Inside the Hot Zone A Soldier on the Front Lines of Biological

Warfare

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© 2020 by Mark G. Kortepeter

Cover designed by University of Nebraska Press; cover image: Electron micrograph of Ebola virus is
from the interior. Photomicrograph of Bacillus anthracis courtesy of the CDC Public Health Image
Library.

All rights reserved.

Potomac Books is an imprint of the University of Nebraska Press.

Library of Congress Cataloging-in-Publication Data

Names: Kortepeter, Mark, author.
Title: Inside the hot zone: a soldier on the front lines of biological warfare / Mark G. Kortepeter, M D ,
M PH , Colonel, U.S. Army (Ret.).
Description: Lincoln: Potomac Books, an imprint of the University of Nebraska Press, [2020]
Includes bibliographical references and index.
Identifiers: LCCN 2019016101
ISBN 9781640121423 (cloth: alk. paper)
ISBN 9781640122765 (epub)
ISBN 9781640122772 (mobi)
ISBN 9781640122789 (pdf)
Subjects: LCSH : Kortepeter, Mark. | Biological warfare—Research—United States. | U.S. Army
Medical Research Institute of Infectious Diseases. | Bioterrorism—Prevention—History—21st century.
| Physicians—United States—Biography.
Classification: LCC UG 447.8 .K 67 2020 | DDC 358/.38—dc23 LC record available at
https://lccn.loc.gov/2019016101

The publisher does not have any control over and does not assume any responsibility for author or third-
party websites or their content.
Dedicated to my parents, Carl Max and Cynthia Kortepeter, and to my uncle
and aunt, Paul and Martha Schmidt, who served as my role models for how
to live and work.
Be sober-minded; be watchful. Your adversary the devil prowls around like a roaring lion, seeking
someone to devour.
—1 Peter 5:8 ESV

Without a measureless and perpetual uncertainty, the drama of human life would be destroyed.
—Winston Churchill
Contents

List of Illustrations
Preface
Prologue: Exposure
1. Beginnings
2. Germs as Weapons
3. The Six “Chessmen of Doom”
4. Hoofbeats
5. The Queen Strikes
6. The Nation’s Bio-Emergency Hotline
7. The Pawn Comes Calling
8. Bioweapons 101
9. Preparing for Biological Warfare
10. Disaster from Within
11. Bow to King Smallpox
12. On the Front Lines
13. Desert Pneumonia
14. The 4M Disaster
15. Countermeasures
16. The Slammer
17. On the Hot Side
18. Descent into Hell
19. Suspicion
20. The Aftermath
21. Down for the Count
22. Behind the Scenes of Pandemic Response
23. Looking Forward—the Challenges Continue
Afterword
Acknowledgments
Glossary
Notes
Index
Illustrations

1. With Cindy in Thailand

2. U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick,
Maryland
3. The 8 Ball at Fort Detrick
4. The “Slammer”
5. Kortepeter and colleagues on camera
6. Biothreat meeting, St. Michaels, Maryland, ca. 1999
7. As chief of medicine, ca. 2001
8. John Ezzell and the Daschle letter
9. Anthrax bacteremia
10. Anthrax colony variants in petri dish
11. Cutaneous anthrax
12. Entrance to the “Cave”
13. Doctors on the SMART-IND team in Kuwait
14. Giving a briefing during a Scud missile attack in Kuwait
15. SMART-IND team en route to the Comfort hospital ship
16. Denise Clizbe and Kelly Warfield at the Slammer
17. Bruce Ivins
18. Bruce Ivins award
19. In BSL-4 lab at USAMRIID
20. Electron micrograph of the Ebola virus
21. At the White House, ca. 2011
22. With Mark Takano, 2014
23. At a Kenya tea plantation
24. With Simon Mardel at WHO , 2018
25. At Hébert School of Medicine, Uniformed Services University, 2015
26. Specimen shipment
27. With colleagues from the NATO Biomedical Advisory Panel
28. USAMRIID operational medicine colleagues at the White House
Preface

