What's baffling me is that no source I've been able to find (in English, anyway) sees fit to mention the cause of this accident beyond blandly citing "human error."
Human Error.
"Well, you know, I was just taking my 12-gallon tank of polio for a walk down by the water treatment plant, and whoops! Butterfingers!"
Usually, the big biotech production plants look a lot like breweries. Giant bioreactors that look like fermentors are hooked up to complex control valves moving fluid from one to the other in the various steps of a complicated process.
My best guess is that a technician accidentally hit the "dump waste" button before the vessel was decontaminated/when it had the wrong solution in it/before the virus was deactivated, etc.
This incident is especially worrisome, but having seen the control boards for one of those giant reactors, I'm not surprised that mistakes are made on occasion.
It seems odd to me that you'd have a waste dump path in such a place which didn't have a secondary decontamination step in it. Running the water through UV sterilization would be an obvious move, and incredibly cheap considering the danger.
>>Drake demonstrated that poliovirus is able to undergo multiplicity reactivation.[23] That is, when polioviruses were irradiated with UV light and allowed to undergo multiple infections of host cells, viable progeny could be formed even at UV doses that inactivated the virus in single infections.
Even if it went to waste while being potent it would go to a secondary containment. If the human error was in the secondary containment then I can see it being released. I have worked as a contractor for various pharma companies and know how they operate. Not all of them are all that good at what they do and paying for brand names is better than the generics because of the levels of quality assurance.
It was likely some polio introduced into secondary and they didn't process it correctly in that area.
I have no information about this case other than the source. However, most human errors like this one are due to unexpected similitude and shared affordances: two things that should not be mixed have the same size, shape, color.
There was a case of a nurse who injected the wrong compound in a baby and killed it a decade ago (in a military hospital in France, one with a stellar reputation): two viles were strikingly similar (one containing vaccine, the other Potassium) even after being told what those were, you would confuse them.
In this case, I'm assuming concentrated virus is not meant to be near water release, therefore no one noticed until yesterday that there were stored in vats that look like possibly fat-digesting bacteria, or chlorine. 40L is a large quantity: the only container I can think of for those is either a metallic oil drum, or that omnipresent industrial blue plastic barrel (the one you see in that infamous scene in Breaking Bad).
Plus a trainee nurse inadvertently killed a patient in France two weeks ago through direct KCl injection. There is now a move to remove all KCl vials and replace them with pre-diluted pouches.
On 8 September 2014, the Federal Public Service (FPS) Health, Food Chain Safety and Environment in Belgium confirmed that samples of mud and water taken from the Rosieres treatment plant, river Lasne and river Dyle, all tested negative for the presence of polio virus.
But... 45L of "concentrated polio virus"? Although it'd probably be classified, I'd love to see the full detailed report on how and why this happened.
I'm not sure it is 45 liters of polio virus. The expression used is "concentrated polio virus solution". I guess that includes whatever they use to produce the virus, or maybe it is a concentrated version of the end product that is taken orally and contains ??? percent of non-virus stuff.
One could even parse that phrase as "a concentrated solution of the stuff we use to create polio vaccin; wasn't used yet, so it should not contain polio virus, but it was in our security zone, so we take this seriously."
Other sources speak of 45 liters of liquid contaminated by live polio virus, which is something different yet.
In summary: I do not know how to interpret that number.
>I'm not sure it is 45 liters of polio virus. The expression used is "concentrated live polio virus solution".
AFAIK, polio-virus only exists/survives in solution/bodily fluids. So "45 liters of polio virus" would be sort of nonsensical if one interpreted it literally. Parsing the second part, the word "concentrated" also means that it wasn't simply some incidentally contaminated wash water or anything like that, but rather it was "concentrated polio virus solution".
>One could even parse that phrase as "a concentrated solution of the stuff we use to create polio vaccin; wasn't used yet, so it should not contain polio virus, but it was in our security zone, so we take this seriously."
