When you play with fire, you get burned. So why do we act surprised when people get burned?
Bacillus Anthracis
Recently, up to 75 workers at the Center for Disease Control may have received an exposure to the anthrax-causing bacterium Bacillus anthracis. To add insult to injury, it was the Ames strain, revered for its virulence and ironically the same one used in the 2001 mail attacks. How does this happen and what can we do?
There is a saying that goes “if you play with fire, eventually you get burned”. In this case, it appears there was an obvious breakdown in the system. Redundancies and engineering controls failed to prevent these exposures. The fact of the matter is that the error was only noticed when materials being gathered for disposal started growing stuff. We may not know the extent of the damage for a month or better, and as unsettling as it is, we’d be foolish to think situations like this won’t playing out again. What we can do is rest in the fact that things can, and hopefully will be done to not repeat the elements that led to this particular situation.
In this instance, product that was to have been rendered safe was not. It was then sent to labs unprepared to handle the real deal. Due to the assumed status of the material, it was delivered to a biosafety level 3 facility, or BSL-3, where personal protective equipment (PPE) requirements are lower. This lower level of PPE is justifiable as overprotection has its own inherent risks. Balancing risk versus consequence can be complex in any business, but even more so in the research world. Lab accidents are frequent and often only make the news when something blows upo or somebody dies. One minute you think you are petting a Chihuahua only to find out later it’s a Boerboel. YIKES!
First of all we must come to the sobering realization that we are all practicing our craft, much like a doctor is only practicing medicine. Many people don’t like to hear that. They would rather believe that the researches playing with menacing disease causing organisms are all knowing all seeing. But the truth is, this isn’t the first time an accident of this magnitude has occurred in a lab. A look at history reveals that “experts” like Ken Alibek, a former Soviet scientist who headed a portion of the world’s largest bioweapons production program, was himself infected with tularemia. And though he survived, his friend Ustinov, a research team leader on the virus Marburg, did not. You see Ustinov, who inadvertently injected himself in the thumb with Marburg, received a fatal dose and experienced a death by liquefaction of his organs. Once again, not an anomaly. Hell, the World Health Organization estimated that 2 million heath care workers worldwide experience percutaneous exposure (needle sticks) to infectious diseases each year. We have yet to engineer the human factor out of risky behavior.
Secondly, so far, this is not Sverdlovsk. One would hope this was not weaponized material, that is milled down to the smallest possible micron and that the spores in any real quantity were contained in the building. There is risk involved when we play with dangerous things, whether it was in the name of science or defense. Lab accidents can and do happen.
The investigation will undoubtedly uncover deviations from standard protocol for the handling of the deadly bacteria. It will be interesting to see what conditions contributed to the accident. Was it factors like organizational pressure, normalization of deviance or plain old simple human error? While none of these findings will provide relief for those exposed, this is a reminder of the inherent dangers of playing with fire.
