DOD Inadvertently Ships Live Anthrax To 9 Labs

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The past 12 months have not exactly been stellar examples of good government lab biosafety, with several high profile `incidents' (see CDC Statement On Possible Lab Exposure To Anthrax), (see CDC Media Statement on Newly Discovered Smallpox Specimens), and the accidental shipment of live H5N1 to a USDA lab in Georgia (see CDC Announces Another Serious Biosecurity Incident).

While no laboratory workers were harmed in the making of these blunders, it nonetheless led to several heated congressional hearings, new lab safety regulations, and a promise that  labs around the country would work fervently to foster a greater `culture of safety’. 

We saw a setback on Christmas Eve when we learned of yet another incident (see CDC Statement On Ebola Lab Incident ) where the BSL-4 Ebola virus was inadvertently shipped to a BSL-2 lab.

Once again, no one was infected, but the CDC's review made additional recommendations for continued safety improvements.

Fast forward almost exactly a year since the first incident - involving anthrax - and we have a report this afternoon that a DOD lab has inadvertently shipped live anthrax to labs in 9 states; California, Texas, Wisconsin, Tennessee, Maryland, Virginia, Delaware, New Jersey and New York.

While details are still coming out, this from NBC News.

Live Anthrax Mistakenly Sent to U.S. Labs

By Jim Miklaszewski and Maggie Fox

Federal health officials say they are investigating the accidental shipment of live anthrax bacteria to labs in nine states. The Centers for Disease Control and Prevention confirms that it's investigating the accidental shipments.

No one's been sickened by the bacteria, which can cause potentially deadly illness although it's easily treated with antibiotics if caught soon enough.

"CDC is investigating the possible inadvertent transfer of a select agent from the U. S. Department of Defense (DOD) to labs in nine states. At this time we do not suspect any risk to the general public," CDC said in a statement sent to NBC News.
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I've looked for, but have not found on the CDC media site, the CDC statement.   Presumably we'll learn more in the next few days. 

All of this is likely to renew calls for greater oversight on the use of select agents, and some restrictions on what types of research that should be permitted. Last year, it was quite the  hot topic, as the following blogs attest.

The Journal Nature Weighs In On Lab Accidents & Biosafety

Thebulletin.org: Making Viruses Deadlier – An Accident Waiting To Happen.

While scientists engaged in this type of work insist that the risks are negligible (see Scientists For Science: GOF Research `Essential’ & Can be Done `Safely’), many others  (see Updating The Cambridge Working Group) are less convinced.

Some earlier blogs on this highly contentious debate include:

mBio: The Risks & Benefits Of `GOF’ Experimentation On Pathogens With Pandemic Potential

The Laboratory Bio-Safety Backlash Continues

ECDC Comment On Gain Of Function Research

Lipsitch & Galvani: GOF Research Concerns

Eurosurveillance: Anthrax Encounters Of The 4th Kind

Credit CDC 

 

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Traditionally there are three ways to contract anthrax. 

• Cutaneous, or through openings in the skin (the most common form of infection)
• Gastrointestinal from the consumption of infected meat
• And inhalational anthrax, from inhaling the spores.

 

Two years ago in UK: The High Cost Of Getting High we looked at the emergence of a rare 4th way in which people were getting infected with Anthrax in the UK, and across Europe; through the injection of recreational heroin.

 

In recent years, batches of heroin have been reported across Europe contaminated with anthrax spores, likely an unintentional contamination during the processing or transporting of the drug – and as you might expect – injecting contaminated heroin often turns out badly for the user.

 

The first cluster was reported in Scotland in 2009, and involved more than 100 cases. Cases resurfaced again in England and parts of Europe in 2012 (see HPA  Case of anthrax confirmed in Oxford). Today the Journal Eurosurveillance  has published a review of the literature, urging that clinicians learn to recognize the signs so that treatment can begin as early as possible.

 

Eurosurveillance, Volume 19, Issue 32, 14 August 2014

Review articles

Injectional anthrax - new presentation of an old disease

T Berger ()^1,2, M Kassirer¹, A A Aran^1,3

1. Israel Defense Force, Medical Corps, Ramat-Gan, Israel
2. Department of Internal Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
3. Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel

---

Bacillus anthracis infection (anthrax) has three distinct clinical presentations depending on the route of exposure: cutaneous, gastrointestinal and inhalational anthrax. Each of these can lead to secondary bacteraemia and anthrax meningitis.

