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It was a critical test to ensure anthrax bacteria had been thoroughly killed so the samples could be safely shipped to researchers at other labs. Yet the Army scientist simply threw out one test tube that showed some of the potentially dangerous anthrax was still alive, and issued “death certificates” for the rest of the batch that was then sent on to another lab, records obtained by USA TODAY show.
Some of the anthrax bacteria in the other test tubes was also still alive, the receiving lab later discovered.
The records, released under the federal Freedom of Information Act, reveal new details of how a scientist at the Army’s Dugway Proving Ground badly misjudged the effectiveness of one of the lab’s three kill procedures in 2007 — long before the discovery in May that the massive biodefense complex in Utah had been mistakenly shipping live anthrax to dozens of unsuspecting labs in the USA and abroad for more than a decade.
The test tube incident led to an enforcement action by federal lab inspectors eight years ago. Yet the Army and federal regulators didn’t detect more widespread problems at Dugway until a defense contractor discovered it had received a live anthrax sample earlier this year.
Biosafety experts contacted by USA TODAY called the 2007 incident egregious and said the discarding of the test tube indicates a potentially cavalier approach in Dugway’s culture of working with a deadly bioterror pathogen. Anthrax spores can cause fatal illness if inhaled and Dugway is a major production and testing facility for the military’s chemical and biological defense programs.
“Ignoring results that invalidate a procedure, destroying data, signing false reports, and knowingly and willfully misrepresenting materials are major offenses,” said Richard Ebright, a microbiologist at Rutgers University in New Jersey who has testified before Congress on lab-safety issues.
“These are (employee) termination offenses in research laboratories and production facilities,” Ebright said. “There has to be accountability.”
It is unknown whether the scientist in the 2007 incident was disciplined. The Pentagon did not respond to USA TODAY’s question about this sent Wednesday.
The Pentagon is currently conducting an accountability investigation of how the recently discovered Dugway anthrax lapses occurred and whether there was any failure of Army leadership. Meanwhile, USA TODAY revealed last week that lab regulators from the Centers for Disease Control and Prevention are investigating whether problems with military specimens of bioterror pathogens may go beyond anthrax, and include new concerns about samples of plague bacteria and encephalitis viruses.
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Despite ongoing investigations by the military, the CDC and Congress, it remains unclear why Dugway’s long history of failing to thoroughly kill anthrax specimens with gamma radiation wasn’t discovered until earlier this year. The 2007 incident involved specimens that had been treated with chlorine dioxide, which along with gamma irradiation was one of four methods in use to kill anthrax at Dugway at that time, the records show. The others involved treatment with heat and treatment with another chemical called formalin.
A Pentagon report on Dugway’s recent anthrax bungling, issued in July, raised questions about why Dugway’s scientific staff and leadership didn’t recognize they had a problem inactivating anthrax. Dugway’s own records, based on its limited testing of irradiated batches, showed a 20% failure rate for inactivating anthrax specimens, the Pentagon investigation team found. "We believe there were indicators that people should have known there was a problem," Deputy Secretary of Defense Bob Work said when the report was released.
Lab regulators at the CDC declined to be interviewed. In an emailed statement the CDC said the 2007 incident at Dugway — as well as other recent, high-profile lab incidents — "show the need for more specific regulatory oversight of laboratories’ inactivation of select agents." Select agent is the federal government’s term for viruses, bacteria and toxins, such as those that cause anthrax, botulism, plague and Ebola, that have the potential to be used as bioweapons.
The CDC said it is working with its regulatory partners at the U.S. Department of Agriculture to explore changes to existing select agent regulations to provide stricter requirements for killing pathogens and conducting tests to validate the samples are really dead. The CDC and the USDA jointly run the Federal Select Agent Program, which oversees labs working with regulated pathogens.
Regarding the 2007 incident, the CDC said that in addition to referring Dugway for enforcement action, CDC staff did a follow-up inspection in August 2009 and "did not observe any biosafety concerns regarding the inactivation of select agents." That inspection "found scientists using appropriate, proven methods to inactivate anthrax spores and conducting sterility testing to confirm inactivation had occurred," the CDC said.
