Skip to content

Get Judicial Watch Updates!

DONATE

Judicial Watch • JW v Postal Service GOA Clear Communication 01101

JW v Postal Service GOA Clear Communication 01101

JW v Postal Service GOA Clear Communication 01101

Page 1: JW v Postal Service GOA Clear Communication 01101

Category:

Number of Pages:25

Date Created:October 24, 2003

Date Uploaded to the Library:September 06, 2018

Tags:anthrax, inhalation, Reopening, Trenton, Daschle, GOA, 01101, Brentwood, Postal, facility, Building, senator, Employees, health, service, Pentagon, State Department, department, office


File Scanned for Malware

Donate now to keep these documents public!


See Generated Text   ∨

Autogenerated text from PDF

United States General Accounting Office
GAO
Testimony
Before the Committee Government
Reform, House Representatives
For Release Delivery
Expected 1:30 p.m. EDT
Thursday, October 23, 2003
U.S. POSTAL SERVICE
Clear Communication with
Employees Needed before
Reopening the Brentwood
Facility
Statement
Bernard Ungar, Director
Physical Infrastructure
Keith Rhodes, Chief Technologist
Center for Technology and Engineering, Applied Research
and Methods
GAO-04-205T
October 23, 2003
U.S. POSTAL SERVICE
Highlights GAO-04-205T, testimony
before the Committee Government
Reform, House Representatives October 21, 2001, the U.S.
Postal Service closed its
Brentwood mail processing facility
after the Centers for Disease
Control and Prevention (CDC)
confirmed that employee there
had contracted inhalation anthrax, often-fatal form the disease. October and 22, two other
Brentwood employees died
inhalation anthrax. The
contamination was linked
letter that passed through the
facility about October 12,
before being opened the office
Senator Daschle (see fig.) the
Hart Senate Office Building
October 15. The Hart Building was
closed the next day. The
Brentwood facility has since been
decontaminated and will soon
reopen. This testimony, which
based ongoing work, provides
GAO preliminary observations
the decisions made closing the
facility and problems experienced communicating with employees, well lessons learned from the
experience.
Because the Postal Service agreed inform Brentwood employees
before the facility reopened that could not guarantee that the
facility completely risk free, GAO making recommendations
this time.
www.gao.gov/cgi-bin/getrpt?GAO-04-205T. view the full product, including the scope
and methodology, click the link above.
For more information, contact Bernard
Ungar (202) 512-2834 ungarb@gao.gov.
Clear Communication with Employees
Needed before Reopening the Brentwood
Facility
The Postal Service decision wait close the Brentwood facility and
refer employees for medical treatment until CDC confirmed that postal
employee had contracted inhalation anthrax was consistent with the advice
the Postal Service received from public health advisers and the information
about health risk available the time. However, because circumstances
differed Brentwood and the Hart Building observed spill the Hart
Building and observable incident Brentwood the Postal Service
response differed from the response Capitol Hill, leading some Brentwood
employees question whether the Postal Service was taking adequate steps protect their health.
The Postal Service communicated information its Brentwood employees
during the anthrax incident, but some the health risk information changed
over time, exacerbating employees concerns about the measures being
taken protect them. Notably, employees later learned that their risk
contracting the disease was greater than originally stated. Other factors,
including difficulties communicating the uncertainty associated with
health recommendations and employees distrust postal managers, also
challenged efforts communicate effectively. Recently, the Postal Service
informed employees that Brentwood, which has been tested and certified
safe for occupancy, 100 percent free anthrax contamination.
However, discussions with GAO, the Service agreed revise future
communications acknowledge that although any remaining risk the
facility likely low, complete freedom from risk cannot guaranteed.
The Postal Service and others have learned since the 2001 anthrax incidents
that (1) the risk contracting anthrax through the mail greater than was
previously believed and more caution needed respond that greater
risk and (2) clear, accurate communication critical managing the
response incident and its aftermath. The Postal Service revising its
guidance respond more quickly and communicate more effectively
employees and the public the event future incident.
Anthrax-Contaminated Letter Opened Hart Building October 15, 2001
Mr. Chairman and Members the Committee: are pleased here discuss issues related the Postal
Service response the anthrax1 contamination the Washington D.C.
Processing and Distribution Center, Brentwood, was commonly
known.2 you know, the facility was renamed the Joseph Curseen Jr. and
Thomas Morris Jr. Processing and Distribution Center memory the
two Brentwood employees who died inhalation anthrax October
and 22, 2001. Inhalation anthrax the most lethal form the disease. The
facility about reopen after being closed years ago this week for
decontamination and renovation. testimony today will focus the (1)
decisions made the Postal Service closing the Brentwood facility and
(2) problems the Postal Service experienced communicating its
employees well (3) lessons that can learned from the experience.
While you also asked address the effectiveness the facility
decontamination, are unable because this issue outside the
scope work that have under way. However, will relay our
observations about communication issues associated with the facility
decontamination. testimony today based largely our ongoing work addressing the
treatment postal employees several postal facilities, including the
Brentwood facility, that were contaminated with anthrax spores late
2001. This work, which expect complete within the next several
months, being done the request Senator Joseph Lieberman and
Representatives Christopher Smith and Eleanor Holmes Norton. Our
work thus far has involved interviews with individuals involved the
response the contamination, including representatives from the Postal
Service, the Department Defense, the Centers for Disease Control and
Prevention (CDC), and state and local public health agencies and postal
unions well reviews relevant documents and literature related
the anthrax response. are also drawing from our completed work
addressing anthrax contamination postal facility Connecticut,3
Technically, the term anthrax refers the disease caused Bacillus anthracis and not
the bacterium its spores. this report, use the term anthrax for ease reading
and reflect terminology commonly used the media and the general public. this report, refer the facility Brentwood.
U.S. General Accounting Office, U.S. Postal Service: Better Guidance Needed
Improve Communication Should Anthrax Contamination Occur the Future,
