Anthrax Incidents of 2001

GAO-04-152

Highlights of GAO-04-152, a report to the Honorable Bill Frist, Majority
Leader, U.S. Senate

In the fall of 2001, letters containing anthrax spores were mailed to news
media personnel and congressional officials, leading to the first cases of
anthrax infection related to an intentional release of anthrax in the
United States. Outbreaks of anthrax infection were concentrated in six
locations, or epicenters, in the country. An examination of the public
health response to the anthrax incidents provides an important opportunity
to apply lessons learned from that experience to enhance the nation's
preparedness for bioterrorism.

Because of your interest in bioterrorism preparedness, you asked GAO to
review the public health response to the anthrax incidents. Specifically,
GAO determined (1) what was learned from the experience that could help
improve public health preparedness at the local and state levels and (2)
what was learned that could help improve public health preparedness at the
federal level and what steps have been taken to make those improvements.

www.gao.gov/cgi-bin/getrpt?GAO-04-152.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich (202)
512-7119.

October 2003

BIOTERRORISM

Public Health Response to Anthrax Incidents of 2001

Local and state public health officials in the epicenters of the anthrax
incidents identified strengths in their responses as well as areas for
improvement. These officials said that although their preexisting planning
efforts, exercises, and previous experience in responding to emergencies
had helped promote a rapid and coordinated response, problems arose
because they had not fully anticipated the extent of coordination needed
among responders and they did not have all the necessary agreements in
place to put the plans into operation rapidly. Officials also reported
that communication among response agencies was generally effective but
public health officials had difficulty reaching clinicians to provide them
with guidance. In addition, local and state officials reported that the
capacity of the public health workforce and clinical laboratories was
strained and that their responses would have been difficult to sustain if
the incidents had been more extensive. Officials identified three general
lessons for public health preparedness: the benefits of planning and
experience; the importance of effective communication, both among
responders and with the general public; and the importance of a strong
public health infrastructure to serve as the foundation for responses to
bioterrorism or other public health emergencies.

The experience of responding to the anthrax incidents showed aspects of
federal preparedness that could be improved. The Centers for Disease
Control and Prevention (CDC) was challenged to both meet heavy resource
demands from local and state officials and coordinate the federal public
health response in the face of the rapidly unfolding incidents. CDC has
said that it was effective in its more traditional capacity of supporting
local response efforts but was not fully prepared to manage the federal
public health response. CDC experienced difficulty in managing the
voluminous amount of information coming into the agency and in
communicating with public health officials, the media, and the public. In
addition to straining CDC's resources, the anthrax incidents highlighted
both shortcomings in the clinical tools available for responding to
anthrax, such as vaccines and drugs, and a lack of training for clinicians
in how to recognize and respond to anthrax. CDC has taken steps to
implement some improvements. These include creating the Office of
Terrorism Preparedness and Emergency Response within the Office of the
Director, creating an emergency operations center, enhancing the agency's
communication infrastructure, and developing databases of information and
expertise on the biological agents considered likely to be used in a
terrorist attack. CDC has also been working with other federal agencies
and private organizations to develop better clinical tools and increase
training for medical care professionals.

In commenting on a draft of this report, DOD stressed the critical role it
played in the public health response, and HHS provided additional examples
of actions taken to enhance national preparedness for bioterrorism and
other public health emergencies.

Contents

  Letter

Results in Brief
Background
Local and State Public Health Officials Identified Strengths in Their

Responses as Well as Areas for Improvement
Experience Showed Aspects of Federal Preparedness That Could

Be Improved
Concluding Observations
Agency Comments

                                       1

                                      4 5

10

21 31 32

Appendix I 	Timeline of Selected Key Events in the Anthrax Incidents

Appendix II Comments from the Department of Defense

Appendix III 	Comments from the Department of Health and Human Services

Appendix IV GAO Contact and Staff Acknowledgments 41

GAO Contact 41
Acknowledgments 41

Related GAO Products

  Table

Table 1: People with Anthrax Infections, Letters Containing
Anthrax Spores, and Facilities Contaminated with Anthrax
Spores in the Six Epicenters 10

Abbreviations

AHRQ Agency for Healthcare Research and Quality
AMI American Media Inc.
CDC Centers for Disease Control and Prevention
DOD Department of Defense
EIS Epidemic Intelligence Service
EOC Emergency Operations Center
EPA Environmental Protection Agency
Epi-X Epidemic Information Exchange
FBI Federal Bureau of Investigation
FDA Food and Drug Administration
FEMA Federal Emergency Management Agency
HAN Health Alert Network
HHS Department of Health and Human Services

MMWR Morbidity and Mortality Weekly Report

NIH National Institutes of Health USAMRIID United States Army Medical
Research Institute of Infectious Diseases

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separately.

United States General Accounting Office Washington, DC 20548

October 15, 2003

The Honorable Bill Frist
Majority Leader
United States Senate

Dear Senator Frist:

In the fall of 2001, letters containing anthrax spores were mailed to news
media personnel and congressional officials, leading to the first cases of
anthrax infection related to an intentional release of anthrax in the
United
States.1 Outbreaks of the disease were concentrated in six locations, or
epicenters, in the country-Florida; New York; New Jersey; Capitol Hill in
Washington, D.C.;2 the Washington, D.C., regional area, which includes
Maryland and Virginia; and Connecticut-where individuals came into
contact with spores from the contaminated letters. The anthrax incidents
caused illness in 22 people, 11 with the cutaneous (skin) form of the
disease and 11 with the inhalational (respiratory) form. Five people died,
all from inhalational anthrax. The anthrax incidents and the illness and
deaths they caused also had an impact on the country beyond the six
epicenters. Across the nation, even in areas far removed from the
epicenters, residents brought samples of suspicious powders to officials
for testing and worried about the safety of their daily mail.

The public health response to the anthrax incidents was complicated by
several factors. The incidents occurred in the turbulent period following
the terrorist attacks of September 11, 2001, when the focus of the nation
was centered on response to those events. In addition, the anthrax

1Anthrax is a serious disease caused by Bacillus anthracis, a bacterium
that forms spores. A bacterium is a very small organism made up of one
cell. A spore is a dormant bacterium cell that can be revived under
certain conditions.

2In this report, we identify Capitol Hill, the complex of congressional
office buildings centering on the U.S. Capitol, as an epicenter distinct
from the Washington, D.C., regional area epicenter because Capitol Hill
functions independently from the District of Columbia. The Office of the
Attending Physician, U.S. Congress, which is an office of the U.S. Navy,
serves as the local health department for Capitol Hill and is responsible
for the health of about 30,000 public officials and staff, as well as
tourists, on Capitol Hill.

incidents were unprecedented. The response was coordinated by the
Department of Health and Human Services (HHS), primarily through its
Centers for Disease Control and Prevention (CDC), and CDC had never
responded simultaneously to multiple disease outbreaks caused by the
intentional release of an infectious agent. Anthrax was virtually unknown
in clinical practice, and many clinicians did not have a good
understanding of how to diagnose and treat it. As a result, public health
officials at the federal, state, and local levels were basing their
actions and recommendations to government officials, other responders,3
and the public on information that was changing rapidly. The response to
the incidents has been characterized by several public officials,
academics, and other commentators as problematic and an indication that
the country was unprepared for a bioterrorist event.

An examination of the response to the anthrax incidents provides an
important opportunity to apply lessons learned from that experience to
enhance the nation's preparedness for bioterrorism and other public health
emergencies. Because of your interest in bioterrorism preparedness, you
asked us to review the public health response to the anthrax incidents.
Specifically, you asked us to determine (1) what was learned from the
experience that could help improve public health preparedness for
bioterrorism at the local and state levels and (2) what was learned that
could help improve public health preparedness for bioterrorism at the
federal level and what steps have been taken to make those improvements.

In studying the response of local and state public health departments, we
interviewed officials from the six epicenters. For a previous report,4 we
had conducted interviews about bioterrorism preparedness with officials
from seven cities and their respective state capitals. These interviews
were conducted from December 2001 through March 2002, and we used
information from these interviews to examine the public health response

3In this report, the term responder refers to any organization or
individual that would respond to a bioterrorist incident. These include
physicians, nurses, hospitals, laboratories, public health departments,
emergency medical services, emergency management agencies, fire
departments, and law enforcement agencies.

4U.S. General Accounting Office, Bioterrorism: Preparedness Varied across
State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7,
2003).

to the anthrax incidents in localities that were not epicenters. To study
federal public health efforts, we interviewed officials from the
Department

of Defense (DOD) and HHS. These officials included representatives from
DOD's Armed Forces Institute of Pathology, Chemical Biological Incident
Response Force, Naval Medical Research Center, and U.S. Army Medical
Research Institute of Infectious Diseases (USAMRIID), and from HHS's
Agency for Healthcare Research and Quality (AHRQ), CDC, Food and Drug
Administration (FDA), National Institutes of Health (NIH), and Office of
the Assistant Secretary for Public Health Emergency Preparedness. To
determine the nature of the information provided by CDC during the
incidents, we examined the materials that CDC disseminated during October
2001 through December 2001. For overall assessments of and information on
the local, state, and federal public health response, we interviewed
members of the academic community and officials of private organizations
representing groups affected by the incidents or involved in the response,
including the American Hospital Association, the American Medical
Association, the American Nurses Association, the American Postal Workers
Union, the American Public Health Association, and the District of
Columbia Hospital Association. We also reviewed media reports of the
incidents from television news services and newspapers, retrospective
analyses of the response published after the incidents, relevant
congressional hearings that were held between October 2001 and December
2001, and materials provided to us by local, state, and federal agencies
and private organizations involved in responding to the attack. To
understand the scientific community's analysis of the anthrax incidents,
we searched the scientific literature using the National Library of
Medicine's PubMed service and reviewed relevant articles. To determine
what was learned from the experience that could help improve public health
preparedness for bioterrorism, we analyzed these materials for common
themes. We focused on what could be learned from the anthrax incidents
that could help improve public health preparedness not specifically for
anthrax or any particular locality but for bioterrorism in general. To
determine what steps have been taken to make those improvements, we
reviewed materials from relevant federal agencies through October 2003.
Although efforts to decontaminate affected facilities are part of the
public health response, they are outside the scope of this report, as is
the criminal investigation associated with the

incidents.5 We conducted our work from May 2003 through October 2003 in
accordance with generally accepted government auditing standards.

