Appendix D
Other Relevant Case Studies

Books could be written about the cases of contamination and decontamination that are relevant to the charges to the Committee on Standards and Policies for Decontaminating Public Facilities Affected by Exposure to Harmful Biological Agents: How Clean is Safe? Here we have selected four relevant studies, chosen largely because committee members are expert in them. Although we can draw some lessons regarding decision making and acceptability of risk, there are limits to the relevance of the cases. Some of them are discussed at the end of this appendix.

BINGHAMTON STATE OFFICE BUILDING

In February 1981 a switch gear failed in the mechanical room of an 18-story office building in Binghamton, New York, creating an electrical arc that lasted for 20 to 30 minutes. Because the building was occupied mostly by state agencies, state officials called it the BSOB (Binghamton State Office Building) (Clarke, 1989). The temperature in the mechanical room rose to an estimated 2000°F, causing a ceramic bushing on a nearby transformer to crack. About 180 gallons of the transformer’s coolant, which contained polychlorinated biphenyls (PCBs), leaked out. The intense heat vaporized the coolant, which then mixed with soot produced from burning wires. The fire alarm triggered the opening of hatches on the roof, which were above the stairwells, and the smoke was sucked from the stairwells. When firefighters opened the door to the mechanical room, the BSOB effectively became an 18-story chimney, drawing the contaminated soot up the stairwells, distributing it to the building’s ventilation system and



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Reopening Public Facilities after a Biological Attack: A Decision Making Framework Appendix D Other Relevant Case Studies Books could be written about the cases of contamination and decontamination that are relevant to the charges to the Committee on Standards and Policies for Decontaminating Public Facilities Affected by Exposure to Harmful Biological Agents: How Clean is Safe? Here we have selected four relevant studies, chosen largely because committee members are expert in them. Although we can draw some lessons regarding decision making and acceptability of risk, there are limits to the relevance of the cases. Some of them are discussed at the end of this appendix. BINGHAMTON STATE OFFICE BUILDING In February 1981 a switch gear failed in the mechanical room of an 18-story office building in Binghamton, New York, creating an electrical arc that lasted for 20 to 30 minutes. Because the building was occupied mostly by state agencies, state officials called it the BSOB (Binghamton State Office Building) (Clarke, 1989). The temperature in the mechanical room rose to an estimated 2000°F, causing a ceramic bushing on a nearby transformer to crack. About 180 gallons of the transformer’s coolant, which contained polychlorinated biphenyls (PCBs), leaked out. The intense heat vaporized the coolant, which then mixed with soot produced from burning wires. The fire alarm triggered the opening of hatches on the roof, which were above the stairwells, and the smoke was sucked from the stairwells. When firefighters opened the door to the mechanical room, the BSOB effectively became an 18-story chimney, drawing the contaminated soot up the stairwells, distributing it to the building’s ventilation system and

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Reopening Public Facilities after a Biological Attack: A Decision Making Framework thence throughout the building. The BSOB was now contaminated with the toxin-laden soot. Closed file cabinets, locked desk drawers, even the spaces between each floor, used as plena for normal air circulation, were contaminated. In addition to PCBs, the contaminants contained furans and dioxins. The BSOB would not reopen for 13 years. The building had cost $17 million to build and about $50 million to decontaminate. The Binghamton case was marked by several risk communication problems. State officials immediately began a cleanup effort, but they used relatively untrained building maintenance workers for the effort. The two local papers soon ran stories of cleanup workers wearing protective suits into nearby uncontaminated buildings to change clothes or use the restroom. The cleanup was poorly supervised; some cleanup workers stole contaminated cash and lottery tickets, and some consumed food and smoked cigarettes in the BSOB. Entrances to the building were not tightly controlled, so nearly 500 people were exposed to the toxins by the time state officials truly closed the building, three weeks after the fire. In the interim, Governor Hugh Carey offered “here and now to walk into Binghamton, to any part of that building, and swallow an entire glass of PCB and then run a mile afterwards…I’d like to meet that local health officer who put that building in that…If I had a couple of willing hands and a few vacuum cleaners I’d clean that building myself…” Similar problems would characterize a medical surveillance program of those exposed in Binghamton. It also appeared to Binghamton residents that the state was not taking their concerns seriously. The day after the fire, the state health commissioner flew to Binghamton to survey the situation, held a press conference, put other people in charge, and returned to Albany. State officials had incited distrust among Binghamton’s citizens, the media, the county medical society, the Binghamton city council, the Broome County Health Department, and unions by belittling possible dangers and pursuing courses of action that were not conservative with respect to the technical science or to risk communication. FORT DETRICK: U.S. ARMY BIOLOGICAL WARFARE LABORATORIES From March 1943 to July 1972 there were several anthrax accidents at the U.S. Army’s Biological Laboratories at Fort Detrick, Maryland. The laboratories’ mission was to conduct offensive and defensive research with highly pathogenic agents or their toxins. Initially, safety procedures, vaccines, medical treatment regimens, antibiotics, and containment facilities were limited, and there were many unknown operational elements and unrecognized risks to employees (military and civilian). The at-risk population in the laboratories was about 1500-1700 people. According to accounts made available to the committee, the decontamina-