GAO-03-316 (Washington, D.C.: Apr. 2003).
GAO-04-205T Reopening the Brentwood Postal Facility
issues related the testing for anthrax that facility,4 and the public
health response the 2001 anthrax incidents.5 Our work being
performed accordance with generally accepted government auditing
standards. The observations that are making are based our ongoing
work and should viewed preliminary.
Before discuss the decisions made closing the Brentwood facility, let briefly place these decisions context. When the Postal Service
learned that letter contaminated with anthrax spores had been sent
through the mail and opened the office Senator Daschle within the
Hart Senate Office Building (Hart Building) October 15, 2001, the Postal
Service reports that immediately understood that the letter passed
through its Brentwood facility. However, that point, the risk
contamination and its consequences the facility were uncertain. The
Postal Service sought advice and guidance from CDC and the District
Columbia (D.C.) Department Health, provided information its
employees, arranged for environmental tests the facility, and provided
some protective equipment, but did not close the facility refer the
facility employees for medical treatment until October 21, when CDC
confirmed that Brentwood employee had inhalation anthrax. The Postal
Service actions contrasted with those taken the Attending Physician
for the U.S. Capitol the individual responsible for the health public
officials and other congressional employees Capitol Hill. The Attending
Physician decided make antibiotics available the most directly
exposed congressional employees the same day the contaminated letter
was opened and advised closure the Hart Building the following day. summary:
The Postal Service decision wait for CDC confirmation case
inhalation anthrax before closing Brentwood and referring its employees
for medical treatment was consistent with the advice received from CDC
and the D.C. Department Health well the information about health
risk available the time. However, the decision raised questions among
Brentwood employees about whether their health was being adequately
protected. the time, CDC advised waiting for such confirmation before
U.S. General Accounting Office, U.S. Postal Service: Issues Associated with Anthrax
Testing the Wallingford Facility, GAO-03-787T (Washington, D.C.: May 19, 2003).
U.S. General Accounting Office, Bioterrorism: Public Health Response Anthrax
Incidents 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003).
GAO-04-205T Reopening the Brentwood Postal Facility
recommending closing facility recommending medical treatment
because CDC and local public health authorities believed unlikely that
postal employees could contract inhalation anthrax from exposure
contaminated mail. The Postal Service decision differed from the
decision close the Hart Building, large part, because there was
observable incident anthrax contamination there which was
immediately recognized potentially high-risk situation whereas there
was observable incident Brentwood. However, even before CDC
confirmed the first case inhalation anthrax Brentwood, some Postal
Service employees questioned whether the Postal Service actions
adequately protected their health.
The Postal Service communicated health risk and other information its
Brentwood employees during the anthrax incident, but some the
information initially provided changed public health knowledge
evolved exacerbating employees concerns about the adequacy the
measures being taken protect them. Most significantly, employees later
learned that their risk contracting the disease was greater than
originally stated. Other factors, including difficulties communicating the
uncertainty associated with health recommendations, the appearance
disparate treatment between Brentwood and congressional employees,
and employees long-standing distrust postal managers, also challenged
efforts communicate effectively. According postal managers, the
Postal Service has made additional efforts communicate with
Brentwood employees since the facility closure, but challenges remain,
including before the facility opens clearly communicate the
impossibility eliminating all risk contamination from the
environment. Recently, for example, the Postal Service informed
employees that Brentwood, which has been tested and certified safe for
occupancy, 100 percent free anthrax contamination. However,
following discussions with about the impossibility eliminating all risk contamination, the Postal Service agreed revise future
communications acknowledge that although any remaining risk the
facility likely low, complete freedom from risk cannot
guaranteed.
The Postal Service, CDC, and others have learned great deal from the
2001 anthrax incidents and have taken various steps address the
problems that occurred and enhance their preparedness for any future
incidents. One the lessons learned that the risk employees
contracting anthrax through the mail greater than was previously
believed and more caution needed respond that greater risk.
Another important lesson learned that clear and accurate
GAO-04-205T Reopening the Brentwood Postal Facility
communication employees critical managing the response
incident and its aftermath. The Postal Service, CDC, and others have taken
steps revise their guidance respond more quickly the event
future anthrax incident and communicate more effectively about such incident with employees and the public. The Postal Service told that would inform Brentwood employees prior opening the Brentwood
facility that while the facility safe for occupancy, impossible
guarantee that risk free.
Background
Anthrax acute infectious disease caused the spore-forming
bacterium called Bacillus anthracis. The bacterium commonly found
the soil and forms spores (like seeds) that can remain dormant for many
years. Although anthrax can infect humans, occurs most commonly
plant-eating animals.
Human anthrax infections are rare the United States and have normally
resulted from occupational exposure infected animals contaminated
animal products, such wool, hides, hair. Infection can occur three
forms, two which are relevant this testimony. They are (1) cutaneous,
which usually occurs through cut abrasion6 and (2) inhalation, which
results from breathing aerosolized anthrax spores into the lungs.7
Aerosolization occurs when anthrax spores become airborne, thus
enabling person inhale the spores into the lungs. After the spores
enter the body, they can germinate into bacteria, which then multiply and
secrete toxins that can produce local swelling and tissue death. The
symptoms are different for each form infection and are thought
appear within about days exposure, although individuals have
contracted inhalation anthrax long days after exposure.
Depending the extent exposure and its form, person can
exposed anthrax without developing infection. Before the 2001
incidents, the fatality rate for inhalation anthrax was approximately