Biodefense Solutions to Protect the Nation

—USAMRIID motto

In 1998 the army transferred me to USAMRIID [pronounced YOU -SAM -RID ], the
U.S. Army Medical Research Institute of Infectious Diseases—the army’s
biological weapon defense laboratory. USAMRIID ’s picturesque setting
nestled below the Catoctin Mountains at Fort Detrick, Maryland, belies the
important germ-warfare defense work ongoing there since the 1950s Cold
War era and continuing today against bioterrorism threats.
When I arrived as a junior public health physician and army major, I had
no idea that by the time I left as a colonel, I would be pulled into the
maelstrom of numerous nationally significant infectious disease crises. I
spent seven and a half years inside USAMRIID , affectionately nicknamed the
“Hot Zone,” after The Hot Zone, Richard Preston’s bestseller about the
institute’s discovery of a new species of Ebola virus. Those seven and a half
years would be the most exciting of my twenty-seven-plus years wearing the
army uniform.
In 1998 the old guard from the former United States’ offensive
bioweapons program (closed in 1969) had moved on. Our mission was
biodefense. It was an amazing time. The vibrant institute was in its heyday in
the afterglow of U.S. success in the first Gulf War and held a unique niche as
the nation’s go-to place for all things related to biodefense. In an era of
openness, knowledge sharing, and relative “innocence,” our scientists
developed new treatments, vaccines, and diagnostics to thwart potential
adversaries like the Soviet Union and Iraq, which might threaten our forces
and the nation with deadly infectious pathogens. It was challenging. It was
exciting. We were a “family.” As with any family, we had our differences and
scientific disagreements, but we worked through them and took care of one
another inside and outside the lab.
Our world changed after the September 11, 2001, terrorist bombings and
the anthrax letter attacks that followed. As quickly as the Berlin Wall went
up, a tall black fence grew around us, reminiscent of the Cold War “behind
the fence” era of the old offensive biological weapons program. The folksy
security guards who watched over our staff late into the night were replaced
by a cadre of police armed with pistols, sniper rifles, and 24/7 video
monitors. New regulations for enhanced safety and security and nonstop
inspections by external agencies bumped science down a notch in priority. In
our finest hour, while supporting the nation after the anthrax attacks, our
colleagues were targeted as criminal suspects, and one scientist tragically
took his own life. Some scientists, frustrated by the constant scrutiny and
changing regulations, voted with their feet and left the institute, thus extending
USAMRIID ’s legacy to other burgeoning containment laboratories across the
country.
During the period I describe in this book, I moved from the lecture hall to
the role of department chief, to the battlefield, to inside the Biosafety Level 4
maximum-containment lab, and finally to the front office. Along the way I
played multiple roles as I gained military rank and position: from containing
the pathogens and the illnesses they cause, to containing the daily crises, to
containing the media explosion and other fallout from crises.
Having read enough narratives by others about what we do, I thought it
was time for someone who has walked the halls to tell USAMRIID ’s side of
how certain newsworthy events unfolded. The stories are real, but they could
easily serve as plotlines in popular fiction or Hollywood thrillers. Many
crises challenged and frightened us, as we didn’t know what would come
next or how each would end, but we faced each one and made the best
decisions we could with the little information available at the time.
Developing countermeasures against deadly pathogens doesn’t happen in a
weekend, a year, or sometimes not even in a lifetime. It requires years of
dedication by determined scientists. I hope the stories I share convey
USAMRIID ’s unique role as a nexus for national response to infectious disease
crises and the vital work of my colleagues who toil away daily in the
nation’s defense, largely unrecognized, and sometimes at their own peril.
They are the unsung heroes, and USAMRIID remains critical for the national
defense against germ weapons because of them.
Unfortunately, for the sake of crafting a story, I can’t include everyone
involved or every challenge. The events I describe are seen through the lens
of many elapsed years, but I have done my best to fact check them with notes,
emails, media reports, and interviews with colleagues. Any mistakes of
recollection are mine.
So here I present an insider’s perspective depicting the dangers, the
drama, the fear, the frustrations, the irony, and the uncertainty encountered as
a physician in the role of “Biodefender” in an unusual and occasionally
threatening environment.
Join me now as I walk through the “Alamo” security kiosk, past the black
fence, up the sidewalk to a two-story tan brick building into a different world
—my world—inside the “Hot Zone.”
Prologue
Exposure

