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Pentagon anthrax blunder reveals 'chain of errors' in government lab protocols Pentagon anthrax blunder reveals 'chain of errors' in government lab protocols
(about 4 hours later)
Scientists say the accidental shipment by the US army of live anthrax from a laboratory in Utah could point to deficiencies in the military’s system for handling the bacteria.Scientists say the accidental shipment by the US army of live anthrax from a laboratory in Utah could point to deficiencies in the military’s system for handling the bacteria.
Related: Anthrax: Pentagon accidentally sent bioweapon to as many as nine statesRelated: Anthrax: Pentagon accidentally sent bioweapon to as many as nine states
On Wednesday, Pentagon officials told reporters Dugway Proving Ground in Utah had inadvertently shipped live anthrax to commercial labs in nine states – California, Delaware, Maryland, New Jersey, New York, Tennessee, Virginia, Texas and Wisconsin – and South Korea. On Wednesday, Pentagon officials told reporters that Dugway Proving Ground in Utah had inadvertently shipped live anthrax to commercial labs in nine states – California, Delaware, Maryland, New Jersey, New York, Tennessee, Virginia, Texas and Wisconsin – and South Korea.
The shipments reportedly began in March 2014, when the anthrax was reported to be inactivated after being irradiated. Shipments of the pathogen continued through April 2015, Reuters reported.The shipments reportedly began in March 2014, when the anthrax was reported to be inactivated after being irradiated. Shipments of the pathogen continued through April 2015, Reuters reported.
Officials have said the mistake did not pose a risk to the public, though four civilians have been placed on a preventative course of medication, which usually includes antibiotics. Twenty-two workers in South Korea are being treated preventatively.Officials have said the mistake did not pose a risk to the public, though four civilians have been placed on a preventative course of medication, which usually includes antibiotics. Twenty-two workers in South Korea are being treated preventatively.
Military officials said army technicians believed they had inactivated the bacteria at the time it was sent, and that all protocols appeared to have been followed.Military officials said army technicians believed they had inactivated the bacteria at the time it was sent, and that all protocols appeared to have been followed.
“The best I can tell there was not human error,” chief of staff Raymond Odierno told reporters on Thursday, Reuters reported, while cautioning that the information was based solely on preliminary reports. The Centers for Disease Control and Prevention (CDC) is investigating the failure.“The best I can tell there was not human error,” chief of staff Raymond Odierno told reporters on Thursday, Reuters reported, while cautioning that the information was based solely on preliminary reports. The Centers for Disease Control and Prevention (CDC) is investigating the failure.
But beyond a broad sketch of the events that led the dangerous pathogen to be shipped to commercial labs, officials at the Department of Defense have released little information. Rather than respond to a list of questions from the Guardian, the department provided a statement recapping reported facts in the story.But beyond a broad sketch of the events that led the dangerous pathogen to be shipped to commercial labs, officials at the Department of Defense have released little information. Rather than respond to a list of questions from the Guardian, the department provided a statement recapping reported facts in the story.
It is unclear, for example, what protocols were in place to inactivate the bacteria, and to confirm that status before the anthrax was shipped and received.It is unclear, for example, what protocols were in place to inactivate the bacteria, and to confirm that status before the anthrax was shipped and received.
“The incident involved exactly the same chain of errors as the CDC shipments of live anthrax bacteria in 2006 and 2014,” Richard H Ebright, professor of chemical biology at Rutgers University, told the Guardian in an email.“The incident involved exactly the same chain of errors as the CDC shipments of live anthrax bacteria in 2006 and 2014,” Richard H Ebright, professor of chemical biology at Rutgers University, told the Guardian in an email.
Ebright said technicians failed to “inactivate a sample, followed by a failure to confirm inactivation before shipping the sample, followed by … a failure to confirm inactivation upon receiving the sample”.Ebright said technicians failed to “inactivate a sample, followed by a failure to confirm inactivation before shipping the sample, followed by … a failure to confirm inactivation upon receiving the sample”.
“This seems to be a problem that happens pretty regularly,” said Gigi Kwik Gronvall, a senior associate at the Center for Health Security at the University of Pittsburgh Medical Center in Baltimore, Maryland.“This seems to be a problem that happens pretty regularly,” said Gigi Kwik Gronvall, a senior associate at the Center for Health Security at the University of Pittsburgh Medical Center in Baltimore, Maryland.