percent, even with appropriate antimicrobial medications.8 People coming contact with anthrax its natural environment have generally not been
Cutaneous means of, relating, affecting the skin. Cutaneous anthrax characterized lesions the skin.
The third form anthrax infection gastrointestinal, which results from ingesting
undercooked contaminated meat. antimicrobial medication either kills slows the growth microbes. Antibiotics are example antimicrobial medications.
GAO-04-205T Reopening the Brentwood Postal Facility risk for inhalation anthrax, and before 2001, cases inhalation
anthrax had been reported the United States since 1976, although 224
cases cutaneous anthrax were diagnosed between 1944 and 1994.9
Fatalities are rare for cutaneous anthrax.
Because few instances inhalation anthrax have occurred, scientific
understanding about the number spores needed cause the disease
still evolving. Before the 2001 incidents, was estimated that person
would need inhale thousands spores develop inhalation anthrax.
However, based the cases that occurred during the fall 2001, experts
now believe that the number spores needed cause inhalation anthrax
could very small, depending person health status and the
aerosolization capacity the anthrax spores. total, the contaminated letters caused illnesses and resulted
deaths from inhalation anthrax. Numerous postal facilities were also
contaminated. The first two cases disease involved media employees
Florida. The employees one whom died contracted inhalation
anthrax and were thought have contracted the disease through
proximity opened letters containing anthrax spores. Media employees
also developed anthrax New York the second location known
affected. The initial cases New York were all cutaneous and were also
thought have been associated with opened envelopes containing
anthrax spores. The initial cases the next site New Jersey involved
postal employees with cutaneous anthrax. The postal employees were
believed have contracted the disease through handling the mail
opposed opening being exposed opened letters containing anthrax
spores. Unlike the incidents other locations, which began when cases
anthrax were detected, the incident the Hart Building the fourth
location began with the opening letter containing anthrax spores
and the resulting exposure the contamination. The discovery
inhalation anthrax the first postal worker from Brentwood revealed that
even individuals who had been exposed only taped and sealed
envelopes containing anthrax could contract the inhalation form the
disease. Subsequent inhalation cases Washington, D.C.; New Jersey;
New York; and Connecticut the sixth location affected underscored
that finding and also demonstrated that exposure and illness could result
Journal American Medical Association, Anthrax Biological Weapon: Medical and
Public Health Management, May 12, 1999. Volume 281, No. 18.
GAO-04-205T Reopening the Brentwood Postal Facility
from cross contamination mail.10 (See app. for time line selected
events related the anthrax incident the fall 2001.) about October 2001, least two letters containing anthrax spores
entered the U.S. mail stream one was addressed Senator Thomas
Daschle, the other Senator Patrick Leahy. The letters were mailed
Trenton, New Jersey, and forwarded the Brentwood facility
Washington, D.C., where they were processed high-speed mail sorting
machines and further processed the facility government mail section
before delivery.11 October 15, staff member Senator Daschle
office opened the contaminated envelope. The envelope contained
powdery substance, which the accompanying letter identified anthrax,
that was released burst dust when the envelope was opened. The
U.S. Capitol Police were notified, and the substance was quickly tested
and confirmed anthrax. Brentwood managers analyzed the path
the letter through the facility. Although the machine that processed the
letter was reportedly shut off least for period time the facility
itself was not closed evacuated that time. Within days, Brentwood
employee was suspected having contracted inhalation anthrax. The
Postal Service closed the facility October 21, 2001, after CDC confirmed
that the employee had the disease. Thereafter, two other Brentwood
employees, Mr. Curseen, Jr., and Mr. Morris, Jr., died. Both were
subsequently found have died inhalation anthrax.
The Brentwood facility large 2-story facility that operated hours
day, days week. About 2,500 employees worked Brentwood,
processing mail one three shifts. Brentwood processed all the mail
delivered addresses Capitol Hill, including the Hart Building.
Brentwood was the second processing and distribution center closed for extended period because anthrax contamination. The Postal Service
reported that plans reopen the facility phases; late November
administrative personnel will begin working the facility and limited mail
processing operations will begin shortly after that. Brentwood expected fully operational spring 2004. The other facility the Trenton
Processing and Distribution Center located Hamilton, New Jersey, was
closed days before Brentwood October 18, 2001, after CDC confirmed
Cross contamination occurs when other pieces mail equipment come contact with
the original source the anthrax.
The letter addressed Senator Leahy was never delivered. Instead, was recovered
November 2001 mail that had been quarantined Capitol Hill October 17, 2001.
GAO-04-205T Reopening the Brentwood Postal Facility
that New Jersey postal employee had cutaneous anthrax. the
process being decontaminated.
Brentwood
Employees
Questioned Whether
the Decision Wait
for Confirmation
Inhalation Anthrax
Adequately Protected
Their Health
The Postal Service decision wait for CDC confirmation case
inhalation anthrax before closing Brentwood and referring the facilities
employees for medical treatment was consistent with the public health
advice the Postal Service received and the health risk information
available the time. However, the Postal Service decision contrasted
with the more immediate decision close the Hart Building after anthrax
contamination occurred. result, postal employees questioned whether
the Postal Service decision adequately protected their health.
The Postal Service
Decision Was Based
CDC Advice and
Available Health Risk
Information
The Postal Service decision wait for CDC confirmation case
inhalation anthrax before closing Brentwood and referring its employees
for medical treatment was consistent with the advice provided CDC
and the D.C. Department Health, well the available health risk
information. CDC called for such confirmation before closing facility
recommending medical treatment because, the time, public health
authorities believed postal employees were unlikely contract inhalation
anthrax from exposure contaminated mail. Postal officials reported that
they consulted CDC and the D.C. Department Health about the possible
health risks Brentwood employees after learning that Senator Daschle