Army officials also declined to be interviewed. In an emailed statement, spokesman Dov Schwartz said the 2007 incident resulted in Dugway officials immediately conducting a review that "found that the viability testing lacked sufficient rigor and (Dugway) revised the viability testing process in 2007 to account for these findings." Dugway also stopped using chlorine dioxide, the chemical used to kill anthrax in the 2007 incident, he said.
"The Army takes these inactivation issues seriously," Schwartz said, noting that Dugway remains under an ongoing moratorium on the handling and shipment of such materials.
USA TODAY first reported in June that Dugway had faced sanctions in 2007 for, what the CDC said at that time, involved shipping anthrax “despite growth of bacteria following the chemical inactivation.”
According to the records, lab regulators in Dec. 2009 determined that Dugway violated federal regulations in its shipment of live anthrax as a result of the 2007 incident — despite identifying viable bacteria in a test designed to validate the kill-step had worked. They also found that while chlorine dioxide was a "scientifically acceptable" way to inactivate anthrax, Dugway didn’t have a standard operating procedure for using the chemical.
The regulatory letters, which redact all references to anthrax, say that a scientist at Dugway had five test tubes of specimens that had supposedly been killed with chlorine dioxide that were being readied for shipment in April 2007 to another facility, whose name was also withheld from the released records.
To make sure the bacteria were dead, samples from the tubes were mixed into a broth made of brain and heart cells — the kind of environment Bacillus anthracis would start to grow in if still alive.
If the anthrax had been successfully treated with chlorine dioxide, none of the bacteria should have grown. And yet the Dugway scientist found a colony of anthrax bacteria growing from one of the test tubes, according to investigators’ review of the scientist’s clinical notebook.
The growth should have called into question the entire batch of anthrax. “This is evidence the inactivation procedure was ineffective,” federal regulators would later write about the incident. It’s unclear why the scientist, who is referred to as a principal investigator or PI, went ahead and shipped the other samples.
“The PI’s notes do not explain why the viable colony grew, whether the inactivation procedure was performed properly, or why the remaining tubes were not retested for viability,” according to a Dec. 9, 2009, letter from Gregory Demske, assistant inspector general for legal affairs at the inspector general’s office. Demske’s letter was presumably sent to an Army official at Dugway Proving Ground. The inspector general’s office redacted the name, title and address of the letter’s recipient from the released records citing secrecy provisions in a 2002 bioterrorism law. The name of the pathogen involved in the violations also was redacted from documents, yet USA TODAY’s FOIA request specifically sought only records about Dugway’s 2007 anthrax inactivation enforcement action.
“Upon completion of the viability check, [redacted] discarded the tube with excessive growth and issued death certificates for the remaining tubes,” the letter said, noting that the recipient of the other specimens found some of it to still be alive.
Laboratory and biosecurity experts said the scientist’s actions described in the letter are troubling.
“While I can’t explain the action of throwing away the tube with growth, I would say that discarding a positive sample is not the appropriate approach to sterility or validation testing,” said Eric Blank, senior director for public health systems at the Association of Public Health Laboratories.
“It is unacceptable laboratory practice, to say the least,” Blank said, adding that additional tests would be required to ensure the organism was killed.
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Amesh Adalja, a senior associate at the UPMC Center for Health Security, said it can unfortunately be easier for researchers to try to make a problem just go away than to report it and face bureaucratic regulatory hurdles.
Adalja said the incident speaks to the biosafety culture at Dugway. “It’s not something that should be acceptable,” Adalja said. “You don’t want people to think that scientists are that cavalier with something that could be potentially dangerous.”
He said Dugway’s lapses have the potential to threaten important research. “Keep in mind that anthrax is a major bioterrorism threat. It’s still a major disease in the developing world,” Adalja said. “You don’t want these lapses to shatter the public confidence in effective research.”
The inspector general’s office said it identified 187 pages of records about the referral of Dugway for an enforcement action because of the 2007 incident. The office, however, said it was withholding 25 pages of records because of bioterrorism secrecy requirements and because some materials were pre-decisional. It released 12 redacted pages to USA TODAY. The rest of the records, because they originated at the CDC and the Army, will need to be released by them, the office said. As of Thursday afternoon, no additional records had been released.
Contributing: Tom Vanden Brook
Read full coverage of USA TODAY’s ongoing investigation of safety and security issues at labs across the country: biolabs.usatoday.com
Follow USA TODAY investigative reporter Alison Young on Twitter: @alisonannyoung
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