Photo by Sam Yu Pvt. Nick Shobe donned a Chemturion-brand full body protective suit during a tour of the BSL-4 patient care containment suite at USAMRIID recently. In the background are aircraft transport isolators for moving patients.

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Although no one contracted a disease from potential exposures mentioned in the reports, the incidents suggest enforcing existing policies and procedures is the institute’s biggest hurdle.

Employees at USAMRIID, the Army’s leading biodefense laboratory, filed 161 biological defense mishap reports between April 1, 2002 and Dec. 1, 2005.

The Frederick News-Post obtained the documents through a Freedom of Information Act request. The mishap reports — filed after any potential exposure to a biological agent — ranged from mundane slips and falls to potential exposures to agents including anthrax, glanders and SARS.

An Army report following the breach in containment spurred USAMRIID to improve its biosurety — biological safety and security — program.

Dr. Philip Brachman, a professor at Emory University Rollins School of Public Health in Atlanta, reviewed the reports. He said USAMRIID may have stringent regulations in place, but in some cases lab personnel weren’t adhering to them.

“USAMRIID has good people,” said Dr. Brachman, who worked at the Centers for Disease Control and Prevention until 1986. “I assume they do the best they can to contain the agents they work with. Every lab you work in has its rules and regulations — the problem is when people don’t follow them.”

While USAMRIID improved its training program after April 2002, human nature is always a factor in safety, USAMRIID Safety Officer Maj. Chris Ansell said.

“Obviously (laboratory supervisors) can’t be everywhere at all times — there’s a human element,” he said. “People can get complacent. Familiarity breeds complacency.”

In one report, rabbits exposed to an aerosol version of tuberculosis briefly bared their snouts to unmasked employees. Though the medical division determined the employees had a negligible risk of exposure, lab personnel absolutely should have been wearing masks, Dr. Brachman said.

“That is not acceptable,” he said.

In another report, an employee who worked with SARS contracted an upper respiratory infection after sharing masks with other lab personnel, a safety violation.

One report states a lab worker didn’t properly decontaminate trays containing SARS, leading several workers to report potential exposure. The report states the person at fault was removed from the lab.

Several incidents reported employees suffering needlesticks, resulting in potential agent exposure. Some of the potential exposures were blamed on haste, others on inattention to the sharp objects.

In one mishap report, a technician was scratched on the hand by a monkey infected with an agent that was redacted in the report. The technician was not wearing protective Kevlar gloves at the time. The report states the supervisor, who was present during the procedure, was at fault for not requiring the technician to wear proper protective gear.

In 2005, routine environmental surveillance in Building 1412 showed anthrax spores outside a “hot” lab, tracked from a contaminated change room shoe rack to other locations within a containment area.

Though the spores were found within containment, and thus the incident wasn’t considered a breach in containment, the incident suggests sloppy safety practices.

Three reports involved lab personnel concerned about exposure to the anthrax spores, which testing found in a change room, elevator, hallways and on a phone in Building 1412.

The USAMRIID medical division determined the three individuals who reported potential exposure had a low risk of anthrax exposure and disease.

Maj. Ansell said the spore spread could have been due to carelessness, passing spores from one’s glove to the hallway, to the elevator, similar to spreading germs such as the common cold.

“The good news is, we caught it and we bleached the heck out of the place,” he said. “It didn’t get to a level of great concern.”

USAMRIID safety officials held a meeting for Building 1412 personnel immediately after the finding to emphasize the importance of adhering to safety protocol, to prevent lab personnel from tracking spores out of laboratories.

In another 2005 incident, negligence resulted in an employee testing positive for a non-pathogenic form of anthrax. A lab worker’s nasal swab indicated contamination.

During the testing period to determine whether the anthrax strain was pathogenic, or disease-causing, USAMRIID’s medical division put the worker, who was previously vaccinated, on prophylactic antibiotics as a conservative measure.

In the incident, a lab worker was handling anthrax spores without using a safety device properly. The worker had not turned on the blower on the hood of the biological safety cabinet he or she was using, as required by the Biosafety in Microbiological and Biomedical Laboratories manual.

The cabinets are used to work with infectious agents and are designed to protect workers from airborne particles. A hood on the cabinet uses a blower to push air into the cabinet, preventing particles inside from escaping the cabinet and exposing workers.

The BMBL requires that safety cabinets and their blowers be used in any manipulation that could generate an aerosol, such as was generated in this incident.

Although the anthrax strain was non-pathogenic, the incident was still a breach in safety protocol, biodefense expert Dr. C.J. Peters said, after reviewing mishap reports between November 2004 and December 2005.

“What if the worker did it again with a highly pathogenic anthrax strain?” Dr. Peters asked in an e-mail to The News-Post.

