Review and Analysis of Reported Anthrax-Related Military Mail Security Incidents in Washington D.C. Metropolitan Area During March 2005

Joseph P. Dudley^*

Science Applications International Corporation,Rockville, MD 20852, USA

*Corresponding Author:

Joseph P. Dudley
Science Applications International Corporation
Rockville, MD 20852, USA
E-mail: joseph.p.dudley@saic.com

Received Date: September 21, 2010; Accepted Date: October 19, 2010; Published Date: October 22, 2010

Citation: Dudley JP (2010) Review and Analysis of Reported Anthrax-Related Military Mail Security Incidents in Washington D.C. Metropolitan Area During March 2005. J Bioterr Biodef 1:101. doi: 10.4172/2157-2526.1000101

Copyright: © 2010 Dudley JP. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

A series of four suspected anthrax contaminated mail incidents occurred at military and civilian facilities in the Washington D.C. metropolitan area during the period between 14-18 March 2005. These incidents precipitated high level biodefense emergency response operations at four different sites in the Washington D.C metropolitan area, including two military installations (the Pentagon, Bolling Air Force Base), a U.S. Postal Service mail processing facility and a commercial office complex. Neither of the two commissioned studies of these incidents conducted by the Rand Corporation and the Government Accountability Office contains a summary of the all the bioterrorism response operations that occurred during this period. The present analysis, however, provides a summary and timeline of the events connected with all four of the interrelated biological agent emergency response operations conducted during March 2005, within a broader contextual framework that allows for a more comprehensive understanding of the spatiotemporal interrelationships between the various biodefense response operations that occurred during this period. Although follow-up investigations did not confirm the presence of anthrax spores at any of the facilities involved, these incidents revealed challenges to effective communications and coordination. The scope and range of the public and private sector emergency operations and entities involved in the response serves as an example of the complexity of this kind of event, particularly in areas such as the Washington DC metropolitan, where coordinated responses by a highly complex area of different entities and jurisdictions are required (military, civilian, federal, state, local). Additionally, the scale of the prophylactic antibiotic treatments of military and civilian personnel conducted during this event (at least 1,100 persons), further emphasizes the importance of recognizing the importance of these incidents for improving capabilities for conducting more coordinated and effective biodefense and bioterrorism emergency response operations.

Introduction

A series of suspected anthrax contaminated mail incidents occurred at military and civilian facilities in the Washington D.C. metropolitan area during the period between 14-18 March 2005. High level biodefense emergency response operations were conducted at four sites which included Department of Defense (DOD) [1] installations in northern Virginia and Washington D.C. (Pentagon Reservation, Arlington County VA; Bolling Air Force Base; Washington D.C.), a US Postal Service mail processing facility in Washington D.C., and an office complex in Falls Church Virginia (Figure 1).

Much of the data and information reviewed in this analysis was drawn from two published commissioned reports on these incidents prepared by Government Accountability Office [2] and the RAND Corporation [3]. The GAO report was commissioned by Congress to analyze the series of events connected with the delayed reporting of positive laboratory confirmations of anthrax from sensor filters at the Pentagon mail facility actions. However, it did not include a summary of the events that occurred at the Defense Intelligence Agency facilities on Bolling Air Force Base. The RAND study was commissioned by the DOD to analyze the conduct and coordination of biodefense operations conducted at military-related facilities involved and did not address the emergency response, medical treatments and environmental testing operations conducted at the US Postal Service mail handling facility in Washington D.C. The V Street Mail Facility was thought to be a possible source for the suspected anthrax contaminated mail at the Pentagon. The present analysis provides information on all four of the biological agent emergency response operations and therefore contains a more comprehensive summary of the bioagent emergency response operations.

