The Lessons of Anthrax Autumn

On Sept. 18, 2001, at least four letters containing anthrax spores were mailed from Trenton, NJ, through the US Postal Service (USPS) system to three major television networks, The New York Post and The National Enquirer newspaper. The last letter was forwarded to the paper’s new address in Fort Lauderdale, Fla. A second batch was mailed from Trenton, NJ, on Oct. 9 to two Democratic senators.
All told, 22 people were infected by the mailings—11 from inhalation anthrax, an often-fatal form of the disease, and 11 from cutaneous anthrax, a readily treatable form. Nine of the 22 who were infected were postal employees, including two of five individuals who died from having inhaled the purified anthrax spores.
At the time, it wasn’t clear whether USPS was being used to launch a massive bioterror attack on the United States or not. But what was clear was the potential to use the postal system to do just that.
The crisis was further exacerbated by a lack of critical information needed to accurately assess the health risk to postal employees. For example, officials from USPS, the Centers for Disease Control and Prevention (CDC) and other public health agencies acknowledged that, early on, they had little knowledge of the characteristics and properties of refined anthrax; the potential for anthrax spores to leak from taped, sealed envelopes; or the effects of these factors on individuals’ health. Public health officials, for example, told Congress’ watchdog agency, the General Accountability Office (GAO), that until the first cases of anthrax were confirmed to be postal employees, there was no evidence that anyone handling unopened mail would be at risk of contracting inhalation anthrax.
USPS responded to this crisis by testing and closing two heavily contaminated processing and distribution centers – the Trenton facility in Hamilton, NJ, and the Brentwood facility in Washington, DC. Testing also identified contamination at 21 other postal facilities, including three processing and distribution facilities in West Palm Beach, Fla., New York City and Wallingford, Conn.
Brentwood was decontaminated and renovated and fully operational as of Dec. 22, 2003. Trenton also has been decontaminated and, as of this writing, was expected to reopen in February 2005. Contaminated areas in the three other processing and distribution centers were isolated and decontaminated, while operations continued elsewhere in the centers.
Last September, the GAO issued a report, Better Guidance Is Needed to Ensure an Appropriate Response to Anthrax Contamination, that summed up the USPS’ response to the anthrax attack, and outlined initiatives the Postal Service—and even other federal agencies—should take in the event of another bioterror attack using the mail.
“According to postal managers, public health officials and union representatives, the Postal Service considered the health risks to its employees ahead of its mission to deliver the mail in deciding whether to close postal facilities,” GAO reported. However, GAO found that, while “the Postal Service had guidance that called for closure following the discovery of a suspicious letter or a powder spill at a facility, it did not consider thisguidance applicable because neither a suspicious letter nor a powder spill was discovered at Trenton or Brentwood. As a result, the Postal Service relied on public health agencies to assess the health risks to its employees, and as long as these agencies advised the Postal Service that the health risks were minimal, it kept the facilities open.”
It wasn’t until the CDC confirmed that employees at Trenton and Brentwood had contracted cutaneous and inhalation anthrax that USPS closed these facilities—within hours.
GAO determined that “critical information that could have alerted public health agencies and the Postal Service to the health risks that postal employees faced, such as the way the spores were prepared and the potential for anthrax spores to leak from taped, unopened envelopes in sufficient quantities to cause inhalation anthrax, was not available to them until after Brentwood’s closure. According to CDC and the Postal Service, they would have made different decisions if they had understood the health risks to postal employees earlier.”
The hunt
Within a month of the anthrax attacks, the USA PATRIOT Act was passed by an admittedly frightened Congress. Although the FBI was given broad new powers to hunt down terrorists, the government’s search for the person or persons who mailed the anthrax-contaminated letters is still ongoing three years later.
The FBI has investigated a number of people it officially considered “persons of interest,” but has been unable to make a case against any of them. Today, the FBI has come up against a brick wall. FBI Assistant Director Michael Mason suggested last year that the case might never be solved.
According to the FBI, the “proposed suspect is an adult male loner with scientific training who is a non-confrontational person, at least in his public life. He lacks the personal skills necessary to confront others. … He may hold grudges for a long time, vowing that he will get even with ‘them’ one day.”
In an effort to stimulate the case, the USPS and the FBI are offering a $2 million reward leading to the arrest and conviction of those responsible for mailing the four anthrax letters.
Further complicating the bureau’s investigation has been its inability to re-create the process that was used to produce the spores used in the attacks. What the FBI has determined, however, is that the anthrax used in the attacks almost certainly had to have originated from USAMRIID or USAMRIID samples given to Dugway Proving Grounds in Utah and/or Porton Downs in Britain. The Defense Department was forced to concede during the anthrax probe that it had been experimenting with weaponized anthrax.
Not surprisingly, certain avenues of investigation by federal authorities have been impeded because of “closely held military secrets.” ABC News reported that “federal investigators” told it “that military and intelligence agencies have withheld a full listing of all facilities and all employees dealing with top-secret anthrax programs where important leads could be found.”
The Washington Post reported that “more than a dozen experts suggest investigators should ‘reexamine the possibility of state-sponsored terrorism, or try to determine whether weaponized spores may have been stolen by the attacker from an existing, but secret, biodefense program or perhaps given to the attacker by an accomplice.’”
The FBI’s hunt for the anthrax attacker—or attackers — continues … HST
GAO reports cited in this article:
Better Guidance Is Needed to Ensure an Appropriate Response to Anthrax Contamination http://www.gao.gov/highlights/d04239high.pdf.
Issues Associated with Anthrax Testing at the Wallingford Facility
http://www.gao.gov/highlights/d03787thigh.pdf.
Clear Communication with Employees Needed before Reopening the Brentwood Facility http://www.gao.gov/highlights/d04205thigh.pdf.
Bioterrorism: Public Health Response to AnthraxIncidents of 2001
http://www.gao.gov/new.items/d04152.pdf.