                                Results in Brief

Local and state public health officials identified strengths in their
responses to the anthrax incidents of 2001 as well as areas for
improvement. These officials said that their planning efforts had helped
to promote a rapid and coordinated response, but they had not fully
anticipated the extent of coordination that would be needed across both
public and private entities involved in the response to the anthrax
incidents. Even though many aspects of their existing response plans had
been made operational, for example, by putting agreements into place, the
aspects that had not been operationalized affected their ability to
coordinate a rapid response to the anthrax incidents. Local and state
officials said that their responses also benefited from previous
experiences, whether gained through exercising their plans or by
responding to emergencies of various kinds. These experiences had allowed
them to build relationships and identify areas for improvement in their
plans and thus to be better prepared to respond to the anthrax incidents.
Local and state officials also stressed the importance of effective
communication throughout the incidents. They reported that communication
among response agencies was generally effective, but they had difficulty
reaching clinicians to provide them with needed guidance. Local and state
public health officials were concerned that the capacity of their
workforce and clinical laboratories was strained and said that their
responses would have been difficult to sustain if the incidents had been
more extensive.

The experience of responding to the anthrax incidents also showed aspects
of federal preparedness that could be improved. CDC was challenged to both
meet heavy resource demands from local and state officials and coordinate
the federal public health response in the face of

5For information on aspects of the response to the anthrax incidents that
are outside the scope of this report, see our reports on those topics:
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.: Apr. 7, 2003); U.S. General
Accounting Office, Capitol Hill Anthrax Incident: EPA's Cleanup Was
Successful; Opportunities Exist to Enhance Contract Oversight, GAO-03-686
(Washington, D.C.: June 4, 2003); and U.S. General Accounting Office, U.S.
Postal Service: Issues Associated with Anthrax Testing at the Wallingford
Facility, GAO-03-787T (Washington, D.C.: May 19, 2003). For a list of our
other work related to bioterrorism preparedness, see the list of related
products at the end of this report.

rapidly unfolding anthrax incidents. CDC has acknowledged that although it
was effective in its more traditional capacity of supporting local
response efforts, it was not fully prepared to manage the federal public
health response. CDC served as the focal point for communicating critical
information during the response to the anthrax incidents and experienced
difficulty in managing the voluminous amount of information coming into
the agency and in communicating with public health officials, the media,
and the public. In addition to straining CDC's resources, the anthrax
incidents highlighted both shortcomings in the clinical tools available
for responding to anthrax, such as vaccines and drugs, and a lack of
training for clinicians on how to recognize and respond to anthrax.

CDC has reviewed its performance during the anthrax incidents, identified
areas for improvement, and taken steps to implement those improvements.
These include restructuring the Office of the Director, building and
staffing an emergency operations center, enhancing the agency's
communication infrastructure, and developing and maintaining databases of
information on and expertise in biological agents considered most likely
to be used in a terrorist attack. CDC has also increased its collaborative
efforts with others within and outside of HHS, for example, by creating a
permanent position of CDC liaison to the Federal Bureau of Investigation
(FBI). CDC has also been working with other federal agencies as well as
private organizations to support the development of better clinical tools,
including new vaccines and treatments for anthrax and other potential
agents of bioterrorism, and increased training for medical care
professionals.

In commenting on a draft of this report, DOD stressed the critical role it
played in the public health response, and HHS provided additional examples
of actions it has taken to enhance national preparedness for bioterrorism
and other public health emergencies.

                                   Background

Anthrax 	Anthrax is an acute infectious disease caused by the
spore-forming bacterium called Bacillus anthracis. The bacterium is
commonly found in the soil, and its spores can remain dormant for many
years. Although anthrax can infect humans, it occurs most commonly in
plant-eating animals. Human anthrax infections have usually resulted from
occupational exposure to infected animals or contaminated animal products,
such as wool, hides, or hair. Both human and animal anthrax infections are
rare in the United States.

Anthrax infection can take one of three forms: cutaneous, usually through
a cut or an abrasion; gastrointestinal, usually by ingesting undercooked
contaminated meat; or inhalational, by breathing airborne anthrax spores
into the lungs. After the spores enter the body through any of these
routes, they germinate into bacteria, which then multiply and secrete
toxins that can produce local swelling and tissue death. The symptoms are
different for each form and usually occur within 7 days of exposure.
Depending on the extent of exposure and its form, a person can be exposed
to Bacillus anthracis without developing an infection. There are several
methods for detecting anthrax spores or the disease itself, for example,
nasal swabs for exposure to spores, blood tests for infections, and wet
swabs for environmental contamination. CDC does not recommend the use of
the nasal swab test to determine whether an individual should be treated,
primarily because a negative result (no spores detected) does not exclude
the possibility of exposure. Confirmation of anthrax infection or the
presence of anthrax spores can require more than one type of test. The
disease can be treated with a variety of antimicrobial medications and is
not contagious.6 With proper treatment, fatalities are rare for cutaneous
anthrax. For gastrointestinal anthrax, between 25 and 60 percent of cases
have resulted in death. For inhalational anthrax, the fatality rate before
the 2001 incidents had been approximately 75 percent, even with
appropriate antimicrobial medications. An anthrax vaccine is available,
but it is indicated for use in individuals at high risk of exposure to
anthrax spores, such as laboratory personnel who work with Bacillus
anthracis.

Because so few instances of inhalational anthrax have occurred, scientific
understanding about the number of spores needed to cause infection is
still evolving. Before the 2001 incidents, it was estimated that a person
would need to inhale thousands of spores to develop an infection. However,
based on some of the cases that occurred during the anthrax incidents,
experts now believe that the number of spores needed to cause inhalational
anthrax could be fewer than that, depending on a person's health and the
nature of the spores.

6An antimicrobial medication either kills or slows the growth of microbes.

    Public Health Response to a Bioterrorist Attack

In the existing model for response to a public health emergency of any
type, including a bioterrorist attack, the initial response is generally a
local responsibility. This local response can involve multiple
jurisdictions in a region, with states providing additional support as
needed. Having the necessary resources immediately available at the local
level to respond to an emergency can minimize the magnitude of the event
and the cost of remediation. In the case of a covert release of a
biological agent such as anthrax, it can be days before exposed people
start exhibiting signs and symptoms of the disease. The model anticipates
that exposed individuals would seek out local clinicians, such as private
physicians or medical staff in hospital emergency departments or public
clinics. Clinicians would report any illness patterns or diagnostic clues
that might indicate an unusual infectious disease outbreak to their state
or local health departments. Local and state health departments would
collect and monitor data, such as reports from clinicians, for disease
trends and evidence of an outbreak. Environmental and clinical samples
would be collected for laboratorians7 to test for possible exposures and
identification of illnesses. Epidemiologists8 in the health departments
would use the disease surveillance systems9 to provide for the ongoing
collection, analysis, and dissemination of data to identify unusual
patterns of disease. Public health officials would provide needed
information to the clinical community, other responders, and the public
and would implement control measures to prevent additional cases from
occurring. The federal government can also become involved, as requested,
by providing assistance with testing of samples and epidemiologic
investigations, providing advice on treatment protocols and other
technical information, and coordinating a national response.

7A laboratorian is one who works in a laboratory; in the medical and
allied health professions, a laboratorian examines or performs tests (or
supervises such procedures) with various types of chemical and biologic
materials, chiefly to aid in the diagnosis, treatment, and control of
disease, or as a basis for health and sanitation practices.

8An epidemiologist is a specialist in the study of how disease is
distributed in populations and the factors that influence or determine
this distribution.

9Disease surveillance systems provide for the ongoing collection,
analysis, and dissemination of health-related data to identify, prevent,
and control disease.

    CDC's Bioterrorism Response Planning Efforts

As early as 1998, CDC had begun its planning efforts to enhance its
capacity to respond effectively to bioterrorism. CDC said it was
responsible for providing national leadership in the public health and
medical communities in a concerted effort to detect, diagnose, respond to,
and prevent illnesses that occur as a result of bioterrorism. In its
strategic preparedness and response plan, CDC anticipated that it would
need to collaborate with local and state public health partners and other
federal agencies in order to strengthen components of the public health
infrastructure.10 As part of this collaboration, CDC initiated a
cooperative agreement program in 1999 to enhance state and local
bioterrorism preparedness. CDC's planning efforts identified the
importance of coordination with the Department of Justice, including the
FBI and the National Domestic Preparedness Office. In addition, CDC said
that there was ongoing coordination with the Office of Emergency
Preparedness within HHS, FDA, NIH, DOD, the Federal Emergency Management
Agency (FEMA), and many other partners, including academic institutions
and professional organizations. At the time of the anthrax incidents, some
of these collaborative efforts were in the planning stage, some were in
the form of working groups, and others were limited in scope to areas such
as laboratory preparedness, training, or new vaccine research.

CDC was also working to make improvements in various aspects of
preparedness and prevention, detection and surveillance, and communication
and coordination. At the time of the anthrax incidents, CDC was working on
creating diagnostic and epidemiologic performance standards for local and
state health departments. In collaboration with NIH and DOD, CDC was
encouraging research for the development of new vaccines, antitoxins, and
innovative drugs. In addition, CDC had developed a repository of
pharmaceuticals and other supplies through the Strategic National
Stockpile.11 CDC was developing educational materials and providing
terrorism-related training to epidemiologists, laboratory workers,
emergency responders, emergency department personnel, and other front-line
health care providers and health and safety personnel.

