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Report to the Honorable Bill Frist, Majority Leader, U.S. Senate:

United States General Accounting Office:

GAO:

October 2003:

Bioterrorism:

Public Health Response to Anthrax Incidents of 2001:

GAO-04-152:

GAO Highlights:

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

Why GAO Did This Study:

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 nationís 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.

What GAO Found:

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 CDCís 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 agencyís 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.

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.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

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

Experience Showed Aspects of Federal Preparedness That Could Be 
Improved:

Concluding Observations:

Agency Comments:

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

Appendix II: Comments from the Department of Defense:

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

Appendix IV: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Related GAO Products:

Table:

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

Abbreviations:

AHRQ: Agency for Healthcare Research and Quality:  

AMI: American Media Inc.:  

CDC: Centers for Disease Control and Prevention: 
 
DOD: Department of Defense:  

EIS: Epidemic Intelligence Service:  

EOC: Emergency Operations Center:  

EPA: Environmental Protection Agency:  

Epi-X: Epidemic Information Exchange:  

FBI: Federal Bureau of Investigation:  

FDA: Food and Drug Administration: 
 
FEMA: Federal Emergency Management Agency:  

HAN: Health Alert Network:  

HHS: Department of Health and Human Services:  

MMWR: Morbidity and Mortality Weekly Report:  

NIH: National Institutes of Health:  

USAMRIID: United States Army Medical Research Institute of Infectious 
Diseases:

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.[Footnote 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;[Footnote 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 
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,[Footnote 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,[Footnote 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 
to the anthrax incidents in localities that were not epicenters. To 
study federal public health efforts, we interviewed officials from the 
Department 
of Defense (DOD) and HHS. These officials included representatives from 
DOD's Armed Forces Institute of Pathology, Chemical Biological Incident 
Response Force, Naval Medical Research Center, and U.S. Army Medical 
Research Institute of Infectious Diseases (USAMRIID), and from HHS's 
Agency for Healthcare Research and Quality (AHRQ), CDC, Food and Drug 
Administration (FDA), National Institutes of Health (NIH), and Office 
of the Assistant Secretary for Public Health Emergency Preparedness. To 
determine the nature of the information provided by CDC during the 
incidents, we examined the materials that CDC disseminated during 
October 2001 through December 2001. For overall assessments of and 
information on the local, state, and federal public health response, we 
interviewed members of the academic community and officials of private 
organizations representing groups affected by the incidents or involved 
in the response, including the American Hospital Association, the 
American Medical Association, the American Nurses Association, the 
American Postal Workers Union, the American Public Health Association, 
and the District of Columbia Hospital Association. We also reviewed 
media reports of the incidents from television news services and 
newspapers, retrospective analyses of the response published after the 
incidents, relevant congressional hearings that were held between 
October 2001 and December 2001, and materials provided to us by local, 
state, and federal agencies and private organizations involved in 
responding to the attack. To understand the scientific community's 
analysis of the anthrax incidents, we searched the scientific 
literature using the National Library of Medicine's PubMed service and 
reviewed relevant articles. To determine what was learned from the 
experience that could help improve public health preparedness for 
bioterrorism, we analyzed these materials for common themes. We focused 
on what could be learned from the anthrax incidents that could help 
improve public health preparedness not specifically for anthrax or any 
particular locality but for bioterrorism in general. To determine what 
steps have been taken to make those improvements, we reviewed materials 
from relevant federal agencies through October 2003. Although efforts 
to decontaminate affected facilities are part of the public health 
response, they are outside the scope of this report, as is the criminal 
investigation associated with the incidents.[Footnote 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 rapidly unfolding anthrax incidents. CDC has acknowledged that 
although it was effective in its more traditional capacity of 
supporting local response efforts, it was not fully prepared to manage 
the federal public health response. CDC served as the focal point for 
communicating critical information during the response to the anthrax 
incidents and experienced difficulty in managing the voluminous amount 
of information coming into the agency and in communicating with public 
health officials, the media, and the public. In addition to straining 
CDC's resources, the anthrax incidents highlighted both shortcomings in 
the clinical tools available for responding to anthrax, such as 
vaccines and drugs, and a lack of training for clinicians on how to 
recognize and respond to anthrax.

