2001 Anthrax Attacks

Description

Please discuss the prime suspect of the 2001 anthrax attacks and his relationship to the attacks. Tell me if you think he is responsible or if he is another Richard Jewell.

700-850 words, with 4 Acadamic sources

Sources MUST be used are attached and this website

https://www.judicialwatch.org/press-room/weekly-updates/32-main-suspect-2001-anthrax-attacks-commits-suicide/

Review of fall 2001 anthrax bioattacks
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Review of Fall 2001 Anthrax Bioattacks
(under construction)
compiled by Wm. Robert Johnston
last modified 17 March 2005
Summary:
From mid-September to November 2001, a number of anthrax-laced letters were mailed to
news media offices on the U.S. east coast and to the U.S. Congress. A total of 22
individuals contracted either cutaneous anthrax (11 cases) or inhalational anthrax (11 cases),
and 5 died (all from inhalational anthrax). Anthrax cases included individuals at targeted
locations (9 cases), postal service employees (9 cases), individuals who handled crosscontaminated mail (2 cases), and individuals with unpinpointed exposures (2 cases). An
additional case of cutaneous anthrax occurred in March 2002 due to laboratory exposure to
collected samples.
The anthrax employed in the letters was a common genetic strain and had been treated to
maximize its tendency to aerosolize. The genetic strain as well as the method of
weaponization suggest the perpetrator(s) had access to U.S. bioweapons research facilities.
The perpetrator (or perpetrators) remain unidentified, although the investigation came to
focus on a domestic source.
Background:
Anthrax is a bacterial disease caused by Bacillus anthracis. Three forms of exposure exist–cutaneous
(skin exposure), gastrointestinal (entering through the digestive system), and inhalation. Naturallyoccurring anthrax is generally contracted from infected livestock. Most modern natural cases of anthrax
are cutaneous. Inhalational anthrax has a higher case-fatality rate than the other two forms. Given the
relatively low LD-50 and the persistence of anthrax in the environment in the form of inert spores,
anthrax has been weaponized by several national bioweapons programs.
Most nations ceased offensive bioweapons research in accordance with the Biological Weapons
Convention treaty. The United States ceased its programs in 1970, but continued research for defensive
purposes. The Soviet Union continued a large-scale biowarfare program. In April 1979 an accidental
leak from a Soviet bioweapons production facility in the city of Sverdlovsk, Russia, resulted in an
anthrax outbreak which caused at 68 deaths (some reports suggest about 100 fatalities among 250 to 450
cases). In 1995 Iraq admitted to research and production of weaponized anthrax. Aum Shinrikyo, a
group which conducted terrorist attacks using sarin nerve gas in Tokyo in 1995, had engaged in research
and attempted use of anthrax but was apparently unsuccessful.
In the United States, anthrax is currently a rare disease. Prior to 2001, the last case of inhalational
anthrax in the United States was in 1976.
Cases: (incomplete)
Cases are discussed in groups by known or presumed exposure site, followed by table 1 listing all cases.
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Boca Raton, Florida: Robert Stevens, 63, a photo editor at the AMI tabloid newspaper Sun, died
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of inhalation anthrax. He was apparently exposed prior to departing on vacation 26 Sept. 2001 and
fell ill 30 Sept. Stephens was brought to JFK Medical Center in Palm Beach at 0230 on 2 Oct.;
four hours later he was comatose. Anthrax was suspected the same day by hospital staff and
confirmed by the CDC on 4 Oct. Stevens died the afternoon of 5 Oct. Tests found anthrax at AMI
offices at 5401 Broken Sound Blvd. in Boca Raton, FL; the building was subsequently
quarantined. Unconfirmed reports suggest that the source was a letter received in late Sept.
addressed to singer Jennifer Lopez. Two mailroom workers tested positive for exposure to
anthrax. One of these workers, E. Blanco, 73, was hospitalized and subsequently diagnosed with
inhalational anthrax 15 Oct.; he recovered and left the hospital about 24 Oct. Two hospitalized coworkers turned out to have pneumonia and recovered. On 13 Oct. five more employees were
found to have been exposed to anthrax. Traces of anthrax were found in a Boca Raton post office
on 15 Oct. and later in two additional post offices (in Boca Raton and Lake Worth). Two
suspected terrorists in the 11 Sept. attacks rented an apartment in Delray Beach from the wife of
the Sun’s editor, although this is believed coincidental.
