An Army investigation into anthrax contamination outside secure labs at the nation's chief biodefense research facility blames cavalier attitudes for the safety breach.
The anthrax leaks were detected in April 2002 at the Army Medical Research Institute of Infectious Diseases at Ft. Detrick, Md. Officials at the facility, which served as the chief forensic lab for the 2001 anthrax mailings that killed five people, revamped security and safety rules last year.
Discovery of the leaks caused a brief scare in nearby Frederick when it was thought that a local laundry contractor could have handled contaminated garments from the lab. No one became ill.
The Army report, obtained Thursday by The Times, also showed that some researchers at the facility doubted its commitment to biosafety.
"The safety program may be more about insulating the institute from criticism than from protecting the workers," one lab supervisor told a military investigator in the detailed report completed in May 2002 and just released under the Freedom of Information Act.
The leaks were detected by a researcher who was conducting independent tests outside the chain of command, triggering the investigation.
"Other workers have mentioned that they might not report [lapses] in the future because of fallout from this episode," the supervisor said. "I think there's a serious problem."
Chuck Dasey, an institute spokesman, said the incident occurred as a new biosecurity program was being shaped.
"There was an institutewide, reenergized emphasis on safety, safety training, safety education, proper laboratory procedures," he said.
No employees were disciplined for safety violations, Dasey added.
The investigator, Col. David L. Hoover of the Walter Reed Army Institute of Research in Silver Spring, Md., indicated in the censored report that the contamination could have come from shipping containers for samples related to the anthrax mailings. He was unable to determine the origin of the leaks.
Three different anthrax strains -- two infectious and one a harmless vaccine -- were detected outside biosafety labs.
The contamination was worrisome because office workers, unlike scientists, were not always vaccinated against anthrax.
Spores were found in numerous locations in an office and changing room adjacent to a lab used to analyze evidence from the deadly mailings. More significant contamination, in a corridor and in high-security labs, was attributed partly to complacency.
Hoover concluded that "multiple episodes of contamination may have occurred" over an unknown period. Viable anthrax spores can persist for decades.
"A laboratory in which there was widespread, long-standing contamination ... represents both a safety and a security threat," said Richard Ebright, a microbiologist at Rutgers University and a biological warfare expert. "Any person with access to a contaminated area would have access to the agent."
Even a small number of spores could be used to grow large quantities of anthrax, he said.
The breach was discovered by Bruce Ivins, an institute researcher.
He detected an apparent anthrax leak in December 2001, at the height of the anthrax mailings investigation, but did not report it. Ivins considered the problem solved when he cleaned the affected office with bleach.
"I didn't keep records or verify the cultures because I was concerned that records might be obtained under the Freedom of Information Act," he said in a sworn statement included in the Army report.
"I was also afraid that reporting would have raised great alarm within the institute, which at the time was very busy" working on the anthrax mailing samples.
Ivins could not be reached for comment.
According to his statement, he renewed his independent tests in April 2002. "I again personally and privately decided to check nonbiocontainment areas to see if containment may have possibly been breached," Ivins said.
His tests led to the discovery of leaked spores and the investigation.
Among the "multiple, apparently long-standing deficiencies" found by the investigator was a failure to routinely monitor or decontaminate "hot labs" where anthrax and other dangerous microbes were handled. Safety supervision was sometimes managed by personnel with inadequate training, the report said.
Researchers are "generally kind of sloppy," a lab supervisor told Hoover. "I recommend to my people to always wear [two pairs] of gloves and to remove the outer pair of gloves after working with [the] agent, since I can't be sure the lab isn't contaminated."
Another researcher noted a chaotic environment as the institute struggled to keep up with anthrax samples flowing in for testing after the mailings. The researcher, identified as chief of the special pathogens branch, compared one secure lab to " 'a rat's nest.' The countertops were dirty, the floor was dirty and the area was disorganized," the scientist told Hoover. "At that time, I made a decision not to process any more samples."
The institute upgraded monitoring and training after the 2002 discovery. It improved record-keeping and archives of dangerous microbes, began a video surveillance system and tightened access controls.
The Ft. Detrick lab plans to spend about $4 million annually on biosafety and security, according to a report last year by military officials.
Ebright, the Rutgers microbiologist, applauded the improvements. If carried out properly, he said, the institute would be far safer and more secure than university labs that use deadly microorganisms.