10Public health infrastructure is the foundation that supports the
planning, delivery, and evaluation of public health activities and is
composed of a well-trained public health workforce, effective program and
policy evaluation, sufficient epidemiology and surveillance capability to
detect outbreaks and monitor incidence of diseases, appropriate response
capacity for public health emergencies, effective laboratories, secure
information systems, and advanced communication systems.

11At the time of the anthrax incidents, the Strategic National Stockpile
was known as the National Pharmaceutical Stockpile.

Through cooperative agreements, CDC was also working to upgrade the
surveillance systems of the local and state health departments and
investing in the Health Alert Network (HAN)12 and Epidemic Information
Exchange (Epi-X)13 communication systems.

    Fall 2001 Anthrax Incidents

In October 2001, an employee of American Media Inc. (AMI) in Florida was
diagnosed with inhalational anthrax, the first case in the United States
in over two decades. By the end of November 2001, 21 more people had
contracted the disease, and 5 people, including the original victim, had
died as a result. Although the FBI confirmed the existence of only four
letters containing anthrax spores, by December 2001 the Environmental
Protection Agency (EPA) had confirmed that over 60 sites, about one third
of which were U.S. postal facilities, had been contaminated with anthrax
spores.

The cases of inhalational anthrax in Florida, the first epicenter, were
thought to have resulted from proximity to opened letters containing
anthrax spores, which were never found. (See table 1.) The initial cases
of anthrax detected in New York, the second epicenter, were all cutaneous
and were also thought to have been associated with opened anthrax letters.
The cases detected initially in New Jersey, the third epicenter, were
cutaneous and were in postal workers who presumably had not been exposed
to opened anthrax letters. Unlike the incidents at other epicenters, which
began when cases of anthrax were detected, the incident on Capitol Hill,
the fourth epicenter, began with the opening of a letter containing
anthrax spores and resulting exposure. The discovery of inhalational
anthrax in a postal worker in the Washington, D.C., regional area, the
fifth epicenter, revealed that even individuals who had been exposed only
to sealed anthrax letters could contract the inhalational form of the
disease. Subsequent inhalational cases in Washington, D.C., New Jersey,
New York, and Connecticut, the sixth epicenter, underscored that

12HAN is a nationwide program designed to ensure communication capacity at
all local and state health departments (including full Internet
connectivity and training), ensure capacity to receive distance learning
offerings from CDC and others, and ensure capacity to broadcast and
receive health alerts at every level.

13Epi-X is a secure, Web-based communication system to enhance
bioterrorism preparedness efforts by facilitating the sharing of
preliminary information about disease outbreaks and other health events
among public health officials across jurisdictions and provide experience
in the use of secure communications.

finding. (For a list of key events in the history of the anthrax incidents
and the public health response to the incidents, see app. I.)

Table 1: People with Anthrax Infections, Letters Containing Anthrax
Spores, and Facilities Contaminated with Anthrax Spores in the Six
Epicenters

Number of infected people

Letter recovered within epicenter

                                   Epicenters

Cutaneous anthrax

Inhalational anthrax Contaminated facilities

                                   Florida    0          2        No      Yes 
                                  New York    7          1       Yes      Yes 
                                New Jersey    4          2       Noa      Yes 
                              Capitol Hill    0          0       Yes      Yes 
                         Washington, D.C.,    0          5      No a      Yes 
                             regional area                           
                               Connecticut    0          1        No      Yes 

Source: CDC.

aAlthough no letters were recovered within the New Jersey and Washington,
D.C., epicenters themselves, the letters found in the New York and Capitol
Hill epicenters have been determined to be the source of the contamination
in New Jersey and Washington, D.C.

Although the anthrax incidents were limited to six epicenters on the East
Coast, the incidents had national implications. Because mail processed at
contaminated postal facilities could be cross-contaminated and end up
anywhere in the country, the localized incidents generated concern about
white powders found in locations beyond the epicenters and created a
demand throughout the nation for public health resources at the local,
state, and federal levels.

Local and state public health officials across the epicenters emphasized
the benefits of their planning efforts for promoting a rapid and
coordinated response, stressed the importance of effective communication
throughout the incidents, and reported that their response capacity was
strained and the response would have been difficult to sustain if the
incidents had been more extensive.

  Local and State Public Health Officials Identified Strengths in Their
  Responses as Well as Areas for Improvement

    Local and State Public Health Officials Relied on Plans for Coordinating
    with a Wide Range of Entities and Identified Areas for Improvement

Epicenters Had Engaged in Some Response Planning but Had Not Anticipated
the Full Extent of Coordination That Would Be Needed

Local and state public health officials were challenged to coordinate
their responses to the anthrax incidents across a wide range of public and
private entities, often across more than one local jurisdiction. Officials
reported that anticipating local needs in emergency response plans, making
those plans operational with formal contracts and agreements, and having
experience with other public emergencies or large events improved their
ability to mount a rapid and coordinated response. When pieces of this
planning process were missing, had not been operationalized, or had not
been tested by experience, coordination of the local response was often
more difficult.

Local and state public health officials reported that they had typically
planned for coordination of their emergency response but had not fully
anticipated the extent to which they would have to coordinate with a wide
range of both public and private entities involved in the response to the
anthrax incidents, both locally and in other jurisdictions. Among others,
public health departments had to coordinate their responses with those of
local and federal law enforcement, emergency responders, the postal
community, environmental agencies, and clinicians.

Most response plans anticipated the need for public health officials to
coordinate with law enforcement and emergency response officials, both
within their community and across jurisdictions. In one epicenter, for
example, a regional organization of local governments had developed
planning guidance that outlined collaborative networks between the public
health and emergency response communities needed to strengthen the
region's response to an event such as the anthrax incidents.

In contrast, the need to link the public health response with the
responses of other public entities affected by the anthrax incidents, such
as environmental agencies, military response teams, and the U.S. Postal
Service, was less likely to have been anticipated in local response plans.
During the response, standard practices for clinical and environmental
testing and use of proper protective clothing and equipment needed to be
coordinated among public health officials, postal officials, police,
firefighters, environmental specialists, and teams from DOD. However,
officials reported that in some cases personnel from environmental and
military groups were meeting with public health officials for the first
time as the response unfolded. When the need for consistency in testing
procedures and standards for protective clothing and equipment had not
been anticipated, officials sometimes had difficulty agreeing on which
procedures and standards to follow. In addition, some plans had not
anticipated the need to forge quick relationships between public health

Some Aspects of Response Plans Had Been Made Operational and Increased
Officials' Ability to Coordinate a Rapid Response

departments and local groups affected by the incidents but not expressly
mentioned in the plans. During the anthrax incidents, the absence of such
a measure proved to be a particular problem for postal officials and
postal union representatives. In part due to this absence of proactive
plans, coordination between public health and postal officials on many of
the details of the response was problematic, and there were difficulties
communicating critical information, such as decisions on how and when to
provide prophylactic, or preventive, treatment to postal workers.

The need for coordination between public health and private groups
affected by the emergency-such as the hospital community-was also not
always fully anticipated in local response plans. Public health officials
in several areas had to work with local hospitals and other facilities to
set up screening and postexposure prophylaxis clinics rapidly, sometimes
in less than 24 hours. In this time they had to identify an appropriate
site location, design patient flow plans, outline staff needs and
responsibilities (medical, pharmacy, counseling, administrative, and
facilities operation components), and obtain medications (including
dealing with the logistics of breaking down and repackaging bulk
medications). Few locations had formally addressed all of these issues
before the anthrax incidents, but those that had addressed at least some
of them reported being able to respond more rapidly.

Officials relied on a variety of formal agreements, such as memoranda of
understanding and legal contracts, to address the needs identified in
their planning documents. These needs included coordination across
disciplines and jurisdictions, access to scientific information, and human
resources support. Local officials reported that putting agreements and
contracts into place to address these needs strengthened their
preparedness both by solidifying links with their public and private
partners and by helping them identify weaknesses that could be addressed
prior to an emergency. When systems had not been put into place to support
plans, coordination of response efforts was more difficult.

Formal agreements had often been put into place to support coordination
among officials within communities and across jurisdictions, but some
aspects of plans that were important for coordinating the response had not
yet been made operational. For example, one official reported having
arranged to link surveillance and environmental health personnel with law
enforcement officials during criminal investigations in the event of an
anthrax attack. Another official had already established agreements with
local counterparts to provide access to prophylaxis. Officials reported
that when formal contacts between officials had not been established,

Experience with Drills and Responding to Emergencies Allowed Officials to
Identify Areas for Improvement in Their Plans

coordination with counterparts in their community and other jurisdictions
during the incidents often relied on personal relationships.

While some public health departments reported having systems in place to
ensure ready access to the scientific information needed to make decisions
and provide information to the media and the public, many reported that
they did not. Officials reported that planning ahead and then taking the
necessary steps to compile available scientific information- including
what was known about anthrax, procedures for testing exposure to anthrax,
treatment protocols, and standards for the types of protective clothing
and equipment that are appropriate for first responders-were important for
responding rapidly and reducing confusion across the parties involved in
the response.

Officials stated that during the response they relied on existing mutual
aid agreements or contracts that gave them access to staff for screening
and mass care clinics, allowed the state to pull local epidemiologists to
support the state response, and addressed licensure issues for staff
brought in from other states. However, these agreements were not always in
place, or only partially covered the needs of the situation, and some
officials had to spend time dealing with issues that could have been
addressed before the event. For example, an official in one epicenter
reported that because a state of emergency had not been declared in the
jurisdiction, there was no system to pay for food for staff who were
working 24-hour shifts in prophylaxis clinics. Several officials in other
localities reported that systems had not been put into place to authorize
payment for overtime work in both public health departments and
laboratories. In addition, one health department received offers of
volunteer help from many physicians, pharmacists, nurses, epidemiologists,
and other concerned citizens. However, it could not use the volunteers
because it did not have a volunteer management system to train providers
and verify credentials.

