'Massive institutional failure' cited for live anthrax shipment

The live anthrax shipment leak from a Department of Defense facility to a commercial laboratory in May was caused by lax systemic procedures for the inactivation of Bacillus anthracis at four military laboratories that deactivate and ship the dangerous bacteria, according to a DOD review.

“By any measure, this was a massive institutional failure with a potentially dangerous biotoxin,” Bob Work, deputy defense secretary at the DOD, said during a press conference. “So the first thing we had to know was, why did it happen.

“The American public expects much more from us, and we should expect much more from ourselves. Secretary [Ash] Carter has made plain he expects these issues be dealt with swiftly and comprehensively to ensure that a failure of this sort never happens again.”

The DOD conducted a 30-day review of its four facilities that deactivate live anthrax for distribution to laboratories less equipped to handle it. The review team included experts from the FBI, the departments of agriculture, defense, energy, and homeland security and academic institutions.

The investigators found that 149 batches of live B. anthracis spores had been deactivated via irradiation by the military facilities since 2003. Fifty-three batches had been distributed to facilities outside the DOD, all of which were accounted for and destroyed.

Of the remaining 96 batches, 33 were in inventory at the Dugway Proving Ground military laboratory in Utah. Seventeen of those batches, delivered in “extremely low concentrations” of liquid, tested positive for the regrowth or presence of live anthrax. There were no reported infections among lab workers.

“Obviously, when over half of anthrax batches presumed to be inactivated instead prove to contain live anthrax spores, we have a major problem, and the numbers confirm this judgment,” Work said. The leaks were not the result of employee malfeasance or incompetence, he said, but rather the fault of facility protocols.

Dugway Proving Ground is the main military facility for the production of anthrax and handles greater quantities of the live bacteria than the other three labs. The irradiation protocols at the Utah facility also were too lax, with too short of a time between irradiation and testing for live spores, according to the review.

No national standards for the deactivation of live B. anthracis exist, and biohazard protocol is also not standardized between the four facilities because they report to different government entities. The DOD plans to work with the CDC to standardize the handling and irradiation of live B. anthracis batches.

“This review taught us lessons we needed to learn,” Work said. “They identified institutional and procedural failures we urgently need to address. We are shocked by these failures.” – by David Costill