U.S. Postal Service:

Better Guidance Is Needed to Improve Communication Should Anthrax Contamination Occur in the Future

GAO-03-316: Published: Apr 7, 2003. Publicly Released: Apr 21, 2003.

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In 2001, letters contaminated with anthrax resulted in 23 cases of the disease, 5 deaths, and the contamination of numerous U.S. Postal Service facilities, including the Southern Connecticut Processing and Distribution Center in Wallingford, Connecticut (the Wallingford facility). GAO was asked to address, among other matters, whether (1) the Postal Service followed applicable guidelines and requirements for informing employees at the facility about the contamination and (2) lessons can be learned from the response to the facility's contamination.

The Wallingford facility first tested positive for anthrax in early December 2001. The contamination was found in samples collected from four mail-sorting machines in November. Analyses of the samples produced quantified results, including about 3 million anthrax colonies, or living anthrax cells, in one of the samples. While this was far more than the amount needed to cause death, none of the employees at the facility became sick from the anthrax contamination. The Postal Service's decision not to inform workers about the number of anthrax colonies identified in December 2001 appears consistent with its guidelines because, according to the Service, it could not validate the results, as required. However, its subsequent decision not to release the results after an employee union requested all the facility's test results in January and February 2002, was not consistent with the Occupational Safety and Health Administration's (OSHA) requirement for disclosing test results that are requested. An OSHA investigation resulted in the Service's release of the quantitative test results in September 2002--about 9 months after the results were first known. Although OSHA did not issue a regulatory citation, it expressed concern about communication deficiencies. In retrospect, the Service's decision not to release the quantitative test results in December 2001 was understandable given the challenging circumstances that existed at the time, the advice it received from public health officials, an ongoing criminal investigation, and uncertainties about the sampling methods used. However, numerous lessons can be learned from the experience, such as the need for more complete and timely information to workers to maintain trust and credibility and to help ensure that workers have essential information for making informed health decisions. Federal guidelines developed in 2002 by GSA and the National Response Team suggest that more--rather than less--information should be disclosed. However, neither the Service's guidelines nor the more recent federal guidelines fully address the communication-related issues that developed in Wallingford. For example, none of the guidelines specifically require the full disclosure of quantified test results. Likewise, OSHA's regulations do not require employers to disclose test results to workers unless requested, which assumes that workers are aware of the test results and know about this requirement.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In his July 2, 2003, response to this recommendation, the Assistant Secretary for the Occupational Safety and Health Administration (OSHA) assured GAO that OSHA would work with other members of the National Response Team (NRT) to (1) revise guidelines for ensuring the timely and accurate disclosure of exposure information to workers and (2) seek advise from other NRT participants about whether additional regulatory action is required in this area. Subsequently, the NRT issued revised guidance indicating that "all sampling methods must be provided in accordance with 29 CFR 1910.1020"--OSHA's regulation on access to exposure and medical records--"and shared and explained to response workers, as well as to workers returning to the facility after clean-up." Moreover, the guidance advises employers under OSHA jurisdiction that sampling results must be made accessible to employees. According to a notation on the cover of the guidance, these and other revisions were made exclusively to deal with concerns identified in GAO's report. In addition, OSHA said that it intended to strengthen its response by directing its regional and area offices to initiate priority action at future sites involving the possible release of chemical, biological, or radiological agents. The revised policy guidance, issued to OSHA Regional Administrators on September 12, 2003, indicates that "whenever a nationally significant event takes place where bulk, area and/or personal samples have been collected, the (OSHA) area and/or regional offices are to ensure employers of emergency personnel provide exposure results to all affected workers and his/her representative(s) in a timely manner. This is per the requirements of 29 CFR 1910.1020, and, as stipulated to GAO, is to be provided regardless of whether the results are requested or not by workers or his/her representative(s)." The new policy, together with the existing regulation on employee access to exposure and medical records, may mitigate the need to revise the existing regulation, according to OSHA. However, if OSHA determines that its alternative action was not sufficient and that a new regulation is warranted, the Assistant Secretary indicated that OSHA would include the matter in the President's regulatory agenda.

    Recommendation: In light of new concerns about the possibility and impact of future terrorist actions using unforeseen hazardous substances, the Assistant Secretary for Occupational Safety and Health should consider whether OSHA regulations should require--in emergency situations--full and immediate disclosure of test results to workers, regardless of whether the information is requested by an employee or his or her designated representative.