Experience with drills and responding to public health emergencies helped
officials identify weaknesses in their plans. These officials stated that
drills ranging from tabletop to full-scale exercises were useful for
testing coordination and response capacities both locally and regionally.
Public health officials also reported that their experience in dealing
with hoax letters and false alarms proved useful, particularly in
supporting coordination with the law enforcement community. In major
metropolitan areas, experience with large events, such as political
conventions, forced local public health departments to develop their
emergency response plans and put the necessary agreements in place to
support those plans. Experience with public health emergencies-including
natural disasters

and outbreaks of infectious disease such as West Nile virus-also allowed
officials to work on coordinating their responses across multiple sites,
test their surveillance systems, and establish links with other public and
private entities.

Where previous experience had not allowed officials to identify and
address shortcomings of their plans, the anthrax incidents tended to
uncover weaknesses. For example, one local public health official reported
that although the agency had planned how to set up a prophylaxis clinic it
had not actually exercised getting people through the testing and
prophylaxis process. During the anthrax response, it took significantly
longer than the agency had anticipated to obtain test results from
overwhelmed laboratories. This official said that if the agency had known
how long it was going to take to get laboratory results, it would have
provided the first doses of prophylaxis for a longer duration to take into
account the additional time required to obtain test results. Another
official reported that the agency's experience with setting up a
prophylaxis clinic during the anthrax response taught the agency how to
select more appropriate sites for mass vaccination or prophylaxis clinics
in emergency situations. Experience also revealed shortcomings in regional
coordination. Several officials noted that although some plans for
coordination across jurisdictions were in place, they had not been
exercised, and so the relationships to support coordination had not been
formed or tested.

    Communicating Effectively during the Incidents Was Challenging

Communication among Response Agencies Was Generally Viewed as Effective

Local officials identified communication among responders and with the
public during the anthrax incidents as a challenge, both in terms of
having the necessary communication channels and in terms of making the
necessary information available for distribution. Good communication can
minimize an emergency, improve response, and reassure the public.
Officials reported that although communication among local responders was
generally effective, there were problems in communicating with some
hospitals and physicians. They also reported that dealing with the media
and communicating messages to the public were also challenging.

Communication among local and state response agencies was generally
perceived to be effective and helped keep agency officials informed and
the public health response coordinated. Channels of communication between
public health agencies and other responders-including law enforcement and
emergency management agencies, hazardous material units, and neighboring
state public health agencies-were already in existence at the time of the
anthrax incidents. Regular conference calls,

Flow of Information to Clinicians Was Problematic

which were initiated during the incidents, were used to distribute
information, raise issues, and answer questions.

In addition to telephone calls, local and state public health offices
relied on fax machines and the Internet to send and receive information
during the incidents. Most local health departments, however, noted that
they did not have backup communication systems that could be used in case
everyday systems became unavailable. In addition, public health workers
did not generally have cell phones, pagers, or laptop computers, which
could provide the means to keep working if it became necessary to vacate a
building during a crisis. In one epicenter, when an agency had to evacuate
its quarters during the incidents and workers could not be at their desks,
many of its communication systems (in addition to the information stored
in the office in electronic formats) became unavailable. Several local
agencies that did not have backup systems available at the time of the
anthrax incidents told us they have concluded that it is important to
invest in such systems to be prepared for any future public health
emergencies.

Local response agencies generally got the information they requested from
other local agencies. For example, in one epicenter, police and fire
departments were given specific protocols for handling suspicious samples
and triaging them for the laboratory. However, there were instances in
which they did not get needed information. For example, a local emergency
response official stated that the local fire department did not know what
protective equipment (such as masks and gloves) firefighters should wear
when responding to a suspected anthrax incident. The fire department
turned to the local health department for answers, but the health
department took weeks to release the protocol.

State and local officials reported difficulty providing needed information
to some hospitals and physicians in a timely way, and members of the
medical community expressed concern about the timeliness of the
information they received. Physicians recognized that they lacked
experience with anthrax and were particularly concerned about missing a
diagnosis because of its high fatality rate. They expected to be given
rapid and specific instructions from public health officials about how to
recognize and treat people who had been exposed. They wanted guidelines,
for example, on how to diagnose inhalational anthrax and how to advise
individuals who worked in post offices. Hospitals in one epicenter
reported receiving daily influxes of people with flulike symptoms. Because
these hospitals were seeking guidance on how to distinguish between
influenza and anthrax symptoms, the hospital

Criminal Investigation Sometimes Hindered Flow of Information to Officials
and the Public

association in the area initiated daily conference calls with concerned
clinicians. The purpose of these calls was to collect questions to ask
other organizations, such as CDC, to coordinate consistent answers to
questions from the public, and to share information about clinical
approaches.

Some of the ways in which local public health agencies tried to
communicate with hospitals and physicians were regarded as relatively
effective by the agencies, but no method worked well for all targeted
recipients. Health departments used various means to make relevant
materials available to hospitals and physicians, including sending faxes
or e-mail messages, posting relevant information on their Web sites,
distributing CD-ROMs, and setting up hotlines. In one state, which had no
confirmed anthrax infections but numerous false alarms, the state public
health department faxed critical information to hospitals throughout the
state. Officials in the department reported that while this system was
useful in disseminating information it was insufficient because it did not
provide a means of receiving information from the hospitals. E-mail worked
well for institutions, but it was an ineffective way of communicating with
physicians, especially those who did not have a hospital-based practice.
Several local public health officials told us that many private physicians
did not have e-mail or Web access. Because electronic messages were not a
feasible way of communicating with many clinicians, there was no way to
get timely information about anthrax to them. Some primary care physicians
were difficult to reach by any mass communication method or even
individually because public health officials sometimes did not have
up-to-date rosters of their telephone numbers. Officials in one state said
they realized during the incidents that they did not have a way to send
information directly to dermatologists, a group of specialists who were
especially important for detecting the cutaneous form of anthrax
infection. Because localities were unable to reach all physicians
directly, government agencies relied on physicians and associations who
did receive the information to serve as conduits. However, government and
association officials agreed that this method did not provide complete
coverage of all physicians.

Local officials reported that the criminal investigation of the anthrax
incidents sometimes hindered their ability to obtain information they
needed to conduct their public health response. For example, public health
officials in one epicenter said that they were unable to get certain
information from the FBI because the local public health officials lacked
security clearances. They said that if they had received more detailed
information earlier about the nature of the anthrax spores in the
envelopes, it might have affected how their agencies were responding. In

Supplying Information to Meet Needs of Media and Local Public Was
Challenging

addition, a laboratory director in one of the epicenters reported that the
criminal investigation led to constraints on his ability to communicate
laboratory results to clinicians.

Just as information was not provided to government agencies because of law
enforcement considerations, officials stated that criminal aspects of the
incidents complicated the distribution of information to the public.
Officials expressed concern about the necessity of withholding some
information from the public. One official reported that communication with
the public was constrained when the situation became a criminal
investigation. She was concerned that information the public needed to
understand its risk was no longer being provided. Officials in one
epicenter told us that they were concerned that constraints on the ability
of local public health departments to communicate could lead to a loss of
credibility. More generally, officials reported that fear in the community
could have been reduced if they had been able to release more information
to the media and the public.

Local and state officials reported that although they were generally
successful in persuading people to seek treatment, they encountered
difficulties in providing needed information to the media and local public
during the anthrax incidents. Because the incidents were taking place in
many locations, local communications were complicated by the public's
exposure to information about other localities and from the national
media.

Local and state officials realized that they needed to use the media to
disseminate information to the public and that they needed to be
responsive to the media so that the information the media were providing
was accurate. Public health and other government officials in the
epicenters held regular press conferences to keep the public informed
about local developments, made officials available to respond to media
requests, and developed informational materials so that the media and the
public could be better informed. Several officials stated that the media
helped in publicizing sources of information such as hotlines and specific
information such as details about who should seek treatment and where to
go for it. However, media analysts have also noted that the media were
sometimes responsible for providing incorrect information. For example,
one official said that when the media reported that nasal swabbing was the
test for anthrax, individuals sought unnecessary nasal swab testing from
emergency rooms, physicians, and the health department, and thereby
diverted medical and laboratory resources from medical care that was
required elsewhere.

Communication with the public was further complicated by the evolving
nature of the incidents and the local public's exposure to information
from other localities and the national media. Comparisons of actions taken
by officials at different points in time and in different areas caused the
public to question the consistency and fairness of actions taken in their
locale. For example, the affected public in some epicenters wondered why
they were being given doxycycline for prophylaxis instead of
ciprofloxacin, which had been heralded in the media as the drug of choice
for the prevention of inhalational anthrax and used earlier in other
epicenters. CDC's initial recommendation for ciprofloxacin was made
because ciprofloxacin was judged to be most likely to be effective against
any naturally occurring strain of anthrax and had already been approved by
FDA for use in postexposure prophylaxis for inhalational anthrax. However,
when it was determined that doxycycline was equally effective against the
strain of anthrax in the letters and following FDA's announcement that
doxycycline was approved for inhalational anthrax, the recommendation was
changed. This change was made because of doxycycline's lower risk for side
effects and lower cost and because of concerns that strains of bacteria
resistant to ciprofloxacin could emerge if tens of thousands of people
were taking it. In epicenters where prophylaxis was initiated after the
recommendation had changed, officials followed the new recommendation and
gave doxycycline to affected people. Local officials were challenged to
explain the switch and address concerns raised by affected groups about
apparently differential treatment. One local official described the
importance of explaining that the switch was also taking place even in
locations that had started with ciprofloxacin.