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Reopening Public Facilities after a Biological Attack: A Decision Making Framework tion efforts at Fort Detrick were technical and social successes. The buildings were effectively rid of pathogenic agents, and the program was trusted by employees at all levels. Several factors contributed to those successes. Great precautions were taken to avoid or minimize activities that might compromise safety, cause damage to facilities, allow release of agents into the environment, or permit cross-contamination among research materials and laboratory animals. A dedicated, well-educated, large (up to 30 people) scientific safety staff was appointed at the start of the program. The staff members ranged from well-trained laboratory technicians through PhDs; a physician served as the safety director. The responsibilities for safety included the examination of task and the conduct of research to evaluate hazards associated with laboratory operations, production, equipment, and facilities design concepts. Safety staff also were to be readily available to all employees outside the chain-of-command structure to address each safety concern. That policy provided a forum for evaluation of employee concerns and for the identification of observed deficiencies, regardless of magnitude. It was also a place in which employees’ inquires were answered. They received assistance and were provided with daily safety awareness. With that program established, all post employees, both military and civilians, shared sincere trust in the safety staff. The safety staff were dedicated and accessible, and they gained experience and knowledge during their involvement in every aspect of post operations and research activities. Their procedures and decisions were transparent to those who might have been affected. Because of their partnership in the facility’s work, the safety staff were placed at a greater risk to multiple agent exposures than were other employees on the post, thereby eliminating the concern about risk exposure and management trust because of their firsthand understanding of the hazards. A philosophy and an approved operating policy existed that no reprisal, punishment, or fault finding was to be promulgated following an accident, judgment error, or equipment or facility damage. The policy was conceptualized by upper management because of the high-risk research mission. It was also seen as a way for all employees to learn from every untoward experience and thus to prevent recurrence. The policy was an exception approved for Fort Detrick by the Military and Civil Service Commission. The policy promulgated reporting of incidences to the safety staff for evaluation and effectively promulgated trust at all levels. A comprehensive medical surveillance program was established from the beginning of the Biological Laboratories. The program encompassed prophylaxis and vaccinations, complete medical surveillance for any suspected or known illness, and complete treatment for known or suspected illness. Before any employee could seek medical services from a private physician, he or she had to obtain clearance from the post physicians. Employees essentially had free medical care because of the willingness and responsibility of the post physician to rule

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Reopening Public Facilities after a Biological Attack: A Decision Making Framework out all possibility of a laboratory-acquired illness. The post maintained a comprehensive medical staff, an outpatient clinic, and a complete isolation/quarantine hospital. A biological safety research program was operated to assess all operational aspects, including equipment and facilities development, and to investigate each laboratory or production procedure. The program evolved into the scientific discipline now called “biological safety.” It identified procedures to ensure safety in every component of work with pathogenic agents, including work with pathogens and their toxins, genetic manipulations, and production of agents and vaccines. The safety elements are applicable to the biomedical and veterinary disciplines and to evaluations against bioterrorism. GRUINARD ISLAND, SCOTLAND In 1942, the War Department of the United Kingdom appropriated from a private owner Gruinard Island, a rocky island about 2 km long and 1 km wide lying just off the northwest coast of Scotland. Before World War II, Gruinard was used for sheep grazing, rough shooting, fishing, collecting bird eggs, and as a picnic spot (Pearson, 1990). In 1942 and 1943 the British government conducted trials on Gruinard to evaluate the potential use of airborne spores of B. anthracis; downwind of bomblet detonation, air was sampled and sheep were exposed (Manchee et al., 1994). The result was light surface contamination over much of the ground, with a majority of material scattered over the ground in the form of large globules of spore slurry in the immediate vicinity and downwind of the detonation point (Manchee et al., 1994). Soil samples taken in 1943, 1944, and 1946 indicated high levels of contamination. Because B. anthracis is persistent, it was reasonable to assume it would remain in the soil for a long period of time. The U.K. Ministry of Supply had purchased Gruinard for £500, with the understanding that the owner could repurchase it for the same amount within 6 months of its being declared “fit for habitation by man and beast” (Manchee and Stewart, 1988; Pearson, 1990). In 1945, the owner sought return of the island. But annual soil sampling between 1946 and 1969 showed persistent contamination, although the number of spores was slowly declining. An extensive survey in 1979 showed that most of the island was not contaminated (Manchee et al., 1994), and that spore contamination was confined to area of about 3 acres (Pearson, 1990). The Ministry of Defence commissioned an Independent Advisory Committee in 1985 to facilitate the return of Gruinard to civilian ownership. The committee reviewed scientific data regarding contamination, advised on and verified decontamination procedures, and advised on the prospect of the land’s return to civil ownership and agricultural use (Pearson, 1990). Two areas were identified for remediation: a larger zone around and including the detonation area and the paddock area where exposed sheep were kept (Manchee and Stewart, 1988).

