Beyond the Breach

USAMRIID Bio Security manager Dr. Catherine Wilhelmsen demonstrates one of the heavy, air tight, doors in the quarantine unit known as the "slammer" at Fort Detrick Monday. She is wearing a positive pressure suit and standing in one of the shower units for cleansing the suits before removal.

FREDERICK — During a two-week period in April four years ago, officials at the Army’s lead biodefense laboratory at Fort Detrick discovered anthrax spores had escaped carefully guarded suites into the building’s unprotected areas.

The breach called into question the ability of the U.S. Army Medical Research Institute of Infectious Diseases to keep its deadly agents within laboratory walls seven months after the terrorism attacks of Sept. 11, 2001, and the anthrax mailings that autumn.

The 2002 incident was considered a containment breach because anthrax was found outside a containment suite, which is a group of laboratories and administrative rooms. USAMRIID uses strict security and sterilization methods to prevent the deadly agents stored inside from escaping.

Through a Freedom Of Information Act request, The Frederick News-Post obtained a 361-page report on the 2002 breach compiled by the U.S. Army Medical Research and Materiel Command, which oversees USAMRIID.

The News-Post also obtained reports of Detrick workers’ potential exposures to biological agents between April 1, 2002, and Dec. 1, 2005.

The News-Post used the USAMRMC report and the potential exposure documents to examine the changes USAMRIID has learned in the last four years, measuring its progress against Army recommendations and providing a rare look behind USAMRIID’s walls.

Finding the contamination

Concern about anthrax spores in supposedly clean areas began months before the April 2002 breach, during late 2001. That fall, anthrax-laced letters were mailed to Sens. Tom Daschle (D-S.D.) and Patrick Leahy (D-Vt.), as well as media outlets in New York and Florida.

In December 2001, a USAMRIID technician told Dr. Bruce Ivins, a microbiologist in USAMRIID’s Division of Bacteriology, that she was concerned she was exposed to anthrax spores when handling an anthrax-contaminated letter.

USAMRIID was in the midst of processing tens of thousands of items and environmental samples to rule out anthrax contamination, including the letters mailed to Sens. Daschle and Leahy.

Dr. Ivins, who still works in the bacteriology division but declined to comment for this story, tested the technician’s desk area that December and found growth that had the earmarks of anthrax.

He decontaminated her desk, computer, keypad and monitor, but didn’t notify his superiors.

In the USAMRMC report, Dr. Ivins told Army investigators he did the unauthorized testing because he was concerned the powder in the anthrax letters and other samples might not be adequately contained.

He again became suspicious of contamination April 8, 2002, when two researchers reported potential exposures to anthrax after noticing flasks they were working with had leaked anthrax, crusting the outside of the glass tubes.

USAMRIID officials found anthrax spores in several rooms within a conainment suite near the potential exposure.

Nasal swabs from one scientist involved in the incident tested positive. The scientist had been previously vaccinated and did not contract the disease.

When the contamination was discovered, Dr. Ivins performed an unauthorized sampling of areas outside containment April 15, according to the USAMRMC report.

He found anthrax spores in his office area; a passbox, which uses UV radiation to allow personnel to safely transfer materials from labs to outside areas such as hallways; and an area where scientists and technicians change from civilian clothing into laboratory garb.

Dr. Ivins found heavy growth of Ames-strain anthrax, a pathogenic or disease-causing form of the agent, on rubber molding surrounding the noncontainment side of a passbox.

His office area tested positive for Ames anthrax spores. The men’s change room tested positive for Ames spores and a few colonies of Vollum 1B, another pathogenic form.

The anthrax found in these areas was a different strain from that in the potential anthrax exposure April 8, suggesting at least two incidents of contamination. USAMRIID works with three anthrax strains: pathogenic strains Ames and Vollum 1B and Sterne, a nonpathogenic vaccine strain.


On April 16, 2002, Dr. Ivins notified the USAMRIID Bacteriology Division chief of the preliminary results from his April 15 sampling. USAMRIID confirmed the contamination April 16.

On April 18, official testing found anthrax spores in areas outside containment, including Dr. Ivins’ office and near a passbox.

A sample taken near the passbox tested positive for more than 200 spores of Ames-strain anthrax.

The testing also revealed spores in a men’s change room, posing a risk of contamination to the Jeanne Bussard center on South Market Street, where USAMRIID’s laundry is routinely processed after being sterilized at Fort Detrick.

The Army’s Center for Health Promotion and Preventive Medicine found no anthrax contamination when it tested the center in the days after the breach.

USAMRIID sterilizes all laundry leaving change rooms, using high temperatures and pressure in machines called autoclaves.

USAMRIID Safety Officer Maj. Chris Ansell recently said all laundry has been autoclaved for years, before April 2002, and tests of the Jeanne Bussard center were an extra step in protecting its workers.

Where did the anthrax come from?

The USAMRMC report states that multiple episodes of anthrax contamination probably occurred in USAMRIID.

The most likely cause of the contamination found in April 2002, the report states, was an employee using old, ineffective bleach to decontaminate a container used to pass items through the passbox, and then placing the contaminated container on his desk.

The passbox contamination also may have occurred after researchers opened an anthrax-laced letter from the 2001 mailing attacks, the report states. The anthrax may have contaminated the outside of Ziploc bags used to transport material out of the passbox.

