in Washington,  D.C. (the V Street Operation). The Skyline Complex incident  occurred later that day when an alarm sounded on the biosafety cabinet  that employees took as a sign that contaminated mail had been passed  from the Pentagon to the Skyline Complex. Finally, at 2:09 p.m., a Skyline  employee called the Fairfax County 911 emergency line. Thus, by Monday evening, the Postal Service had suspended operations at  its V Street Operation and had immediately begun dispensing antibiotics to  its employees. In total, over 160 Postal Service employees were treated for  their possible exposure to anthrax. Mail-screening contractor did not quarantine mail until it received  negative test results from the laboratory. DOD Did Not Fully Follow the Federal Framework for Coordinating Responses at the Pentagon

DOD did not fully follow the federal framework for coordinating a  response to the potential anthrax incident at the Pentagon; instead, it  chose to make decisions on its own. CDC recommended antibiotics for  employees of the V Street Operation because (1) of the confluence of the  two incidents, which, at the time, were viewed as involving the presence of  anthrax; (2) DOD had already started its employees on antibiotics; and   (3) the employees could have been exposed to anthrax several days earlier  because they process mail to the Pentagon. DOD Took Numerous Actions That Address Problems Related to the Incidents

DOD took numerous actions that address problems related to the  Pentagon and Skyline Complex incidents. Other actions, including  selecting a new mail-screening contractor and improving procedures for  releasing quarantined mail, were a direct response to what occurred. At  the Skyline Complex, DOD’s actions included prohibiting the use of  equipment for screening mail unless the equipment is being operated  within the context of a comprehensive mail-screening program. DOD’s Actions Do Not Fully Resolve Identified Problems

DOD’s actions resolve many of the problems that arose in the March 2005  incidents but not all. In April 2006—more than 1 year after the incident— another senior health official reiterated that DOD has the authority to  make final decisions on medical treatment at the Pentagon without  collaboration or consultation with other agencies, including HHS. DOD Still Has Not Ensured That Its Mail Facilities Have Reviewed Mail Security Plans, As Required

TMA did not have a mail security plan for the Skyline Complex at the time  of the incidents, and although federal mail management regulation and  DOD’s mail manual require such a plan, it has not subsequently developed  one. DOD Has Not Ensured That Its Facilities in the National Capital Region Are Appropriately Using Biosafety Cabinets

Gaps remain in the actions DOD has taken to ensure the appropriate use  of biosafety cabinets for mail screening in DOD-leased mail facilities in the  national capital region. Two of these  agencies—DOD and GSA—provided written comments. Furthermore, while DOD is  developing a new policy to define the roles and responsibilities of senior  DOD leadership―including those involved in making medical treatment  decisions―during incidents at the Pentagon, it only partially agreed with  our remaining recommendation, related to the need for DOD to make  future medical decisions within the participatory decision-making  framework specified in the NRP and NIMS. To determine what problems occurred and why they occurred, we  obtained, reviewed, and analyzed, among other documents, (1) all  available timelines and after-action reports prepared by federal, state, and  local agencies that were involved in the response; (2) the Pentagon’s mail- screening contract and procedures; (3) TMA’s mail procedures; (4) federal  mail management and other applicable regulations related to occupant  emergency plans; (5) DOD requirements, including its mail manual; (6)  applicable guidance on the coordination of incidents with appropriate  organizations, including the National Response Plan (NRP) and its  Biological Incident Annex and the National Incident Management System  (NIMS) and; (7) CDC guidance related to the provision of medical services  to potentially affected employees, including its guidance on the timing of  antibiotics to affected individuals. To determine the extent to which the actions taken address the problems  that arose at the two mail facilities during the March 2005 incidents, we  reviewed and analyzed, among other things, the Pentagon’s new mail- screening contract and its draft (1) mail-screening operating procedures,  (2) laboratory procedures, (3) notification procedures, and (4) procedures  for communicating information to the public.
Why GAO Did This Study

In March 2005, two well-publicized and nearly simultaneous incidents involving the suspicion of anthrax took place in the Washington, D.C., area. The incidents occurred at Department of Defense (DOD) mail facilities at the Pentagon and at a commercial office complex (Skyline Complex). While these incidents were false alarms, DOD and other federal and local agencies responded. The Postal Service suspended operations at two of its facilities and over a thousand DOD and Postal Service employees were given antibiotics as a precaution against their possible exposure to anthrax. This report describes (1) what occurred at the Pentagon and Skyline Complex mail facilities, (2) the problems we identified in detecting and responding to the incidents, (3) the actions taken by DOD that address the problems that occurred, and (4) the extent to which DOD's actions address the problems.

What GAO Found

Events leading up to the Pentagon incident began when a laboratory that tested samples from the Pentagon's mail-screening equipment informed DOD's mail-screening contractor that test results indicated the presence of anthrax in the mail. By the time the contractor notified DOD 3 days later, suspect mail had already been released and distributed throughout the Pentagon. DOD evacuated its mail-screening and remote delivery facilities, notified federal and local agencies, and dispensed antibiotics to hundreds of employees. The Skyline Complex incident began the same day when Fairfax County, Virginia, emergency personnel responded to a 911 call placed by a Skyline employee that an alarm had sounded on a biosafety cabinet used to screen mail. Local responders closed the complex and decontaminated potentially exposed employees, and DOD dispensed antibiotics to the employees. Similarly, the Postal Service suspended operations at two facilities and dispensed antibiotics to its employees. Laboratory testing later indicated that the incidents were false alarms. Analysis of these incidents reveals numerous problems related to the detection and response to anthrax in the mail. At the Pentagon, DOD's mail-screening contractor did not follow key requirements, such as immediately notifying DOD after receiving evidence of contamination. At the Skyline Complex, DOD did not ensure that the complex had a mail security plan or that it had been reviewed, as required. The lack of a plan hampered the response. DOD also did not fully follow the federal framework--including the National Response Plan, which was developed to ensure effective, participatory decision making. Instead of coordinating with other agencies that have the lead in bioterrorism incidents, DOD unilaterally dispensed antibiotics to its employees. DOD has taken numerous actions that address problems related to the two incidents. At the Pentagon, DOD's actions included selecting a new mail-screening contractor and defining the roles and responsibilities of senior leadership, including those involved in making medical decisions. Related to Skyline, DOD prohibited its mail facilities in leased space within the Washington, D.C., area from using biosafety cabinets to screen mail unless the equipment is being operated within the context of a comprehensive mail-screening program. While DOD has made significant progress in addressing the problems that occurred, its actions do not fully resolve the issues. One remaining concern is whether DOD will adhere to the interagency coordination protocols specified in the national plan for future bioterrorism incidents involving the Pentagon. This concern arises because, more than 1 year after the incident, DOD reiterated that it has the authority to make medical decisions without collaborating or consulting with other agencies. DOD also has not ensured, among other things, that its mail facilities (1) have the required mail security plans and (2) are appropriately using biosafety cabinets for screening mail.