    Response Capacity Was Strained and Would Have Been Difficult to Sustain

Elements of the local and state public health response systems-including
the public health department and laboratory workforce as well as
laboratories-were strained by the anthrax incidents to an extent that many
local and state officials told us that they might not have been able to
manage if the crisis had lasted longer. The anthrax incidents required
extended hours for many public health workers investigating the incidents,
as well as the assignment of new tasks, including the staffing of
hotlines, to some workers. Aside from problems of workforce capacity, some
clinical laboratories were not prepared in terms of equipment, supplies,
or available laboratory protocols to test for anthrax, and most of them
were unprepared for and overwhelmed by the large number of environmental
samples they received for testing. The systems experienced these stresses
in spite of assistance from CDC and DOD, and temporary transfers of local,
and in some cases regional, resources.

Public Health Workers Were Overwhelmed with Work

During the anthrax incidents, the workload increased greatly at local and
state health departments and laboratories and across the country. The
departments heightened their disease surveillance, investigated false
alarms and hoaxes as well as potential threats, tested large numbers of
samples, and performed other duties such as answering calls on telephone
hotlines that were set up to respond to questions from the public. Health
departments across the nation received thousands of such calls. For
example, officials at one location told us that they received 25,000 calls
over a 2-week period during the crisis. Nine states-Colorado, Connecticut,
Louisiana, Maryland, Montana, North Dakota, Tennessee, Wisconsin, and
Wyoming-reported to CDC that during the week of October 21 to 27, 2001,
they received a total of 2,817 bioterrorism-related calls. These nine
states also reported that during that week they conducted approximately 25
investigations per state and had from 8 to 30 state personnel engaged
full-time in the responses in each state.

Some local and state health departments had to borrow workers from other
parts of their agencies or from outside of their agencies, such as from
CDC and DOD, to meet the greater demands for surveillance, investigation,
laboratory testing, and other duties related to the incidents. Several
agencies realized that they lacked staff in particular specialties, such
as environmental epidemiology. Some state public health departments did
not have enough epidemiologists to investigate the suspected cases in
their localities and had to borrow staff from other programs. Health
workers were pulled from other jobs to work in the field or to staff the
telephone hotlines. Staff borrowed from other parts of the agency were
sometimes unable to fulfill their traditional public health duties, such
as working on prevention of sexually transmitted diseases, and some
routine work was delayed. In spite of the borrowing, staff at some
agencies worked long hours over a number of weeks. In some cases, state
laboratories had to borrow staff from various parts of their health
department because laboratory workers were overwhelmed and the
laboratories required staffing for 24 hours a day, 7 days a week. In some
locations, CDC provided epidemiologists and laboratorians to help fill
gaps in staff.

Some borrowed workers had to be trained for their new duties while the
incidents were ongoing. Some workers had to be trained or cross-trained in
two fields, requiring additional time from other staff and resources from
the department. Some borrowed staff had to be trained for the specific
tasks required by the incidents. Finding sufficient numbers of people who
were appropriately trained or could be efficiently trained to staff the
telephone hotlines effectively was also a challenge. Local officials

Laboratories Handled Huge Volumes of Samples, and Some Were Underequipped
to Do So

reported that even if sufficient staff were found, calls were not always
handled effectively, especially when the caller needed mental health
services.

Many officials we interviewed were concerned about their ability to deal
with demand on staff in future crises. Since the anthrax incidents, some
states have sent members of their staff for additional training. Some
officials emphasized that surge capacity should be flexible to ensure
preparedness for various types of future bioterrorism incidents.

In addition to overwhelming the laboratory workforce, the large influx of
samples strained the physical capacity of the laboratories. Public health
laboratories around the country tested thousands of white powders and
other environmental samples as well as clinical samples. According to CDC,
during the anthrax incidents, laboratories within the Laboratory Response
Network14 tested more than 120,000 samples, the bulk of which were
environmental samples. Officials from one state told us that its
laboratories did not have the capacity to handle the volume of work they
received. Some local and state public health laboratories could not
analyze anthrax samples because of limitations of equipment, supplies, or
laboratory protocols. For example, in some states there were a limited
number of biological safety cabinets, which were needed to prevent
inhalation of anthrax spores by laboratory workers during the testing of
samples. Some laboratories did not have the chemicals needed to conduct
the appropriate tests. In some states, none of the state laboratories
could conduct an essential diagnostic test for anthrax, the polymerase
chain reaction test. In another state, only one of three state
laboratories could perform this test. Some state and local laboratories
were not prepared to take the safety precautions required to test samples
for anthrax. Local laboratories were even less capable of doing anthrax
testing. Samples for confirmatory testing were sent to CDC or to DOD's
USAMRIID. In addition to performing confirmatory testing, DOD also
provided other laboratory support to state and local officials. For
example, the samples from one epicenter were sent to DOD, and the
department sent mobile laboratories to two other epicenters to assist with
testing samples.

14The Laboratory Response Network was established in 1999 by CDC, DOD, and
the Association of Public Health Laboratories to maintain state-of-the-art
capabilities for biological agent identification and characterization. The
network is a multilevel system designed to link local and state public
health laboratories with advanced capacity clinical, military, veterinary,
agricultural, water, and food-testing laboratories. About 100 laboratories
participate in the network, with at least one network laboratory in each
state.

  Experience Showed Aspects of Federal Preparedness That Could Be Improved

Moreover, although some laboratories were relatively well prepared to test
clinical samples, they were not expecting the hundreds of environmental
samples they received and did not have protocols prepared for testing
them. It was the volume of these environmental samples, rather than the
volume of the clinical samples, that overwhelmed the laboratories. Among
the environmental samples, there were white powder samples that arrived
without any assessment by law enforcement as to the level of threat they
posed. At least one state laboratory developed protocols so that law
enforcement personnel could triage samples, thereby increasing the
likelihood that only those samples with a relatively high threat level
would be forwarded to the laboratory for further testing. Even where
protocols for testing these samples were available, it was a
time-consuming and unfamiliar task for the laboratory to label them, track
their progress, and ensure that their results were reported to the
appropriate authority.

CDC led the federal public health response to the anthrax incidents, and
the experience showed aspects of federal preparedness that could be
improved. During the anthrax incidents, CDC was designated to act on
behalf of HHS in providing national leadership in the public health and
medical communities. As the lead agency in the federal public health
response, CDC had to not only provide public health expertise but also
manage the public health response efforts across epicenters and among
other federal agencies. While local and state officials reported that
CDC's support of their responses to the rapidly unfolding anthrax
incidents at the local and state levels was generally effective, CDC
acknowledged that it was not fully prepared for the challenge of
coordinating the public health response across the federal agencies. CDC
experienced difficulty serving as the focal point for communicating
critical information during the response. In addition to straining CDC's
resources, the anthrax incidents highlighted shortcomings in the clinical
tools available for responding to anthrax, such as vaccines and drugs, and
a lack of training for clinicians on how to recognize and respond to
anthrax.

    CDC Provided Support to Meet Heavy Resource Demands from Local and State
    Officials

CDC effectively responded to heavy resource demands from state and local
officials to support the local responses. CDC reported that its support
activities included surveillance; clinical, epidemiologic, and
environmental investigation; laboratory work; communications; coordination
with law enforcement; medical management; administration of prophylaxis;
monitoring of adverse events; and decontamination. As new epicenters
became involved, CDC dispersed additional agency staff to assist local and
state health departments and other groups playing a role in the response
efforts, eventually deploying more than 350 employees to the

six epicenters. In addition, because even the perception of danger
required a public health response, CDC also provided assistance as
requested in localities beyond the epicenters. From October 8 to 31, 2001,
CDC's emergency response center received 8,860 telephone inquiries from
all 50 states, the District of Columbia, Puerto Rico, Guam, and 22 foreign
countries. CDC's callers included health care workers, local and state
health departments, the public, and police, fire, and emergency
departments and included requests for information about anthrax vaccines,
bioterrorism prevention, and the use of personal protective equipment.
Thus CDC not only provided resources to the epicenters but also had to
coordinate local efforts nationwide.

Local public health offices required varying levels of assistance from
CDC. For example, in one epicenter local officials looked to CDC to lead
the epidemiologic investigation and relied primarily on CDC staff. In
contrast, local officials in another epicenter led the local disease
outbreak investigation and control effort and CDC staff supplemented a
large local team. In most of the epicenters, the team sent by CDC included
Epidemic Intelligence Service (EIS) officers, who are specially trained
epidemiologists, to help with the investigation. The team's epidemiologic
investigation used the traditional two-pronged approach in which it
completely investigated either the case or the circumstance of a confirmed
exposure and conducted intensive surveillance to identify any other
anthrax cases or exposures. Laboratory testing proved to be an important
tool in the epidemiologic investigation, and the CDC team also included
laboratorians, who assisted with laboratory testing. In one epicenter, CDC
also sent one of its anthrax experts to provide guidance and assist the
local and state officials.

    CDC Reported It Was Not Fully Prepared to Coordinate the Federal Public
    Health Response

In addition to playing its traditional role of supporting local and state
public health departments, CDC also was confronted with the challenge of
coordinating the public health activities of multiple federal agencies
involved in the response, a task for which it acknowledged it was not
wholly prepared. CDC described having to create an ad hoc emergency
response center in an auditorium from which to manage the federal public
health response, which involved numerous agencies. These included FDA,
which, among other activities, provided guidance on treatment and
addressed drug and blood safety issues. In addition, NIH provided
scientific expertise on anthrax. CDC also coordinated with federal
agencies working on the environmental and law enforcement aspects of the
response efforts. DOD was responsible for testing all of the anthrax
letters that were recovered and was involved in the transportation and

testing of environmental samples as well as the cleanup of contaminated
buildings. EPA was in charge of the cleanup of contaminated sites. FEMA
assisted the President's Office of Homeland Security in establishing and
supporting an emergency support team. The FBI led the criminal
investigation.

