Posted: Sunday, January 4, 2015 2:00 am
While sitting in a boiling hot water bath in a Fort Detrick lab, a plastic tube holding a biological warfare agent popped open. Steam rose up out of the bath.
A microbiologist walked into the room. And another.
One stood in the room for 10 minutes as they discussed what to do, the steam spreading through the lab.
In all, six people were potentially exposed to Burkholderia mallei, a bacteria that causes an infectious disease called glanders. The bacteria can be spread via aerosol, contaminated food and water and was used as a biological weapon during World War II.
The potential exposure, as documented in occupational hazard reports from the U.S. Army Medical Research Institute of Infectious Diseases, happened Sept. 19, 2013, and is one of three events at USAMRIID over the past two years that potentially exposed multiple employees to a single mistake.
The Frederick News-Post obtained copies of the mishap and occupational hazard reports from USAMRIID, the National Institute of Allergy and Infectious Diseases’ Integrated Research Facility and the National Biodefense Analysis and Countermeasures Center at Fort Detrick through Freedom of Information Act requests filed in 2014.
USAMRIID provided 185 reports that were filed between January 2012 and the end of August 2014.
NBACC provided 306 reports that were filed between September 2011, when the lab was certified to work with biological select agents and toxins, and the end of June 2014.
NIAID-IRF provided 11 reports that were filed between April 2014, when it was certified, and the end of August 2014.
The names of the people involved in reporting the incidents, some locations and names of toxins were redacted by the agency that provided the documents.
The six people involved in the Sept. 19 incident at USAMRIID were given antibiotics and more training.
“We have made sure (through) both our suite specific training and our annual training for personnel that all personnel maintain situational awareness of what is happening in our suites,” said Dr. David Harbourt, USAMRIID biosafety officer.
According to the reports, USAMRIID staff considered using tubes with screw caps instead of snap caps after the Sept. 19 incident, among other procedural changes.
“There was a review of the (standard operating procedure) for handling any potential exposures, emphasizing that the individual is to immediately leave the lab, close off access to the lab and then notify the safety office, supervisor, Occupational Health and Biosurety (offices),” the report states.
On May 23, 2014, a USAMRIID microbiologist was working with TC-83, a virus derived from Venezuelan equine encephalitis, when tubes of the virus broke and released the substance while spinning inside a centrifuge.
“Used wrong tubes,” the report states.
The U.S Department of Health and Human Services considers Venezuelan equine encephalitis a potential biological weapon, especially if it is turned into an aerosol.
The microbiologist and a lab technician were potentially exposed to the virus when the vials broke, and a postdoctoral fellow was potentially exposed when he or she walked by the centrifuge and closed the lid.
All three were instructed to return to regular duty after the incident and were retrained on safety procedures.
“Every mishap is handled on a case-by-case basis,” Harbourt said. “No single response will be the same to every mishap because it depends on the root cause.”
At NIAID-IRF, lab personnel are required to have annual training on safety procedures, protocols and protective equipment, according to National Institutes of Health spokesman Brad Moss.
The same is also required at NBACC. Staff have routine response drills with potential exposure scenarios.
“The purpose of these drills is to ensure appropriate response and to limit subsequent potential exposures,” Moss said in an email.
There were no recorded incidents of multiple potential exposures stemming from a single event at NBACC or NIAID-IRF since those labs were first certified to work with biological select agents and toxins. NBACC was certified in September 2011 and NIAID-IRF was certified in April 2014.
“All three facilities follow the proper biological safety processes and do the required amount of training,” said Bob Hawley, a member of Frederick’s Containment Lab Community Advisory Committee and former chief of the safety office at USAMRIID. Hawley worked at USAMRIID from 1988 to 2003.
The number of people working at the Army lab grew from about 300 when he started to nearly 800 when he left.
“The culture, and the climate of course, change as you deal with more people and getting them to realize the importance of safety,” Hawley said. “That was a constant challenge.”
One way to address that is through “proper and frequent” risk communication, he said.
NBACC has about 180 employees, according to its director, Dr. Pat Fitch.
“We’re in this perpetual loop of lessons learned,” Fitch said.
At the Department of Homeland Security lab, the director said they often run through hypothetical situations in addition to required training to review their safety procedures.
One of those situations was a June 2014 incident at the Centers for Disease Control and Prevention in Atlanta, where 41 people were tagged “potentially at risk” for exposure to anthrax after a lab incident.
According to the CDC’s after-action report, none of those people became ill due to an anthrax exposure.
When the report came out in July 2014, Fitch said he sat down with NBACC leadership and ran through a drill based on the CDC incident.
“It didn’t happen here, thank goodness, but let’s pretend for a second it did,” he said. “What’s a list of things we would be doing right now?”
Fitch said NBACC ensured personnel were adequately trained, had up-to-date training and had the opportunity to provide feedback on safety policies.
Despite the precautions, simple human error can still lead to mistakes in the lab.
At USAMRIID in May 2014, a research technician dropped a bottle of acetic acid while putting it away in storage and was exposed to the fumes for five minutes. A coworker who was in the lab at the time also reported that the bottle broke and had no contact with the chemical.
A third employee was cleaning up the spill when some of the fumes got under their respirator hood, resulting in mildly irritated eyes.
Acetic acid is the main component in vinegar and is not considered a biological select agent or toxin.
“This was an accident,” a supervisor wrote on the May 2 occupational hazard report. “No fault of personal methods or procedure.”
Follow Sylvia Carignan on Twitter: @SylviaCarignan.
Categories: . Accidental Pathogen Releases