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Reopening Public Facilities after a Biological Attack: A Decision Making Framework In 1986 the British tried to decontaminate Gruinard: B. anthracis spores were inactivated by drenching the soil with fluid biocides (the solution was 5% formaldehyde in seawater). Subsequent sampling revealed pockets of surviving spores which were then treated with undiluted formalin (Manchee and Stewart, 1988; Manchee at al., 1994). In 1986-1987, decontamination was verified using the following measures: Soil samples were tested; the sera of indigenous rabbits were examined for antibodies to anthrax—none were found; and a local farmer grazed 40 sheep on the island for 6 months, with no ill effect (Pearson, 1990). In 1988 the Independent Advisory Committee issued its final report, announcing that “… we believe that chances of persons or animals contracting anthrax on Gruinard Island are so remote that the island can be returned to civil use” (Pearson, 1990). In 1990 Gruinard was repurchased by heirs of the previous owner (Pearson, 1990). The property transfer, however, has not been without controversy. According to Willis (2002), “some doubts remain locally about the extent and effectiveness of the clean-up process, along with a legacy of bitterness.” HAZELTON RESEARCH PRIMATE QUARANTINE UNIT In 1989, monkeys began to die at the Hazelton Research Unit in Reston, Virginia. At first, officials thought the problem was a common monkey virus, but samples sent to the U.S. Army Medical Research Institute of Infectious Diseases soon revealed the animals were dying of Ebola virus. The situation worsened when officials realized the virus was spreading through the air; one monkey handler became ill (Alexander, 1998). The monkeys were euthanized and the building was decontaminated before its destruction. The Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and the U.S. Army oversaw the decontamination process; several other federal organizations also were involved. The building was sealed, hosed down with concentrated bleach, and then decontaminated with paraformaldehyde, after which it was sealed for 3 days. The Hazelton facility cost $12 million to build and the owner tried to sell it for about $4 million. At the end of 6 years, and on the market for $1 million, the owner decided to bulldoze the building and sell the land. CONCLUSIONS All of the cases reviewed here demonstrated the central role that risk communication, transparency of decision making, and trust play in establishing an acceptable and safe level of decontamination. At Hazelton, officials could not overcome the stigma of Ebola. At Gruinard, officials could not gain the trust of local people. Both problems involved a lack of trust. The Binghamton case was characterized by lack of transparency and by dismissive postures on the part of officials toward the concerns of the public and

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Reopening Public Facilities after a Biological Attack: A Decision Making Framework workers. The result was mistrust that contributed to the building being closed for 13 years. If New York officials had instituted something similar to this report’s recommendations regarding an analytic deliberative process, many of the problems experienced in Binghamton could have been avoided. Because the Binghamton State Office Building housed state agencies, closing it had few economic consequences; it could remain closed for so long without severe disruption. That would not be true for the contamination of a major American airport, and the need to reopen would be more pressing. REFERENCES Alexander, L. 1998. Decontaminating Civilian Facilities: Biological Agents and Toxins. IDA Paper P-3365. Alexandria, Virginia: Institute for Defense Analyses. Clarke, L. 1989. Acceptable Risk? Making Decisions in a Toxic Environment. Berkeley, California: University of California Press. Manchee, R.J., and D.P. Stewart. 1988. The decontamination of Gruinard Island. Chemistry in Britain July: 690-692. Manchee, R.J., M.G. Broster, A.J. Stagg, and S.H. Hibbs. 1994. Formaldehyde solution effectively inactivates spores of Bacillus anthracis on the Scottish Island of Gruinard. Applied and Environmental Microbiology 60(11): 4167-4171. Pearson, G.S. 1990. Gruinard Island returns to civil use. The ASA Newsletter 5. Willis, E.A. 2002. Landscape with dead sheep: what they did to Gruinard Island. Medicine, Conflict and Survival 18(2): 199-210.