letter opened October 15, 2001 contained anthrax. Even though the
letter would have passed through Brentwood, the public health authorities
said that they did not consider the facility employees risk, given the
results ongoing investigations anthrax incidents Florida and New
York and the scientific understanding that time. Specifically,
discussed, postal employees were known have developed symptoms anthrax after contaminated letters had passed through the postal
system the way destinations Florida and New York, and anthrax
spores were not considered likely leak out, escape from, taped and
well-sealed envelope sufficient quantities cause inhalation anthrax.
Accordingly, the Postal Service reported that kept the Brentwood facility
open order keep the mail moving. This goal was important
managers whom interviewed, who cited the psychological importance keeping the mail flowing the aftermath the September terrorist
attacks.
GAO-04-205T Reopening the Brentwood Postal Facility October 18, 2001, CDC confirmed that postal employee New Jersey
had cutaneous anthrax. that day, the Postal Service, consultation
with the New Jersey Department Health and Senior Services, closed the
Trenton Processing and Distribution Center. According New Jersey
public health officials, the facility was closed facilitate environmental
testing the Trenton facility. While the contaminated letters Senator
Daschle and Senator Leahy were both processed through the Trenton and
Brentwood facilities, not clear why the Postal Service did not take the
same precautionary measures Brentwood. are pursuing this issue
part our ongoing work.
Although the Postal Service followed CDC advice and kept Brentwood
open until CDC confirmed case inhalation anthrax, the Postal Service
took interim steps protect its employees. First, the Postal Service
arranged for series environmental tests the Brentwood facility, even
though reported that CDC had advised the Postal Service that did not
believe such testing was needed that time. The results the first test
taken and available October 18, 2001 were from quick test
conducted local hazardous materials response team. The results were
negative. Three days later, October 21, 2001, CDC confirmed that
Brentwood employee had inhalation anthrax, and the Postal Service
closed the facility and referred its employees for medical treatment. The
positive results more extensive environmental testing also conducted October 18, 2001 were not available until October after the
facility had already closed. addition, Postal Service managers said they
asked the D.C. Department Health three times before October for
nasal swabs and antibiotics for Brentwood employees; however, the health
department said the swabs and antibiotics were unnecessary. have not
yet been able confirm this information with the D.C. Department
Health. Finally, the Postal Service took actions protect its employees
from low-level environmental risks. For example, provided protective
equipment such gloves and masks and, according postal managers,
shut down the mail-sorting machine that processed the Daschle letter,
least for time. Additionally, the Postal Service provided information
handling suspicious packages and required facility emergency action plans updated. 1999, the Postal Service developed guidance for responding anthrax
and other hazardous incidents. The guidance, which was developed
response hundreds hoaxes, includes steps for notifying first
responders, evacuating employees, and providing information and medical
care employees. The Postal Service reported that the guidance deals
with observable events specifically, spills not events that are not
GAO-04-205T Reopening the Brentwood Postal Facility
observable, such aerosolization powders. result, the Postal
Service said that did not view the guidance being applicable the
situation that occurred Brentwood.
Given that the situation Brentwood differed from the situation
contemplated its guidance, the Postal Service sought advice from CDC
and others. According CDC officials, the health and safety postal
employees was always the first concern postal managers during
discussions with CDC. Furthermore, they said that the Postal Service was
receptive their advice about the need close Brentwood protect
postal employees after diagnosis inhalation anthrax was confirmed.
The Decisions Made
Brentwood and Capitol
Hill Differed Because the
Circumstances and
Decisionmakers Differed
The Postal Service decision wait for confirmed case inhalation
anthrax before closing the facility and referring employees for medical
treatment differed from the decision implement precautionary measures
immediately after anthrax contamination was identified the Hart
Building. The decisions differed, part, because there was observable
incident the Hart Building, but not Brentwood. addition, different
parties made the decisions. Brentwood, the Postal Service made the
decision consultation with CDC and the D.C. Department Health.
These parties were not involved the decision-making the Hart
Building. Instead, because the Hart Building one many congressional
offices surrounding the U.S. Capitol, the Attending Physician for the U.S.
Congress who functions independently from the District Columbia
provided advice and made decisions about how deal with the
contamination there.12
The incident the Hart Building was immediately viewed high risk
employees there because the envelope opened Senator Daschle office
contained visible white powder that the accompanying letter identified anthrax, which was quickly confirmed testing the substance.
Consequently, the Office the Attending Physician the U.S. Congress
arranged for congressional employees receive antibiotics immediately
and advised closure the Hart Building the following day.
The Office the Attending Physician, U.S. Congress, office the U.S. Navy.
serves the local health department for Capitol Hill and responsible for about 30,000
public officials and other congressional staff, well tourists, Capitol Hill.
GAO-04-205T Reopening the Brentwood Postal Facility
Since 2001, the Postal Service has developed new guidance address
security risks the mail. Its Interim Guidelines for Sampling, Analysis,
Decontamination, and Disposal Anthrax for U.S. Postal Service
Facilities first issued November 2001 states that postal facilities will closed confirmed case inhalation anthrax identified when
evidence suggests that anthrax has been aerosolized postal facility.
The Postal Service said that plans complete update these
guidelines soon, and plan determine whether the new guidelines will
adequately address the situation that occurred Brentwood part our
ongoing work. addition, the Postal Service has tested and begun
install new biodetection technology postal facilities. This technology
designed enhance safety quickly identifying unobservable evidence aerosolized anthrax, thereby allowing for prompt response. plan
review the guidance associated with this technology complete our
work.
Communication
Problems