    Agency Affected: United States Postal Service

  2. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team--which the Environmental Protection Agency chairs--revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance states that there are no validated sampling methods for anthrax and, depending on the type of sampling and analyses, various procedures may be necessary to confirm or validate sampling results.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to define what is meant by the validation of test results and explain the steps that must be taken to validate sampling or testing methods that are undertaken by the agency itself or by another organization.

    Agency Affected: United States Postal Service

  3. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team--of which the General Services Administration is a member--revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance states that there are no validated sampling methods for anthrax, and, depending on the type of sampling and analyses, various procedures may be necessary to confirm or validate sampling results.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to define what is meant by the validation of test results and explain the steps that must be taken to validate sampling or testing methods that are undertaken by the agency itself or by another organization.

    Agency Affected: General Services Administration

  4. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team, assisted by the Postal Service, revised its technical assistance guidance in November 2003. The revised guidance states that there are no validated sampling methods for anthrax and, depending on the type of sampling and analyses, various procedures may be necessary to confirm or validate sampling results. The Postal Service also issued revised internal guidance which references and "subscribes" to National Response Team's new sampling and analytical guidelines. In addition, the Service's revised guidance specifies that initial test results from all sampling methods must be cultured to confirm the results.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to define what is meant by the validation of test results and explain the steps that must be taken to validate sampling or testing methods that are undertaken by the agency itself or by another organization.

    Agency Affected: United States Postal Service

  5. Status: Closed - Not Implemented

    Comments: Although the National Response Team, assisted by officials from the Postal Service, issued revised guidelines for communicating test results, the guidelines do not specifically address the terminology that should be used to communicate (1) quantitative test results or (2) limitations associated with test results. Given the variety of possible scenarios and the extensive nature of the terminology that could be used to explain test results, it may not be practical to provide specific guidance in this area.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the terminology that should be used to communicate quantitative test results to employees and others (e.g., the number of colony-forming units per gram or square inch of material sampled) and any limitations associated with the test results.

    Agency Affected: General Services Administration

  6. Status: Closed - Not Implemented

    Comments: Although the National Response Team, with the General Services Administration as a member, issued revised guidelines for communicating test results, the guidelines do not specifically address the terminology that should be used to communicate (1) quantitative test results or (2) limitations associated with test results. Given the variety of possible scenarios and the extensive nature of the terminology that could be used to explain test results, it may not be practical to provide specific guidance in this area.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the terminology that should be used to communicate quantitative test results to employees and others (e.g., the number of colony-forming units per gram or square inch of material sampled) and any limitations associated with the test results.

    Agency Affected: Environmental Protection Agency

  7. Status: Closed - Not Implemented

    Comments: Although the National Response Team, which is chaired by the Environmental Protection Agency issued revised guidelines for communicating test results, the guidelines do not specifically address the terminology that should be used to communicate (1) quantitative test results or (2) limitations associated with test results. Given the variety of possible scenarios and the extensive nature of the terminology that could be used to explain test results, it may not be practical to provide specific guidance in this area.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the terminology that should be used to communicate quantitative test results to employees and others (e.g., the number of colony-forming units per gram or square inch of material sampled) and any limitations associated with the test results.

    Agency Affected: General Services Administration

  8. Status: Closed - Implemented

    Comments: The Postal Service revised its guidance in response to GAO's recommendation. The revised guidance states the Postal Service's commitment to (1) comply with applicable Occupational Safety Health Administration regulations and (2) provide immediate notification of anthrax test results to union representatives and management associations. More specifically, the guidelines require facility managers to provide test results, including quantified test results, to employees and others as soon as possible.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of the Environmental Protection Agency (EPA), as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require prompt communication of test results, including quantified results when available, to workers and others.

    Agency Affected: United States Postal Service

  9. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team, which is chaired by the Environmental Protection Agency, revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance includes information about the need for documenting the basis for decision-making. Specifically, the guidance states that "it is essential to develop and maintain accurate and complete records documenting advice received from public health officials on how to communicate health-related information to workers and the general public."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of the Environmental Protection Agency (EPA), as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require prompt communication of test results, including quantified results when available, to workers and others.