Since 2009, anthrax has emerged among heroin users in Europe, presenting a novel clinical manifestation, ’injectional anthrax’, which has been attributed to contaminated heroin distributed throughout Europe; before 2009 only one case was reported. During 2012 and 2013, new cases of injectional anthrax were diagnosed in Denmark, France, Germany, and the United Kingdom. Here we present a comprehensive review of the literature and information derived from different reporting systems until 31 December 2013.

Overall 70 confirmed cases were reported, with 26 fatalities (37% case fatality rate).The latest two confirmed cases occurred in March 2013. Thirteen case reports have been published, describing 18 confirmed cases. Sixteen of these presented as a severe soft tissue infection that differed clinically from cutaneous anthrax, lacked the characteristic epidemiological history of animal contact and ten cases required complimentary surgical debridement. These unfamiliar characteristics have led to delays of three to 12 days in diagnosis, inadequate treatment and a high fatality rate. Clinicians’ awareness of this recently described clinical entity is key for early and successful management of patients.

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Of note, no human-to-human transmission has been documented among injectional anthrax cases.  While inhalational anthrax doesn’t spread from human to human, there is a slight risk of transmission from drainage from opens sores that come with the cutaneous form.

Although most of the cases in today’s report presented with serious soft tissue infections – up to, and including necrotising fasciitis - none showed the classic black lesion (eschar) that gives the disease its name (anthrax is Greek for `coal’).

Credit CDC PHIL

Gastrointestinal, respiratory and neurological symptoms were also described, with disease progression often leading to septic shock, organ failure, and sometimes death.

 

The authors wrote:

 

Injectional anthrax presents a challenge for physicians often due to lack of evident case clusters, unfamiliar clinical presentation and severe course of disease. Unlike cutaneous anthrax, injectional anthrax is typically a systemic infection with high mortality rate (Table 4). This may be attributed to the deeper and greater inoculation of spores, higher rates of septicaemia, delayed diagnosis and to factors specific to drug addicts including delayed medical consultation, malnutrition, presence of concomitant diseases such as HIV infection and defective immune response.

 

For people who inject drugs (PWIDs), anthrax is admittedly pretty far down the list of the bad things that can happen to you.  Even during the biggest outbreak in Scotland,  the incidence was estimated to be only 1.96 infections per thousand addicts.

 

During the `bad old days’ of the 1970s, I would see 1 or 2 heroin overdoses per shift, and many of them were well beyond any help from the bolus of Narcan (naloxone) I carried when when I arrived.

 

Beyond simple O.D.s, viral and bacterial infections are a constant danger, and can result in illness and even death. Hepatitis C, Hepatitis B, HIV, wound botulism, Staphylococcus aureus, and even tetanus are among the nasties that drug users are at increased risk of contracting.

 

While the sharing of needles is the cause of many of these infections, you don’t have to indulge in that particularly unwise practice to end up with a potentially fatal infection. Reusing your own needles, or injecting into a contaminated (dirty) arm, can easily introduce bacteria into the user’s system

 

Proof, I suppose, that we humans seem to have an infinite capacity to find new ways to wreak havoc on ourselves.

 

To close this out, a little good news. According to the CDC, this 4th type of Anthrax exposure hasn’t been reported here in the United States.

 

Injection Anthrax

Recently, another type of anthrax infection has been identified in heroin-injecting drug users in northern Europe. This type of infection has never been reported in the United States.

Symptoms may be similar to those of cutaneous anthrax, but there may be infection deep under the skin or in the muscle where the drug was injected. Injection anthrax can spread throughout the body faster and be harder to recognize and treat. Lots of other more common bacteria can cause skin and injection site infections, so a skin or injection site infection in a drug user does not necessarily mean the person has anthrax.

Upcoming House Sub-Committee Hearing On Lab Safety

CDC Anthrax Timeline – Credit CDC

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Even before Friday’s announcement by the CDC that one of their labs had accidentally shipped H5N1 contaminated virus samples to a USDA lab, the House Energy and Commerce Oversight and Investigations Subcommittee had scheduled a hearing on last month’s CDC Anthrax incident (see CDC Statement On Possible Lab Exposure To Anthrax).