Although CDC's planning efforts prior to the anthrax incidents had
identified the importance of coordination with other federal agencies for
an effective response to bioterrorism, and CDC had developed some working
groups among federal agencies, CDC sometimes had to adjust its response as
events unfolded to facilitate coordination of more practical issues such
as conducting simultaneous investigations in the field. For example, CDC
told us that in one epicenter both CDC and the FBI, which needed to
collect samples for the forensic investigation, identified the need to
gain a better understanding of one another's work. During the incidents,
CDC provided a liaison to the FBI, and the agencies worked together to
collect laboratory samples. Since the anthrax incidents, CDC has held
joint training with the FBI to discuss what they learned from their
experience that could facilitate working together in the future.

CDC has made several efforts to improve coordination since the anthrax
incidents, including major structural changes within the agency, creation
of a permanent emergency operations center (EOC), and increased
collaborative efforts with others within and outside of HHS. Officials
point to the creation of the Office of Terrorism Preparedness and
Emergency Response, which is part of the Office of the Director, as a
major change. The primary services of this office are to provide strategic
direction for CDC to support terrorism preparedness and response efforts,
secure and position resources to support activities, and ensure that
systems are in place to monitor performance and manage accountability. The
office manages the cooperative agreement program to enhance local and
state preparedness and jointly manages the Strategic National Stockpile
with the Department of Homeland Security. The office also manages the EOC,
which was created to promote quicker and better-coordinated responses to
public health emergencies across the country and around the globe. The EOC
is staffed 24 hours a day, 7 days a week, and the staff includes officials
from FEMA, DOD, and other agencies. CDC also created a permanent position
of CDC liaison to the FBI to increase collaboration with that agency.

    CDC Experienced Difficulty Serving as Focal Point for Communicating Critical
    Information during Response to Anthrax Incidents

CDC Had Difficulty Managing the Influx of Information to Produce and
Disseminate Guidance Rapidly

CDC served as the focal point for information flow during the anthrax
incidents, but experienced some difficulty in fulfilling that role. In
addition to the varied responsibilities involved in leading the public
health response, the agency concurrently had to collect and analyze the
large amount of incoming information on the anthrax incidents, assemble
and analyze the available scientific information on anthrax, and produce
guidance and other information based on its analyses for dissemination to
officials, other responders, the media, and the public. CDC officials
reported that the agency had difficulty producing and disseminating this
guidance rapidly as well as difficulty conveying information to the media
and the public.

CDC officials acknowledged that the agency was not always able to produce
guidance as quickly as it would have liked. When the incidents began, it
did not have a nationwide list of outside experts on anthrax, and it had
not compiled all of the relevant scientific literature on anthrax.
Consequently, CDC had to do time-consuming research to gather background
information to inform its decisions, which slowed the development of its
guidance. CDC has since compiled background information and lists of
experts not only for anthrax but also for the other biological agents
identified as having the greatest potential for adverse public health
impact with mass casualties in a terrorist attack, and it has made the
background information available on its Web site.15

CDC officials reported that CDC also had difficulty compiling the
information it received during the incidents. Although CDC's role as focal
point for information was a familiar one, the magnitude of information it
received was unusual. CDC received a tremendous amount of information via
e-mail, phone, fax, and news media reports from such sources as the
agencies and organizations in the epicenters of the incidents, public
health departments not in the epicenters, other federal agencies, and
international public health organizations. CDC also received information
from its staff in the field, but encountered some problems in those
communications. Agency officials have said there were communication
problems between epidemiologic staff in the field and at headquarters,
which CDC attempted to address by holding "mission briefings" through its
emergency response center; however, these briefings were not conducted
regularly. CDC's efforts to manage all of this incoming

15These agents, which are labeled Category A agents, are anthrax,
botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers.

information and associated internal communication problems were
complicated by its concurrent responsibility for coordinating the
day-to-day activities involved in the federal public health response to
the unfolding incidents.

According to CDC, both clinical and environmental guidance was developed
during the incidents by using working groups of six to eight employees who
were subject matter experts. Keeping up with the influx of new information
that was being acquired daily proved to be a challenge for these working
groups. CDC officials told us that no group at CDC was responsible for
collecting and analyzing all of the data that were coming in and that few
people at CDC had time to read their e-mail messages during the incidents.
Since the incidents, CDC has established teams of scientists from inside
and outside CDC whose only role is to review and analyze information
during a crisis; CDC does not intend for these teams to be involved in
day-to-day response operations.

As the working groups incorporated new information into their analyses,
the guidance they were producing changed accordingly. For example, as the
epidemiologic investigation expanded, CDC had to revise its assessment of
the risk of developing inhalational anthrax from letters containing
anthrax spores. Early on, CDC was acting on the theory that there was
little risk of contracting inhalational anthrax from sealed letters. The
incidents in the Washington, D.C., regional area, the fifth epicenter,
represented a turning point in the epidemiologic investigation. The
discovery of inhalational anthrax in a postal worker who presumably had
been in contact only with sealed anthrax letters required CDC to revise
its assessment. From this point on, CDC presumed that any exposure would
put an individual at risk and changed its recommendation regarding who
should get prophylaxis accordingly. CDC began to recommend prophylaxis for
all individuals who had been in contact with sealed as well as unsealed
anthrax letters, whereas earlier the agency had not been recommending such
treatment unless an individual had been exposed to an opened letter.

Initially, CDC relied on the HAN communication system and its Morbidity
and Mortality Weekly Report (MMWR) publication to disseminate its guidance
and other information; however, during the incidents there were
difficulties with both of these methods. At the time of the incidents, all
state health departments were connected to the HAN system. However, only
13 states were connected to all of their local health jurisdictions, and
therefore HAN messages could not reach many local areas. Some states were
satisfied with the information they received via HAN, but others

CDC Had Difficulty Conveying Information to Media and Public

claimed they did not get much information from HAN and what they did get
was incomplete. During the incidents, CDC expanded its list of HAN
recipients to include additional organizations, including medical
associations. MMWR is issued on a weekly basis, and so the information in
the latest issue was not always completely up-to-date for incidents that
were unfolding by the hour. For example, information published in MMWR on
October 26, 2001, contained the notice that the information was current as
of October 24, 2001. In addition to these structural barriers to getting
information out quickly to those who needed it, CDC's internal process of
clearing information before issuance through HAN or MMWR was
time-consuming. CDC has since changed its clearing process so that
information can get out faster. The agency also made a number of other
changes during the incidents to address some of the difficulties it
encountered in providing information to the public health departments and
clinicians. These included bringing in professionals from other
communication departments in CDC to help get information out quickly,
issuing press releases twice a day, and holding telebriefings. Since the
incidents, CDC has taken actions to expand its communication capacity,
including developing an emergency communication plan, increasing the
number of health experts on staff, and establishing a pressroom, in which
the Director of CDC gives press briefings on public health efforts. In
addition, it has developed, and posted to its Web site, information to
assist local and state health officials in detecting and treating
individuals infected with agents considered likely to be used in a
bioterrorist attack.

During the anthrax incidents, the media and the public looked to CDC as
the source for health-related information, but CDC was not always able to
successfully convey the information that it had. Media analysts and other
commentators have asserted that although CDC officials were the most
authoritative spokespersons they were not initially the most visible. In
an October 2001 nationwide poll, respondents indicated that they
considered the Director of CDC and the U.S. Surgeon General to be better
sources of reliable information about the outbreak of disease caused by
bioterrorism than other federal officials mentioned in the survey.

Another problem CDC encountered in its efforts to communicate messages to
the public was difficulty in conveying the uncertainty associated with the
messages, that is, the caveat that although the messages were based on the
best available information, they were subject to change when new facts
became known. As a bioterrorist event unfolds and new information is
learned, recommendations about who is at risk and how people should be
treated may change, and the public needs to be prepared that changes may
occur. Local officials and academics have

criticized CDC's communication of uncertainty during the anthrax
incidents. CDC officials have acknowledged that they were unsuccessful in
clearly communicating their degree of uncertainty as knowledge was
evolving during the incidents. For example, although there were internal
disagreements at CDC over the appropriate length of prophylaxis, this
uncertainty was not effectively conveyed to the public. Consequently, in
December 2001, when many people were finishing the 60-day antimicrobial
regimen called for in CDC's guidance, the public questioned CDC's
announcement that patients might want to consider an additional 40 days of
antimicrobials. Since the incidents, CDC officials have acknowledged the
necessity of expressing uncertainty in terms the public can understand and
appending appropriate caveats to the agency's statements.

    Anthrax Incidents Strained Some Aspects of Federal Response Capacity

CDC's Epidemiologic and Laboratory Resources Were Strained

The anthrax incidents highlighted some of the strengths of the federal
public health response capacity, while also reflecting some of its
limitations. CDC's experience with epidemiologic investigations was drawn
on extensively and effectively, and the Laboratory Response Network played
an important role. Not all the clinical tools that were needed to
identify, treat, and prevent anthrax infection were available, and those
that were available had shortcomings. Although CDC's bioterrorism
preparedness training program for clinicians had begun at the time of the
incidents, most clinicians had not yet been trained to recognize and
report anthrax infection.

CDC's skills in disease investigation were heavily relied on during the
anthrax incidents. CDC teams worked with local and state public health
departments and law enforcement to determine what happened with each case.
CDC's EIS was an important component of the agency's response. The
availability of trained epidemiologists enabled CDC to send numbers of
them to each epicenter to provide temporary staff to help investigate the
nature and extent of the local incident. CDC reported that because of the
number of epicenters and calls for assistance from other localities, its
staff, both at headquarters and in the field, were spread thin. The level
of assistance provided by CDC depended on the needs of the local public
health departments and therefore varied considerably by location. For
example, while CDC epidemiologists augmented the staff of some local and
state health departments who would have been severely overtaxed without
CDC's help, the agency characterized its role in one epicenter as
supplementary to that epicenter's team of epidemiologists.

