Anthrax slip-ups raise fears about planned biolabs, including UTMB's new BSL-4 in Galveston
by Dan Vergano and Steve Sternberg
October 14, 2004
Bruce Ivins was troubled by the dust, dirt and clutter on his officemate's desk, and not just because it looked messy. He suspected the dust was laced with anthrax.
And he was in a position to know. Ivins, a biodefense expert, and his officemate were deeply involved in Operation Noble Eagle -- the government's response to the Sept. 11, 2001, attacks that killed almost 3,000 Americans and the anthrax attacks that killed five more less than a month later.
It was December 2001. Ivins, an authority on anthrax, was one of the handful of researchers at the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Md., who prepared spores of the deadly bacteria to test anthrax vaccines in animals. He knew enough to grow alarmed when his officemate complained, as she had frequently of late, about sloppy handling of samples coming into the lab that could be tainted with anthrax.
"I swabbed approximately 20 areas of (her) desk, including the telephone computer and desktop," Ivins later reported to Army investigators. Half of the samples, he found, "were suspicious for anthrax," betraying the clumpy brown appearance of anthrax colonies under a microscope.
Rather than reporting contamination to his superiors, Ivins said, he disinfected the desk. "I had no desire to cry wolf," he later told an Army investigator.
Months later, Army investigators would see Ivins' desk cleanup as the first sign of an alarming anthrax contamination at the nation's most renowned biodefense laboratory. A 361-page U.S. Army report on the events of that winter and the following spring, recently obtained through a Freedom of Information Act request, opens a rare window into the government's guarded biodefense establishment.
Today, the view from that window frightens critics of the government's plans to establish similar labs in urban centers throughout the country. They say it's too dangerous to bring deadly microbes into populated areas. In July, hundreds of Boston-area scientists and activists marched to oppose plans to construct a biodefense lab at Boston University. Supporters say such facilities are needed to fight bioterrorism.
But the new safety concerns echo fears expressed in late 2001 and early 2002 after anthrax spores, too small for the naked eye to see, escaped from a supposedly secure lab suite and into the scientists' offices. Within USAMRIID, 88 people were eventually tested for exposure to anthrax. The incident also raised fears that anthrax had leaked into nearby Frederick, Md.
Anthrax spores are infectious, and they're potentially deadly for years. When spores get into the skin, they cause pus-filled blisters that burst to form black scabs. Hence the name anthrax, from the Greek word for anthracite coal. Untreated skin infections are fatal about 25% of the time. Spores can be ingested in spoiled meat or inhaled in the air. Without prompt treatment, gastrointestinal and inhalation anthrax will kill you.
Researchers express relief that no one was hurt or killed in the episode, but Stephanie Loranger of the Federation of American Scientists asks, "Fort Detrick is one of the premier biodefense labs, and if they have problems, what does it mean for all the others?"
A time of turmoil
December 2001 was almost two months after the inhalation-anthrax death of tabloid photo editor Bob Stevens in Atlantis, Fla. Stevens' death was the first from five anthrax-laced letters that infected 22 people, hobbled the U.S. postal system and shut down the Hart Senate Office Building in Washington after Sen. Tom Daschle, D-S.D., received one of the letters. The person who sent the deadly envelopes has never been caught.
It was a frantic time at the biodefense lab. The criminal investigation, dubbed Amerithrax by the FBI, was in full swing and USAMRIID was the only national laboratory giving authorities round-the-clock biodefense analysis, spokeswoman Caree Vander-Linden says.
The six-member team that worked in the lab equipped to handle anthrax had swollen to a staff of 85. Most had to learn how to handle the bacteria "on the fly," says USAMRIID's commander Col. Erik Henchal, who headed the forensic effort. As many as 70 researchers slept in cars or on cots as they scrambled to keep up with a deluge of specimens flooding the lab.
Over roughly eight months, USAMRIID researchers ran tests on 30,000 suspect envelopes, packages and other items that arrived at the lab.