February 11, 2004

Around five o’clock on a cool, cloudy evening, a petite, strawberry-blond
woman in her late twenties went to work at a research institute on Fort
Detrick, Maryland, an army base thirty minutes north of the nation’s capital.
She told colleague Dianne Negley in the hallway that she was heading into
the lab for a short time. In a locker room for a Biosafety Level 4 (BSL-4)
laboratory, the highest level of lab containment, she performed the usual entry
ritual. She changed out of her street clothes, removed her watch and wedding
ring, and donned scrubs and socks. She passed from the “cold” side locker
room that was free of any infectious pathogens into a “warm” side staging
area where she taped on gloves, inserted ear plugs, and stepped into an
encapsulating, blue, airtight “space” suit with an attached second set of
gloves. After pulling the thick sealing zipper from her shoulder down across
her front and snapping an air hose into a suit valve, she felt a cool hiss of air
spray on her face and neck. As air filled the suit, she puffed up like the
Michelin Man; then she walked through a series of airtight doors and entered
the “hot” side of a government lab containing the deadliest infectious disease
agents on the planet.
Kelly Warfield held a PhD in molecular virology, was an experienced
scientist, an army wife, and the mother of a three-year-old boy. Someone who
saw her at the grocery store and didn’t know what she did for a living might
mistake her for a schoolteacher. She worked as a postdoctoral researcher at
the United States Army Medical Research Institute for Infectious Diseases
(USAMRIID ) testing experimental treatments for Ebola virus infection. Known
to those in the field as “YOU -SAM -RID ,” or simply “rid,” it is, more or less,
the Pentagon of biodefense—the nation’s premier research institute
developing medical countermeasures against germ-warfare pathogens. Set
behind a tall, reinforced black fence, with tan exterior walls and narrow
windows, it looks more like a prison than a research center. Numerous
laboratory airflow intake and exhaust pipes that penetrate the flat roof
provide a clue to the trained observer of the specialized laboratory
capabilities and scientific activities occurring inside.
Kelly entered BSL-4 lab suite AA -5 to check on ten mice she had infected
with Ebola virus two days earlier in her search for a cure. One of the most
feared infectious pathogens, Ebola kills up to 90 percent of its victims. After
ensuring she had adequate air filling the space suit, she unhooked herself
from the air hose and waddled down the central white cinder-block corridor
dotted with laboratory equipment, video monitors, and multiple coiled
yellow air hoses hanging like giant Slinkys from the ceiling.
At the end of the corridor, Kelly pushed open a door to enter the animal
room, and she pulled a container of mice off a metal rack. She placed the
mice in a beaker inside the laboratory biosafety cabinet (a “hood”), where
she could work with them safely. As she studied the animals, none of the
mice showed any signs of illness yet. It was still too early. Even so, the virus
was already multiplying rapidly inside their bodies.
Kelly sat in front of the bench-level hood, protected by a glass shield
while her hands worked inside. One by one, Kelly picked up the mice,
flipped them belly-up in her left hand, and injected an immune globulin
preparation using a syringe with a thin, twenty-five-gauge needle. It was
routine work, something she had done thousands of times before, always with
slow and careful hands. As she prepared to inject the fifth mouse, it twitched
in her hand, kicking the needle a few millimeters off its precise trajectory. In
the flash of a millisecond, she had no time to adjust to avoid disaster. The
needle arced downward to the left, pierced through two layers of gloves, and
grazed the fleshy heel of her left thumb, just below the joint.
She felt no pain. For a moment she wondered whether the needle had even
broken the skin. But when she squeezed her thumb, a tiny dot of blood welled
up through the layers of gloves. Just a tiny scratch, but it was as lethal as a
hand grenade. That syringe had contained some nonspecific control antibody,
not the disease agent. Nevertheless, the needle had been inside four Ebola-
infected mice. Her gut plunged like a free-falling elevator, and she shouted,
“FUCK! FUCK! FUCK!”
But with the hiss of the air flowing into her suit, alone in the silence of the
airtight lab, no one could hear her scream.
Did the needle carry enough virus particles to infect her? It only takes a
few to start the cascade that could kill. Kelly knew about the deadly horror
that might be coming. She also knew there was no effective treatment. During
the first week after infection, the virus launches a clandestine attack on your
lymph nodes, bone marrow, spleen, and liver. Around the eighth day, the
infection emerges, plummeting your energy and skyrocketing your
temperature. Everything aches—your head, your muscles, your joints.
Bloodshot lines snake across your eyes, and a spotty red rash grows on your
skin like poppies in a field. Your appetite plunges. Over the next several
days, your stomach and bowels open above and below, expelling liters and
liters of fluid. Blood trickles from your nose and mouth like drips from leaky
faucets and oozes from wherever needles penetrate your skin. You are in the
thick of Ebola virus disease or hemorrhagic fever. Delirium comes calling as
a blessing in disguise to veil your mind from the inevitable end. As your
blood pressure bottoms out, your kidneys shut down, and you enter a death
spiral.
The shock of the event may have briefly disconnected Kelly’s perception
of reality. Despite the impact a momentary delay in decontaminating the
wound might have on her possible survival, she went into autopilot, tidying
things up, meticulously putting all the needles away in a Ziploc bag. Next,
she got up and put the mouse cage back in place, not realizing in her daze that
she had left some mice in the beaker in the biosafety cabinet.
From there Kelly moved quickly to the decontamination shower, where
warm water and a chemical mist sprayed on her suit from nozzles above and
all around her. She doused her suit repeatedly with water and chemicals and
then aborted the shower’s usual seven-minute cycle early. Leaving a trail of
water dripping off the suit and puddling on the floor, she unzipped and
dropped the suit to the floor and tore off her gloves. Then she called Dianne,
whom she had seen earlier in the hallway, but she got an answering machine.
Her second call reached Lisa Hensley, another experienced BSL-4
researcher. “Lisa, this is Kelly. I’ve had a needle-stick accident. I need you
to come down.” Kelly then grabbed the emergency bite kit next to the shower
door and scrubbed her wound raw with antiseptic.
When Lisa received the distress call, she rushed down to the lab and in her
haste was still pulling on her scrubs when she entered the lab’s “warm” side.
The faces of two other colleagues appeared at the window of the airlock
door to assist. Lisa and Kelly left together and flew through the personal
shower into the locker room, but a glitch in the electronic sensor failed to
trigger the locker-room exit door to open. So they pushed the emergency exit
button and broke out of the lab, setting off the institute alarm.
As they hurried through the darkened hallways en route to the clinic past
flashing lights with alarm bells ringing, word of the accident spread quickly.
Colleagues emerged from offices and labs to follow them, like the Pied
Piper, across the institute to the clinic, where my path would intersect with
Kelly’s for the first time.