These events began when a private laboratory located in Richmond Virginia obtained positive laboratory confirmation of anthrax spores on samples from a detection filter collected from a mail handling facility at the Pentagon on the evening of Thursday March 10th, 2005. However, there was a protracted delay of at least 60 hours in the reporting of multiple positive laboratory test results for anthrax from the Pentagon remote mail processing facility (from 1600 Friday March 11th until 0925 Monday March 14th ), which resulted in the distribution of potentially contaminated mail to the Pentagon and other DOD offices in northern Virginia. These incidents resulted in a cascading series of major emergency response operations at the Pentagon, the Skyline Complex and the V Street Mail Facility on Monday 14 March 2005 that affected tens of thousands of people. The series of events connected with the detection of suspected anthrax contaminated mail from the Pentagon mail facility were followed by a biological agent sensor alarm later that week (on Friday March 18th 2005) at a another military mail facility on Bolling Air Force Base in Washington D.C. which processes mail for the Defense Intelligence Agency.

Bioterrorism emergency response operations involving FBI, police, fire, public health and hazardous materials response operations were set in motion and the incidents precipitated a mass antibiotic prophylaxis treatment campaign involving approximately 1,100 people, including DOD and contractor personnel at the Pentagon (~900) and Skyline Drive Complex (45) and Postal Service employees at the V Street Mail Facility in Washington D.C. (>160). These four incidents, although closely linked in time and space and connected to suspected bioagent contaminated mail deliveries between military installations and office facilities in the Washington D.C. area, involved very different containment and response scenarios among federal military and civilian agencies and local emergency response agencies that participated in the biological agent emergency containment and management response [3].

The first of these incidents occurred at the Pentagon, following a reported positive laboratory test result for anthrax from a swab sample collected from sensor filters on 10 March 2005 from the Pentagon mail processing facility. The situation was complicated by the fact that the original laboratory confirmation was not communicated to DoD officials until three days after the first positive test result was reported by the laboratory; test results from filter samples collected on Thursday March 10, which gave positive results during laboratory testing on Friday March 11 were not communicated to DOD until 0925 hrs on Monday March 14. This delay of more than 60 hours in the reporting of initial positive laboratory test result, coupled with other miscommunications from the contractor, resulted in the distribution of potentially contaminated mail to the Pentagon and at least one off-site mail facility.

The Skyline Complex incident began later that same day, Monday March 14, when emergency personnel (including police, fire, public health and hazardous materials units) responded to a 911 call from the a Department of Defense office complex where an alarm had sounded on a biosafety cabinet used to screen mail. Mailroom personnel had received a warning from the Pentagon Remote Delivery Facility (RDF) earlier in that day about possible contamination of that day’s mail delivery. A third bioagent emergency containment and response operation was initiated on the night of 14 March 2005 at the VSMF. This operation resulted from the possibility that the anthraxcontaminated mail detected from filter samples at the Pentagon RDF on March 10 had originated from that facility. The last reported incident in this series occurred on Friday 18 March 2005, as the result of an automated biosensor detector alarm at a mail-handling facility used by the Defense Intelligence Agency at Bolling Air Force Base in Washington D.C. The FBI conducted follow-up tests and the DIA RDF incident was officially classified as a false alarm following testing of environmental samples from the facility.

No positive laboratory tests on filter specimens or environmental samples collected from any of the four facilities were reported from any of the samples analyzed by US Army Medical Research Institute of Infectious Diseases, the Federal Bureau of Investigation and the Centers for Disease Control and Prevention. However, recent research has shown that cross-contamination of mail within sorting machines or mail containers can occur and that detectable trace amounts of anthrax spores be detected from secondarily contaminated mail [4]. In light of this new research, it seems possible that the initial positive test result from the Pentagon remote mail facility may have come from trace contamination caused by residual spores from the 2001 anthrax letters attacks that were still present on mail equipment or mail containers in a postal facility somewhere and that secondary trace contamination of an articles of mail may have occurred from contaminated mail containers that not been in use since that time, or from a trace amount of residual spores released during the repair or removal of cryptically contaminated mail handling equipment at a mail processing facility somewhere in the mail system that services military mail systems in the Washington D.C. area.