USAMRIID Commander Col. George Korch Jr., who was deputy commander during April 2002, said recently the institute still has not conclusively determined where the anthrax originated.

The spores could have existed in USAMRIID for years, biodefense expert Dr. C.J. Peters said earlier this year, as anthrax spores are extremely resistant.

Dr. Peters, the director for biodefense at the University of Texas Medical Branch Center for Biodefense and Emerging Infectious Diseases, served as USAMRIID’s deputy commander for several years until 2000.

Lax safety adherence

The USAMRMC report on the 2002 incident states — based on affidavits by scientists and officials — that USAMRIID had a comprehensive system of procedures in place that should prevent exposures if followed, but adherence to and enforcement of those procedures was lax.

The report was completed by investigating officer Col. David Hoover of the Walter Reed Army Institute of Research in Silver Spring.

Safety problems included researchers improperly using the passbox, improperly handling biohazard waste, lab clutter, unlabeled chemical bottles and poor housekeeping.

In one affidavit, USAMRIID’s biological safety officer and safety and occupational health manager said USAMRIID’s commander and division chiefs had been very responsive to any safety concerns he or she raised, but the responsiveness of laboratory supervisors to safety issues needed improvement.

Unconcerned about safety

An affidavit by USAMRIID’s safety and occupational health specialist also cited supervisory problems in handling safety violations — “a lack of teeth in the safety program,” he or she said.

“(Name redacted) has been very supportive, but there is not much interest from others in the headquarters in enforcing safety problems.”

The official, whose name was blacked out in the report, said he or she knew of some lab workers not showering, part of standard decontamination procedures.

In the report, the specialist states this example of some researchers having cavalier attitudes toward safety:

“For example, I went into a virology suite one day,” the specialist said. “He (no name specified) went through the hot change room stark naked carrying two library books and a bottle of Pepsi. I went in through the change room and found him sitting in the office drinking the Pepsi and wearing scrubs.

“I informed the individual that the Pepsi and the books from Frederick County Library should not have come in through the hot area but only through the passbox. Also, the library books would need to be autoclaved out of the suite.

“The researcher didn’t think these issues were important so I addressed it with (name redacted) and (he or she) addressed it with the supervisor.

“There was minimal support from the supervisor and division chief. In general, the virology division chief does not support safety concerns.”

‘Kind of sloppy’

In another affidavit, a research investigator in the bacteriology division, who served as a suite supervisor for about two years until mid-April 2002, questioned the efficacy of USAMRIID’s safety program.

The scientist said he or she routinely saw lab personnel not wearing latex gloves, standard laboratory protective equipment.

“Team anthrax are generally kind of sloppy,” the scientist states in the report. “I think there’s a serious problem. I recommend to my people to always wear one pair of gloves and to remove the outer pair of gloves after working with agent, since I can’t be sure the lab isn’t contaminated.

“There is institutional skepticism and a feeling that the safety program may be more about insulating the institute from criticism than from protecting the workers,” the scientist said. “Other workers have mentioned they might not report in the future because of the fallout from this episode.”

Discipline after report

Despite affidavits with finger-pointing at some individuals not following safety protocol, USAMRIID’s Col. Korch said no disciplinary action was taken against scientists named in the report.

“One thing you really want to avoid is, if you find a safety violation, you want to make sure there is an openness and acceptance about not being too punitive,” Col. Korch said. “You want to make people feel that they are openly contributing in a way that is not going to shut down (their) inclination to say ‘Hey, this happened.’”

USAMRIID spokeswoman Caree Vander Linden said that after the 2002 breach, the institute focused on learning from the incident and making necessary changes to prevent a similar occurrence.

After the breach, USAMRIID’s safety office began a weekly environmental surveillance of labs to catch agents in areas where they shouldn’t be. In the report, several scientists state surveillance cultures had once been routine but were rarely done by 2002.

Risk to Frederick

Dr. Peters said the 2002 breach revealed more about containment problems than a real danger to USAMRIID’s workers or the surrounding community, because while anthrax is deadly it isn’t contagious and the number of spores found was relatively small.

Of areas that tested positive for anthrax, nearly all had no more than three spores and one (near the passbox) had 200 spores, while a few thousand spores are necessary to infect the average person.

Anthrax is a disease caused by Bacillus anthracis, a bacterium that forms spores, according to the Centers for Disease Control and Prevention.

Anthrax can be contracted through spores in the digestive tract, on the skin or in the lungs. Inhalation anthrax — caused by breathing in spores — is more lethal than skin-contracted, or cutaneous, anthrax. The well-refined anthrax spores contained in the 2001 mailings traveled easily through air into victims’ noses and lungs.

The CDC classifies bioterrorism agents such as anthrax into categories. Anthrax is classified in Category A, agents that may spread across a large area and need a great deal of planning to protect the public’s health.

USAMRIID researchers who work with anthrax are vaccinated against the agent with the current licensed anthrax vaccine, known as Anthrax Vaccine Adsorbed, or AVA.

No breaches of containment — the confirmed presence of agents where they shouldn’t be — have been reported before or after April 2002.

In USAMRIID’s 37-year history, researchers have reported five infections from biological agents they’ve worked with in the laboratories.

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