“Even if people are not following the protocol … then perhaps the protocol should be modified to make sure it’s easier to follow, and more likely to bring about compliance. It’s more, to me, that not enough is known about the situation.”“Even if people are not following the protocol … then perhaps the protocol should be modified to make sure it’s easier to follow, and more likely to bring about compliance. It’s more, to me, that not enough is known about the situation.”
Gronvall noted that the military had made a point of reporting the incident. “In many other, different places in the world there would be no notice that something happened incorrectly,” she said.Gronvall noted that the military had made a point of reporting the incident. “In many other, different places in the world there would be no notice that something happened incorrectly,” she said.
In some cases, clearing laboratories appears to have been left to state officials, as in New Jersey. There, state health, environmental and police hazardous materials responders were sent to the private lab.In some cases, clearing laboratories appears to have been left to state officials, as in New Jersey. There, state health, environmental and police hazardous materials responders were sent to the private lab.
Eleven months ago, a similar incident played out at CDC headquarters in Atlanta, Georgia.Eleven months ago, a similar incident played out at CDC headquarters in Atlanta, Georgia.
There, a lack of “standard operating procedures” led to dozens of employees being exposed to anthrax after a high-containment laboratory inadvertently sent live anthrax to labs with lower contaminant levels, where workers were not equipped to handle such dangerous pathogens.There, a lack of “standard operating procedures” led to dozens of employees being exposed to anthrax after a high-containment laboratory inadvertently sent live anthrax to labs with lower contaminant levels, where workers were not equipped to handle such dangerous pathogens.
The mistake happened after workers did not fully inactivate a pathogenic strain of the bacteria. Normally labs irradiate anthrax, but scientists at the CDC were working on new methods to inactivate the material for local health departments that might not have expensive irradiation machines.The mistake happened after workers did not fully inactivate a pathogenic strain of the bacteria. Normally labs irradiate anthrax, but scientists at the CDC were working on new methods to inactivate the material for local health departments that might not have expensive irradiation machines.
Both Ebright and the Government Accountability Office (GAO) have been critical of the government’s expansion of high-containment laboratories without an overarching regulatory body.Both Ebright and the Government Accountability Office (GAO) have been critical of the government’s expansion of high-containment laboratories without an overarching regulatory body.
“There are approximately 1,500 US laboratories authorized to work with fully active, fully virulent, biological weapons agents,” said Ebright, who has worked to sound the alarm on lab safety since funding increased in 2002. “This number is too large by a factor of 10 to 20.”“There are approximately 1,500 US laboratories authorized to work with fully active, fully virulent, biological weapons agents,” said Ebright, who has worked to sound the alarm on lab safety since funding increased in 2002. “This number is too large by a factor of 10 to 20.”
Because labs have at least some risk of making mistake with such agents, the GAO and Ebright said the more labs, the bigger the risk to the public. Because labs have at least some risk of making mistakes with such agents, the GAO and Ebright said the more labs, the bigger the risk to the public.
At least three agencies, including the Defense Department, the CDC and the Department of Agriculture, oversee such labs, and regulators largely rely on “self-policing”, the GAO reported. At least three agencies, including the defense department, the CDC and the Department of Agriculture, oversee such labs, and regulators largely rely on “self-policing”, the GAO reported.
“Oversight is critical in improving biosafety and ensuring that high-containment laboratories comply with regulations,” the report said. “However, our work has found that aspects of the current oversight programs … depend on entities’ monitoring themselves and reporting incidents to the regulators.”“Oversight is critical in improving biosafety and ensuring that high-containment laboratories comply with regulations,” the report said. “However, our work has found that aspects of the current oversight programs … depend on entities’ monitoring themselves and reporting incidents to the regulators.”
Stopping the spread of such bacteria is just one problem with such a diffuse system. The GAO also found that labs could duplicate efforts and waste taxpayer money without coordinated government oversight.Stopping the spread of such bacteria is just one problem with such a diffuse system. The GAO also found that labs could duplicate efforts and waste taxpayer money without coordinated government oversight.
More labs began working with dangerous agents like anthrax in the 1990s, but the number grew substantially after a number of anthrax-laced letters were sent to lawmakers and media outlets through the US Postal Service in 2001. Since then, the CDC has led the investment of at least $9bn in state and local health agencies.More labs began working with dangerous agents like anthrax in the 1990s, but the number grew substantially after a number of anthrax-laced letters were sent to lawmakers and media outlets through the US Postal Service in 2001. Since then, the CDC has led the investment of at least $9bn in state and local health agencies.