Case Studies

The events connected to these suspected anthrax mail incidents occurred at two sites in northern Virginia and two sites in Washington D.C. over a five day period from Thursday 10 March to Friday 18 March 2005. Reported details and timelines for the emergency response operations conducted at each of these sites are summarized in the case studies presented below. Unless otherwise cited, the technical data and date/time information summarized in this analysis are based on the findings of the GAO investigation of these incidents conducted between June 2005 and August 2006 [2] and an independent analysis conducted for the Office of the Secretary of Defense (OSD) by the RAND National Defense Institute [3].

Pentagon Remote Delivery Facility

The first event in the series of incidents began on Thursday afternoon, 10 March 2005 at the Pentagon RDF, a 250,000-squarefoot shipping and receiving facility adjoining the Pentagon. Mail from the U.S. Postal Service and commercial delivery services is processed at the RDF by technicians dressed in protective gear, who screened mail over a custom-designed table equipped with four filters intended to capture any particles that might fall from the mail. The table used a negative airflow system that was intended to keep microscopic particles from dispersing back into the mail-screening facility. Swab samples from these filters were collected and tested on a daily basis, in order to identify possible mail contamination by anthrax spores or other biological hazards. At the time of this incident, irradiated first class mail for the Pentagon was delivered to the RDF from the USPS VSMF, where irradiated mail for federal agencies in Washington D.C. area is processed prior to delivery under a mail biosecurity system established in the wake of the anthrax letter attacks of September- October 2001 [5].

Following a routing mail screening at remote mail delivery facility at the Pentagon on 10 March 2005, swab samples from four biosensor filters collected and sent for testing to a contractoroperated laboratory facility located in Richmond VA operated by Commonwealth Biotechnologies, Inc., (CBI) under a subcontract to the prime contractor Vistronix, Inc., [2,6].

According to the contractor’s account of events associated with the incident, the CBI laboratory issued their first positive test result report at ~ 1600 hrs on Friday afternoon that one of four swab samples collected and tested from Thursday’s mail at the Pentagon facility was positive for anthrax to the Director of Vistronix. The Director reportedly requested CBI conduct additional testing, but did not notify DOD officials of the initial positive test results. At about 0600 hrs on Monday 14 March, the Vistronix Director reportedly informed a member of his staff (the site supervisor) that while laboratory results for Thursday’s mail had not yet been received, test results for Wednesday’s mail were negative and mail from that day was cleared for release. The site supervisor apparently misunderstood the communication, however and ordered his staff to release the quarantined mail from both Wednesday and Thursday. At about 0630 hrs on Monday 14 March, mail from the suspected contaminated consignment was released and processed for distribution to offices located throughout the Pentagon and DOD organizations at other locations in northern Virginia.

Vistronix only notified Defense Department post office officials of the positive anthrax test results at about 0925 hrs on Monday 14 March 2005, following a communication from CBI that a second positive result was obtained during additional tests on the Thursday swab sample conducted over the weekend. By the time the official notification of a positive test result had been received, however, mail from the suspected anthrax-contaminated batch had already been picked up and distributed to the Pentagon and some offsite facilities. The Pentagon Force Protection Agency (PFPA) was notified of the positive test results at 1015 hrs and the facility was evacuated at about 1030 hrs [7]. Following the notification of a positive laboratory test for anthrax from a sensor filter specimen collected four days earlier, the PFPA responded by (Figure 2).

• Shutting down the Pentagon RDF

• Mobilizing security personnel and antiterrorism units to secure the perimeter around the Pentagon RDF

• Evacuating the majority of the employees from the Pentagon RDF to an emergency quarantine site established at a former Pentagon child care facility

• Coordinating with RDF personnel to identify possible recipients of the suspected contaminated mail consignment

• Obtaining culture specimens from all personnel who may have had contact with mail deliveries, began providing antibiotic treatments to exposed personnel (Figure 2)

The Arlington County Emergency Communications Center sent emergency personnel to the Pentagon RDF after it was notified of a possible bioagent emergency through official channels at about 1037 hrs and the PFPA continued to lead emergency response operations on the Pentagon Reservation in the hours that followed. According to a DOD timeline of the incident, DOD also attempted to notify the following federal and local offices:

• 1210 hrs: First broadcast message sent to local public safety and emergency management response agencies.