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New York City, New York: A letter addressed to NBC news anchor Tom Brokaw contained
anthrax. E. O’Connor, the staff member who opened it (around 20 Sept.) contracted cutaneous
anthrax, becoming symtopmatic about 29 Sept. O’Connor saw a doctor on 1 Oct. who suspected
anthrax; she subsequently recovered. The letter was postmarked 18 Sept. from Trenton, NJ, and
contained a brown granular material. (Initial suspicion erroneously focused on a letter postmarked
20 Sept. from St. Petersburg, FL, accompanied by a white powder.) A police officer and two
laboratory technicians who handled the letter were exposed to spores, it was announced 14 Oct.
Anthrax was at one point suspected to have been spread to the Manhattan office of Governor
Pataki, but later tests discounted this.
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New York City, New York: The 7-month old son of an ABC employee has tested positive for
cutaneous anthrax, it was announced 15 Oct. The child recovered. It is suspected but not
established that the child was exposed in a visit to ABC offices on West 66th St. in New York
City on 28 Sept. The child was hospitalized shortly thereafter.
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New York City, New York: C. Fletcher, 27, a female staff member of CBS has developed
cutaneous anthrax from an unknown source, presumed to be a letter, it was announced 18 Oct.
The employee, an assistant to Dan Rather, has recovered. She is a British citizen.
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New York City, New York: J. Huden, 30, an employee of the New York Post, contracted
cutaneous anthrax; the source is unknown but is presumably a letter. She first noticed symptoms
on 22 Sept. and was prescribed antibiotics, but was not tested for anthrax until after Oct. 12. Two
other New York Post employees also developed cutaneous anthrax. A letter was recovered at this
location.
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Washington, DC, area: A letter addressed to Senate Majority Leader Tom Daschle tested
positive for anthrax. The letter was opened in his office in the Hart building across from the
Capitol in Washington, DC, on 15 Oct. About 40 staffers were in his office at the time; about 28
were found to have been exposed. The letter was postmarked 9 Oct. from Trenton, NJ, and
contained a white powder. The House of Representatives recessed on 17 Oct. for several days to
allow decontamination of office areas. During the period of recess contamination by anthrax was
found in several locations, including sites in the Hart office building. From 25-27 Oct. anthrax
contamination was found in the following sites: a CIA building; a building where White House
mail is processed; and a Supreme Court site. A media employee present at the Senate office
building when the original letter was opened was diagnosed with inhalation anthrax around 26
Oct., but later concluded not to have anthrax.
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Two Washington postal workers died of inhalation anthrax on 22 Oct.: Joseph P. Curseen, 47, and
Thomas L. Morris, Jr., 55: on 21 Oct. a postal worker from Washington’s Brentwood postal
facility went to the emergency room of an area hospital and was sent home diagnosed with the flu;
on 22 Oct. he was brought back by ambulance. Both this individual and another Brentwood postal
worker hospitalized the morning of 22 Oct. died later that day. Two other workers are confirmed
by 23 Oct. to have inhalation anthrax (one 35-year old male who handles mail and one 41-year old
female postal union official), with 9 others showing possible symptoms.
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Trenton area, New Jersey: On 18 Oct. two postal workers in New Jersey were reported to have
cutaneous anthrax. One was a female letter carrier at the West Trenton post office in Ewing, NJ,
who developed symptoms on 27 Sept. The other was a 35-year old man who is a letter sorter in
Hamilton, NJ. These exposures presumably represent contact with letters mailed from this
location. On 23 Oct. a female postal worker from Trenton is reported to have inhalation anthrax.
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Virginia: One employee of the State Department, a mail handler, developed anthrax.
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New York City, New York: Kathy Nguyen, a hospital supply worker, developed anthrax and
died 31 Oct. 2001. The source of her exposure was never identified. The subway system in New
York City was tested extensively following identification of her case but with negative results.