Exacerbated Postal
Service Employees
Concerns
The Postal Service communicated health risk and other information its
Brentwood employees during the anthrax crisis, but some the
information initially provided changed public health knowledge
evolved, intensifying employees concerns about whether adequate
measures were being taken protect them. Most significantly,
information the amount anthrax necessary cause inhalation
anthrax and the likelihood postal employees contracting the disease
turned out incorrect. Other factors, including difficulties
communicating the uncertainty associated with health recommendations
and employees long-standing distrust postal managers, also challenged
efforts communicate effectively. The Postal Service has made additional
efforts communicate with Brentwood employees since the facility
closure, but challenges remain, particularly the need effectively
communicate information any possible residual risks.
Some Information
Communicated Postal
Employees Changed
The Postal Service used wide variety methods communicate
information employees;13 however, some the information initially
provided changed with changes public health knowledge. For example, the basis the science that time, the Postal Service and CDC
Methods for communicating information included briefings, newsletters, fact sheets,
videos played closed circuit televisions its facilities, and toll-free information line. addition, the Postal Service regularly updated its Web site and, after the facility closed,
mailed information its employees homes.
GAO-04-205T Reopening the Brentwood Postal Facility
initially informed employees that individual would need exposed 8,000 10,000 spores contract inhalation anthrax. This view turned
out incorrect when two women New York and Connecticut died
from inhalation anthrax October and November 2001 without trace
anthrax spores being found their environments. Their deaths caused
experts conclude that the number spores needed cause the disease
could very small, depending person health status and the
aerosolization capacity the spores.
Postal employees were also told that they were little risk contracting
inhalation anthrax because, the view public health officials, anthrax
was not likely escape from taped and well-sealed envelope
sufficient amounts cause inhalation anthrax. addition, October 12,
2001, CDC issued health advisory, which the Postal Service distributed
its employees, indicating that very difficult refine anthrax into
particles small enough permit aerosolization. This information also
proved incorrect when the U.S. Army Medical Research Institute
Infectious Diseases analyses the anthrax Senator Daschle letter
mid-October 2001 revealed that the substance was not only small enough escape from the pores taped and well-sealed envelope but also
highly refined and easily dispersed into the air.14
Finally, error occurred October 10, when the Postal Service
instructed employees pick suspicious letters and isolate them
sealed containers. The message was corrected within few days when
employees were instructed not touch suspicious letters. Nevertheless,
Brentwood employees spoke with cited the miscommunication
indication that the Postal Service was not concerned about their safety. result these and other issues, union and management officials report
lingering bitterness between Brentwood employees and postal
management.
Communicating
Information Proved
Challenging
Communicating information proved challenging for several reasons. First,
the incidents occurred the turbulent period following the terrorist
attacks September 11, 2001, when the nation was focused the
response those events. addition, the anthrax incidents were
unprecedented. The response was coordinated the Department
According the Postal Service, learned the results the Army analysis after the
Brentwood closure.
GAO-04-205T Reopening the Brentwood Postal Facility
Health and Human Services, primarily through CDC, and CDC had never
responded simultaneously multiple disease outbreaks caused the
intentional release infectious agent. Furthermore, when the incidents
began, CDC did not have nationwide list outside experts anthrax,
and had not yet compiled all the relevant scientific literature.
Consequently, CDC had time-consuming research gather
background information about the disease before could develop and
issue guidance. Moreover, since anthrax was virtually unknown clinical
practice, many clinicians did not have good understanding how
diagnose and treat it. result, public health officials the federal,
state, and local levels were basing their health-related actions and
recommendations information that was constantly changing. According the testimony CDC Associate Director for Science, National
Institute for Occupational Safety and Health, before Subcommittee
this Committee last year, CDC clearly did not know what did not
know last October [2001] and this the cardinal sin that resulted tragic
deaths.
Effective communications were further complicated the evolving
nature the incidents and the media extensive coverage the response anthrax other localities. Comparing the various actions taken
officials different points time and different locations confused
postal employees and the public and caused them question the
consistency and fairness actions being taken protect them. For
example, when employees the Brentwood postal facility received
doxycycline for prophylaxis instead ciprofloxacin, they incorrectly
concluded that they were receiving inferior drug. part, this was
because the media had characterized ciprofloxacin the drug choice
for the prevention inhalation anthrax. Ciprofloxacin also had been used the primary medication earlier responses, including the response
anthrax atthe Hart Building. CDC initially recommended ciprofloxacin for
several reasons;15 however, when CDC subsequently determined that the
anthrax was equally susceptible doxycycline and other drugs, began
The first reason for recommending ciprofloxacin was that, absent information about the
strain susceptibility various drugs, CDC considered most likely effective against
any naturally occurring strain anthrax. Also, the newest antimicrobial available, CDC
considered less likely that terrorists would have had time engineer resistant strain
anthrax. Finally, the Food and Drug Administration had already approved ciprofloxacin for
the postexposure prophylaxis for inhalation anthrax.
GAO-04-205T Reopening the Brentwood Postal Facility
recommending the use doxycycline instead.16 The switch
doxycycline was considered desirable for variety reasons, including
its (1) lower risk for side effects, (2) lower cost, and (3) greater
availability. Local and CDC officials spoke with told that they were
challenged explain the switch medications and address
perceptions differential treatment.
Additional misunderstandings arose over the administration nasal
swabs postal employees. Nasal swabs are samples taken from the nasal
passages soon after possible exposure contamination determine the