    Agency Affected: General Services Administration

  10. Status: Closed - Implemented

    Comments: The General Services Administration (GSA) worked with other members of the National Response Team to revise the team's requirements for disclosing test results. In addition, GSA revised its guidelines for federal mail centers to include information about Occupational Safety Health Administration's disclosure requirement. The revised guidance indicates that test results, including quantified results, should be communicated "...as quickly as possible, preferably without waiting for a request."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of the Environmental Protection Agency (EPA), as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require prompt communication of test results, including quantified results when available, to workers and others.

    Agency Affected: Environmental Protection Agency

  11. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team--which is chaired by the Environmental Protection Agency--revised its technical assistance guidance in November 2003. The revised guidance emphasizes the need for a communications strategy that includes the timely release and explanation of sample results. According to the guidelines, confirmation or validation of sampling results depends on the type of sampling and analyses used, and recommends that communications include an explanation of how to interpret the information, and the limitations of the methods used to generate that information.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the actions that should be taken if test results cannot be validated, including a strategy for communicating unvalidated results.

    Agency Affected: Environmental Protection Agency

  12. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team, assisted by the Postal Service, revised its technical assistance guidance in November 2003. The revised guidance emphasizes the need for a communications strategy that includes the timely release and explanation of sample results. According to the guidelines, confirmation or validation of sampling results depends on the type of sampling and analyses used and recommends that communications include an explanation of how to interpret the information, and the limitations of the methods used to generate that information. The Postal Service also revised its internal guidelines in response to GAO's recommendation. The revised guidelines state that due to the confusion surrounding the use of the term "validation," the Postal Service would no longer use the term. Instead, the revised guidelines use the term "confirmation" in reference to sample results and specify that all sample results must be confirmed by the Centers for Disease Control and Prevention or state public health laboratories using culture methods before releasing results to employees or the public.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the actions that should be taken if test results cannot be validated, including a strategy for communicating unvalidated results.

    Agency Affected: General Services Administration

  13. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team--of which the General Services Administration is a member--revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance emphasizes the need for a communications strategy that includes the timely release and explanation of sample results. According to the guidelines, confirmation or validation of sampling results depends on the type of sampling and analyses used and recommends that communications include an explanation of how to interpret the information, and the limitations of the methods used to generate that information.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the actions that should be taken if test results cannot be validated, including a strategy for communicating unvalidated results.

    Agency Affected: Environmental Protection Agency

  14. Status: Closed - Implemented

    Comments: The National Response Team, which the Environmental Protection Agency chairs, issued revised technical assistance guidance in November 2003. The revised guidance specifically indicates that the revisions had been made solely to address the specific concerns identified in GAO's report and, as a result, now include a specific reference to the Occupational Safety and Health Administration's (OSHA) regulatory requirement for providing access to exposure and medical records (29 CFR 1910.1020). The revised guidance indicate that "all sampling methods must be provided in accordance with 29 CFR 1910.1020 and shared and explained to response workers, as well as to workers returning to the facility after clean-up." Moreover, the guidance advises employers under OSHA jurisdiction that sampling results must be made accessible to employees.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to reflect OSHA's regulations for disclosing test results requested by workers or their designated representatives

    Agency Affected: General Services Administration

  15. Status: Closed - Implemented

    Comments: The National Response Team--whose membership includes the General Services Administration (GSA)--revised its technical assistance guidance in November 2003. The revised guidance specifically indicates that the revisions had been made solely to address the specific concerns identified in GAO's report and, as a result, now include a specific reference to the Occupational, Safety, and Health Administration's (OSHA) regulatory requirement for providing access to exposure and medical records (29 CFR 1910.1020). The revised guidance indicate that "all sampling methods must be provided in accordance with 29 CFR 1910.1020 and shared and explained to response workers, as well as to workers returning to the facility after clean-up." Moreover, the guidance advises employers under OSHA jurisdiction that sampling results must be made accessible to employees. GSA revised its guidance for federal mail centers--also issued in December 2003--to indicate that "all information relevant to apparent and credible biological threats should be provided to employees as quickly as possible, preferably without waiting for a request."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to reflect OSHA's regulations for disclosing test results requested by workers or their designated representatives