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Oxford, Connecticut: Ottilie Lundgren, a retired 94-year-old woman, died of inhalation anthrax
on 21 Nov. 2001. Investigation eventually indicated that she was exposed through crosscontamination of mail. One of the anthrax letters mailed to Congress passed through a postal
sorting machine 20 seconds before a letter addressed to a location 6 km from Lundgren’s
residence. This letter was presumably the letter mailed 9 Oct. to Senator Leahy which was
misdirected and was discovered 16 Nov. in isolated mail. The local post office handling
Lundgren’s mail was found contaminated by anthrax.
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Houston(?), Texas: An unnamed laboratory worker developed cutaneous anthrax in March 2002.
The lab was among a large number of labs enlisted to process anthrax samples in conjunction with
response to the bioattacks. The worker handled anthrax samples without gloves, causing infection
through a cut.
Table 1: Cases of anthrax associated with fall 2001 bioterrorism
CDC
case
#
name *
onset
lab
age sex
diagnosis
race
type
exposure
site
letter
1
J. Huden
9/22/01
10/19/01
31
F
white
C
NY Post,
New York
City, NY
5
2
E. O’Conner
9/25/01
10/12/01
38
F
white
C
NBC, New
York City,
NY
2
C
? (USPS,
?
Hamilton,
New Jersey)
3
R. Morgano
9/26/01
10/18/01
39
M
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white
statu
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4
E. Blanco
9/28/01
10/15/01
73
M
hispanic I
AMI, West
Palm Beach, 1
FL
5
T. Heller
9/28/01
10/18/01
45
F
white
C
USPS,
Hamilton,
NJ
1//5C
6
C.
9/28/01
Chamberlain
10/12/01
23
F
white
C
NBC, New
York City,
NY
2
3
7
anonymous
9/29/01
10/15/01
0.6
M
white
C
ABC, New
York City,
NY
8
Robert
Stevens
9/30/01
10/4/01
63
M
white
I
AMI, West
Palm Beach, 1
FL
9
C. Fletcher
10/1/01
10/18/01
27
F
white
C
CBS, New
York City,
NY
4
10
P.
O’Donnell
10/14/01 10/19/01
35
M
white
C
USPS,
Hamilton,
NJ
6/7-C
11
N. Wallace
10/14/01 10/28/01
56
F
black
I
USPS,
Hamilton,
NJ
6/7-C
I
USPS,
Hamilton,
NJ
6/7-C
I
USPS
Brentwood,
6-C
Washington,
DC
I
USPS
Brentwood,
6-C
Washington,
DC
died
10/22/
I
USPS
Brentwood,
6-C
Washington,
DC
died
10/22/
12
J. Patel
13
L.
Richmond
14
Thomas
Morris, Jr.
15
Joseph
Curseen
10/15/01 10/29/01
10/16/01 10/21/01
10/16/01 10/23/01
10/16/01 10/26/01
43
56
55
47
F
M
M
M
Asian
black
black
black
died
10/5/0
USPS
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16
anonymous
10/16/01 10/22/01
56
M
black
I
Brentwood,
Washington, 6-C
DC
17
L. Burch
10/17/01 10/29/01
51
F
white
C
? (New
Jersey)
?
5
18
anonymous
10/19/01 10/22/01
34
M
hispanic C
NY Post,
New York
City, NY
19
D. Hose
10/22/01 10/25/01
59
M
white
I
State Dept.,
Alexandria,
VA
6-C
20
M.
10/23/01 10/28/01
Cunningham
38
M
white
C
NY Post,
New York
City, NY
5
21
Kathy
Nguyen
10/25/01 10/30/01
61
F
Asian
I
? (New
York City,
NY)
?
22
Ottilie
Lundgren
11/14/01 11/21/01
94
F
white
I
(residence,
7-C
Oxford, CT)
C
laboratory
(UTHSC?),
Houston?,
TX
23
anonymous
3/1/02
3/5/02
?
M
?
died
10/31/
died
11/21/
1//7L
* Notes to table: several survivors have chosen not to be publically identified; those
survivors that have chosen to be publically identified are listed here only by first initial and
last name. Type of anthrax case is cutaneous (C) or inhalation (I). Number of letter of
known or presumed exposure is identified in table 2; “-C” indicated cross-contamination,
not direct exposure, from that letter. This table is based pricipally on Jernigan et al. (2001)
(excepting names of individuals).
