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 The U.S. Centers for Disease Control and Prevention said an
internal probe found multiple failures by individual scientists and
a lack of agency-wide safety policies led to the potential exposure
of more than 80 lab workers to live anthrax at its Atlanta campus
last month. Researchers in a high-security bioterror lab sent
samples of what they thought were inactivated bacteria to colleagues
in a lower-security lab, with fewer protections.
Investigators also discovered a previously unreported incident:
Workers at a separate high-security CDC influenza lab sent samples
containing a dangerous strain of bird flu to counterparts at the
U.S. Department of Agriculture in March. Mishandling avian flu could
have far graver consequences than anthrax does, though no one has
been found to have been infected in either case.
The two incidents represent the latest in a series of breaches at
the CDC in the last decade that are drawing fresh scrutiny from
Congress, including questions about the agency's ability to oversee
potentially dangerous research. The CDC said its findings provide a
"wake-up call" to overhaul the standards governing experiments with
deadly pathogens nationwide.
Biosecurity has focused on "how to keep bad guys out of the lab,"
Michael Osterholm of the University of Minnesota and a member of the
National Science Advisory Board for Biosecurity, which advises the
federal government, said in a telephone interview. "One of the
critical issues we need to focus on is the good guys who just forget
to do it safely."
The CDC's director, Dr. Thomas Frieden, called the bird flu incident
“the most distressing,” in part because it occurred six weeks ago
but was not reported to senior agency leadership.
"I learned about it less than 48 hours ago," he told reporters in a
teleconference, adding that the events likely "have people
questioning government."
"We need to look at our culture of safety throughout all of our
laboratories," Frieden said. "I’m upset, I'm angry. I've lost sleep
over it and I'm doing everything I can to make sure it doesn't
happen again."
Frieden also pointed to the discovery this month of six vials of
smallpox in an unused room at the National Institutes of Health
campus in Bethesda, Maryland, near Washington. Frieden disclosed on
Friday that two of the vials dated from 1954 contained live smallpox
virus, a global scourge for centuries.
The CDC's anthrax report does not name any of the responsible
individuals. Frieden said the CDC would discipline any staff who
knowingly violated research procedures or failed to report a lab
breach.
"These repeated safety failures raise grave concerns about the CDC’s
ability to ensure strict procedures, protocols and training are
followed," said Representative Tim Murphy, chairman of a House
Energy and Commerce subcommittee that has called Frieden to testify
on Wednesday.
The Senate Health, Education, Labor and Pensions Committee is also
pressing U.S. Department of Health and Human Services, which
oversees the CDC, for answers, according to a letter to HHS
Secretary Sylvia Burwell.
An HHS spokesman said the CDC has outlined "corrective actions" to
prevent future mishaps at its laboratories.
"Dr. Frieden is leading those efforts," the spokesman said.
The CDC is suspending any transfers inside or outside the agency of
biological materials, including infectious agents and even
inactivated specimens, from high-biosecurity labs. Both the CDC
bioterror lab that handled the anthrax bacteria and the agency's
influenza lab are closed pending further study of what happened.
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BIRD FLU CONCERNS
Outside experts agreed that shipping what CDC scientists believed
were samples of a fairly benign form of influenza but which were
mixed with the highly pathogenic H5N1 bird flu was even more
alarming than the anthrax incident. "The last place you want to be
mixing up samples is in influenza," said Osterholm. "The ability for
that to jump from the lab bench to the community is substantially
greater."
H5N1, although highly lethal, is not easily transmitted from one
infected person to another, which would limit its spread in case of
a lab-acquired infection or an escape from a lab.
Other scientists raised alarm over the CDC disclosure that the same
lab responsible for the anthrax incident had a similar lapse in
2006, when researchers transferred what they thought was inactivated
bacteria to another facility.
"That the same kind of incident can recur shows that the CDC does
not learn from its own mistakes," molecular biologist Richard
Ebright of Rutgers University and an expert on biosafety said in a
telephone interview.
Just a year earlier, the CDC published recommendations on how to
prevent shipments of what scientists believe to be inactivated
anthrax but which are in fact viable.
THE ANTHRAX PROBE
In the anthrax case, investigators found that the scientists failed
to follow an approved study plan that met safety requirements and
lacked standard procedures to document when microbes are properly
inactivated. The researchers were not aware of the most recent
scientific literature on how best to inactivate the bacteria.
Once CDC officials were alerted to the breach, their response also
fell short. For instance, CDC scientists in other labs first learned
of the event not through official communication but "by witnessing
CDC closing and/or decontaminating laboratories," the report said.
Other deficiencies noted in the report included inconsistent
decontamination procedures in the affected labs and a lack of clear
command for handling the incident in the first week after it
occurred.
To prevent future mishaps, CDC is creating a "lead laboratory
science" position to be accountable for safety and setting up an
external advisory committee on biosafety.
Rutgers' Ebright suggested that an outside agency should oversee
CDC's work with dangerous pathogens.
"Without removing the responsibility for oversight from the very
organization that carries out the work, it's hard to think that the
recommendations will really be implemented," he said.
(Reporting by Sharon Begley in New York and Julie Steenhuysen in
Chicago; Additional reporting by David Morgan in Washington; Editing
by Michele Gershberg, Jonathan Oatis and Dan Grebler)
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