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

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

Background:

Anthrax:

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

Anthrax infection can take one of three forms: cutaneous, usually 
through a cut or an abrasion; gastrointestinal, usually by ingesting 
undercooked contaminated meat; or inhalational, by breathing airborne 
anthrax spores into the lungs. After the spores enter the body through 
any of these routes, they germinate into bacteria, which then multiply 
and secrete toxins that can produce local swelling and tissue death. 
The symptoms are different for each form and usually occur within 7 
days of exposure. Depending on the extent of exposure and its form, a 
person can be exposed to Bacillus anthracis without developing an 
infection. There are several methods for detecting anthrax spores or 
the disease itself, for example, nasal swabs for exposure to spores, 
blood tests for infections, and wet swabs for environmental 
contamination. CDC does not recommend the use of the nasal swab test to 
determine whether an individual should be treated, primarily because a 
negative result (no spores detected) does not exclude the possibility 
of exposure. Confirmation of anthrax infection or the presence of 
anthrax spores can require more than one type of test. The disease can 
be treated with a variety of antimicrobial medications and is not 
contagious.[Footnote 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.

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 laboratorians[Footnote 7] to test for possible exposures 
and identification of illnesses. Epidemiologists[Footnote 8] in the 
health departments would use the disease surveillance systems[Footnote 
9] 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.

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.[Footnote 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.[Footnote 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. 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)[Footnote 12] and Epidemic Information Exchange (Epi-X)[Footnote 
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 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:

Epicenters: Florida; Number of infected people: Cutaneous anthrax: 0; 
Number of infected people: Inhalational anthrax: 2; Letter 
recovered within epicenter: No; Contaminated facilities: Yes.

Epicenters: New York; Number of infected people: Cutaneous anthrax: 7; 
Number of infected people: Inhalational anthrax: 1; Letter 
recovered within epicenter: Yes; Contaminated facilities: Yes.

Epicenters: New Jersey; Number of infected people: Cutaneous anthrax: 
4; Number of infected people: Inhalational anthrax: 2; Letter 
recovered within epicenter: No[A]; Contaminated facilities: Yes.

Epicenters: Capitol Hill; Number of infected people: Cutaneous anthrax: 
0; Number of infected people: Inhalational anthrax: 0; Letter 
recovered within epicenter: Yes; Contaminated facilities: Yes.

Epicenters: Washington, D.C., regional area; Number of infected people: 
Cutaneous anthrax: 0; Number of infected people: Inhalational anthrax: 
5; Letter recovered within epicenter: No[A]; Contaminated 
facilities: Yes.

Epicenters: Connecticut; Number of infected people: Cutaneous anthrax: 
0; Number of infected people: Inhalational anthrax: 1; Letter 
recovered within epicenter: No; Contaminated facilities: 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.

[End of table]

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.

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 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, 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 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, 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 
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 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.

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

Response Capacity Was Strained and Would Have Been Difficult to 
Sustain:

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

Public Health Workers Were Overwhelmed with Work:

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

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

Some borrowed workers had to be trained for their new duties while the 
incidents were ongoing. Some workers had to be trained or cross-trained 
in two fields, requiring additional time from other staff and resources 
from the department. Some borrowed staff had to be trained for the 
specific tasks required by the incidents. Finding sufficient numbers of 
people who were appropriately trained or could be efficiently trained 
to staff the telephone hotlines effectively was also a challenge. Local 
officials 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 Network[Footnote 14] 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.

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

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

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

In addition to playing its traditional role of supporting local and 
state public health departments, CDC also was confronted with the 
challenge of coordinating the public health activities of multiple 
federal agencies involved in the response, a task for which it 
acknowledged it was not wholly prepared. CDC described having to create 
an ad hoc emergency response center in an auditorium from which to 
manage the federal public health response, which involved numerous 
agencies. These included FDA, which, among other activities, provided 
guidance on treatment and addressed drug and blood safety issues. In 
addition, NIH provided scientific expertise on anthrax. CDC also 
coordinated with federal agencies working on the environmental and law 
enforcement aspects of the response efforts. DOD was responsible for 
testing all of the anthrax letters that were recovered and was involved 
in the transportation and testing of environmental samples as well as 
the cleanup of contaminated buildings. EPA was in charge of the cleanup 
of contaminated sites. FEMA assisted the President's Office of Homeland 
Security in establishing and supporting an emergency support team. The 
FBI led the criminal investigation.