Source letters: (incomplete)
Only four letters used for the anthrax attacks were recovered by investigators. At least three additional
letters are presumed based on sites where cases developed. Two known letters (and the three presumed
letters) were mailed on 18 Sept. to news media offices in Florida (1) and New York City (4). Two
known letters were mailed on 9 Oct. to the Washington, DC, offices of Senators Daschle and Leahy (the
Leahy letter never reached its destination). The anthrax in the 9 Oct. letters was more readily
aerosolized, with the result of multiple anthrax cases (some fatal) among postal employees.
Table 2: Known and presumed anthrax letters
letter date mailed date recovered
target
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resulting cases (by CDC #)
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1
9/18/01
no
AMI, FL
4, 8
2
9/18/01
(9/20/01)
NBC, NY
2, 6
3
9/18/01
no
ABC, NY
7
4
9/18/01
no
CBS, NY
9
5
9/18/01
(9/22/01)
NY Post, NY 1, 18, 20
6
10/9/01
10/15/01
Daschle, DC
13, 14, 15, 16
7
10/9/01
11/16/01
Leahy, DC
19, 22
5
10, 11, 12
unknown
3, 17, 21
Anthrax origin: (incomplete)
Perpetrator: (incomplete)
Other reports:
A letter to a doctor in a foreign country tested positive for anthrax. CDC genetic typing found that this
anthrax was a different strain from those used in the domestic attacks. The CDC report only identifies
the country as “Country B”. This is probably the letter received by a doctor in Chile, carrying a Florida
return address but postmarked from Switzerland. Based on the genetic typing this is not related to the
U.S. attacks.
On 19 Oct. 2001 authorities had reported that a travel brochure received by a family in Buenos Aires,
Argentina, tested positive for anthrax. The letter was mailed from Miami, FL. This may have later been
proven false.
A number of additional letters were initially reported to contain anthrax, but were found not to contain
anthrax after further testing. This includes: a letter to a Microsoft facility in Reno, NV, mailed from
Malaysia; one to the New York Times building in New York City; one to a New York Times office in
Brasilia, Brazil; one to a doctor in Nairobi, Kenya, mailed from Atlanta, GA.
Response: (incomplete)
The total cost of the anthrax bioattacks was certainly over $1 billion. Decontamination of the Senate
office building, conducted by the EPA, cost $23 million. Decontamination of the Brentwood postal
facility cost $130 million. Decontamination of the Hamilton postal facility was not completed until
March 2005. Through 2002, the U.S. Postal Service had received $700 million in funding for
decontamination of facilities, health care, and procurement of irradiation equipment for irradiating mail.
Additional uncounted costs at local levels include cleanup and response to false alarms over “white
powder” of household origin, and lost productivity associated with resultant work stoppages.
References:
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Barakat, L. A., et al., 20 Feb. 2002, “Fatal inhalational anthrax in a 94-year-old Connecticut
woman,” Journal of the American Medical Association, 287:893-898.
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Centers for Disease Control, 12 Oct. 2001, “Notice to readers: Ongoing investigation of anthrax-Florida, October 2001,” Morbidity and Mortality Weekly Report, 50(40):877.
Centers for Disease Control, 19 Oct. 2001, “Notice to readers: Investigation of anthrax associated
with intentional exposure and interim public health guidelines, October 2001,” Morbidity and
Mortality Weekly Report, 50(41):889-893.
Centers for Disease Control, 26 Oct. 2001, “Update: Investigation of bioterrorism-related anthrax
and interim guidelines for exposure management and antimicrobial therapy, October 2001,”
Morbidity and Mortality Weekly Report, 50(42):909-919.
Centers for Disease Control, 2 Nov. 2001, “Update: Investigation of bioterrorism-related anthrax
and interim guidelines for clinical evaluation of persons with possible anthrax,” Morbidity and
Mortality Weekly Report, 50(43):941-948.
Centers for Disease Control, 9 Nov. 2001, “Update: Investigation of bioterrorism-related anthrax
and adverse events from antimicrobial prophylaxis,” Morbidity and Mortality Weekly Report, 50
(44):973-976.
