The Sunshine Project Biosafety Bites #21 (v.2) - 11 January 2007

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The Sunshine Project

Biosafety Bites #21 (v.2) - 11 January 2007

http://www.sunshine-project.org

The Bird Flu Lab Accident that Officially Didn't Happen, or How the

University of Texas at Austin Could Have Caused the Next Influenza

Pandemic, but Everybody Lived to Cover It Up

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Don't ask the National Institutes of Health (NIH) about the genetically

engineered influenza pandemic that might have started in Austin, Texas

in April 2006. That's because until NIH reads this Biosafety Bites, they

almost certainly haven't heard anything about it. And that shows yet

again that the US biotechnology and laboratory safety oversight system

is a dangerous failure.

NIH's Office of Biotechnology Activities (OBA) doesn't enforce

biosafety rules, so the University of Texas (UT) didn't report the

unsettling Bird Flu accident. UT must have reasoned: Why draw attention

to a lab accident when there's no cost for burying such incidents? It

surely wouldn't be the first time such an event has been swept under the

rug.

BSL-3 in the Heart of Texas

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

According UT records obtained by the Sunshine Project, the accident

happened on a Wednesday afternoon, 12 April 2006. A postdoc was working

in the Molecular Biology Building ( " MBB " ) on the University of Texas

campus in Austin, just a couple minutes' walk away from tightly packed

dormitories, the kind of place where a virulent new influenza strain

might eagerly take hold. A little over a kilometer south is the Texas

Capitol and a warren of state office buildings teeming with public

employees.

Centrifuge Accident Aerosolizes Genetically Engineered Influenza

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

The postdoc was working alone in a beefed-up BSL-3 laboratory wearing a

full lab suit. A respirator system provided oxygen through an air hose.

The high-tech safety measures were in place because the viruses in the

lab were not your average flu. They were something much more dangerous.

They were genetically engineered influenza strains that mixed and

matched genes of the common human H3N2 influenza and those of deadly

H5N1 " Bird Flu " . The kind of unpredictable reassorted flu strain that

public health officials fear could cause the next human pandemic.

In the BSL-3 lab, a quantity of the engineered influenza was ready for

work. It had been grown mixed with cells. The experiments required

purified virus. So, a little after 2:00PM, the researcher transferred a

quantity of the virus mixture into a tube. The tube was capped and

placed in a centrifuge on a lab bench. The centrifuge

would separate out the virus through spinning - centrifugal force.

But the tube was of the wrong type for the centrifuge. There were two

almost identical centrifuges in the lab, and their non-interchangeable

parts had become mixed up.

The postdoc pushed a button and the centrifuge began to spin. Because

the tube was the wrong type, its cap didn't fit correctly. It cracked.

The centrifuge lost balance. Turning the machine off, the postdoc

observed that the level of virus fluid in the tube had gone down and

that its exterior had become wet, both indicators of a leak. This was a

serious problem because as the machine spun around, the leaked virus had

become aerosolized, at least within the centrifuge.

The Inevitable Human Error

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

The problem was then compounded by human error, an ever-present factor

in lab work. Rather than waiting for the aerosolized flu to settle, the

centrifuge was immediately opened. In an invisible puff of air, virus

particles wafted out of the machine. Now, the virus was floating around

the whole lab, stirred by air movements, then slowing settling on

exposed surfaces or being sucked out the exhaust which, hopefully, had

effective HEPA filtration (the UT documents are silent on this item).

It was something like a Bird Flu victim walking into the room and

coughing all around, spreading virus where he went. Except this mixed up

lab creation of H5N1 virus was possibly more efficient at infecting

humans than natural " Bird Flu " because of its H3N2 human influenza

parts.

The researcher sprayed Lysol and wiped up surfaces in the work area,

exited the lab, took a shower, and put on new clothes. Within hours, the

postdoc was taking Tamiflu, in the hope that it would stop the virus if

the researcher had been infected. For several uncomfortable days, the

University of Texas staff waited to see if the researcher developed

symptoms. None are reported to have appeared.

The University of Texas at Austin had dodged a bullet. It took longer

for a UT biosafety team to straighten out the lab and reopen it. Under

any of a variety of plausible scenarios, the accident might resulted in

disaster. For example, if the cap leaked but didn't crack, without the

postdoc noticing, thereby multiplying the danger to include everyone

working in the lab over a longer time.

UT's Bird Flu Hybrid and Deceptive Records

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

Reading UT's records, it is clear that the University was thinking in

terms of public relations from practically the moment that the accident

occurred. UT records unscientifically discuss (downplay) the risks and

neglect to precisely describe the flu strain. For example, they state

that the virus should be considered like far less

dangerous H3N2 despite it being a hybrid with " some genes from H5N1 " .

This is deceptive, because the bug that causes flu is composed of only 8

short pieces of RNA that collectively encode just 11 proteins.