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

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

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

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

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

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

Initially, CDC relied on the HAN communication system and its Morbidity 
and Mortality Weekly Report (MMWR) publication to disseminate its 
guidance and other information; however, during the incidents there 
were difficulties with both of these methods. At the time of the 
incidents, all state health departments were connected to the HAN 
system. However, only 13 states were connected to all of their local 
health jurisdictions, and therefore HAN messages could not reach many 
local areas. Some states were satisfied with the information they 
received via HAN, but others claimed they did not get much information 
from HAN and what they did get was incomplete. During the incidents, 
CDC expanded its list of HAN recipients to include additional 
organizations, including medical associations. MMWR is issued on a 
weekly basis, and so the information in the latest issue was not always 
completely up-to-date for incidents that were unfolding by the hour. 
For example, information published in MMWR on October 26, 2001, 
contained the notice that the information was current as of October 24, 
2001. In addition to these structural barriers to getting information 
out quickly to those who needed it, CDC's internal process of clearing 
information before issuance through HAN or MMWR was time-consuming. CDC 
has since changed its clearing process so that information can get out 
faster. The agency also made a number of other changes during the 
incidents to address some of the difficulties it encountered in 
providing information to the public health departments and clinicians. 
These included bringing in professionals from other communication 
departments in CDC to help get information out quickly, issuing press 
releases twice a day, and holding telebriefings. Since the incidents, 
CDC has taken actions to expand its communication capacity, including 
developing an emergency communication plan, increasing the number of 
health experts on staff, and establishing a pressroom, in which the 
Director of CDC gives press briefings on public health efforts. In 
addition, it has developed, and posted to its Web site, information to 
assist local and state health officials in detecting and treating 
individuals infected with agents considered likely to be used in a 
bioterrorist attack.

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

Anthrax Incidents Strained Some Aspects of Federal Response Capacity:

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

CDC's Epidemiologic and Laboratory Resources Were Strained:

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

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

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

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

Available Clinical Tools Had Shortcomings:

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

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

Methods of prophylaxis for people exposed to anthrax spores were 
available and apparently effective, but there were several difficulties 
with these methods. There was uncertainty about how to assess exposure 
to determine who should be given prophylaxis; initially only one drug 
had been approved for prophylaxis, and it was approved only for 
prophylaxis of inhalational anthrax; the optimal length of prophylaxis 
for those thought to have been exposed to anthrax spores was unknown; 
prophylactic drugs had to be taken for months and had side effects; and 
the anthrax vaccine requires more than one dose, had not been approved 
for postexposure prophylaxis, and was in short supply. Nasal swabs and 
blood tests were used early in the investigation to assess exposure, 
but these were not reliable methods. When there was uncertainty about 
who was exposed or how great their risk from exposure was, prophylaxis 
was sometimes recommended for all workers in a facility with some 
contamination, regardless of how close to the contamination the workers 
had been. This prophylaxis often started with an initial supply of 
medication while test results were awaited. For example, some people 
were given a 10-day supply of drugs and asked to return within 10 days 
to learn whether they needed to continue taking the drugs. Initially, 
CDC, with advice from NIH, recommended prophylaxis for 60 
days.[Footnote 16] The drugs had side effects, and the rate of 
compliance with the regimen was typically about 40 percent. Since the 
incidents, federal agencies have been developing and evaluating tools 
for detecting anthrax spores. Such tests could enable field workers to 
make better initial assessments of exposure at particular locations to 
determine who should get prophylaxis. CDC is working with other federal 
agencies to support the development of new methods of prophylaxis for 
anthrax and other potential agents of bioterrorism.