 

Hearing Notice: Subcommittee on Oversight and Investigations to Examine Anthrax Incident

July 8, 2014

Director of the Centers for Disease Control and Prevention to Testify on Recent Anthrax Exposure

The Subcommittee on Oversight and Investigations, chaired by Rep. Tim Murphy (R-PA), has scheduled a hearing for Wednesday, July 16, 2014, at 10 a.m. in room 2123 of the Rayburn House Office Building. The hearing is entitled “Review of CDC Anthrax Lab Incident.” Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention (CDC), will be among the witnesses testifying.

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An incident which was closely followed by the equally disturbing discovery of six vials of unsecured smallpox at an FDA lab in Bethesda, Md. (see CDC Media Statement on Newly Discovered Smallpox Specimens).

Despite their age (vials dated 1954), and a sub-optimal storage environment for decades, on Friday we learned that samples taken from two of the vials were still viable, and growing in a CDC Lab (see CDC Announces Another Serious Biosecurity Incident).

 

The third - and arguably most serious incident – involved the cross contamination of H9N2 samples with highly pathogenic H5N1, and then shipping them to an unsuspecting USDA lab in Georgia.   Worse, once the discovery was made by the USDA lab, the incident went `unreported’ to upper management at the CDC for another six weeks.

 

March 12

• CDC Influenza Division (ID) shipped low pathogenic avian influenza H9N2 to USDA SEPRL in Athens, Ga
  Genetic analysis confirmed identity of H9N2
• Shipment delivered on March 13 to USDA Southeast Poultry Research Laboratories (SEPRL) (Athens GA)
  SEPRL observed pathogenicity in chickens inconsistent with H9N2 virus
  SEPRL performed molecular analyses on SEPRL virus stock and material sent by CDC
  SEPRL confirmed highly pathogenic H5N1 contamination and destroyed all SEPRL virus stocks in biosafety level 3 (BSL-3) enhanced

May 23

• SEPRL notified CDC ID that SEPRL virus stock was contaminated and destroyed

May 23

• CDC ID confirmed H9N2 virus was contaminated by H5N1 virus

July 9

• CDC Responsible Official was notified; investigation is ongoing

 

A revelation that led to another press release from the House Sub-Committee on Friday, which indicates a widening of the scope of the hearing scheduled for Wednesday.

 

Upton, Murphy Comment On Additional CDC Safety Failures

July 11, 2014

CDC Head Will Testify on Recent Anthrax Incident WEDNESDAY

WASHINGTON, DC – House Energy and Commerce Committee Chairman Fred Upton (R-MI) and Oversight and Investigations Subcommittee Chairman Tim Murphy (R-PA) responded to the latest announcement by the Centers for Disease Control and Prevention (CDC) on additional safety breaches. As part of the ongoing investigation into the potential exposure of more than 80 workers at a CDC lab in Atlanta to live anthrax, committee leaders earlier this week sent letters to the CDC and HHS Inspector General seeking documents and information. CDC Director Dr. Tom Frieden is scheduled to testify before the Oversight and Investigations Subcommittee next Wednesday, July 16, at 10 a.m.

Chairman Upton commented, “The repeated breakdown in protocols and safety failures involving the world’s deadliest germs and pathogens is wholly unacceptable. The consequences of such carelessness could not be more dire. This latest revelation underscores the need for our investigation and the importance of next week's hearing to review the safety measures and practices at the CDC. Past fixes by CDC several years ago apparently were not followed and not adequately implemented. We will seek to find out why CDC thinks its latest actions will prove more effective than past efforts, and whether congressional intervention may be necessary. We look forward to hearing directly from Dr. Frieden next Wednesday and will seek his firm commitment that such safety lapses are over.”

Subcommittee Chairman Murphy added, “With the release of today’s report, we’ve learned the dangerous transfer of possible live anthrax bacteria by the CDC’s Atlanta lab was not an isolated incident by a rogue scientist, but rather one of multiple mishaps over the last several years that were violations, or apparent violations, of federal regulations for handling deadly biological material. These repeated safety failures raise grave concerns about the CDC’s ability to ensure strict procedures, protocols, and training are followed and an area we will examine further at Wednesday’s Oversight and Investigations Subcommittee hearing.”