location and extent exposure site, but not diagnose infection.
Nasal swabs were administered congressional employees October
after the contaminated letter was opened determine which employees
might have been exposed and based this where and how far the
aerosolized anthrax spores had spread. Some Brentwood employees
questioned why they did not also receive nasal swabs this time and saw
this difference evidence disparate medical treatment. noted, the
Postal Service reported requesting nasal swabs for its employees, but the
CDC and the D.C. Department did not consider them necessary. Nasal
swabs were then provided least some employees after Brentwood
was closed October 21. However, further confusion appears have
occurred about the purpose the nasal swabs when employees who were
tested did not receive the results the swabs. The confusion occurred
partly because the Postal Service issued bulletin dated October 11, 2001,
that incorrectly indicated that nasal swabs were useful diagnosing
anthrax and the media described nasal swabs the test for anthrax. The
bulletin was subsequently corrected, but the media continued refer
the swabs test. Public health officials acknowledged that this
confusion about the purpose the nasal swabs created great deal
anxiety within the postal community and the public. result, public
health entities continued collect the samples when people asked for
them, simply allay the individuals fears.
Another area confusion relates the process used administer the
anthrax vaccine interested postal employees. When the vaccine used
the military became available sufficient quantities that could
provided others, CDC offered postal employees and congressional
staff. While considered safe, had not been approved for use
The recommendation use doxycycline also followed the Food and Drug
Administration approval the drug for inhalation anthrax.
GAO-04-205T Reopening the Brentwood Postal Facility
postexposure situations. Consequently, the Food and Drug Administration
required CDC administer the vaccine using extensive protocols related the distribution investigational new drug. These protocols
required postal employees complete additional paperwork and undergo
additional monitoring which, according some Brentwood employees,
gave some employees the impression that they were being used guinea
pigs for unsafe treatment. CDC officials acknowledged that CDC did
not effectively communicate information about the vaccine program and
that, hindsight, these deficiencies probably resulted the wrong
perception.
CDC officials have also acknowledged that they were unsuccessful
clearly communicating the degree uncertainty associated with the
health information they were providing, which was evolving during the
incidents. For example, although there were internal disagreements within
CDC over the appropriate length prophylaxis, this uncertainty was not
effectively conveyed postal employees and the public. Consequently,
December 2001, when postal employees and others were finishing their 60day antimicrobial regimen called for CDC initial guidance, they
questioned CDC advice about the need consider taking the drugs for additional days. CDC officials have since acknowledged the need
clearly state when uncertainty exists about the information distributed
the public and appropriately caveating the agency statements.
Long-Standing Labor
Relations Issues
Compounded
Communication Issues
CDC, local public health officials, union representatives, and postal
officials told that employees mistrust postal managers complicated
efforts communicate information them. According these parties,
postal employees were often suspicious management motives and
routinely scrutinized information they received for evidence any ulterior
motives. This view appears consistent with the results our past work,
which has identified persistent workplace problems exacerbated
decades adversarial labor-management problems. These problems were serious that 2001, reported that long-standing and adversarial
labor-management relations affected the Postal Service management
challenges.17 The need address this long-standing issue was also raised
U.S. General Accounting Office, Major Management Challenges and Program Risks: U.S.
Postal Service, GAO-01-262 (Washington, D.C.: Jan. 2001).
GAO-04-205T Reopening the Brentwood Postal Facility the July 2003 report the President Commission the Postal
Service.18
The Postal Service Has
Made Additional Efforts
Improve Communication
with Employees, but
Challenges Remain
According postal managers, the Postal Service has made additional
efforts communicate with the employees who were Brentwood,
including holding town hall meetings explain the facility
decontamination process postal employees and the public. The Postal
Service has reported that also updating its 1999 guidance for
responding anthrax and other hazardous materials. present,
however, the revision the guidance has not yet been completed and is,
therefore, unclear whether the revisions will address the issues that
occurred Brentwood. Nevertheless, the Postal Service assisted the
National Response Team group federal agencies with
responsibility for planning, preparing, and responding activities related the release hazardous substances the development improved
guidance entitled Technical Assistance for Anthrax Response. This
guidance provides number recommendations about communicating
information during emergency situations, including the need for agencies admit when you have made mistake not know the information.
While information the process and outcome decontamination efforts technically complex and therefore challenging present clearly the
public, the revised guidelines may helpful future discussions about
the safety facility. have not reviewed the details the facility
decontamination its subsequent testing and, therefore, cannot comment the effectiveness decontamination efforts. However, general,
discussions about the success decontamination and any residual risk
individuals center two related topics. The first topic entails
discussion the degree which contamination has been reduced,
bearing mind that all sampling and analytical methods have limit
detection below which spores may present but undetected. Against that
backdrop, also important discuss how many anthrax spores are
required infect humans and explain that the number variable,
depending upon the route infection (e.g., skin contact inhalation) and
the susceptibility each individual infection. light this,
particularly important properly communicate Brentwood employees clear understanding the decontamination approach that was
Report the President Commission the United States Postal Service, Embracing the
Future: Making the Tough Choices Preserve Universal Mail Service, July 31, 2003.
GAO-04-205T Reopening the Brentwood Postal Facility
undertaken the facility and the nature and extent any residual risk
there. Likewise, the Postal Service communications employees must clear and unbiased (1) clearly communicate the limitations testing