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

Few Clinicians Had Been Trained to Recognize Anthrax:

During the anthrax incidents, it became apparent that few clinicians 
had been trained to recognize anthrax infections. In November 2000, CDC 
had created a national training plan for bioterrorism preparedness and 
response. The plan outlined training required to implement the agency's 
Bioterrorism Event Response Operational Plan and strategies for 
training public health and medical professionals in collaboration with 
partners (chiefly public health organizations and professional groups 
such as the American Medical Association). At the time of the anthrax 
incidents, CDC had been implementing the plan for less than a year, and 
relatively few people had been trained: CDC reports that by October 
2001 about 12,000 physicians, nurses, and other medical professionals 
had completed the programs. However, CDC estimated that during the 
incidents more than one million medical professionals participated in 
its anthrax-related training programs via satellite, Web, video, and 
phone. In addition to CDC's training programs, which continue to be 
available, CDC collaborates with professional organizations, such as 
the American Medical Association and the American Nurses Association, 
to provide training for their members, and other federal agencies 
present training programs on bioterrorism (for example, AHRQ) or fund 
training programs on bioterrorism (for example, the Health Resources 
and Services Administration).

Concluding Observations:

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

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

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

Agency Comments:

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

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

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

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

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

Sincerely yours,

Janet Heinrich 
Director, Health Care--Public Health Issues:

Signed by Janet Heinrich: 

[End of section]

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

Table 2: 

Date: Tuesday, 9/11/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* Terrorist attack on World Trade Center and Pentagon prompts 
heightened epidemiologic surveillance activities in some areas.

Date: Wednesday, 9/26/01 through Monday, 10/01/01; Events Occurring on 
That Date: Events Determined Retrospectively to Have Occurred on That 
Date (in italics): * In New York (NY), two NBC employees, a New York 
Post employee, and the child of an ABC employee and in New Jersey (NJ), 
two U.S. Postal Service (USPS) employees, one from the West Trenton 
postal facility and one from Hamilton postal facility, seek medical 
attention for skin conditions; * In Florida, an American Media Inc. 
(AMI) employee is admitted to the hospital with a respiratory 
condition.

Date: Tuesday, 10/02/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* The Centers for Disease Control and Prevention (CDC) issues a Health 
Alert Network (HAN) alert regarding preparedness for bioterrorism, 
acknowledging the public's concern about smallpox and anthrax and 
providing information about preventive measures; * In Florida, a 
second AMI employee is admitted to the hospital, with a diagnosis of 
meningitis.

Date: Thursday, 10/04/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* CDC and the Florida Department of Health announce confirmation of a 
case of inhalational anthrax. The infected person is an AMI employee, 
and the cause of the infection is unknown.

Date: Friday, 10/05/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In Florida, an AMI employee becomes the first anthrax victim to die.

Date: Sunday, 10/07/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In Florida, the AMI building is closed after anthrax spores are 
found.

Date: Monday, 10/08/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In Florida, prophylaxis of AMI employees begins.

Date: Wednesday, 10/10/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* Because the source of the AMI employee's anthrax exposure is believed 
to have been a letter, USPS begins nationwide employee education on 
signs of anthrax exposure and procedures for handling mail to avoid 
anthrax infection.

Date: Friday, 10/12/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NY, the New York City Department of Health (NYCDOH) announces the 
confirmation of a case of cutaneous anthrax in an NBC employee; * USPS 
says that it will offer gloves and masks to all employees who handle 
mail.

Date: Monday, 10/15/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* On Capitol Hill, an employee opens a letter addressed to Senator 
Daschle thought to contain anthrax spores. People thought to be in the 
vicinity of the letter when it was opened are treated with 
ciprofloxacin, at the time the only drug approved for postexposure 
prophylaxis for anthrax; * In Florida, CDC confirms a second case of 
inhalational anthrax in an AMI employee; * In NY, NYCDOH announces a 
second case of cutaneous anthrax, in a child of an ABC employee.

Date: Thursday, 10/18/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In the Washington, D.C., regional area (DC),[A] USPS reports that 
although it believes that the Daschle letter, which was processed at 
the Brentwood postal facility, was extremely well sealed and that there 
was a minute chance that anthrax spores escaped into the facility, it 
is testing the facility for anthrax contamination; quick tests are 
negative, other tests are sent to the laboratory; * In NJ, laboratory 
testing confirms cutaneous anthrax in two USPS employees, one from the 
West Trenton postal facility and one from the Hamilton postal 
facility; * In NY, NYCDOH announces a third case of cutaneous anthrax, 
in a CBS employee; * In Florida, USPS closes two postal facilities 
contaminated with anthrax spores for cleaning; * In a telebriefing, 
the Director of CDC provides information about anthrax, including risk 
of exposure, availability of vaccines and antimicrobial medications, 
screening tests, symptoms, and what to do with suspicious mail and also 
explains CDC's role in the investigation; * CDC broadcasts part one of 
a live satellite and Web broadcast on anthrax for clinicians; * FDA 
announces that it has approved doxycycline for postexposure prophylaxis 
for anthrax; * In DC, a USPS employee who works at the Brentwood 
postal facility seeks medical attention.