The Laboratory Response Network proved to be an asset, and some state and
local officials told us they were satisfied with the laboratory response
during the anthrax incidents. At that time, CDC laboratories, like many of
the laboratories in the network, were inundated with samples and operated
24 hours a day to help epidemiologists determine exposure and risk by
testing samples to confirm cases. From October 2001 to December 2001, the
network laboratories processed more than 120,000 samples for Bacillus
anthracis. Public health laboratories other than those at CDC tested 69
percent of these samples, DOD laboratories tested 25 percent, and CDC
laboratories tested 6 percent. In addition to testing samples at its
laboratories, DOD also assisted the epicenters by providing personnel for
laboratories in the epicenters and at CDC and operating portable
laboratories to support local investigations. In addition to testing
samples, CDC laboratories distributed chemicals needed for testing samples
to network laboratories and developed a new testing method that permitted
better diagnostics from biopsy samples. CDC used the network to send
information to state bioterrorism response coordinators in local and state
laboratories. State laboratories also communicated with each other and
with CDC by using the network.

However, there were signs of strain in the Laboratory Response Network.
USAMRIID officials told us that USAMRIID, as well as other military and
civilian laboratories, is set up to process clinical samples and was
unprepared to process the volume and types of environmental samples that
it received. They noted that many of the procedures for obtaining
environmental samples from objects, such as keyboards and telephones, had
never been standardized. Officials reported that they spent a great deal
of time developing and validating these procedures as the incidents
unfolded. In addition, DOD laboratory officials told us that they had to
process overflow samples from overwhelmed laboratories at CDC and in the
epicenters. DOD officials expressed concern about dependence on DOD
laboratory resources for civilian emergencies, noting that in wartime
DOD's laboratories are needed to support military operations.

The Strategic National Stockpile was also an asset in CDC's response
efforts. The anthrax incidents underscored the benefits of having a system
in place to transport antimicrobials and vaccines quickly to areas that
need them during emergencies. The Strategic National Stockpile program
delivered antimicrobial medications for postexposure prophylaxis and
provided for the transportation of anthrax vaccine, clinical and
environmental samples, and CDC personnel, including epidemiologists,
laboratory scientists, pathologists, and special teams of researchers.

Available Clinical Tools Had Shortcomings

Not all of the clinical tools that physicians needed to identify, treat,
and prevent anthrax infection were available, and those that were had
shortcomings. Clinicians did not suspect and had difficulty promptly
diagnosing anthrax because of their inexperience with the disease and
because of the nonspecific nature of its presenting symptoms. Cutaneous
anthrax can be confused with cellulitis or a spider bite. Inhalational
anthrax is difficult to distinguish from other respiratory illnesses, such
as pneumonia or influenza. Routine laboratory and radiological testing did
not always clearly signal anthrax infection, and, even after physicians
did suspect it, the laboratory tests needed to confirm it were
time-consuming, laborious, and required that samples be sent to
specialized laboratories. Diagnostic tests that are more accurate and can
yield results more quickly are in development.

Treatment for anthrax infection was available, but it was not effective in
almost half of the inhalational cases. Both inhalational and cutaneous
anthrax, once diagnosed, were treated with a combination of intravenous
antimicrobial medications. All of the patients with cutaneous anthrax
recovered, but 5 of the 11 patients with inhalational anthrax did not. The
drugs worked by killing the bacteria that develop from anthrax spores
following germination of those spores in the body. However, anthrax
bacteria produce toxins, and no treatments were available that could
destroy these toxins. For this reason, the antimicrobial drugs used to
treat inhalational anthrax were ineffective in those patients in whom the
bacteria had already produced too much toxin by the time treatment was
initiated. CDC is working with other agencies within HHS, such as NIH, and
other federal agencies, including DOD, to support the development of new
treatments for anthrax and other potential agents of bioterrorism.

Methods of prophylaxis for people exposed to anthrax spores were available
and apparently effective, but there were several difficulties with these
methods. There was uncertainty about how to assess exposure to determine
who should be given prophylaxis; initially only one drug had been approved
for prophylaxis, and it was approved only for prophylaxis of inhalational
anthrax; the optimal length of prophylaxis for those thought to have been
exposed to anthrax spores was unknown; prophylactic drugs had to be taken
for months and had side effects; and the anthrax vaccine requires more
than one dose, had not been approved for postexposure prophylaxis, and was
in short supply. Nasal swabs and blood tests were used early in the
investigation to assess exposure, but these were not reliable methods.
When there was uncertainty about who was exposed or how great their risk
from exposure was, prophylaxis was sometimes recommended for all workers
in a facility with some

Few Clinicians Had Been Trained to Recognize Anthrax

contamination, regardless of how close to the contamination the workers
had been. This prophylaxis often started with an initial supply of
medication while test results were awaited. For example, some people were
given a 10-day supply of drugs and asked to return within 10 days to learn
whether they needed to continue taking the drugs. Initially, CDC, with
advice from NIH, recommended prophylaxis for 60 days.16 The drugs had side
effects, and the rate of compliance with the regimen was typically about
40 percent. Since the incidents, federal agencies have been developing and
evaluating tools for detecting anthrax spores. Such tests could enable
field workers to make better initial assessments of exposure at particular
locations to determine who should get prophylaxis. CDC is working with
other federal agencies to support the development of new methods of
prophylaxis for anthrax and other potential agents of bioterrorism.

HHS reported that at the time of the anthrax incidents no system or data
collection instruments existed for monitoring the nearly 10,000 people who
were receiving prophylaxis and thus it did not have a way to collect
information on the compliance with, adverse events from, or effectiveness
of prophylaxis. CDC attempted to collect this information retrospectively,
but acknowledged that this method is not optimal. To improve preparedness
for future incidents, CDC and FDA have created a post-event surveillance
working group that is responsible for developing a system capable of
collecting this kind of data.

During the anthrax incidents, it became apparent that few clinicians had
been trained to recognize anthrax infections. In November 2000, CDC had
created a national training plan for bioterrorism preparedness and
response. The plan outlined training required to implement the agency's
Bioterrorism Event Response Operational Plan and strategies for training
public health and medical professionals in collaboration with partners
(chiefly public health organizations and professional groups such as the
American Medical Association). At the time of the anthrax incidents, CDC
had been implementing the plan for less than a year, and relatively few
people had been trained: CDC reports that by October 2001 about 12,000
physicians, nurses, and other medical professionals had completed the
programs. However, CDC estimated that during the incidents more than

16Later, CDC recommended expanding prophylaxis for those already on it to
include an additional 40 days of antimicrobial drugs, with or without
three doses of the anthrax vaccine.

Concluding Observations

one million medical professionals participated in its anthrax-related
training programs via satellite, Web, video, and phone. In addition to
CDC's training programs, which continue to be available, CDC collaborates
with professional organizations, such as the American Medical Association
and the American Nurses Association, to provide training for their
members, and other federal agencies present training programs on
bioterrorism (for example, AHRQ) or fund training programs on bioterrorism
(for example, the Health Resources and Services Administration).

The anthrax incidents of 2001 required an unprecedented public health
response. The specific nature of the incidents and the nature of the
response varied across the epicenters and other localities across the
country. In each epicenter, local officials had to coordinate responses
that were a combination of local, state, and federal efforts. In addition,
local public health officials in the epicenters were challenged to mount
an intensive response that included identifying and treating people
already infected with anthrax as well as people who had been exposed and
could become infected, identifying contaminated areas and preventing
additional people from being exposed, processing thousands of samples
suspected of containing anthrax, and responding to thousands of calls from
concerned members of their communities.

The public health response to the anthrax incidents both demonstrated the
benefit of public health preparedness measures already in place or under
way at the local, state, and federal levels and emphasized the need to
reinforce or expand on those measures. The specific strengths and
weaknesses of the public health response identified by local and state
public health officials varied. Nonetheless, public health officials from
all locations identified general lessons learned for public health
preparedness. The lessons identified fall into three general categories:
the benefits of planning and experience; the importance of effective
communication, both among those involved in the response efforts and with
the general public; and the critical importance of a strong public health
infrastructure to serve as the foundation from which response efforts can
be mounted for bioterrorism or other public health emergencies.

  Agency Comments

CDC was instrumental in supporting local and state efforts throughout the
anthrax incidents, for example, by sending epidemic investigators into the
field and providing laboratory expertise. DOD resources and expertise were
also required to support several epicenters. CDC was challenged with the
unfamiliar task of coordinating the extensive federal public health
response efforts. Before the incidents began, CDC officials had recognized
that the agency was not fully prepared to coordinate a major public health
response effort and indeed had identified areas that needed improvement in
testimony before Congress on the day before it confirmed the first case of
inhalational anthrax in Florida. CDC officials have acknowledged that the
agency did not perform as well as it would have liked during the
incidents. The agency has taken steps to improve future performance,
including creating the Office of Terrorism Preparedness and Emergency
Response within the Office of the Director, building and staffing an
emergency operations center, enhancing the agency's communication
infrastructure, and developing and maintaining databases of information
and expertise on the biological agents the federal government considers
most likely to be used in a terrorist attack.

We obtained comments on our draft report from DOD and HHS. (See apps. II
and III.) DOD highlighted that lessons learned from its support of the
public health response could aid in the development of expanded
capabilities within the civilian sector to improve the nation's public
health preparedness. DOD emphasized its capabilities that were vital to
the success of the public health response, including environmental
assessment, transportation of contaminated articles, laboratory testing,
and cleanup of contaminated locations. The environmental cleanup was
beyond the scope of this report.

HHS found the report to be informative and provided additional examples of
actions taken to enhance national preparedness for bioterrorism and other
public health emergencies. These examples included the establishment of
the Office of Public Health Emergency Preparedness; the accelerated
acquisition of antimicrobial drugs for the Strategic National Stockpile;
and the expansion of basic and targeted research and upgrading of research
facilities focused on the pathogens most likely to be used as bioterrorism
agents.

