By Kim Smiley

The Pentagon recently announced that live anthrax samples were mistakenly shipped to as many as 24 laboratories in 11 different states and two foreign countries.  The anthrax samples were intended to be inert, but testing found that at least some of the samples still contained live anthrax.  There have been no reports of illness, but more than two dozen have been treated for potential exposure.  Work has been disrupted at many labs during the investigation as testing and cleaning is performed to ensure that no unaccounted-for live anthrax remains.

The investigation is still ongoing, but the issues with anthrax samples appear to have been occurring for at least a year without being identified.  The fact that some of the samples containing live anthrax were transported via FedEx and other commercial shipping companies has heightened concern over possible implications for public safety.

Investigations are underway by both the Centers for Disease Control and the Defense Department to figure out exactly what went wrong and to determine the full scope of the problem. Initial statements by officials indicated that there may be problems with the procedure used to inactivate the anthrax.   Investigators so far have indicated that the work procedure was followed, but it may not have effectively killed 100 percent of the anthrax as intended.  Technicians believed that the samples were inert prior to shipping them out.

It may be tempting to call the issues with the work process used to inactivate the anthrax as the “root cause” of this problem, but in reality there is more than one single cause that contributed to this issue and more than one solution should be used to reduce the risk of future problems to acceptable levels.  Clearly, there is a problem if the procedure used to create inactive anthrax samples doesn’t kill all the bacteria present and that will need to be addressed, but there is also a problem if there aren’t appropriate checks and testing in place to identify that live anthrax remains in samples.  When dealing with potentially deadly consequences, a work process should be designed where a single failure cannot create a dangerous situation if possible.  An effective test for live anthrax prior to shipping the sample would have contained the problem to a single facility designed to handle live anthrax and drastically reduced the impact of the issue.  Additionally, an another layer of protection could be added by requiring that a facility receiving anthrax samples test them upon receipt and handle them with additional precautions until they were determined to be fully inert.

Building in additional testing does add time and cost to a work process, but sometimes it is worth it to identify small problems before they become much larger problems.  If issues with the process used to create inert anthrax samples were identified the first time it failed to kill all the anthrax, it could have been dealt with long before it was headline news and people were unknowingly exposed to live anthrax. Testing both before shipping and after receipt of samples may be overkill in this case, but something more than just working to fix the process for creating inert sample needs to be done because inadvertently shipping live anthrax for more than a year indicates that issues are not being identified in a timely manner.

6/4/2015 Update: It was announced that anthrax samples that are suspected of inadvertently containing live anthrax were sent to 51 facilities in 17 states, DC and 3 foreign countries (Australia, Canada and South Korea). Ten samples in 9 states have tested positive for live anthrax and the number is expected to grow as more testing is completed. 31 people have been preventative treated for exposure to anthrax, but there are still no reports of illness. Click here to read more.