and the associated risks while, the same time, (2) avoid inducing
unnecessary fear concern. provided with clear and unbiased
information, employees will able make informed decisions about
their health and future employment. this regard, the Postal Service has
given employees who worked Brentwood opportunity
reassigned certain other mail processing centers the region they
not want return Brentwood. our view, providing complete information employees important for
them make informed decisions about working Brentwood. According recent information that the Postal Service provided its employees,
the facility, which public health authorities have certified safe for
occupancy, 100 percent free anthrax contamination and there
remaining health risk the facility. This latter information not
consistent with what CDC Associate Director for Science, National
Institute for Occupational Safety and Health, told this Committee
Subcommittee the District Columbia July 2002. Specifically, she
said that while science-based process can allow workers safely return Brentwood, not possible eliminate risk entirely guarantee
that building absolutely free risk. discussed our concerns with
Postal Service officials about their characterization the facility
completely free anthrax contamination, and they agreed revise their
statements indicate that not possible guarantee that building
absolutely risk free. According the Postal Service, misunderstanding
resulted the incorrect information being distributed employees
before the document had been fully reviewed. The Postal Service said that would correct the information and distribute the new information
employees who worked Brentwood within the next weeks.
Lessons Learned and
Implications for
Reopening the
Facility
The Postal Service, CDC, and others have learned great deal from the
2001 anthrax incidents and have taken various steps address the
problems that occurred and enhance their preparedness for any future
incidents. Among the lessons learned are that the risk employees
contracting anthrax through contaminated mail greater than was
previously believed and more caution needed respond that greater
risk. now clear, for example, that anthrax spores can released
the air, aerosolized, when sealed letters pass through the Postal
Service processing equipment and that limited number anthrax
spores can cause inhalation anthrax susceptible individuals. This
GAO-04-205T Reopening the Brentwood Postal Facility
increased risk contracting inhalation anthrax indicates that decisions
about closing facilities need consider other factors well the
presence observable substance, such powder. The Postal
Service and CDC have responded this need for greater caution
developing guidance for closing facility that establishes evidence
aerosolization, well confirmation diagnosis inhalation
anthrax, criterion for closure. have not yet evaluated this guidance determine whether specific enough make clear the
circumstances under which postal facility should closed adequately
protect employees and the public. recognize that developing such
guidance difficult, given that the Postal Service experiences many
hoaxes and needs accomplish its mission well ensure adequate
protection its employees health.
Another important lesson learned during the 2001 anthrax incidents that
clear and accurate communication critical managing the response incident. Because the risk information that was provided employees
changed over time and some the information was communicated
ways that employees reportedly found confusing difficult
understand, the fears that would naturally accompany bioterrorism
incident were intensified and distrust management, which already
existed the workplace, was exacerbated. CDC, particular, has
recognized the importance communicating the uncertainty associated
with scientific information preserve credibility the event that new
findings change what was previously understood. this regard, our work the sampling and analytical methodologies used test for and identify
anthrax contamination addresses the uncertainty involved these efforts.
The Postal Service agrees that although the Brentwood facility has been
tested and certified safe for occupancy, the Postal Service cannot assert
that the building 100 percent free anthrax contamination.
Accordingly, the Postal Service stated that would inform Brentwood
employees before opening the facility that the Postal Service cannot
guarantee that the building absolutely risk free.
This concludes prepared statement. will happy respond any
questions you other members the Committee may have.
Contacts and
Acknowledgments
Should you your staff have any questions concerning this report, please
contact (202) 512-2834 Keith Rhodes (202) 512-6412. can also reached e-mail ungarb@gao.gov. Individuals making key
contributions this testimony were Don Allison, Hazel Bailey, Jeannie
GAO-04-205T Reopening the Brentwood Postal Facility
Bryant, Derrick Collins, Dwayne Curry, Elizabeth Eisenstadt, and Kathleen
Turner. Drs. Jack Melling and Sushil Sharma provided technical expertise.
GAO-04-205T Reopening the Brentwood Postal Facility
Appendix Time Line Selected Events
Related the Anthrax Incident the Fall
2001
Date
Events Occurring That Date
Tuesday,
Terrorist attacks the World Trade Center and Pentagon prompt heightened concerns about
possible bioterrorism.
9/11/01
Tuesday,
10/02/01 Florida, American Media Inc. (AMI) employee admitted the hospital with respiratory
condition.
The Centers for Disease Control and Prevention (CDC) issues alert about bioterrorism,
providing information about preventive measures for anthrax.
Thursday,
CDC and the Florida Department Health announce that AMI employee has inhalation anthrax.
10/04/01
Friday,
AMI employee dies inhalation anthrax.
10/05/01
Monday,
10/08/01
The Postmaster General announces that Postal Inspection Service working with other law
enforcement agencies the Florida incident.
Wednesday, 10/10/01
The Postal Service begins nationwide employee education signs anthrax exposure and
procedures for handling mail avoid anthrax infection.
Friday, NY, the New York City Department Health (NYCDOH) announces the confirmation case cutaneous anthrax NBC employee.
10/12/01
The Postal Service says that will offer gloves and masks all employees who handle mail.
(On about) Daschle letter passes through Brentwood.
Boca Raton post office, which had direct access the AMI mail, tested for anthrax and Palm
Beach County Department Health administers nasal swabs and offers 15-day supply
ciprofloxacin postal employees.
Monday,
10/15/01 Capitol Hill, employee opens letter addressed Senator Daschle. Staff that office,
adjacent office, and first responders are given nasal swabs and 3-day supply antibiotics. NJ, State Department Health and Senior Services (NJDHSS) assures Trenton employees that
they have low risk contracting anthrax.
Anthrax confirmed Boca Raton post office.
Tuesday, 10/16/01