DOD and HHS also made technical comments, which we incorporated where
appropriate.

We are sending copies of this report to the Secretary of DOD, the
Secretary of HHS, and other interested officials. We will also provide
copies to others upon request. In addition, the report will be available
at
no charge on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at
(202) 512-7119. Another contact and key contributors are listed in
appendix IV.

Sincerely yours,

Janet Heinrich
Director, Health Care-Public Health Issues

Appendix I: Timeline of Selected Key Events in the Anthrax Incidents

Events Occurring on That Date Date Events Determined Retrospectively to
Have Occurred on That Date (in italics)

Tuesday, 9/11/01  o  	Terrorist attack on World Trade Center and Pentagon
prompts heightened epidemiologic surveillance activities in some areas.

Wednesday, 9/26/01  o  In New York (NY), two NBC employees, a New York
Post employee, and the child of an ABC employee through and in New Jersey
(NJ), two U.S. Postal Service (USPS) employees, one from the West Trenton
postal Monday, 10/01/01 facility and one from Hamilton postal facility,
seek medical attention for skin conditions.

o  In Florida, an American Media Inc. (AMI) employee is admitted to the
hospital with a respiratory condition.

Tuesday, 10/02/01  o  	The Centers for Disease Control and Prevention
(CDC) issues a Health Alert Network (HAN) alert regarding preparedness for
bioterrorism, acknowledging the public's concern about smallpox and
anthrax and providing information about preventive measures.

o  In Florida, a second AMI employee is admitted to the hospital, with a
diagnosis of meningitis.

Thursday, 10/04/01  o  	CDC and the Florida Department of Health announce
confirmation of a case of inhalational anthrax. The infected person is an
AMI employee, and the cause of the infection is unknown.

Friday, 10/05/01  o  In Florida, an AMI employee becomes the first anthrax
victim to die.

Sunday, 10/07/01  o  In Florida, the AMI building is closed after anthrax
spores are found.

Monday, 10/08/01  o  In Florida, prophylaxis of AMI employees begins.

Wednesday, 10/10/01  o  	Because the source of the AMI employee's anthrax
exposure is believed to have been a letter, USPS begins nationwide
employee education on signs of anthrax exposure and procedures for
handling mail to avoid anthrax infection.

Friday, 10/12/01  o  	In NY, the New York City Department of Health
(NYCDOH) announces the confirmation of a case of cutaneous anthrax in an
NBC employee.

o  USPS says that it will offer gloves and masks to all employees who
handle mail.

Monday, 10/15/01  o  	On Capitol Hill, an employee opens a letter
addressed to Senator Daschle thought to contain anthrax spores. People
thought to be in the vicinity of the letter when it was opened are treated
with ciprofloxacin, at the time the only drug approved for postexposure
prophylaxis for anthrax.

o  In Florida, CDC confirms a second case of inhalational anthrax in an
AMI employee.

o  In NY, NYCDOH announces a second case of cutaneous anthrax, in a child
of an ABC employee.

Thursday, 10/18/01  o  	In the Washington, D.C., regional area (DC),a USPS
reports that although it believes that the Daschle letter, which was
processed at the Brentwood postal facility, was extremely well sealed and
that there was a minute chance that anthrax spores escaped into the
facility, it is testing the facility for anthrax contamination; quick
tests are negative, other tests are sent to the laboratory.

o  	In NJ, laboratory testing confirms cutaneous anthrax in two USPS
employees, one from the West Trenton postal facility and one from the
Hamilton postal facility.

o  In NY, NYCDOH announces a third case of cutaneous anthrax, in a CBS
employee.

o  In Florida, USPS closes two postal facilities contaminated with anthrax
spores for cleaning.

o  	In a telebriefing, the Director of CDC provides information about
anthrax, including risk of exposure, availability of vaccines and
antimicrobial medications, screening tests, symptoms, and what to do with
suspicious mail and also explains CDC's role in the investigation.

o  CDC broadcasts part one of a live satellite and Web broadcast on
anthrax for clinicians.

o  FDA announces that it has approved doxycycline for postexposure
prophylaxis for anthrax.

o  In DC, a USPS employee who works at the Brentwood postal facility seeks
medical attention.

Appendix I: Timeline of Selected Key Events in the Anthrax Incidents

Events Occurring on That Date
Events Determined Retrospectively to Have Occurred on That Date (in
italics)

Date

Friday, 10/19/01  o  	In DC, a USPS employee who works at both the
Brentwood postal facility and a Maryland postal facility is admitted to a
hospital with suspected inhalational anthrax.

o  	In NJ, the Hamilton and West Trenton postal facilities are closed, and
the New Jersey Department of Health and Senior Services recommends that
all USPS employees from both facilities receive prophylaxis.

o  	In NJ, laboratory testing confirms cutaneous anthrax in a second USPS
employee who works at the Hamilton postal facility.

o  In NY, NYCDOH announces a fourth case of cutaneous anthrax, in a New
York Post employee.

Saturday, 10/20/01  o  	In DC, a third USPS employee who works at the
Brentwood postal facility is admitted to a hospital with a respiratory
condition.

Sunday, 10/21/01  o  	In DC, the USPS employee who worked at the Brentwood
and Maryland postal facilities and was admitted to the hospital on
10/19/01 is confirmed to have inhalational anthrax.

o  	In DC, the Brentwood and Maryland postal facilities, are closed.
Evaluation and prophylaxis of employees begin.

o  	In DC, a USPS employee who worked at the Brentwood postal facility and
who initially sought medical attention on 10/18/01 is admitted to a
hospital with suspected inhalational anthrax and becomes the second
anthrax victim to die.

o  	In DC, a fourth USPS employee who worked at the Brentwood postal
facility seeks medical attention at a hospital. His chest X-ray is
initially determined to be normal, and he is discharged.

Monday, 10/22/01  o  	In DC, the USPS employee who worked at the Brentwood
postal facility and who sought medical attention on 10/21/01 and was
discharged is admitted to the hospital with suspected inhalational
anthrax, and becomes the third anthrax victim to die.

o  	In DC, the USPS employee who was admitted to the hospital on 10/20/01
is confirmed to have inhalational anthrax.

o  	In DC, prophylaxis is expanded to include all employees and visitors
to nonpublic areas at the Brentwood postal facility.

o  CDC rebroadcasts part one of the live satellite and Web broadcast on
anthrax for clinicians.

Wednesday, 10/24/01  o  	In NY, USPS begins giving prophylaxis to
employees at six New York City postal facilities where contaminated
letters may have been processed.

Thursday, 10/25/01  o  	In DC, a State Department mail facility employee
is called back to the hospital for admission; test taken the previous day
is positive for inhalational anthrax.

o  In NY, NYCDOH announces a fifth case of cutaneous anthrax, in a second
NBC employee.

o  CDC initiates daily telebriefings to provide updates on the anthrax
incidents.

Saturday, 10/27/01  o  In NY, NYCDOH announces the sixth case of cutaneous
anthrax, in a second New York Post employee.

Sunday, 10/28/01  o  	In NJ, laboratory testing confirms inhalational
anthrax in a USPS Hamilton employee who was admitted to a hospital with
suspected inhalational anthrax on 10/19/01.

Monday, 10/29/01  o  	In NY, preliminary tests indicate anthrax in a
hospital employee who was admitted with suspected inhalational anthrax on
10/28/01. The hospital where she works is temporarily closed, and NYCDOH
recommends prophylaxis for hospital employees and visitors.

o  	In NJ, laboratory testing confirms cutaneous anthrax in a woman who
receives mail directly from the Hamilton facility. The woman originally
sought medical attention on 10/18/01 and was admitted to the hospital on
10/22/01 for a skin condition.

o  	In NJ, laboratory testing confirms a second case of inhalational
anthrax, in a USPS Hamilton employee who initially sought medical
attention on 10/16/01 and was admitted to the hospital on 10/18/01 with a
respiratory condition.

Wednesday, 10/31/01  o  In NY, the hospital employee becomes the fourth
anthrax victim to die.b

      Appendix I: Timeline of Selected Key Events in the Anthrax Incidents

Events Occurring on That Date Date Events Determined Retrospectively to
Have Occurred on That Date (in italics)

Thursday, 11/01/01  o  CDC broadcasts part two of the live satellite and
Web broadcast on anthrax for clinicians.

Friday, 11/2/01  o  In NY, NYCDOH announces the seventh case of cutaneous
anthrax, in a third New York Post employee.

Wednesday, 11/21/01  o  	In Connecticut, an elderly woman, who was
admitted to the hospital for dehydration on 11/16/01, becomes the fifth
anthrax victim to die.b

o  	The Connecticut Department of Public Health, in consultation with CDC,
begins prophylaxis for USPS employees working in the Seymour and
Wallingford postal facilities.

Friday, 12/21/01  o  	CDC expands the options for those on prophylaxis to
include extending the duration of drug therapy and adding the anthrax
vaccine.

Source: CDC, Connecticut Department of Public Health, District of Columbia
Department of Health, FDA, Florida Department of Health, New Jersey
Department of Health and Senior Services, NYCDOH, Office of the Attending
Physician of the U.S. Congress, and USPS.

aThe Washington, D.C., regional area includes Washington, D.C., Maryland,
and Virginia.

bAs of September 30, 2003, the source of exposure had not been confirmed.

Appendix II: Comments from the Department of Defense

Appendix II: Comments from the Department of Defense

Appendix III: Comments from the Department of Health and Human Services

Appendix III: Comments from the Department of Health and Human Services

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact Michele Orza, (202) 512-6970

Acknowledgments 	In addition to the contact named above, Robert Copeland,
Charles Davenport, Donald Keller, Nkeruka Okonmah, and Roseanne Price made
key contributions to this report.

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