Assuming " some genes from H5N1 " means at least three RNA pieces or

more, or the RNA to encode three proteins, UT's hybrid Bird Flu virus

would be about 25% H5N1 (somewhere between 3/11ths and 3/8ths), and

potentially much more if the " some genes " were larger ones. That's

certainly enough H5N1 genetic material to create an unpredictable and

potentially extremely dangerous (pandemic) reassortant. Tiny differences

in genes can make huge differences in the bug. Nobody

knows for sure how dangerous UT's flu was because, by good fortune,

this story doesn't end in human infection.

UT's report also deceptively states " CDC recommends BSL2 practices for

H3N2, but it was decided that BSL3 would be prudent for use with this

agent, " as if UT was acting with an abundance of caution. But UT was was

working with a potentially pandemic combination of H5N1 and H3N2. And

well before April 2006, there had been scientific discussion and

government recommendations made about the need for BSL-3 or higher

containment for flu viruses like UT's. Thus, contrary

to the implication of its PR-wise assertions, UT was not taking any

major steps above and beyond the basic measures that should have been

used for such a virus.

Echoes of 2005's Flu Accident

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

It must have weighed heavily on the minds of University of Texas public

relations officials (who were called less than 2 hours after the

accident) that one year before, on 12 April 2005, global headlines were

dominated by the story of Meridian Biosciences Inc., which sent 3,700

samples of potentially dangerous noncontemporary H2N2 flu to labs in the

US and across the world. If the UT accident became public at that time,

its occurrence on the anniversary of the

Meridian story might have cast an extra bright and unflattering light

on the University of Texas, potentially unsettling the Molecular Biology

Building's many neighbors, many of whom would be unhappy to learn that

they came too close for comfort to being ground zero of a deadly flu

pandemic.

Need for Federal Reporting

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

Although it would serve public health and accountability ends, perhaps

it is presently optimistic to expect a university to quickly issue bad

news about itself, especially when that bad news evokes images of it

authoring a public health disaster. But it must be expected that such

accidents definitely will be reported to the federal officials that

oversee lab safety so that, at least, other labs can learn from the

mistake and, for example, not put two identical centrifuges whose parts

are NOT interchangeable in the same lab. And so that federal safety

officials and funders could examine the accident and impose penalties if

institutional safety

deficiencies are identified.

Accident, Revised Out of Existence

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

But it does not appear that anybody outside UT found out about the

incident until the Sunshine Project requested the accident report. UT

fought to keep it under wraps. While the Texas Attorney General's office

was weighing a UT petition to keep the accident details secret, somebody

got cold feet. A UT official left two messages on the Sunshine Project

answering machine offering to explain what happened, if the Public

Information Act request was withdrawn. (We did not respond.)

The Public Information Act request revealed that UT never finalized its

accident report and it did not inform NIH. Instead, it made the accident

disappear.

How? On the morning after, officials interviewed the postdoc.

Remarkably, they recorded that the postdoc's account of the accident had

dramatically changed overnight. UT's Environmental Health and Safety

Office writes " The researcher thought that the volume of the tube had

changed, but was not 100% sure of the original volume. " The liquid on

the exterior of the tube? It " may have been from condensation " . The

lid? It, at least, was still broken.

The accident was miraculously converted into a figment of the postdoc's

imagination. Pondering the possibility of being at the center of an

embarrassing incident that might impair funding and anger UT leaders,

was there pressure to change the story? The postdoc knows for certain;

but in the absence of any enforced reporting requirements, there were

precious few incentives to move forward with accident reporting. Or

perhaps UT management insisted that nothing happened unless the

Tamiflu-taking postdoc affirmed absolute certainty of details remembered

while in the midst of scrambling to contain a potentially

life-threatening accident?

Certainly, UT management seized upon the (reported) " not 100% sure "

statement. On that basis UT decided that an accident had not occurred.

The following gem of illogic (read carefully) provides the University's

reasoning that the accident didn't happen: " There is the possibility

that there was no leak and therefore no contamination occurred. "

The following Monday (17 April), UT's Institutional Biosafety Committee

(IBC) held a previously scheduled meeting. The incident was briefly

discussed. In the IBC minutes, a new version of events appears, one that

omits several critical details from the accident report. According to

the IBC account, the postdoc's concern was said to have been that the

tube (not cap) had cracked, but that thankfully, it hadn't. It was a

mistaken impression by the young researcher. The tube was fine. And " the

liquid on the tube " ? It was " probably condensation " . The broken cap

isn't mentioned. Nor is the prematurely opened centrifuge. Nor is the

decrease in the volume of the virus in the tube.

Condensation? According to the accident report, the " condensation " was

observed not long after the tube was filled and almost immediately after

it had been spinning at several hundred, perhaps several thousand,

revolutions per minute. If it was condensation and not virus culture,

then UT seems to have set a world laboratory record for the

fastest-forming and most remarkably adhesive water condensation ever

seen.

But as far as UT was concerned, the case was closed. No authorities

were told. Officially, no accident took place, although despite the fact

that nothing officially happened, UT curiously proceeded to

decontaminate the entire lab " as if the contamination had occurred. " The

accident report remained labeled " draft " and was not finalized.

And there the story would have ended, before this Biosafety Bites.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

Buddhist philosopher at-large

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