• 1215 hrs: FBI’s Washington Field Office and the Weapons of Mass Destructions Operations Unit at FBI Headquarters.

• 1230 hrs: Office of the Postmaster General—the executive head of the Postal Service.

• 1240 hrs: Department of Homeland Security’s Operations Center.

• 1300 hrs: Centers for Disease Control and Prevention (CDC)

Although the Department of Health and Human Services (HHS) is the primary U.S. government agency responsible for a public health response, it was the CDC emergency operations center in Atlanta — not DOD — that first contacted the HHS operations center with information regarding the suspect anthrax incident at the Pentagon. As officials from additional federal agencies became aware of the incident, several interagency conference calls were held. The first of these calls was convened by HHS officials at 1700 hrs on Monday to determine what analyses had been performed, what procedures had been used by the laboratory and how the Pentagon samples had been collected, in order to determine whether the two incidents were linked, whether any anthrax exposures had occurred and what the appropriate response should be. According to DHS and HHS officials, DOD could not adequately answer these and other questions.

During the afternoon, DOD sent the samples from CBI in Richmond VA to the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) in Frederick MD (a distance by road of about 120 miles) for confirmation analyses and began providing initial 3-day course of antibiotics to about 889 potentially affected employees at the Pentagon. Persons receiving antimicrobial post-exposure prophylaxis (PEP) included employees and technicians working at the RDF and persons working in the Pentagon who received mail from the contaminated mail consignment from Thursday March 10th [2].

Over the next few days, additional testing of the Pentagon sensor filter specimens as well as environmental samples taken from the Pentagon conducted by the USAMRIID laboratories at Fort Detrick reportedly determined that anthrax was not present in samples collected from the Pentagon’s mail-screening facility. Agency officials involved in the response believe that the initial positive test result could have been caused by cross contamination at CBI, although no similar incidents involving possible cross-contaminated samples had been reported from this laboratory during the years that the laboratory tested samples from the Pentagon before or after these events occurred. The Pentagon RDF reopened on Friday 18 March 2005, that same day that a biological agent sensor alert was reported from a Defense Intelligence Agency mail service facility at Bolling Air Force in Washington, D.C.

The Skyline Complex

The Skyline Complex incident occurred at a TRICARE Management Activity (TMA) office suite in Falls Church, Virginia on the afternoon of the same day (March 14) that the positive lab reports were first reported to the Pentagon RDF. TMA is the organization responsible for managing and directing the TRICARE program, DOD’s health benefits program for military beneficiaries and the office receives mail from the Pentagon RDF. The Skyline complex where the TMA offices are located is an office tower complex owned by a private company, which provides leased office space to other DOD organizations, other federal agencies and private businesses.

The incident began after TMA was informed that there was a problem involving the morning mail delivery from the Pentagon RDF mail delivery, after the morning mail had been handled and sorted into mailboxes for distribution. While TMA staff were pulling mail out of mailboxes and attempting to retrieve mail that had already been collected, an alarm sounded on the biosafety cabinet used in screening mail, which employees interpreted took as a sign that contaminated mail had been passed from the Pentagon to the Skyline Complex. TMA personnel made a 911 call at 1409 hrs saying that an alarm had sounded on a biosafety cabinet used to screen mail. Fairfax County emergency personnel responded to a 911 call from the Skyline facility with fire, police, public health and hazardous material units. Local officials instituted a lockdown on the facility and implemented an biohazard incident response operation that included the collection and testing of environmental samples.

The incident response effort over the next few hours, undertaking the following operations:

• Locking down the entire Skyline Complex and securing all exits to prevent anyone from entering or Leaving the facility; shutting down building elevator services.

• Shutting down ventilation and heating/air condition systems, distributing health information to the quarantined occupants.