Date: Friday, 10/19/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In DC, a USPS employee who works at both the Brentwood postal 
facility and a Maryland postal facility is admitted to a hospital with 
suspected inhalational anthrax; * In NJ, the Hamilton and West Trenton 
postal facilities are closed, and the New Jersey Department of Health 
and Senior Services recommends that all USPS employees from both 
facilities receive prophylaxis; * In NJ, laboratory testing confirms 
cutaneous anthrax in a second USPS employee who works at the Hamilton 
postal facility; * In NY, NYCDOH announces a fourth case of cutaneous 
anthrax, in a New York Post employee.

Date: Saturday, 10/20/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In DC, a third USPS employee who works at the Brentwood postal 
facility is admitted to a hospital with a respiratory condition.

Date: Sunday, 10/21/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In DC, the USPS employee who worked at the Brentwood and Maryland 
postal facilities and was admitted to the hospital on 10/19/01 is 
confirmed to have inhalational anthrax; * In DC, the Brentwood and 
Maryland postal facilities, are closed. Evaluation and prophylaxis of 
employees begin; * In DC, a USPS employee who worked at the Brentwood 
postal facility and who initially sought medical attention on 10/18/01 
is admitted to a hospital with suspected inhalational anthrax and 
becomes the second anthrax victim to die; * In DC, a fourth USPS 
employee who worked at the Brentwood postal facility seeks medical 
attention at a hospital. His chest X-ray is initially determined to be 
normal, and he is discharged.

Date: Monday, 10/22/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In DC, the USPS employee who worked at the Brentwood postal facility 
and who sought medical attention on 10/21/01 and was discharged is 
admitted to the hospital with suspected inhalational anthrax, and 
becomes the third anthrax victim to die; * In DC, the USPS employee 
who was admitted to the hospital on 10/20/01 is confirmed to have 
inhalational anthrax; * In DC, prophylaxis is expanded to include all 
employees and visitors to nonpublic areas at the Brentwood postal 
facility; * CDC rebroadcasts part one of the live satellite and Web 
broadcast on anthrax for clinicians.

Date: Wednesday, 10/24/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NY, USPS begins giving prophylaxis to employees at six New York 
City postal facilities where contaminated letters may have been 
processed.

Date: Thursday, 10/25/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In DC, a State Department mail facility employee is called back to 
the hospital for admission; test taken the previous day is positive for 
inhalational anthrax; * In NY, NYCDOH announces a fifth case of 
cutaneous anthrax, in a second NBC employee; * CDC initiates daily 
telebriefings to provide updates on the anthrax incidents.

Date: Saturday, 10/27/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NY, NYCDOH announces the sixth case of cutaneous anthrax, in a 
second New York Post employee.

Date: Sunday, 10/28/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NJ, laboratory testing confirms inhalational anthrax in a USPS 
Hamilton employee who was admitted to a hospital with suspected 
inhalational anthrax on 10/19/01.

Date: Monday, 10/29/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NY, preliminary tests indicate anthrax in a hospital employee who 
was admitted with suspected inhalational anthrax on 10/28/01. The 
hospital where she works is temporarily closed, and NYCDOH recommends 
prophylaxis for hospital employees and visitors; * In NJ, laboratory 
testing confirms cutaneous anthrax in a woman who receives mail 
directly from the Hamilton facility. The woman originally sought 
medical attention on 10/18/01 and was admitted to the hospital on 10/
22/01 for a skin condition; * In NJ, laboratory testing confirms a 
second case of inhalational anthrax, in a USPS Hamilton employee who 
initially sought medical attention on 10/16/01 and was admitted to the 
hospital on 10/18/01 with a respiratory condition.

Date: Wednesday, 10/31/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In NY, the hospital employee becomes the fourth anthrax victim to 
die.[B].