The Lessons of Anthrax
The response to the anthrax attacks yielded two key lessons.
Lesson 1: Save life
“First, it is important for agencies to err on the side of caution—meaning that agencies should choose a course of action that poses the least risk of harm to individuals—when considering actions to protect people from uncertain and potentially life-threatening health risks,” GAO concluded.
But “because public health officials underestimated the health risks involved and did not communicate any uncertainty associated with the inferences they made based on scientific knowledge and experience, actions to protect postal employees were delayed,” GAO stated. “Furthermore, existing guidance did not addresscertain circumstances, such as the unobservable contamination that the Postal Service faced at the Trenton and Brentwood facilities in 2001.”
The Postal Service twice revised its guidance to address some of the circumstances it faced, but GAO found that the most recent guidance issued in December 2003 failed to define some key terms, including those that would trigger a decision to evacuate a facility; outdated references that could cause confusion during a future response; and failure to address some of the circumstances that the Postal Service faced and could face again, such as what steps would be taken in the period between a diagnosis of inhalation anthrax in a postal employee and confirmation of the disease.
As GAO pointed out, “the Postal Service communicated information to affected postal employees about the health risks posed by, and the extent of, anthrax contamination at the five facilities in GAO’s review, but problems with accuracy, clarity and timeliness led employees to question the information they received. Problems with accuracy stemmed from incomplete information about health risks, and problems with clarity occurred as information on the medical response to anthrax contamination changed with experience. Problems with timeliness occurred when the Postal Service delayed the release of quantitative data (anthrax spore counts) for one facility, in part because it was uncertain what the results meant for worker safety and public health. To communicate more effectively, the Postal Service has established a center to coordinate information within the postal system and has worked with other agencies to develop guidelines for responding to anthrax.”
However, GAO pointed out in its latest report, the USPS’ “revised guidance does not reflect the proactive measures that the Postal Service has recently taken, such as closing 11 postal facilities in November 2003 after a preliminary test—not a confirmed result—from a routine air sample at a US Navy mail-processing facility indicated the possibility of anthrax contamination.”
The uncertainty of health risk information demonstrated by the gap between what public health agencies knew about anthrax and what they learned over time pointed to a need for agencies to err on the side of caution when considering actions to protect people in uncertain and potentially life-threatening situations.
The Commander of the US Army Medical Research Institute of Infectious Diseases (USAMRIID) noted in testimony before a subcommittee of the House Committee on Government Reform in May 2003 that there is “still much to be learned about the effects of this agent [anthrax] under conditions different from those encountered during natural outbreaks.” In particular, he said, the health effects of aerosolized anthrax spores on human populations are poorly understood, and there is no scientific consensus on the lethal dose for humans.
Thus, any level of contamination could potentially harm some individuals. Consequently, USAMRIID has advised agencies to initially err on the side of caution “in the absence of surety” while taking full advantage of all available expertise to formulate a future long-term response. In addition,due to such factors as limitations in testing methods and the uncertainty of the anthrax dose necessary to cause infection, representatives from the Environmental Protection Agency and the US Army’s Dugway Proving Ground have also indicated the advisability of taking a cautious approach when dealing with anthrax.
Lesson 2: Share information
“The second key lesson [learned],” GAO found, “is that agencies need to share information in a timely manner. Collocating liaisons from CDC and the Postal Inspection Service with FBI headquarters officials—who were in charge of the investigation—facilitated timely information sharing. Nevertheless, agencies reported that information was not always shared within and among public health agencies and the Postal Service. Several factors may have hindered theprompt exchange of information, including unclear responsibilities for decision making and postal employees’ distrust of postal management.”
GAO reported that “agencies have taken steps to improve information sharing. Additionally, the Postal Service is working with the Department of Homeland Security and other entities responsible for dealing with terrorist activity to formulate government wide policies and procedures for, among other things, paying for emergency medical services. While these policies and procedures should help avoid future confusion about such matters as where employees should go for emergency medical services and who will pay for them, it is not known when they will be available. As a result, if another emergency arises in the interim, confusion—such as occurred in New Jersey—could again cause delays in payments to providers and/or disputes over payments.”
After reviewing the draft report, USPS officials agreed with the thrust of GAO’s recommendations. For example, the Postal Service said that it either had revised or would revise and clarify its guidance. The Postal Service also said that it was taking alternative action to address GAO’s recommendation about the need for policies and procedures for paying providers of emergency medical services. Finally, although the Postal Service said that GAO concluded that its decisions in 2001 were appropriate under the circumstances, GAO did not draw conclusions on this issue.
“As stated in our report, our first objective was to describe the factors considered in deciding whether to close the five postal facilities and the actions taken to protect postal employees—not to assess the appropriateness of the Postal Service’s actions and decisions,” GAO stated.
For its part, CDC provided detailed written comments to clarify portions of GAO’s draft report. CDC objected to GAO’s use of the term “assumptions” to describe how it arrived at its public health recommendations. CDC noted that its recommendations were based on the best available science, as well as its “inferences from previous experience and [its] epidemiological observations in Florida and New York, where no disease occurred among postal workers.”
Consequently, GAO revised its report to more clearly describe the limitations of available knowledge and experience in the fall of 2001 and how these limitations led to the development of incorrect inferences and working assumptions about the health risk to postal employees.
While some outstanding issues continue to linger around the Postal Service’s post-anthrax emergency response plan, GAO officials believe USPS is well on its way to clearing them up. Similarly, the attack and response has caused the CDC and other public health agencies—state, local and federal—to reassess longstanding presumptions about anthrax exposure and the measures necessary to address contact with this potentially lethal bug.

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