Yes, one could parse the statement in a way most favorable to GSK (and to everyone's hopes), but that is not a prudent way to treat such accidents, especially if we have no evidence to support such a generous interpretation. Fortunately, the article links its source: http://www.ecdc.europa.eu/en/publications/Publications/commu...
>>On 6 September, the Belgium authorities informed the European Commission, the Netherlands, ECDC and WHO about an
incident that occurred on 2 September 2014. Following a human error, 45 litres of concentrated live polio virus solution were
released into the environment by the pharmaceutical company, GlaxoSmithKline (GSK), in Rixensart, Belgium.
The press release is very brief and concise. It leaves little room for linguistic gymnastics.
>I do not know how to interpret that number.
Here, I'll try. If you live downriver from the Belgian GSK plant, don't drink river water, or swim in the river. Also, confirm your polio vaccination status.
>>On [2 Sep 2014], following a human error, 45 litres of concentrated live polio virus solution were released into the environment by the pharmaceutical company, GlaxoSmithKline (GSK), in Rixensart city, Belgium. The estimated viral rejection of live virus Saukett (Salk) serotype 3 was of 10 to the 13th, cell culture infectious dose 50 percent (CCID 50). The liquid was conducted directly to a water-treatment plant (Rosieres) and released after treatment in river Lasne, affluent of river Dyle, which is affluent of the Escaut/Scheldt river.
So, one could also parse the information in a worst-case way, that is that the 45L of concentrated live poliovirus solution was released into a sewage treatment plant where they had a polio-party and subsequently became many hundreds of thousands of litres of poliovirus solution.
I've worked in labs with far less threatening (but still deadly) microorganisms and I could never imagine making a mistake with such a giant flask. It had to have been mislabelled or maybe someone used used autoclave tape to seal something on the top? Only a idiot would pour an unlabelled solution of that size down the drain...
Indeed, the article mentions that this was "released into the environment by the pharmaceutical company, GlaxoSmithKline".
I originally read about this at this excellent site I'm following for Ebola news, http://promedmail.org/ (and also now using to learn a lot about plant pathogens etc.)
Their item quotes a source with more info and has some very good editorial content on potential problems, including details on recent downstream outbreaks: http://promedmail.org/direct.php?id=2771817
>let's cross fingers this doesn't become the obvious "vaccine manufacturers are spreading viruses" that anti-vaccine conspiracy theorists need.
Well, considering the historical behavior of for profit enterprises, it's not something that would be beneath them.
If it wasn't for tight regulation and the huge media backslash they'd be pouring the stuff by the tons. But in any place/country/era where they could bypass such stuff, businesses have done so.
Just so we are clear, you believe that the individual people working at this pharmaceutical company- many thousands of people- are all mass murderers, held in check only by the orders of their PR department.
I think a better way to look at it is a pharmaceutical company is full of people that would obey the ignorant orders of a middle manager in a hierarchy with incorrect safety procedures or obey the orders of a small group of evil managers colluding to bypass those procedures without the knowledge of their subordinates.
There's no reason you need more than a handful of people to be deliberately evil. Plenty of people will follow them unknowingly or under the threat of losing their jobs.
Do you believe that the German people in 1933-1945 were all (or many millions of them) mass murderers and "evil"? The reality of it is that they just followed orders, and that doing a little part doesn't directly feel like being a murderer, especially if its celebrated by your peers and superiors. The "banality of evil" and all.
But in the case we're talking about it's even easier. For one, it doesn't have to be "many thousands of people" working in the company. Just a few, entrusted by the upper echelons. In the same way that companies historically employed thugs, mafia etc, to beat and even murder union members and strikers. It's not like it was something openly decided in a company meeting. Usually it takes the form "take care of the problem, the less I know the better" from some superiors (with an implicit knowledge of what that entails).
Well as much as I hate it, it is indeed a case of a vaccine manufacturer spreading the virus it makes vaccines against. Let's just hope that there is a a deep inquiry and that they do more than just fire the employee who did a mistake.