Centers for Disease Control, 16 Nov. 2001, “Update: Investigation of bioterrorism-related anthrax,
2001,” Morbidity and Mortality Weekly Report, 50(45):1008-1010.
Centers for Disease Control, 30 Nov. 2001, “Update: Investigation of bioterrorism-related
inhalational anthrax–Connecticut, 2001,” Morbidity and Mortality Weekly Report, 50(47):10491051.
Centers for Disease Control, 21 Dec. 2001, “Notice to readers: Additional options for preventive
treatment for persons exposed to inhalational anthrax,” Morbidity and Mortality Weekly Report,
50(50):1142, 1151.
Centers for Disease Control, 5 Apr. 2002, “Suspected cutaneous anthrax in a laboratory worker-Texas, 2002,” Morbidity and Mortality Weekly Report, 51(13):279-281.
Federal Bureau of Investigation, 9 Nov. 2001, “Amerithrax Press Briefing,” FBI, on line
[http://www.fbi.gov/anthrax/amerithrax.html].
Freedman, A., et al., 20 Feb. 2002, “Cutaneous anthrax associated with microangiopathic
hemolytic anemia and coagulopathy in a 7-month-old infant,” Journal of the American Medical
Association, 287:869-874.
Graysmith, Robert, 2003, Amerithrax: The Hunt for the Anthrax Killer, Berkley Books (New
York, NY).
Guillemin, Jeanne, 1999, Anthrax: The Investigation of a Deadly Outbreak, Univ. of California
Press (Berkeley, CA).
Gursky, Elin, Thomas V. Inglesby, and Tara O’Toole, 2003, “Anthrax 2001: Obervations on the
medical and public health response,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice,
and Science, 1:97-110.
Hoffmaster, Alex R., Collette C. Fitzgerald, Efrain Ribot, Leonard W. Mayer, and Tanja Popovic,
Oct. 2002, “Molecular subtyping of Bacillus anthracis and the 2001 bioterrorism-associated
anthrax outbreak, United States,” Emerging Infectious Diseases, 8:1111-1116.
Inglesby, Thomas V., et al., 12 May 1999, “Anthrax as a biological weapon: Medical and public
health management,” Journal of the American Medical Association, 281:1735-1745.
Inglesby, Thomas V., et al., 1 May 2002, “Anthrax as a biological weapon, 2002: Updated
recommendations for management,” Journal of the American Medical Association, 287:22362252.
Jernigan, Daniel B., et al., and the National Anthrax Epidemiologic Investigation Team, Oct.
2002, “Investigation of bioterrorism-related anthrax, United States, 2001: Epidemiologic
findings,” Emerging Infectious Diseases, 8:1019-1028.
Mina, B., et al., 20 Feb. 2002, “Fatal inhalational anthrax with unknown source of exposure in a
61-year-old woman in New York City,” Journal of the American Medical Association, 287:858862.
Rosenberg, Barbara Hatch, 22 Sept. 2002, “The anthrax attacks,” Federation of American
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Scientists, on line [http://www.fas.org/], accessed Sept. 2002.
Thompson, Marilyn W., 2003, The Killer Strain: Anthrax and a Government Exposed,
HarperCollins (New York, NY).
various news reports (print, broadcast, and on line), Sept.-Nov. 2001.
© 2001, 2005 by Wm. Robert Johnston.
Last modified 16 March 2005.
Return to Home. Return to Terrorism, Counterterrorism, and Unconventional Warfare.
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9/5/2006
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
October 2003
BIOTERRORISM
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.
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
1
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
21
31
32
Timeline of Selected Key Events in the Anthrax
Incidents
34
Appendix II
Comments from the Department of Defense
37
Appendix III
Comments from the Department of Health and
Human Services
39
GAO Contact and Staff Acknowledgments
41
GAO Contact
Acknowledgments
41
41
Appendix I
Appendix IV
Related GAO Products
4
5
10
42
Table
Table 1: People with Anthrax Infections, Letters Containing
Anthrax Spores, and Facilities Contaminated with Anthrax
Spores in the Six Epicenters
Page i
10
GAO-04-152 Public Health Response to Anthrax Incidents
Abbreviations
AHRQ
AMI
CDC
DOD
EIS
EOC
EPA
Epi-X
FBI
FDA
FEMA
HAN
HHS
MMWR
NIH
USAMRIID
Agency for Healthcare Research and Quality
American Media Inc.