That same day in 2004, I was finishing up work in the clinical wing of
USAMRIID . It had been a quiet Wednesday, filled with the usual administrative
tasks of running the Division of Medicine: chairing lengthy meetings,
preparing briefings, reviewing research studies, and dealing with tons of
email. I looked forward to going home early—a welcome change from the
usual late nights in the office. That would not happen.
Now into my third year as the medicine chief, I oversaw the institute’s
program to protect and vaccinate lab workers, basically to keep them from
being infected by the pathogens they studied. Our scientists conducted
research on anthrax, plague, tularemia, Ebola, and many other biological
weapon threats, developing and testing vaccines and treatments against them
in animals like mice, rabbits, guinea pigs, and monkeys. Anyone stepping
foot inside the labs came through us for a rigorous initial evaluation, after
which they received recommended vaccines and annual physical
examinations.
I had a nice corner office at the end of a long, white-tiled corridor,
complete with its own bathroom, narrow window, large mahogany desk, and
a beat-up white love seat turned gray with use. I left my office for a meeting
and headed toward the nurse’s station at the opposite end of the hall, walking
past brown corduroy-covered walls interspersed between the offices. As I
approached the front of the clinic, a young virologist rushed around the
corner, breathless. The words she blurted out made me freeze: “We have an
Ebola exposure in the lab!”
I felt like someone had kicked me in the stomach. As the physician in
charge, my mind immediately raced through the enormous implications. A
member of the lethal filovirus family, Ebola is a Risk Group 4 pathogen, a