Date: Thursday, 11/01/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* CDC broadcasts part two of the live satellite and Web broadcast on 
anthrax for clinicians.

Date: Friday, 11/2/01; Events Occurring on That Date: Events Determined 
Retrospectively to Have Occurred on That Date (in italics): * In NY, 
NYCDOH announces the seventh case of cutaneous anthrax, in a third New 
York Post employee.

Date: Wednesday, 11/21/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* In Connecticut, an elderly woman, who was admitted to the hospital 
for dehydration on 11/16/01, becomes the fifth anthrax victim to 
die.[B]; * The Connecticut Department of Public Health, in consultation 
with CDC, begins prophylaxis for USPS employees working in the Seymour 
and Wallingford postal facilities.

Date: Friday, 12/21/01; Events Occurring on That Date: Events 
Determined Retrospectively to Have Occurred on That Date (in italics): 
* CDC expands the options for those on prophylaxis to include extending 
the duration of drug therapy and adding the anthrax vaccine.

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

[A] The Washington, D.C., regional area includes Washington, D.C., 
Maryland, and Virginia.

[B] As of September 30, 2003, the source of exposure had not been 
confirmed.

[End of table]

[End of section]

Appendix II: Comments from the Department of Defense:

HOMELAND DEFENSE:

Ms. Janet Heinrich, Director Health Care - Public Health Issues U.S. 
General Accounting Office Washington, DC 20548:

1 4 OCT 2003:

Dear Ms. Heinrich:

This is the Department of Defense (DoD) response to the GAO final 
report, "Bioterrorism: Public Health Response to Anthrax Incidents of 
2001" dated October 6, 2003 (Code 290288/ GAO-04-152).

DOD acknowledges receipt of the final report and notes it contains no 
specific recommendations for departmental action, however, we believe 
the report should be amended for two specific purposes. First, the 
report should highlight the significant role the Department played in 
supporting civilian public health response during this unprecedented 
biological attack on American soil. In addition, amending the report to 
reflect the lessons learned from DOD's support can aid the development 
of expanded capabilities within the civilian sector to help improve the 
nation's public health preparedness. Specific technical comments for 
your consideration are also attached.

During the period from October 2001 through January 2002, DOD supported 
civilian public health and law enforcement authorities by employing its 
unique weapons of mass destruction (WMD) response capabilities to 
perform environmental assessments, transportation of contaminated 
articles, laboratory confirmation testing and cleanup of locations 
suspected of anthrax contamination. These capabilities were vital to 
the success of the public health response.

Immediately following the Fall 2001 anthrax attacks, the United States 
Capitol Police contacted DOD and requested assistance to conduct 
environmental assessments, testing and evaluation of air and source 
samples for anthrax spores in the House and Senate office spaces. DOD 
responded by dispatching the Marines and sailors of the Chemical 
Biological Incident Response Force (CBIRF), 4th Marine Expeditionary 
Brigade (Anti-Terrorism) to address this threat. Subsequently, CBTRF 
was assigned in direct support of the Federal Bureau of Investigation - 
Hazardous Materials Response Unit at the United States Postal Service 
Mail P Street Facility to conduct biological-hazard reconnaissance and 
collection and over packing of congressional mail.

Additionally, the laboratories of the U.S. Army Medical Research 
Institute of Infectious Diseases (USAMRID) and the U.S. Navy Naval 
Medical Research Center (NMRC), were also pressed into service to 
support the Center of Disease Control to conduct confirmation testing 
of contaminated samples for the presence of anthrax.

These capabilities were unique to the DoD and resulted from the 
Department's past contingency planning for WMD response in an overseas 
warfighting environment. At the time of the attacks, no other Federal 
government agency then possessed the capability and requisite 
experience for addressing biological agent contamination across the 
full range of activities from:

assessment to confirmation testing and subsequent decontamination and 
cleanup. Accordingly, with this extensive biological defense 
experience, training and expertise, DoD is fully prepared to assist 
civilian public health officials in the future to expand their 
development of WMD response capabilities.

DoD appreciates the opportunity to provide this additional information 
on its role and we look forward to working with you on improving our 
nation's future bioterrorism preparedness.