Centers for Disease Control and Prevention
Department of Defense
Epidemic Intelligence Service
Emergency Operations Center
Environmental Protection Agency
Epidemic Information Exchange
Federal Bureau of Investigation
Food and Drug Administration
Federal Emergency Management Agency
Health Alert Network
Department of Health and Human Services
Morbidity and Mortality Weekly Report
National Institutes of Health
United States Army Medical Research Institute of
Infectious Diseases
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Page ii
GAO-04-152 Public Health Response to Anthrax Incidents
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
1
Anthrax 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.
2
In 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.
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GAO-04-152 Public Health Response to Anthrax Incidents
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
3
In 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.
4
U.S. General Accounting Office, Bioterrorism: Preparedness Varied across State and
Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7, 2003).
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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
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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
5
For 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.
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
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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.
6
An antimicrobial medication either kills or slows the growth of microbes.
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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.
7
A 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.
8
An epidemiologist is a specialist in the study of how disease is distributed in populations
and the factors that influence or determine this distribution.
9
Disease surveillance systems provide for the ongoing collection, analysis, and
dissemination of health-related data to identify, prevent, and control disease.
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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.
10
Public 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.
11
At the time of the anthrax incidents, the Strategic National Stockpile was known as the
National Pharmaceutical Stockpile.
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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
12
HAN 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.
13
Epi-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.
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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
Epicenters
Florida
Cutaneous
anthrax
Inhalational
anthrax
0
2
Letter
recovered
within
epicenter
Contaminated
facilities
No
Yes
New York
7
1
Yes
Yes
New Jersey
4
2
Noa
Yes
Capitol Hill
0
0
Yes
Yes
a
Washington, D.C.,
regional area
0
5
No
Yes
Connecticut
0
1
No
Yes
Source: CDC.
a
Although 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
Identified Strengths in
Their Responses as
Well as Areas for
Improvement
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.
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Local and State Public
Health Officials Relied on
Plans for Coordinating
with a Wide Range of
Entities and Identified
Areas for Improvement
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.
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 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
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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.
Some Aspects of Response
Plans Had Been Made
Operational and Increased
Officials’ Ability to Coordinate
a Rapid Response
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,
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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 Emergencies
Allowed Officials to Identify
Areas for Improvement in Their
Plans
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
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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
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
Response Agencies Was
Generally Viewed as Effective
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,
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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.
Flow of Information to
Clinicians Was Problematic
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
Criminal Investigation
Sometimes Hindered Flow of
Information to Officials and the
Public
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
Supplying Information to Meet
Needs of Media and Local
Public Was Challenging
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.
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
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GAO-04-152 Public Health Response to Anthrax Incidents
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
Laboratories Handled Huge
Volumes of Samples, and Some
Were Underequipped to Do So
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.
14
The 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.
Page 20
GAO-04-152 Public Health Response to Anthrax Incidents
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.
Experience Showed
Aspects of Federal
Preparedness That
Could Be Improved
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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.
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GAO-04-152 Public Health Response to Anthrax Incidents
CDC Experienced
Difficulty Serving as Focal
Point for Communicating
Critical Information during
Response to Anthrax
Incidents
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 Had Difficulty Managing
the Influx of Information to
Produce and Disseminate
Guidance Rapidly
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
15
These agents, which are labeled Category A agents, are anthrax, botulism, plague,
smallpox, tularemia, and viral hemorrhagic fevers.
Page 24
GAO-04-152 Public Health Response to Anthrax Incidents
information and associated internal communication problems were
complicated by its concurrent responsibility for coordinating the day-today 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
Page 25
GAO-04-152 Public Health Response to Anthrax Incidents
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 timeconsuming. 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.
CDC Had Difficulty Conveying
Information to Media and
Public
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
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GAO-04-152 Public Health Response to Anthrax Incidents
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. Sinc…
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