Sverdlovsk, Three Mile Island, and Government Oversight of Biological Safety

To those of us who follow the world of biodefense, it seems as though every week brings news of a high-profile lapse in biosafety. In just the past month, we’ve seen an employee from the Pasteur Institute Korea transport samples of the coronavirus that causes Middle East respiratory syndrome (MERS) on a commercial airliner and reports that the Centers for Disease Control and Prevention (CDC) shipped chikungunya virus without first performing tests to ensure that the specimens had been completely inactivated. These come on top of such disturbing stories as the US Army’s Dugway Proving Ground accidentally shipping live anthrax to almost 200 facilities and slip-ups at the CDC involving ebolavirus and avian influenza.

While each of these incidents would be alarming in its own right, collectively they imply a systemic failure to properly control biological agents. Determining the extent and severity of the problem is made even more difficult because consistent rules for reporting these types of biosafety events do not exist under the government’s Select Agent Program (SAP). For example, a review this year by the Government Accountability Office found that the number of incidents of incomplete inactivation between 2003 and 2015, similar to what occurred with the Dugway anthrax samples, was at least twice as high as initially reported. Clearly, a more comprehensive and thorough accounting is needed.

The corrosive impact that a lack of oversight can have on biosafety is apparent in the admittedly extreme case of the Sverdlovsk anthrax leak in 1979, in which a Soviet biological weapons facility near present-day Yekaterinburg, Russia unintentionally infected the city with a cloud of anthrax spores. Coincidentally, the incident occurred only five days after the Three Mile Island (TMI) nuclear accident in Pennsylvania, and the two events actually contain a number of similarities. Both were caused, in large part, by errors in maintenance: at Sverdlovsk, technicians neglected to replace an exhaust system filter, while at TMI, staff had isolated an auxiliary feedwater pump during routine maintenance in violation of US Nuclear Regulatory Commission (NRC) rules. Both resulted in the release of toxic materials into the environment: about a gram of anthrax at Sverdlovsk and 370 PBq of (biologically-inert) radionuclides from TMI. The consequences of both were severe as well: casualty estimates from the anthrax release range from 60 to over 100, and while no direct health effects from the Three Mile Island accident have been conclusively documented, the economic cost may have been in excess of $1 billion, in addition to the permanent damage done to the US nuclear industry’s public image.

If the events themselves bear similarities, the official responses to them could not have been more different. The Soviet government responded to the Sverdlovsk incident in its typical manner with a campaign of disinformation, blaming the anthrax cases on contaminated meat and destroying associated hospital records. Biopreparat, the Soviet biological weapons program, added yet more layers of secrecy to hide its involvement, making it even less accountable to the government of the Soviet Union, let alone its people. By the time the Soviet Union collapsed, the government had almost entirely lost operational control over the bioweapons program.

In stark contrast, the Three Mile Island accident prompted the NRC to make significant changes to how US nuclear power plants are regulated and operated. The agency instituted a number of policies such as tracking significant events and safety system actuations to determine which initiating events that might result in a radiological release were most common and issuing guidance to operating plants to reduce their frequency. In the years since TMI, accident precursors, reactor trips, and occupational radiation exposures at nuclear plants have decreased precipitously, in some cases by an order of magnitude. The NRC has also taken steps to increase transparency in its findings, such as publishing safety and performance assessments for all operating plants. This allows for public scrutiny and an informed conversation regarding the risks associated with civilian nuclear power.

What lessons can we take away from Sverdlovsk and Three Mile Island? The most obvious insight is that operational safety can be greatly enhanced by effective oversight, and effective oversight requires a well-informed regulator. A consistent and uniform mechanism for tracking biological safety incidents, perhaps through the SAP, would provide regulatory agencies with a better idea of the nature of the problem and allow them to spot trends. By publishing data on laboratory failures, organizations could be held accountable for poor performance and best practices could be more easily identified. The real lesson from Three Mile Island and the Nuclear Regulatory Commission’s response is that with enhanced scrutiny, the likelihood and severity of an accidental release drops and biological research can become safer and more secure. And in the end, isn’t that what biodefense is all about?

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