This week’s embarrassing revelations is the news that the Department of Defense mistakenly shipped live anthrax spores to all 50 states and nine countries, many more than they had previously admitted to. While this poses no immediate public health threat, as anthrax is not spread person-to-person, the continued reports of lapses certainly do not inspire confidence.
The current scorecard shows that anthrax shipments from Dugway Proving Ground were sent to 194 labs in all states, three territories (Guam, Puerto Rico, The U.S. Virgin Islands) and Washington, D.C., and to Japan, United Kingdom, South Korea, Australia, Canada, Italy, Germany, Norway and Switzerland. This is a marked increase from the initial May report of 18 labs in nine states, and then the June addition of two countries. Deputy Defense Secretary Bob Work was certainly prescient when he said in June that the scandal over the military's mistaken shipment of live anthrax spores around the world would get worse. Work described the errors at Dugway diplomatically, stating, “By any measure, this was a massive institutional failure with a potentially dangerous biotoxin.”
That more shipments were found is not a surprise. The problem is that the Pentagon just keeps this news trickling out, a constant reminder of their embarrassing mistakes. As Dr. Amesh Adalja, UPMC biosecurity expert, noted, “It is not surprising that the mistaken live anthrax shipments were wide-reaching given that there clearly was a problem with how deactivation of spores was confirmed. The event reaffirms the need to ensure that deactivation of anthrax spores is confirmed prior to shipment.”
There have been no deaths or serious illnesses from this error, although some workers were given Ciprofloxacin as prophylaxis against infection.
A bigger problem is that, despite the hand-wringing and reviews, the Pentagon has not found a “single root cause” for its worst biosafety fiasco in years. Dugway made two major errors repeatedly over a decade. First, they failed to irradiate the anthrax spores adequately to inactivate them. Second, their tests to confirm that the anthrax was dead were inadequate. The same pattern was seen last year in a lapse by the CDC, which sent live anthrax spores to another lab. As I noted in my post about the initial revelations, someone took shortcuts, using unapproved sterilization techniques. The U.S. is not alone in botching handling of select agents; the Guardian found many similar mistakes at UK labs.
The Pentagon placed the blame for the anthrax fiasco on a lack of scientific consensus. Instead, they should look at why they have allowed inadequate procedures to go on for decades without appropriate safeguards and why there is no consensus between the CDC and Defense Department as to how anthrax should be treated.
A Government Accountability Office report in June also found that the Defense Department also “mismanaged the program to fix crumbling infrastructure at its vast array of facilities for chemical and biological defense.” The problems aren’t just with anthrax. In a noteworthy series, USA Today’s Alison Young and Nick Penzenstadler have reported on other security failures with bioterror germs.
The GAO found a series of systematic safety lapses and has recommended a single agency have the oversight of biotoxins.
Rather than a hodgepodge of minor fixes, I reiterate what I said previously—that the Department of Defense should look at these problems from a systems safety engineering perspective. As MIT’s Dr. Nancy Leveson stated, “So if it is a procedures problem, they should not just investigate and fix the procedures. Systems thinking would require that they also examine why inadequate procedures were created and allowed to exist and how to prevent that in the future.”
It would be refreshing if the Department of Defense undertook this type of comprehensive review so that we could get on with research and important issues.
Addendum: After this was posted, the Department of Defense announced this:
Secretary of the Army John M. McHugh has directed an immediate safety review at all nine Department of Defense labs and facilities involved in the production, shipment, and handling of live and inactivated select agents and toxins.
The Army has also expanded the existing suspension of production, handling, testing, and shipment of Anthrax to include Critical Reagents Program (CRP) and other agents and toxins. This suspension applies at all four DoD labs involved in these activities: Dugway Proving Ground Life Sciences Test Facility, Edgewood Chemical and Biological Center, U.S. Army Medical Research Institute of Infectious Diseases, and the Naval Medical Research Center Biological Defense Research Directorate.
