Ebola
virus sent out of high-security lab was likely dead: CDC
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[February 05, 2015]
By Julie Steenhuysen
CHICAGO (Reuters) - An internal
investigation of an Ebola incident at a U.S. Centers for Disease Control
and Prevention laboratory in December found that samples sent to a
lower-security lab were "unlikely" to have contained live virus and
posed no threat to staff, the CDC said on Wednesday.
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The close call followed mishaps involving anthrax and a deadly
strain of bird flu, raising questions about how the agency handles
the world's deadliest pathogens.
CDC Director Dr. Tom Frieden said the agency had made "real
progress" to improve safety, "but we have more to do."
The report found that on Dec. 22, a scientist working with Ebola,
which in 2014 caused the worst recorded outbreak in West Africa,
inadvertently transferred a small amount of virus from a high-biosecurity
lab to a lower-biosecurity one not authorized to handle live Ebola.
A chief cause of the breach, the investigation concluded, was the
"lack of a written study plan," a document that outlines specific
steps to be followed in an experiment. The report also noted a
failure to design the study to minimize the possibility of human
error.
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"That concerned me," said Scott Becker of the Association of Public
Health Laboratories. "I thought that was one of the issues they
uncovered after the first lab incident."
According to the report, the scientist placed Ebola into two sets of
tubes, one to inactivate it and another to merely isolate it. The
tubes were identical except for a blue cap and label on one. But the
caps had been removed, leaving no visual cue as to which was which,
and the wrong tubes were sent to the lower-biosecurity lab down the
hall.
CDC scientist Michael Shaw said most labs have adopted a material
transfer certification, in which two scientists have to certify that
pathogens were inactivated before they leave the lab. But the Ebola
lab, which has been swamped by the West African outbreak, had not
adopted it for internal transfers.
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"It was a mistake. They were mortified when they discovered it had
happened," Shaw said.
The report also took CDC to task for "lack of project oversight,"
noting the deadly-pathogens lab lacks a full-time manager.
The CDC said it is looking into changes to prevent further
incidents, such as using colored liquids and different-sized
containers to differentiate live from killed pathogens.
CDC last month said it installed surveillance cameras to ensure
procedures are performed correctly.
(Reporting by Julie Steenhuysen; Additional reporting by Sharon
Begley; Editing by Steve Orlofsky)
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