• Collecting emergency contact information from the occupants.

• Collecting and testing environmental samples from the complex.

• Attempting to remove filters from the biosafety cabinet in order to perform additional tests.

At about 1930 hrs, Fairfax County responders began individual decontamination of 45 of the complex’s employees who were believed to be at high risk for exposure to anthrax and began releasing quarantined Skyline Complex personnel in the absence of any definitive test results from the facility. Antibiotics were dispensed to 45 individuals at 1400 hours on Tuesday, approximately 24 hours after the initial 911 call to local authorities to report a possible biohazard incident at Skyline Towers.

USPS “V” Street Mail Facility

The V Street Mail Facility, located in the N.E. section of the District of Columbia, processes first-class mail for the Pentagon and other federal agencies in the Washington D.C. area, under a biosecurity system established in the wake of the anthrax letter attacks of 2001 which requires that most mail for delivery to federal offices with ZIP Codes between 20201 and 20597 is irradiated at a facility in New Jersey before shipment to the V Street facility for final routing and delivery [5].

Postal Service officials first learned about the anthrax emergency response operations at the Pentagon through the local media, although DOD official reportedly attempted to contact the Postmaster General by telephone to inform him of the Pentagon incident at about 1230 hrs, but neither the Postmaster General nor other ranking USPS executive were available to receive the call and the Postal Service’s Senior Vice President for Government Relations said that the voice mail message that was left did not convey any urgency about the potential for anthrax in the mail. USPS officials first learned that DOD had provided antibiotics to Pentagon employees during the first interagency conference call regarding the emergency operations, which was conducted at about 1700 hrs on Monday 14 March 2005.

Operations at the VSMF were suspended at 1815 hrs. Following the shutdown of operations, more than 160 employees at the VSMF were treated with emergency antibiotic prophylaxis for possible anthrax exposure. Environmental testing at the facility began on Tuesday 15 March with technical support from the CDC’s National Institute for Occupational Safety and Health (NIOSH), which had performed previous environmental monitoring evaluations at the facility in the aftermath of the 2001 anthrax attacks [8]. Results from laboratory testing of environmental samples from the VSMF were received the morning of Wednesday 16 March and the facility was reopened at 1345 hrs that same day.

DIA Remote Mail Facility, Bolling Air Force Base

On the morning of 18 March 2005, a remote mail handling facility for the DIA was shut down following an initial positive test of incoming mail for hazardous biological agents. Although the GAO investigation concluded that the Bolling AFB incident was not directly linked to the Pentagon and Skyline Complex incidents [2], the location and timing of this event are of particular significance because there is a mail processing facility on Bolling AFB that handles mail for the White House where evidence of anthrax spores was detected in conjunction with the weaponized anthrax letter attacks of October 2001 [9].

The DIA RDF handles mail for DIA headquarters offices at Bolling AFB in a facility separated from the main Defense Intelligence Analysis Center (DIAC). Mail processing occurs in a mailroom equipped with protective measures and showers that can be used for decontamination. Mailroom personnel run tests for biological hazards on site. In addition to mail-processing equipment and personnel, the RDF also houses the DIA’s Response Management Program (RMP) Office. On 18 March 2005, the mailroom staff was batch-processing mail in accordance with established procedures when the hazardous substance detection system indicated the possible presence of anthrax during the processing cycle.

The mailroom staff sheltered in place and notified DIA security, who initiated a full emergency response operation by DIA security personnel and DOD emergency response assets from Naval District of Washington Fire and Emergency Services (NDW/ES), including firefighting units, the NDW/ES HAZMAT team, Bolling AFB medical clinic staff, the 11th Wing Bio/Environmental Unit and a PFPA team. NDW/ ES response team established a decontamination site. Following the discovery that two DIA RMP employees from the RDF had entered the main DIAC building, the Incident Commander ordered the DIAC locked down and all staff inside to shelter in place until the potentially contaminated personnel could be located.

