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The following article is an excerpt from the book,

It's For The Animals! Natural Care & Resources

by Helen L. McKinnon 


When Employees in the HEALTH fields Make SERIOUS MISTAKES

- Are they NOT properly trained or totally INCOMPETENT?

It's one thing when it's the cashier at a department store making an innocent mistake.  However, it's an ENTIRELY DIFFERENT matter when it comes to workers in HEALTH related field who are inadequately trained or incompetent. 

To follow is a recent scary incident involving people working at a Children's hospital being exposed to deadly Anthrax due to a MISTAKE by a laboratory employee (edited with highlights/bold type/italics, for emphasis):


A ProMED-mail post

ProMED-mail is a program of the International Society for Infectious Diseases

Date: Fri, 11 Jun 2004

From: Richard Wilsnack rwilsnac at medicine . nodak . edu (omit spaces when typing in address)

Source: Oakland [California] Tribune [edited]

Workers exposed to anthrax; Live samples sent to Children's Hospital

Oakland by mistake

- -----------------------------------------------

At least 6 researchers working on an anthrax vaccine at Children's Hospital Oakland Research Institute were exposed to the dangerous live agent, possibly due to a shipping mix-up, officials said Thursday. The workers -- including a lead researcher, 2 lab technicians and an animal handler -- handled the live anthrax bacterium. Several other researchers were also present. None has shown signs of illness, and 7 are now on the antibiotic Cipro as a precautionary measure. The incident poses no risk to any other staff, the surrounding community or Children's Hospital, which is about one mile from the research facility, state health officials said.

"All the proper procedures are being followed here," said Dr. Richard Jackson, public health officer for the state Department of Health Services, which is investigating. [I am sure that the DHS follows proper procedures. - Mod.MHJ]

The institute's researchers believed they were working with a dead sample of the anthrax bacterium, but were inadvertently shipped live anthrax by their supplier, Southern Research Institute of Frederick, MD, hospital officials said. Children's Hospital Oakland Research Institute is not authorized to handle live anthrax. The sealed liquid agent was shipped via FedEx, double-boxed, about 3 months ago to Oakland, officials said.

Researchers began injecting what they thought was dead anthrax [bacilli or spores; 'anthrax' is the disease - Mod.MHJ] into mice 28 May 2004. Over that weekend, 10 mice died in separate cages, and animal handlers placed the mice in a freezer. It was not brought to the immediate attention of lead researchers that all the mice in the 1st experiment had died.

Last Friday, another batch of mice was inoculated with the deadly agent. On Monday, those mice, too, were dead, and the lead researcher obtained cultures from the cavity of a dead mouse. By Wednesday, the researchers discovered the anthrax organism growing [in] the abdominal cavity of the dead mouse.

"From there, the investigations continued at a rapid pace," said Dr. Ann Petru, a pediatric infectious disease expert at the institution. The institute contacted the state Department of Health Services and the federal Centers for Disease Control and Prevention, which launched their own investigations. Agents from the Federal Bureau of Investigation's bioterror unit transported the infected dead mice to the state's laboratory in Richmond on Wednesday afternoon, where evidence of the live bacterium was confirmed.

Samples have been sent to the CDC in Atlanta for further testing, Jackson said. Nasal samples from the lab workers are also being evaluated, with results expected next week, Petru said. CDC spokeswoman Rhonda Smith said how the live agent was accidentally sent to Children's Hospital is under investigation. "We're working with the California Department of Health Services, the shipping and receiving institutions and the FBI to determine what happened and how we can prevent it from happening again," Smith said.

Southern Research Institute's Thomas Voss, who is in charge of the institute's emerging infectious disease program, said the company is investigating what happened. He said it's unclear whether the institute did ship live anthrax to Oakland. Voss said the institute's hot labs in Frederick and Birmingham, Ala., handle most "select agents" listed with the CDC, and that they are one of 350 entities registered to handle live anthrax. He said the institute rarely ships out the agents. "We receive agents on a routine basis," Voss said. "But on our end, we ship very infrequently. I can't even recall shipping live agents."

Dr. Frederick Murphy, a microbiologist at University of California, Davis, said such mixups are extremely rare. "It's much more serious than it used to be," Murphy said. "There's all kinds of protocols in place to prevent these mistakes." Namely, deadly live bacteria require extensive permits to ship and are typically handled by couriers. The agents would be encased in a safe-like container to prevent tampering or any exposure.

Edward Hammond, director of the Sunshine Project, a watchdog group on biological weapons research, said with so many federal funds pouring into biodefense research, there should be more controls in place. "This hospital clearly did not have the ambition [sic -- ability? capacity?] to handle such agents," Hammond said.

Neighbors of the institute, located on Martin Luther King Jr. Drive, are wondering the same thing. "When (the institute) opened, they told us they would be researching meningitis, but they never talked about anthrax," said Bob Brokyl, a North Oakland activist. Brokyl noted that a senior center is housed in the same building as the institute, which is surrounded by a working-class neighborhood. "I'm really angry and nervous because ... {T]hey said they would never have anything dangerous there. The great children's hospitals of our country are where a lot of the most incredible research is done -- major research in infectious disease," he said.

[Byline: Rebecca Vesely, Robert Gammon, Jill Tucker & Associated Press]

- --

Richard W. Wilsnack, Ph.D.

Department of Neuroscience

University of North Dakota School of Medicine & Health Sciences

Grand Forks, ND 58202-9037

[We need reports like this on a Friday afternoon to lighten the week. It is hard to work out what they were trying to do by injecting mice with a dead product. My one suspicion, if they knew what they were up to, would be to develop antibodies to the spore exosporium. Michelle Mock at the Pasteur Institute, Paris, has nicely shown that if you mix dead spores with PA [protective antigen] you get enhanced immunity. Sterne vaccine is pathogenic for mice at certain doses but can be used safely at lower doses. Plus it is available and certainly cheaper than whatever they got from SRI, which might well have been intended to be dead Sterne anyway. From their nasal swabbing to the pointless prescription of Cipro, institutional spin, and the certainty of official visits from CDC, there is enough to satisfy anyone's need for schadenfreude and superiority. With the unbelievable sums of money flowing around the US in response to the perceived BT threats, it is a wonder that we have not had more reports of institutional embarrassment like this. Before the letters of 2001 there were probably only about a dozen US institutes working with _B. anthracis_; now apparently there are 350. Are we better off?

Enjoy your weekend. Thanks also to Philip Henika and Paul Cheek for sending reports on this event. - Mod.MHJ]



End of ProMED-AHEAD Digest V2004 #145


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