Part the Hart Senate Office Building closed the morning, and the remainder the building
closed the evening. Over the next days, all Hart building and other Capitol Hill employees who
request them are given nasal swabs and 3-day supply antibiotics.
Wednesday,
The Postal Service arranges for environmental testing Brentwood.
10/17/01
GAO-04-205T Reopening the Brentwood Postal Facility
Date
Events Occurring That Date
Thursday, local hazardous materials response team conducts quick tests Brentwood, which are
negative for anthrax. contractor conducts more extensive testing the evening.
10/18/01
Postmaster General Potter holds press conference Brentwood, part reassure employees
they are low risk.
CDC confirms cutaneous anthrax New Jersey postal employee, and second suspected case
identified. NJ, the Trenton facility closed. Employees are sent home. NY, NYCDOH announces another case cutaneous anthrax, CBS employee. Florida, the Postal Service cleans two postal facilities contaminated with anthrax spores.
CDC distributes press release announcing that the Food and Drug Administration has approved
doxycycline for postexposure prophylaxis for anthrax. the DC, postal employee who works the Brentwood facility seeks medical attention.
Friday, 10/19/01 NJ, the NJDHSS refers postal employees their private physicians for medical treatment.
Employees begin seeking treatment local hospital. DC, postal employee who works Brentwood admitted hospital with suspected
inhalation anthrax. NJ, laboratory testing confirms cutaneous anthrax second postal employee who works the
Trenton postal facility.
Saturday,
10/20/01 DC, another postal employee who works the Brentwood facility admitted hospital with
respiratory condition.
CDC arrives the Brentwood facility meet with Postal Service management.
Sunday,
10/21/01 DC, the postal employee who was admitted the hospital 10/19/01 confirmed have
inhalation anthrax. DC, Brentwood closed. Evaluation and prophylaxis employees begin. DC, Brentwood employee who had initially sought medical attention 10/18/01 admitted hospital with suspected inhalation anthrax and becomes the first postal employee (and second
anthrax victim) die. DC, another postal employee who worked the Brentwood facility seeks medical attention
hospital. His chest X-ray initially determined normal, and discharged.
Monday,
10/22/01 DC, the postal employee who worked the Brentwood facility and who sought medical attention 10/21/01 and was discharged readmitted the hospital with suspected inhalation anthrax,
and becomes the second postal employee (and third anthrax victim) die. DC, prophylaxis expanded include all employees and visitors nonpublic areas the
Brentwood facility.
The postal employee who was admitted the hospital October confirmed have
inhalation anthrax.
The Postal Service learns that environmental tests Brentwood are positive for anthrax.
Sunday, NJ, postal employee Trenton confirmed have inhalation anthrax.
10/28/01
GAO-04-205T Reopening the Brentwood Postal Facility
Date
Events Occurring That Date
Monday, NY, preliminary tests indicate anthrax hospital employee who was admitted with suspected
inhalation anthrax 10/28/01. The hospital where she works temporarily closed, and NYCDOH
recommends prophylaxis for hospital employees and visitors.
10/29/01 NJ, laboratory testing confirms cutaneous anthrax woman who receives mail directly from
the Trenton facility. The woman originally sought medical attention 10/18/01 and was admitted the hospital 10/22/01 for skin condition. NJ, laboratory testing confirms second case inhalation anthrax, Trenton postal
employee who initially sought medical attention 10/16/01 and was admitted the hospital
10/18/01 with respiratory condition.
Wednesday, 10/31/01 NY, the hospital employee becomes the fourth anthrax victim die.
Friday, NY, NYCDOH announces another case cutaneous anthrax, New York Post employee.
11/2/01
Wednesday, 11/21/01 Connecticut, elderly woman, who was admitted the hospital for dehydration 11/16/01,
becomes the fifth anthrax victim die.
The Connecticut Department Public Health, consultation with CDC, begins prophylaxis for
postal employees working the Wallingford postal facility.
Friday,
CDC offers the anthrax vaccine postal employees.
12/27/01
Source: Information provided U.S. Postal Service, Centers for Disease Control and Prevention, Connecticut Department Public Health, D.C. Department Health, Food and Drug Administration,
Florida Department Health, New Jersey Department Health and Senior Services, New York City Department Health, and Office the Attending Physician the U.S. Congress.
(543082)
GAO-04-205T Reopening the Brentwood Postal Facility
This work the U.S. government and not subject copyright protection the
United States. may reproduced and distributed its entirety without further
permission from GAO. However, because this work may contain copyrighted images
other material, permission from the copyright holder may necessary you wish
reproduce this material separately.
GAO Mission
The General Accounting Office, the audit, evaluation and investigative arm
Congress, exists support Congress meeting its constitutional responsibilities
and help improve the performance and accountability the federal
government for the American people. GAO examines the use public funds;
evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance help Congress make informed
oversight, policy, and funding decisions. GAO commitment good government reflected its core values accountability, integrity, and reliability.
Obtaining Copies
GAO Reports and
Testimony
The fastest and easiest way obtain copies GAO documents cost
through the Internet. GAO Web site (www.gao.gov) contains abstracts and fulltext files current reports and testimony and expanding archive older
products. The Web site features search engine help you locate documents
using key words and phrases. You can print these documents their entirety,
including charts and other graphics.
Each day, GAO issues list newly released reports, testimony, and
correspondence. GAO posts this list, known Today Reports, its Web site
daily. The list contains links the full-text document files. have GAO e-mail
this list you every afternoon, www.gao.gov and select Subscribe e-mail
alerts under the Order GAO Products heading.
Order Mail Phone
The first copy each printed report free. Additional copies are each.
check money order should made out the Superintendent Documents.
GAO also accepts VISA and Mastercard. Orders for 100 more copies mailed
single address are discounted percent. Orders should sent to:
U.S. General Accounting Office
441 Street NW, Room
Washington, D.C. 20548 order Phone:  Voice:
TDD:
Fax:
(202) 512-6000
(202) 512-2537
(202) 512-6061 Report Fraud,
Waste, and Abuse
Federal Programs
Contact:
Public Affairs
Jeff Nelligan, Managing Director, NelliganJ@gao.gov (202) 512-4800
U.S. General Accounting Office, 441 Street NW, Room 7149
Washington, D.C. 20548
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 (202) 512-7470