 

House E&C Subcommittee hearings are usually broadcast live at this link:

 

 http://energycommerce.house.gov/studio/webcasts

 

All of this comes after several years of debate over the safety of government and university laboratories, and concerns over potentially dangerous work on DURC (Dual Use of Concern) and GOF (Gain of Function) research projects.

 

For those unfamiliar with the lexicon of biomedical research, GOF research involves the creation of viruses and/or bacteria with enhanced virulence, transmissibility, or host range  while DURC is defined as:

 

. . . life sciences research that, based on current understanding, can be reasonably anticipated to provide knowledge, information, products, or technologies that could be directly misapplied to pose a significant threat with broad potential consequences to public health and safety, agricultural crops and other plants, animals, the environment, materiel, or national security

 

Proponents of these types of research projects argue that the risks of an accidental release are small, that they can open up new avenues of knowledge in the world of bioengineering, and perhaps tip us off as to the what pathogens have the most pandemic potential, and even help in the early development of a vaccine. 

 

Opponents argue that these potential benefits are overstated, and the risks of an accidental release from one of the hundreds of labs doing this type of work are underappreciated (see The Debate Over Gain Of Function Studies Continues).

 

While we don’t know what Dr. Frieden will say before the subcommittee on Wednesday, on Friday he did say:

 

“And fundamentally, and this is relation to the previous question from the wall street journal as well, one of the things that we want to do is reduce the number of laboratories that work with dangerous agents to the absolute minimum necessary.  Reduce the number of people who have access to those laboratories to the absolute minimum necessary.  Reduce the number of dangerous pathogens we work with in those laboratories.”

 

This week, you can expect to see a good deal of media coverage of this topic, but a good one to start your week with is this from Reuters:

 

 

ANALYSIS-How to fix U.S. biosecurity leaks? Close some labs

Source: Reuters - Mon, 14 Jul 2014 05:00 GMT

By Sharon Begley and Julie Steenhuysen

July 14 - In the wake of disclosures that top government labs mishandled anthrax, smallpox and avian flu, U.S. health authorities are considering the once unthinkable: cutting the burgeoning number of labs working with the planet's most dangerous microbes.

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In 2012 we saw a year-long self imposed moratorium on controversial GOF research by a group of major researchers, to allow time for `public discussion and scientific debate’ of the issue, but in the end, very little of that actually took place.

 

Instead – except for the occasional scathing newspaper editorial (see NYTs  An Engineered Doomsday) – this debate has been largely conducted in academic circles or in research journals.

 

Now, the debate finds itself once again on the front page, and this time it will be conducted under the formidable shadow of three very high-profile biosecurity lapses in what are assumed to be the best, and safest, labs in the country. 

 

Which means that advocates of  GOF & DURC research have a big job ahead of them to convince an increasingly skeptical public, and traditionally risk adverse politicians, of the wisdom and safety of continuing – particularly in anything less than the highest biosecurity settings.

Stay tuned.

CDC: Press Conference Transcript, Audio & Timelines For Lab Incidents

H5N1 Photo Credit – CDC PHIL

 

 

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For those who missed yesterday’s bombshell press conference on recent government lab biosafety incidents involving anthrax, smallpox and  avian H5N1, the CDC has posted the audio file, transcript, and some timeline graphics. 

 

While there has been a great deal of excellent media coverage over the past 18 hours (including Helen Branswell’s  What happened at the CDC’s flu lab? & Lisa Schnirring’s More problems shutter CDC labs, prompt review for CIDRAP News), many will still want to hear this press conference in its entirety.

 

Press Briefing Transcript

CDC Press Conference on laboratory quality and safety after recent lab incidents

Friday, July 11, 2014 11:30 a.m. ET

• Audio recording  [MP3, 10.3 MB]

 

 

These incidents are still under investigation, and so there are still large gaps in our understanding of how they occurred.  The H5N1 cross-contamination incident in particular has two large and critical holes in the timeline (see below) that will require filling in. 

 

The first is what transpired between March 12, when the (presumed H9N2) samples are shipped from the CDC to the USDA lab in Athens, Ga and May 23rd, when the USDA determined they were working not with H9N2, but with the highly pathogenic H5N1 virus.  

