(Austin, 18 April 2005) - A leaky aerosol chamber manufactured by the
University of Wisconsin at Madison was responsible for three
laboratory-acquired tuberculosis infections in a Seattle BSL-3 lab
last year. The infections have not been made public until now. Nearly
twenty Madison chambers exist across the US and in India, New
Zealand, and Northern Ireland. While tuberculosis is not a biological
weapons agent, the accident underscores the inherent dangers when
working with dangerous disease agents, and the grave safety risks of
the US biodefense program, which is encouraging more scientists to
deliberately aerosolize bioweapons agents in Madison chambers and
similar equipment.
The Madison chamber incident is the latest to be reported in a series
of US lab accidents, including infections and/or mishandling of
anthrax, tularemia, and pandemic influenza. At the encouragement of
the National Institutes of Health (NIH), Madison chambers have been
purchased for use in Massachusetts, Connecticut, New York, North
Carolina, Georgia, Texas, Colorado, Wisconsin, and California, as
well as India, Northern Ireland, and New Zealand. More of the suspect
chambers may be in use; but the legal counsel of the University of
Wisconsin at Madison has refused to answer questions and has been
reluctant to promptly answer requests filed under Wisconsin open
records law.
The Chamber: The Madison aerosol chamber is a specialized type of lab
equipment. The chamber is used to infect animals with disease through
their lungs. Cultures of organisms causing tuberculosis or the
bioweapons agents anthrax, Q fever, or brucella and others are placed
in a part of the device called a nebulizer, which mixes the agents
with air. The resulting aerosol is directed into a metal chamber in
which animals have been placed on racks. The animals then breathe in
the agent. The integrity of the complicated device's "O rings",
seals, and other fittings is critical to preventing the aerosols from
escaping the chamber and causing accidental infections. But the
Madison chamber in Seattle, Washington leaks badly, and in 2004 it
caused three laboratory-acquired tuberculosis infections at a BSL-3
lab shared by Corixa Corporation and the Infectious Disease Research
Institute (IRDI).
"Foolproof": In late 2003, the Seattle lab began using a Madison
aerosol chamber to infect guinea pigs with tuberculosis. Several
batches were exposed over a period of months. By March 2004, a
serious problem was detected when three employees, who previously
tested negative for tuberculosis, came back with positive tests, or
"conversions", indicating that they had been exposed to the agent.
The State of Washington opened an investigation. The State's report
was obtained by the Sunshine Project and is available at our website.
According to the report, in 2003 the IDRI team was trained to use the
chamber by its inventor, a professor at Texas A&M University. IDRI
was also trained by representatives of the University of Wisconsin at
Madison. According to the State of Washington's investigation, Dr.
David McMurray, the inventor and a tuberculosis researcher, made
audacious safety claims about the chamber. The report says that
McMurray claimed that "the chamber was so safe that there was no need
to even locate it in a BSL-3 environment", that it was "foolproof",
and that "respirator use was not necessary".
The Leaks: Interviews with IDRI staff by state investigators revealed
that a leaky airflow meter was probably responsible for the
infections. The investigation also revealed that IDRI staff had
repeatedly encountered other dangerous problems. The chamber operator
told state investigators "the Chamber seals deteriorate quickly,
crack and last about a month" and in June 2004, well after the first
problems were thought to be fixed, "another big leak was recently
found." Another researcher said "several seals of the Chamber were
found to be cracked". IDRI does not conduct biodefense research.
Leak Replicated, No Apparent Safety Advisory: The airflow meter also
leaked in tests of a Madison chamber located in Fort Collins,
Colorado. Although the University of Wisconsin at Madison was
contacted by the State of Washington in the course of the
investigation, two Madison aerosol chamber customers contacted by the
Sunshine Project say that they have not received any safety
advisories. Nor has the chamber's manual been changed in response to
the State's findings. The current manual, obtained by the Sunshine
Project under Wisconsin open records law, is dated 22 April 2002.
Biodefense Use: Many Madison chambers are used for tuberculosis
studies; but others are used for biodefense. In December 2003, the
Madison chamber was presented at a National Institute of Allergy and
Infectious Disease (NIAID) biodefense workshop. Biodefense use
includes: At Texas A&M University, scientists are using it to
aerosolize brucella and Q fever. At the University of Texas Medical
Branch at Galveston, it is used by an anthrax researcher funded by
the Department of Defense and NIAID. With NIAID encouragement, other
biodefense projects using the Madison chamber are likely planned or
even underway.
Known Madison Aerosol Chambers and Locations*
---------------------------------------------
University of California San Francisco, CA
Corixa / Colorado State Univ. Fort Collins, CO
Yale University New Haven, CT
University of North Carolina Chapel Hill, NC
University of Georgia Athens, GA
Harvard University Cambridge, MA (possibly 2 chambers)
Corixa / IDRI Seattle, WA
HHMI / Albert Einstein Univ. Bronx, NY
Rockefeller University New York, NY
University of Texas HSC San Antonio, TX
Univ. of Texas Medical Branch Galveston, TX
University of Texas HSC Tyler, TX
Texas A&M University College Station, TX (possibly 2 chambers)
University of Wisconsin Madison, WI (presumed)
Queens University Belfast, N. Ireland
Astra Zeneca Bangalore, India
AgResearch Wallaceville Upper Hutt, New Zealand
*Some chambers may not yet be delivered. Source: Open Records
requests to the University of Wisconsin at Madison, and "Pulmonary
Delivery of Mycobacteria and Other Respiratory Pathogens to Small
Animals in a Specially-Designed Aerosol Chamber", presentation to the
NIAID Workshop "Aerosol Challenge Technology and Applications in
Biodefense", Bethesda, 3 December 2003, URL: http://www2.niaid.nih.gov/Biodefense/Research/AEROSOL/davemcmurray.htm
Conclusions: The Sunshine Project has been calling attention to the
safety and security dangers of the US biodefense program since 2000.
This case underscores how the 'precise, clean and neat' public image
of BSL-3 and BSL-4 facilities that is promoted by NIAID and labs is
frequently at odds with messy and risky realities.
According to the Sunshine Project's Edward Hammond, "It should not
fall to a small non-profit to reveal incidents such as this one. In
this case, the institutions involved apparently didn't even inform
their peers about the problems. Public safety and an informed debate
about the biodefense program require the government to mandate public
disclosure of all significant lab accidents. This may be more cold
water on overheated biodefense safety claims; but we frankly wonder
how many more serious problems have been kept out of the public eye."
The United States does not have comprehensive laboratory safety law.
The Madison chamber failure and consequent lab-acquired infections
are yet more evidence of the urgent need for binding laboratory
biosafety law, backed by enforceable international standards.
-END-
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