Army investigators have recommended laboratory safety procedures at Fort Detrick be reviewed after finding lapses following the infection of a biodefense worker with tularemia.
The infected woman survived the tularemia infection, which is a potentially fatal respiratory disease, following a brief hospitalization at Walter Reed Army Medical Center in December.
The U.S. Army Medical Research Institute of Infectious Diseases, in an executive summary of an internal investigation, said that the unidentified woman probably inhaled the tularemia bacteria between November 13 and November 17.
Investigators could not pinpoint one significant event, such as a spill or dropped flask, but noted several lapses in proper laboratory techniques that, when combined, may have increased the woman's risk of exposure.
Among the lapses cited in the report was potentially contaminated waste that wasn't placed in a cabinet designed to contain bacteria. The waste was instead deposited in a waste container inside the sealed laboratory suite.
The woman, who had not taken part in a voluntary immunization with an experimental tularemia vaccine, wasn't wearing a battery-powered device that delivers filtered air into a plastic hood, which is required.
The woman instead wore a half-face filter respirator, which had been deemed sufficient as blood tests showed the woman had developed antibodies to tularemia.
The worker also was not clear on proper procedures for illness reporting and did not immediately report her symptoms. When her symptoms were finally reported, the woman did not immediately notify the institute's Special Immunization Clinic for an evaluation to determine if her illness was work-related.
Among the report's recommendations are a call for a review of standard lab procedures for working with tularemia, a re-evaluation of vaccination policies and the use of personal protective gear for tularemia, and the formulation of an official policy for reporting illnesses and monitoring employee absences.