They also tested about 320,000 environmental samples from such places as the Hart Senate Office Building and Washington, D.C.'s Brentwood postal center, which lost two employees exposed to the lethal letters. (In addition to the Florida victim and the postal workers, an elderly woman from Oxford, Conn., and a Vietnamese immigrant from New York City were killed.)
"They were running just fantastic numbers of (anthrax) samples," says biodefense expert D.A. Henderson of the University of Pittsburgh. "I'm not sure what they have accomplished is appreciated."
In April 2002, four months after Ivin's initial suspicions, the contamination resurfaced. A microbiologist spotted the liquid slurry in which anthrax is grown leaking from flasks inside a secure lab suite. He reported the episode up the chain of command, which set off alarms throughout the lab. Ivins did more tests.
This time he found that three strains of anthrax had escaped the supposedly secure "Biosafety Level 3," or BL-3, laboratory, which is designed to enable scientists to safely work with deadly microbes. Two of the strains were used in biodefense work. One of them may have come from the envelope sent the previous October to Daschle's office.
Powdered anthrax from the Daschle envelope so readily surfed currents of air that it frightened USAMRIID experts who opened the envelope.
"The good news is nobody got the disease," says Alan Zelicoff, a biodefense expert who is now a consultant at ARES Corp., a risk analysis firm. "The bad news is that nobody got the disease because just about everybody near the BL-3 suite had been vaccinated."
It was during that period, as the anthrax investigation gained momentum, that Ivins' officemate "repeatedly expressed concern to (Ivins) that she may have been exposed to anthrax spores when handling powder," according to the Army's report.
The leak inside the BL-3 lab was found on April 8. Over the next two weeks, Ivins and other researchers tested lab surfaces to confirm the extent of the contamination. Eighteen lab workers were tested for anthrax exposure. Nasal swabs from one of them tested positive for anthrax. Army officials acknowledged the incident in an April 19 press release.
Anthrax was found in three places outside the containment lab. Colonies of two anthrax strains were found in the "clean change room" where male scientists disrobe before showering and donning sterile suits to enter the secure lab suite. The strains were Sterne, a benign form used in inoculations, and Vollum 1B, once Fort Detrick's signature bioweapons strain. Vollum 1B was grown from the blood of lab microbiologist William Boyle, who died after inhaling anthrax in a 1951 lab accident, hence the B in the name.
Further away from the lab suite, researchers found three strains of anthrax in the office called B-19 that Ivins and his colleague shared: Sterne, Vollum 1B and Ames. Ames is now the preferred strain for biodefense research and was the strain found in the Daschle letter.
Their tests also found more than 200 colonies of Ames strain on the lab's "passbox." The passbox is a 2-foot-square ultraviolet-bathed portal -- a blue glow emanating around the edges of its door -- used for safely passing potentially contaminated material into and out of the laboratory suite.
Fears in the community
As the investigation continued, word was leaking out. On April 20, USAMRIID officials got irate calls from Frederick's mayor and a visit from local U.S. Rep. Roscoe Bartlett, R-Md., who told Army investigators that he thought the incident was being "blown out of proportion" and "gives the terrorists an advantage."
Bartlett also wanted his nearby horse farm tested for anthrax. One day later he showed up at the lab, bearing a soil sample from his farm, which turned out to be negative for anthrax. He now says the public was never at risk and the lessons learned from the episode have made USAMRIID's safety standards stronger.
Fear that spores had escaped into the community in USAMRIID's dirty laundry prompted officials to dispatch technicians to the base's laundry at the Jeanne Bussard Center, a rehabilitation center for the developmentally disabled in Frederick.
One laundry worker's doctor had already called the base to query about the exposure risk. On April 20, the team collected 32 samples to test for possible anthrax contamination. Nothing was found.
The formal probe of how the contamination occurred began April 24, led by an Army investigator from Walter Reed Army Institute of Research. In 20 interviews over two weeks, investigators learned that some lab workers had been concerned about possible exposure for months, beginning with the botched handling of the Daschle letter that sent 16 people to the infirmary for preventive antibiotics.
By the time the investigation drew to a close, about 1,120 sites in the lab, the off-site laundry and the laundry's delivery vans had been tested. About 90 people had been evaluated for exposure, and many of them treated with preventive antibiotics. No one became ill and no other traces of anthrax were found.