    Agency Affected: United States Postal Service

  16. Status: Closed - Implemented

    Comments: The National Response Team, assisted by the Postal Service, revised its technical assistance guidance in November 2003. The revised guidance specifically indicates that the revisions had been made solely to address the specific concerns identified in GAO's report and, as a result, now include a specific reference to the Occupational, Safety, and Health Administration's (OSHA) regulatory requirement for providing access to exposure and medical records (29 CFR 1910.1020). The revised guidance indicate that "all sampling methods must be provided in accordance with 29 CFR 1910.1020 and shared and explained to response workers, as well as to workers returning to the facility after clean-up." Moreover, the guidance advises employers under OSHA jurisdiction that sampling results must be made accessible to employees. The Postal Service also revised its internal guidance to address GAO's recommendation. For example, the Postal Service's December 2003 revised guidance for responding to anthrax notes that the "Postal Service is obligated to provide testing information to employees and their unions when requested," and that it is "committed to complying with applicable OSHA regulations."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to reflect OSHA's regulations for disclosing test results requested by workers or their designated representatives

    Agency Affected: General Services Administration

  17. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team, which is chaired by the Environmental Protection Agency, revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance includes information about the need for documenting the basis for decision-making. Specifically, the guidance states that "it is essential to develop and maintain accurate and complete records documenting advice received from public health officials on how to communicate health-related information to workers and the general public."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require documentation of the basis for decisions made, including the (1) advice the organization receives from public health officials and others about the communication of health-related information to workers and others, as appropriate, and (2) specific content of what the organizations communicate to workers and others.

    Agency Affected: United States Postal Service

  18. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team, assisted by the Postal Service, revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance includes information about the need for documenting the basis for decision-making. Specifically, the guidance states that "it is essential to develop and maintain accurate and complete records documenting advice received from public health officials on how to communicate health-related information to workers and the general public." The Postal Service also revised its internal guidance in December 2003. The revised guidance stresses the importance of documentation, including documentation of the advice and content of health-related information it receives.

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require documentation of the basis for decisions made, including the (1) advice the organization receives from public health officials and others about the communication of health-related information to workers and others, as appropriate, and (2) specific content of what the organizations communicate to workers and others.

    Agency Affected: General Services Administration

  19. Status: Closed - Implemented

    Comments: Responding to GAO's recommendation, the National Response Team--of which the General Services Administration is a member--revised its technical assistance guidance in November 2003. According to the document, the revisions were made solely to address the specific concerns identified in GAO's report. The revised guidance includes information about the need for documenting the basis for decision-making. Specifically, the guidance states that "it is essential to develop and maintain accurate and complete records documenting advice received from public health officials on how to communicate health-related information to workers and the general public."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to require documentation of the basis for decisions made, including the (1) advice the organization receives from public health officials and others about the communication of health-related information to workers and others, as appropriate, and (2) specific content of what the organizations communicate to workers and others.

    Agency Affected: General Services Administration

  20. Status: Closed - Implemented

    Comments: In November 2003, the National Response Team, which is chaired by the Environmental Protection Agency, revised its guidelines to address the specific concerns in GAO's report. The revised guidelines emphasize the need for a communications strategy that will identify the key messages and determine who will convey them. In addition, the guidance suggests that agencies "identify appropriate and credible persons to communicate messages and address concerns."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the agencies that should be involved in deciding what to communicate to workers and others, as appropriate.

    Agency Affected: General Services Administration

  21. Status: Closed - Implemented

    Comments: In November 2003, the National Response Team, which includes the General Services Administration as a member, revised its guidelines to address the specific concerns in GAO's report. The revised guidelines emphasize the need for a communications strategy that will identify the key messages and determine who will convey them. In addition, the guidance suggests that agencies "identify appropriate and credible persons to communicate messages and address concerns."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the agencies that should be involved in deciding what to communicate to workers and others, as appropriate.

    Agency Affected: United States Postal Service

  22. Status: Closed - Implemented

    Comments: In November 2003, the National Response Team, assisted by the Postal Service, revised its guidelines to address the specific concerns in GAO's report. The revised guidelines emphasize the need for a communications strategy that will identify the key messages and determine who will convey them. In addition, the guidance suggests that agencies "identify appropriate and credible persons to communicate messages and address concerns." Recognizing that the agencies involved will vary depending upon both the type of incident and the location, the Postal Service also revised its internal guidance to specify that it will consult "with the relevant federal, state and local agencies in deciding on appropriate communications to employees and others."

    Recommendation: To help prevent the reoccurrence of the communications problems that occurred at the Wallingford facility, the Postmaster General; the Administrator of GSA; and the Administrator of EPA, as Chairperson of the National Response Team, should work together to, where applicable, revise guidelines to specify the agencies that should be involved in deciding what to communicate to workers and others, as appropriate.

    Agency Affected: United States Postal Service

 

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