 

How the virus sample became cross contaminated, and how that went undetected for 40 days, remain open questions.

Even more troubling is how the discovery of this mistake could have been made on May 23rd - and shared between two major government agencies (USDA & CDC) - and yet senior management at the CDC were not informed until July 7th, a gap of more than six weeks.

 

March 12

• CDC Influenza Division (ID) shipped low pathogenic avian influenza H9N2 to USDA SEPRL in Athens, Ga
  Genetic analysis confirmed identity of H9N2
• Shipment delivered on March 13 to USDA Southeast Poultry Research Laboratories (SEPRL) (Athens GA)
  SEPRL observed pathogenicity in chickens inconsistent with H9N2 virus
  SEPRL performed molecular analyses on SEPRL virus stock and material sent by CDC
  SEPRL confirmed highly pathogenic H5N1 contamination and destroyed all SEPRL virus stocks in biosafety level 3
  (BSL-3) enhanced

May 23

• SEPRL notified CDC ID that SEPRL virus stock was contaminated and destroyed

May 23

• CDC ID confirmed H9N2 virus was contaminated by H5N1 virus

July 9

• CDC Responsible Official was notified; investigation is ongoing

 

The H5N1 flu incident, while apparently contained, could have been an economic disaster had the virus escaped the USDA lab and entered the poultry and/or wild bird population of the United States. 

 

Regarding the Anthrax investigation, you’ll also find a graphic timeline available at this link.

 

Although none of these incidents resulted in the infection of lab personnel, or the release of a pathogen outside of the lab, they all had the potential to do so – and in the words of the CDC’s Director, `These events should never have happened.’  

An obviously anguished Dr. Frieden went on to say:

`Together, these events I’m sure have many people asking and questioning government labs.  They may be wondering whether we're doing what we need to do to keep our workers and our communities safe.  And I think it's fair to raise those questions.  I’m disappointed by what happened, and frankly, I’m angry about it.'

 

The post mortem on all of this is likely to be long and messy, and the fallout is likely to extend well beyond the CDC and USDA labs. These incidents show that no matter how sophisticated the laboratory, no matter how detailed the safety protocols, there is always the risk of human error.

 

Something which is sure to re-ignite the debate over the wisdom and safety of GOF (`Gain of Function’) and DURC (`Dual Use of Concern’) research has been simmering for several years.  While I’ll have more on that in future blogs, for now you may wish to revisit:

 

The Call For Urgent Talks On `GOF’ Research Projects

U.S. Issues New DURC Oversight Rules

Nature: H5N1 viral-engineering dangers will not go away

CDC Statement On Possible Lab Exposure To Anthrax

Electron micrograph (SEM) depicted spores from the Sterne strain of Bacillus anthracis bacteria. – Credit CDC

 

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Based on the reports thus far, it appears that the risks to those who were potentially exposed to anthrax at a CDC lab facility in Atlanta last week are pretty low.   It has been a week since the likely exposure took place, and thus far, no employees have developed symptoms.

 

First the statement, then I’ll have a bit more.

 

 

Media Statement

For Immediate Release: Thursday, June 19, 2014
Contact: CDC Media Relations
(404) 639-3286

CDC Lab Determines Possible Anthrax Exposures: Staff Provided Antibiotics/Monitoring

CDC announced today that approximately 75 Atlanta-based staff are being monitored or provided antibiotics because they may have been unintentionally exposed to live Bacillus anthracis (anthrax) after established safety practices were not followed.

Out of an abundance of caution, CDC is taking aggressive steps to protect the health of all involved, including providing protective courses of antibiotics for potentially exposed staff. Based on most of the potential exposure scenarios, the risk of infection is very low. Based on the review to date, CDC believes that other CDC staff, family members, and the general public are not at risk of exposure and do not need to take any protective action.  Although the investigation continues, early reports show that one of its Roybal campus biosafety level 3 (BSL3) labs was preparing B. anthracis samples for research in other CDC labs at lower biosafety levels to yield new means of detecting dangerous pathogens in environmental samples. However, the lab used a procedure that did not adequately inactivate the samples.

The potentially infectious samples were moved and used for experimentation in three CDC Roybal campus laboratories not equipped to handle live B. anthracis.  Workers, believing the samples were inactivated, were not wearing adequate personal protective equipment while handling the material.