Military investigators concluded that the Sterne and Vollum 1B colonies had probably persisted in Building 1425 for years, perhaps as far back as the U.S. offensive biowarfare program ended by President Richard Nixon in 1969. The Ames strain likely escaped the lab because workers didn't thoroughly decontaminate shipping containers with fresh bleach. USAMRIID's Henchal suspects that a researcher who handled a poorly decontaminated container may have spread the Ames spores outside of the containment area.
A question the report leaves unanswered is whether that Ames strain came from the Daschle letter, which would elevate the episode to a higher level of concern. "It is a little ambiguous," says C.J. Peters, of the University of Texas Medical Branch at Galveston, formerly one of USAMRIID's experts on deadly microbes. "If this is from the (Daschle) powder, it could be re-aerosolized and somebody could get hurt really bad. If it's from ordinary culture, it's not that dangerous."
Lt. Col. Jeffrey Adamovicz, who was then deputy chief of bacteriology at USAMRIID, says it's unlikely that the contamination stemmed from aerosolized spores, noting that spores would have been found in air filters throughout the building. They were not.
Henchal insists that the contaminating anthrax never posed an airborne threat to anyone. Despite acknowledging that the FBI has genetically typed the Ames strain found outside the containment lab, as well as the Daschle letter anthrax, Henchal declined to say whether the two were the same. "I'm not convinced I know the source of the contamination," he says.
No one was disciplined for the contamination. Ivins couldn't be reached for comment. USAMRIID declined to permit interviews with staff mentioned in the report. Henchal says lessons from the incident have been used in a revamped biosecurity program. "We're not going to take any shortcuts on safety," he says.
Broader safety concerns
That such a slip-up occurred in the research center that pioneered safety procedures now used worldwide to deal with lethal microbes raises broader questions, experts say.
"The message here from a scientific and policy standpoint is profound," Zelicoff says. "Facilities that are medical and microbiological may not be suitably equipped for dealing with aerosolized versions of the organisms that they otherwise deal with in great safety. . . . These facilities probably ought not be located in a heavily populated area. How do you contain smoke?"
About 50 maximum-containment labs nationwide harbor the deadliest of bacteria, viruses and toxins. Forty more biodefense research labs are planned in cities such as Atlanta and Boston. In addition to the furor over the plans in Boston, opponents have also taken aim at a lab to be built at the University of Texas Medical Branch in Galveston, citing concerns about excessive secrecy and biosafety.
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, which is building its own facility at Fort Detrick, notes that accidents are rare and that planned labs are unlikely to be as deluged with the flood of samples that arrived at USAMRIID as part of the anthrax investigation.
"Most scientists do things in a very careful way," Fauci says. "The chance that they'll be working in the same rushed atmosphere they faced at Fort Detrick is very small."
Ultimately, the unsolved 2001 anthrax killings still shadow Fort Detrick. The Ames strain of anthrax used in the letters, and found in the contamination incident, was first used in biodefense studies there.
For that reason, the FBI briefly shut down parts of the lab this July to look for more clues, searching for stray spores that might match those used in the attack. In August, FBI investigators carted away more lab equipment for analysis, looking for clues that may reveal a link of some kind between the lab and the attacks that can be presented to a grand jury.
Army investigators concluded that years of sloppy practices at the lab resulted from neglect of safety procedures, compounded by the pressure of a high-profile criminal case. One researcher described a common room in the lab area as a "rats' nest." And experts say the "sloppiness" documented in the report may complicate prosecution if the anthrax killer is ever caught, especially if defense lawyers can cast doubt on USAMRIID'S reliability.
"Any defense lawyer should read this report carefully and keep it in mind when DNA results are being quoted against his (or) her client," says Martin Hugh-Jones of Louisiana State University, a leading expert on anthrax. "I now understand why the FBI (anthrax) letter team is so fascinated by USAMRIID."
Contributing: Robert Barbrow and Susan O'Brian
For more information on biodefense labs at Universities, visit the Sunshine Project