Single employees, no matter how senior they are, shouldn't be able to perform an action like this. There's got to be systemic gross incompetence to even allow a single employee opportunity to access a large batch of fatal disease carrying material without oversight. I doubt very much this was a case of "oh the intern threw out the wrong barrel of disease, shucks".
I am from Belgium (and currently living there). Newspapers reported at the time that it actually was 45 liters of a solution contaminated with the polio virus, not 45 liters of a polio virus concentrated solution.
Luxembourg borders Belgium, and Lac de la Haute Sûre at its closest point is only two miles from the Belgian border; so, it is conceivable that Belgians might get water from that lake.
>(CS) Authorities have decided to stop using water from the Lac de la Haute Sûre for drinking water treatment, following the spread of a pesticide in the water after a spill in Belgium.
I know it very well, as I live in Luxembourg[1] and I have to explain it to everyone I spoke to in my native country, Italy (normal questions are "so, how is it your life in Bruxelles?" "what about your living in Belgium" etc..)
So thanks for your unneeded geography lesson and now if you would be so kind to open the link you'll read why Luxembourgish newspaper were talking about some pesticide in a Belgian lake...
[1] and if we want to be really really precise, the south province of Belgium at the border with Luxembourg and France is called Province of Luxembourg, so we should talk about Province of Luxembourg and Grand Duchy of Luxembourg.
Something is being covered up and the explanation for such huge mistake doesn't add up.
1. Why was such a large amount of a potent virus stored in one container or multiple container?
2. Why all of it was available to a single/group of persons ?
3. If it's a group of person, then it must be a planned act.
4. How can Pharmaceutical companies pour something directly into the water channels without going through some kind of filteration and detection system ?
5. Why there is not more internet/media coverage on a such a big incident ?
You can safely assume there are drains in the floor wherever these things are stored. The drains would be for carrying away cleaning solutions for the environment.
Someone broke something, or opened something, or knocked over something. 45 liters of water is about 100 US pounds, so it was probably a single smallish, somewhat portable storage unit that got affected.
I agree the wording is less than ideal, but I'm not sure there is a 'coverup'.
> Wild polioviruses are classified as risk group 2. The rationale for the minimal biosafety levels is the near universal immunization of the population with OPV and/or IPV.
Biosafety Level 2 (BSL-2) is the currently recommended minimal standard for all countries. To ensure safe handling of wild polioviruses and potentially infectious materials as eradication nears (Pre-Eradication), BSL-2, hereafter referred to as BSL-2/polio, should be enhanced by specific practices described in this document
(Box 10).
Don't attribute to malice what can be attributed to simple stupidity.
It was 45L of concentrated polio virus solution. 45L is about the upper limit of a human portable storage vessel for liquids. 10 gallon portable water coolers are common, and we're talking 12 gallons here.
My guess is someone was corner-rolling it to transport it a short distance rather than getting a coworker or using a dolly. All it takes is the lid being improperly secured and all that liquid is going down a floor drain.
The virus doesn't live long outside the body, with the exception being an infected person faeces.
This is likely not receiving much media attention because it's not a big incident. Aside from a few waste treatment workers who'll have to be extra cautious the city will simply cut back on workers going down into the sewers for a couple weeks.
Unless faeces are getting into the water supply, there's negligible risk. And if faeces were getting into the water supply, there'd be a bigger news story here than this incident.
I don't think this is such a big deal. After massive dilution and water treatment, there won't be any viable particles left to infect anyone from the 5% unvaccinated Belgians. Let's hope I'm right.
Indeed. Are you going to study 45L of it under a microscope though? The Polio part I'm OK with its the "45L of concentrate" that I can't understand.
You have 100 tons of explosive? Yes...I need it...for research. And 1kg will definitely not be enough for my research....has to be 100 tons. See what I'm getting at?
Originally when I read I thought "perhaps there was a leak in a barrel or something like this. I glazed over the "following human error" part.
Hypothesizing brings me to conclusion that this has to be caused at least in part by companies probably trying to streamline by merging branches or departments.