Dr. Peters worked at USAMRIID from 1977 to 2000 and served as deputy commander in the late 1990s. He also served as USAMRIID’s Medical Division chief and Disease Assessment Division chief.

Dr. Peters now works at the University of Texas Medical Branch in Galveston, Texas, as director for biodefense at the UTMB Center for Biodefense and Emerging Infectious Diseases.

Dr. Frank Malinoski, a former USAMRIID medical virologist, echoed Dr. Peters’ sentiment, questioning what would have happened if the worker were using a pathogenic strain.

“It’s not a large leap for me to say this was an issue of containment,” he said. Maj. Ansell and Dr. Ellen Boudreau, chief of USAMRIID’s Special Immunizations Program, said the employee cited in the incident was a “repeat offender” and now works in a lower-risk lab.

When potential exposures are due to employee errors, disciplinary action depends on whether the incident was caused by simple or gross negligence, Maj. Ansell said.

USAMRIID safety officials said if a researcher is reported not following safety protocol, he or she must complete retraining and then may be moved to laboratories with lower risk and less responsibility.

Personnel with repeated safety offenses documented by their supervisors may be fired, USAMRIID spokeswoman Caree Vander Linden said.

“Everybody can make a mistake and have a bad day,” she said. “It’s a judgment call — was this a person who just slipped up one time? People are people and there will be some degree of human error no matter where you work.”

Dr. Steven Hinrichs, director of the University of Nebraska Center for Biosecurity in Omaha, said laboratories’ biggest challenge in developing safety systems is the researchers themselves.

“Almost always, the weakest link in any safety process is the individual,” he said. “There’s always variation when you’re working with humans in the system.”

Maj. Ansell said while USAMRIID hopes to increase safety adherence as much as possible, safety officials want to avoid an us-versus-them, punitive relationship. A good working relationship between researchers and safety officials, he said, increases reporting of biological defense mishaps.

Biological defense accidents are monitored by USAMRIID’s biosurety staff, which includes security staff, the USAMRIID Safety Office, the USAMRIID Medical Division and the division’s Special Immunizations Program. The SIP provides preventive measures such as vaccines, as well as treatments such as antibiotics.

Dr. Boudreau said biological defense mishaps include every possible breach in protection from agents, including paper cuts. Maj. Ansell said USAMRIID’s rates of mishaps are declining.

She said the medical division encourages lab personnel to report any potential exposure to agents, no matter how unlikely the risk of agent exposure. The medical division evaluates reports of potential exposures, determining the risk of exposure to the agent and of contracting disease.

Physicians in the biosafety medical division also assess the individual’s risk of exposure to the agent.

The medical division recommends treatment following a potential exposure, consulting outside experts if necessary, Ms. Vander Linden said.

The assessment includes what agent the worker was using, what he or she was doing at the time, which personal protective equipment he or she was using, whether the worker was using it properly and the status of the worker’s immunizations.

The risk of exposure or disease is categorized as no risk, negligible (exposure highly unlikely), minimal (exposure unlikely), moderate (exposure likely) or high risk (exposure highly likely).

Though lab personnel are vaccinated against any agents they may come in contact with, antibiotics are generally given as an extra measure to lab personnel whose exposure risk is determined to be minimal or greater.

Lab personnel who are potentially exposed to BSL-4 agents are quarantined in “the slammer,” a BSL-4 containment patient care suite, for as long as three weeks.

Of the 17 times lab personnel have been quarantined in the slammer since 1969, no one has contracted an illness due to an exposure, Ms. Vander Linden said.

A worker was quarantined in the slammer most recently in February 2004. The post-doctoral fellow was potentially exposed to ebola via a needle stick and spent three weeks in the suite under observation as a precaution. The worker was found to never have been infected.

A 2004 study by USAMRIID scientists found that between 1989 and 2002, the institute’s SIP clinic evaluated 234 individuals for potential exposure to agents of bioterrorism and nonbioterrorism.

Of these persons potentially exposed, five resulted in confirmed laboratory-acquired infections. None was fatal and all patients recovered fully.

The 14-year period was evaluated by USAMRIID’s Janice Rusnak, Mark Kortepeter, John Aldis and Dr. Boudreau. The scientists published their findings in the August 2004 issue of the Journal of Occupational and Environmental Medicine.

The diseases that resulted in those personnel were glanders, Q fever, vaccinia, chikungunya, and Venezuelan Equine Encephalitis.

In the most serious of the five cases of infection, a case of glanders occurred in a person with type I diabetes, resulting in liver and spleen abscesses and respiratory failure. The person was successfully treated for glanders and recovered.

The individual admitted not wearing latex gloves during some periods of laboratory work. Glanders is most often contracted through the skin.

Out of the 234 persons evaluated, 162 cases were assessed as minimal, negligible or no risk; 67 were assessed as moderate or high risk.