Lab safety investigators also determined that, sometime between June 6 and June 13, procedures used in two of the three labs may have aerosolized the spores.  Environmental sampling was done, lab and hallway areas were decontaminated and laboratories will be re-opened when safe to operate.

The unintentional exposure was discovered June 13 when the original bacterial plates were gathered for disposal and B. anthracis colonies (live bacteria) were found on the plates. These plates had appeared negative for B. anthracis at the time samples were distributed to the other CDC laboratories.  The review began immediately to assess the health risk, and those workers handling the plates were immediately notified.

CDC’s guiding principles for laboratory work are to ensure the safety of all staff and the community and be as transparent as possible about our work as we conduct high-quality scientific research to protect people in this country and around the world.

CDC continues its internal review to determine why validated procedures were not used by the lab. Also, CDC has reported the incident to the Federal Select Agent Program.  Given that CDC expert protocols were not followed, disciplinary action(s) will be taken as necessary.  In addition, CDC will review the safety protocol again with all employees who work in this area.

It is CDC’s obligation to ensure that people feel safe and are safe in the workplace and the community as we conduct our life-saving laboratory work. We will report findings of this review and all steps we take to improve lab-safety processes as a result of this incident. 

 

 

Mistakes or accidents at high biosecurity-level laboratories are admittedly rare events, but they are not completely unheard of, even at the CDC.  Between 2003 and 2009, US government laboratories reported 395 incidents that involved the potential release of select agents, according to this report from CIDRAP NEWS.

 

Although it seems likely that this latest incident is contained, it will likely fuel existing biosecurity concerns over controversial Gain of Function (GOF) experiments; those designed to enhance the transmissibility or virulence of dangerous pathogens – including the H5N1 virus (and most recently the 1918 pandemic virus).

 

While most researchers offer broad assurances on the safety of high security laboratories - as today’s incident shows –even the most professionally run high security lab is vulnerable to human error. Last November, in BMC Medicine: Containing Laboratory Escape Of Pandemic Viruses, we looked at a report that found the risks of seeing an accidental release from one of these labs is far from zero.

 

For more on the contentious debate over the risk of accidental releases from labs, and the pursuit of GOF research, you may wish to revisit:

 

Lipsitch & Galvani: GOF Research Concerns.

Laurie Garrett On Biosecurity Reforms

H7N9: Reigniting The `Gain Of Function’ Research Debate

More ICEID Coverage From CIDRAP

 

 

 

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From the ICEID 2010 Conference going on this week in Atlanta, Lisa Schnirring of CIDRAP News has been keeping us updated.   You can find all of her reports from the conference here.

 

Last night Lisa filed a report on research into protecting workers from airborne pathogens - particularly in the health care environment – and dealing with workplace anthrax contamination.

 

Last year, the debate over how to protect HCWs sprung to the forefront when, early on in the pandemic, it became apparent that there were too few N95 masks stockpiled.

 

Nurses Protest Lack Of PPE’s

Report: Nurses File Complaint Over Lack Of PPE

California Nurses Association Statement On Lack Of PPE

 

Fortunately, the novel H1N1 virus did not turn out to be as virulent as SARS, or H5N1, and the crisis gradually subsided.

We may not be so lucky with the next airborne pathogen.

 

But safety issues go beyond PPEs (Personal Protective Equipment) like N95 masks. As the following report tells us, we’ve a serious shortage of negative pressure isolation rooms in this country as well.

 

 

 

Research continues on shielding workers from airborne pathogens

Lisa Schnirring Staff Writer

Jul 14, 2010 ATLANTA (CIDRAP News) – The early response to the H1N1 pandemic exposed ongoing sore points regarding protection of workers in healthcare and other settings during epidemics or bioterrorist attacks, and federal researchers today highlighted current efforts to address some of the concerns.

 

They covered emerging issues such as a need for more surge capacity for airborne-pathogen isolation units and possible enhancements for guidance on responding to anthrax attacks in workplace settings. The experts presented their updates in a panel discussion at the International Conference on Emerging Infectious Diseases (ICEID).

 

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CIDRAP also has another mini-roundup of some of the slide presentation abstracts from the conference.

 

ICEID NEWS SCAN: School closures, pneumonia and flu deaths, raw milk demand, sprout outbreaks