If I'm a fly on the wall in the board room I'm sure I hear something like: "Sure, of course it makes financial sense to manage all barrels of stuff headed for water-treatment facility in the same warehouse, and by the same team, as where we keep our barrels full of polio and other harmful viruses. Layoff the other department, close down the other warehouse, and merge the two asap"
I'm sorry, but for me when I read something this horrific nothing works better than a little sarcasm / humor.
I think the points (yes I think sarcasm can be a valid channel through which to voice your concerns) I'm trying to make here are:
1) People making decisions for corporations as large as GlaxoSmithKline tend to be disconnected from the impact of their decisions.
2) There are only 2 reasons something like this can happen. (a) Malice, or (b) incompetence. I reluctantly choose 'b'.
3) In general it's the people who actually make the mistake who get fired, and not the incompetence in the board room that creates the environment where these kinds of mistakes can actually be made.
As a side-note, I live in midwest in U.S. and am not a reporter or involved in media, so I'm pretty ill-equipped to go seeking out facts which I'm sure even a skilled reporter will have a difficult time trying to uncover.
Not sure why you got so heavily downvoted. It's a reasonable question. There are a few books looking at causes of human errors that result in death or accident.
Usually the cause is wider than just "Bob didn't follow procedure", and includes things like "Management had Bob working 56 hour weeks in scattered locations which caused fatigue".
People incentivise the wrong thing; they misunderstand the psychology of work[1]; they use poor design; etc.
Other examples include surgeon's resistance to counting equipment before and after surgery - this WHO protocol saves lives and reduces adverse events but some surgeons strongly resisted implementing it.
> BRITISH NUCLEAR Fuels has admitted that it has discovered twice as many faked safety checks on its highly dangerous mixed-oxide fuel as previously thought.
> The nuclear fuel was destined to be part of a second export consignment to Japan, where environmentalists are planning huge protests against the scheduled arrival of the first consignment later today.
> The company originally estimated that quality-control data relating to 11 lots of mixed-oxide (MOX) fuel had been falsified, but an internal investigation has identified 22 lots that were forged. British Nuclear Fuels (BNFL) launched its inquiry last week after The Independent revealed serious lapses in its quality-control procedures relating to MOX fuel for Japan. Three employees have been suspended.
In the software world this manifests as redundant-but-required input. Don't ask the user for a value that can be safely calculated or determined an already known value.
From the excellent series of books What Went Wrong by Trevor Kletz:
...our first choice should be to see if we can remove the hazard—the inherently safer approach. For example, could we use a nonflammable solvent instead of a flammable one?...the second best choice is to control the hazard with protective equipment, preferably passive equipment, as it does not have to be switched on. As a last (but frequent) resort, we may have to depend on procedures. Thus, as a protection against fire, if we cannot use nonflammable materials, insulation (passive) is usually better than water spray turned on automatically (active), but that is usually better than water spray turned on by people (procedural). In some companies, however, the default action is to consider a change in procedures first, sometimes because it is cheaper but more often because it has become a custom and practice carried on unthinkingly. [1]
[1] Trevor Kletz. Still Going Wrong!: Case Histories of Process Plant Disasters and How They Could Have Been Avoided. Burlington, Massachusetts: Gulf Professional Publishing, 2003. ISBN 978-0750677097, page. 208.
Was this quote and quote "misstake" or real misstake?
I mean if they sell a vaccine, Polio is exterminated
no need to sell the vaccine but if you accidentally spread it again you still can sell the vaccine.
Polio is not exterminated even if it is absent since a while in Belgium. Even if some cases appear in Belgium, the reemerence of an epidemic is improbable in such a highly vaccinated area, unless some anti-vaxxer community manage to catch it.
You are probably confusing it with smallpox which has been eradicated.
And of course the Sheeple well keep buying the vaccine, because they have been made dumb and compliant by chemtrails and fluoride, ripe to be overthrown by the shadow Illuminati of Nazis flying UFOs from their hidden Antarctic base.
Human Error.
"Well, you know, I was just taking my 12-gallon tank of polio for a walk down by the water treatment plant, and whoops! Butterfingers!"
I just. I don't. How.