Sincerely,

Paul McHale:

Signed by Paul McHale:

Attachments a/s:

[End of section]

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

DEPARTMENT OF HEALTH & HUMAN SERVICES	office of Inspector General:

Washington, D.C. 20201:

OCT 10 2003:

Ms. Janet Heinrich:

Director, Health Care - Public Health Issues United States General 
Accounting Office Washington, D.C. 20548:

Dear Ms. Heinrich:

Enclosed are the Department's comments on your draft report entitled, 
"Bioterrorism: Public Health Response to Anthrax Incidents of 2001." 
The comments represent the tentative position of the Department and are 
subject to reevaluation when the final version of this report is 
received.

The Department appreciates the opportunity to comment on this draft 
report before its publication.

Sincerely,

Signed by: 

Dara Corrigan:

Acting Principal Deputy Inspector General:

The Office of Inspector General (OIG) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for General Accounting Office 
reports. OIG has not conducted an independent assessment of these 
comments and therefore expresses no opinion on them.

Comments of the Department of Health and Human Services on the General 
Accounting Office's Draft Report. "Bioterrorism: Public Health Response 
to Anthrax Incidents of 2001" (GAO-04-152):

The Department of Health and Human Services (HHS) appreciates [lie 
opportunity to comment on the above-referenced draft report. The report 
provides an informative account of a) the role of the Centers for 
Disease Control and Prevention (CDC) in responding to the public health 
emergency engendered by the anonymous, surreptitious, and malicious 
distribution of wcaponized Bacillus anthracis (B. anthracis) through 
the U.S. mail system during October 2001; b) the lessons learned from 
that unique experience; and c) actions to enhance CDC's readiness for 
further bioterrorisin incidents and other public health emergencies. 
The report should become a valuable reference document for policy 
makers, public health professionals, and members of the general public 
concerned with U. S. national preparedness in the ever-present threat 
of bioterrorism and its myriad potential manifestations.

The U.S. General Accounting Office could enhance the utility ol the 
report by making explicit that the CDC role, invaluable as it was, is 
only part of the story. During the weeks following the appearance of 
the letters laced with B. anthracis spores, the Office of the Secretary 
of Health and Human Services maintained an ad hoc emergency operations 
center under the personal direction of the Deputy Secretary with a view 
toward ensuring appropriate direction and coordination of all HHS 
assets deployed during the crisis, including those of CDC. To cite but 
one example, HHS deployed 325 U. S. Public Health Service Commissioned 
Officers to help effect mass distribution of antibiotics, triaging, 
assessment, patient education, and counseling of 37,000 persons at risk 
of exposure to B. anthracis:

Moreover, in the wake of the anthrax incidents, HHS undertook a host of 
significant actions - including but going well beyond those CDC-based 
activities noted in the report - to enhance preparedness for 
bioterrorism and other public health emergencies. "these other actions 
include a) the Secretary's creation of the Office of Public Health 
Preparedness (subsequently codified in statute and renamed the Office 
of Public Health Emergency Preparedness) and, through it, the 
establishment of the Secretary's Command Center and the Secretary's 
Emergency Response Teams; b) an unprecedented increase of support for 
public health departments, hospitals, other health care entities, and 
communities throughout the nation to enhance Stale mid local 
preparedness for public health emergencies; c) accelerated acquisition 
of antibiotics for the National Pharmaceutical Stockpile (subsequently 
renamed in statute as the Strategic National Stockpile) to improve 
preparedness for further anthrax attacks or other bioterrorism 
incidents; d) accelerated acquisition of enough closes of smallpox 
vaccine to cover the entire TI. S. population in the event of a 
terrorist-induced smallpox outbreak; e)significant expansion of basic 
and targeted research and upgrading of research facilities focused on 
the pathogens most. likely to be used as bioterrorism agents; and f) in 
view of the potential for food to be a medium for terrorism, 
substantial augmentation of efforts to protect the security and safety 
of the T J. S. food supply.

Technical and Other Comments:

We have also provided technical and other comments on the draft for 
your consideration and use in finalizing the report; these comments are 
being submitted separately.

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments:

GAO Contact:

Michele Orza, (202) 512-6970:

Acknowledgments:

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

[End of section]

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FOOTNOTES

[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.

[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).

[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.

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

[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.

[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.

[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.

[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. 

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

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

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