The NDW/ES event chronology documented in the Rand study indicates that this incident was declared “closed” approximately three hours after the initial alarm [3]. Personnel who were within the RDF during the event were offered medical assistance. FBI personnel arrived after the event was over to collect samples for lab testing. Extensive environmental testing did not identify anthrax and followon tests of mailroom personnel were also reported as negative.

Conclusions

The scale of quarantine and prophylactic antibiotic treatment operations conducted during the suspected anthrax mail incidents of March 2005 was second only to that implemented to those conducted in Washington D.C. in conjunction with the anthrax letter attacks of September-October 2001. Although follow-up investigations did not confirm the presence of viable anthrax spores at any of the facilities involved, the number of people given prophylactic antibiotic treatments for suspected possible anthrax spore exposure during these events was second only to that recorded in Washington D.C. during the anthrax letter attacks of September-October 2001. The scale and scope of the bioterrorism emergency response undertaken at both military and civilian facilities in the Washington D.C. area during these events further emphasizes the importance of analyzing the lessons-learned from these incidents for improving institutional capabilities for responding efficiently and appropriately to future bioterrorism response contingencies and ensuring effective communication and coordination between and among federal, state and local governments.

The incidents connected with this series of events revealed important challenges and obstacles to the coordination and communication of public and private sector emergency responses to possible terrorist bioweapon attacks. Nonetheless, the institutional responses mobilized during these events clearly demonstrated the ability for military and civilian organizations at all sites to rapidly implement coordinated emergency response operations according to established procedure as soon as personnel were aware of the possibility of mailroom bioagent contamination issue. Although follow-up investigations reportedly did not confirm the presence of viable anthrax spores at any of the facilities involved, the incidents connected with this series of events revealed important challenges and lessons-learned for enhancing the coordination and communication of future public and private sector emergency responses to potential terrorist attacks involving anthrax or other biological agents.

Acknowedgements

Barbara Price, Laura Peitersen, Jeanne Marin and anonymous reviewers provided helpful reviews and comments on preliminary drafts of this manuscript. The author thanks Jason Edmonds for interesting discussions on the phenomenon of mail cross-contamination by anthrax spores.

References

1. Department of Defense (2005) Positive Initial Detection for Anthrax at Pentagon. News Release No. 255-05, 14 March 2005, U.S. Office of the Assistant Secretary of Defense, Washington, D.C.
2. Government Accountability Office (2006) Incidents at DOD Mail Facilities Exposed Problems That Require Further Actions. United States Government Accountability Office. Washington, D.C.
3. RAND National Defense Institute (2006) Analysis of Department of Defense Plans and Responses to Three Potential Anthrax Incidents in March 2005. Executive Summary. RAND National Defense Institute. RAND Corporation. Santa Monica, CA.
4. Edmonds J, Clark P, Williams L, Lindquist HD, Martinez K, Gardner W, et al. (2010) Multigeneration cross contamination of mail with Bacillus species spores by tumbling. Applied Environmental Microbiology 76: 4797-4804.
5. Government Accountability Office (2008) United States Postal Service: Information on the Irradiation of Federal Mail in the Washington, D.C., Area. GAO-08-938R. United States Government Accountability Office, Washington, D.C.
6. CBI (2004) Vistronix, Inc. and Commonwealth Biotechnologies, Inc. jointly extend contract with Department of the Army to Provide Secure Correspondence Screening Services. Press Release– March 29, 2004, Commonwealth Biotechnologies, Inc. Richmond, Virginia.
7. American Forces Press Service (2005) Hazardous Materials Teams Investigating Alarm on Pentagon Reservation. Washington D.C.
8. National Institute for Occupational Safety and Health - Division of Surveillance (2002) Handling Irradiated Mail / Health Hazard Evaluation Report: U.S.P.S. National Institute for Occupational Safety and Health - Division of Surveillance, Hazard Evaluations and Field Studies.
9. National Defense University (2002) Anthrax In America: A Chronology and Analysis of the Fall 2001 Attacks. Center for Counterproliferation Research, National Defense University, Washington, D.C.

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