CDC Mistakenly Sent Dangerous Pathogens in Five Different Incidents
CDC laboratories in Atlanta accidentally sent potentially deadly pathogens to outside facilities in five different instances throughout the past decade, according to a CDC report released Friday, the Washington Post reports (Sun/Dennis, Washington Post, 7/11).
The report is the result of an internal investigation that CDC conducted following an incident in which live anthrax strains were sent to an outside lab last month.
CDC last month confirmed that as many as 75 scientists who work in the agency's laboratories might have been exposed to live anthrax bacteria earlier this month after a batch of the pathogen was transferred from one lab to another without the necessary safety precautions.
According to the report, the anthrax incident occurred because of CDC employees' "failure to follow an approved, written study plan that met all laboratory safety requirements."
The report also revealed that earlier this year, CDC laboratory employees accidentally mixed a benign avian flu virus with a highly lethal strain, called H5N1, and shipped the mixture to a U.S. Department of Agriculture laboratory. While no human exposures have been reported, CDC has closed its influenza lab "until adequate procedures are put in place" to ensure similar instances do not occur (Gever, MedPage Today, 7/11). The mix-up resulted in the rapid deaths of the test chickens used for research, according to the New York Times. According to experts, if the strain would have gotten out of the facilities, human deaths could have occurred and the virus could have devastated the country's poultry industry.
Meanwhile, CDC Director Thomas Frieden, who only found out about the influenza incident last week, lambasted the agency for not reporting it to senior CDC officials earlier. He said, "I was, just frankly stunned and appalled" by the incident and how it was handled (Fausset/McNeil, New York Times, 7/13).
In addition, the report detailed three similar incidents that occurred over the last decade, including:
- A 2006 incident in which a CDC bioterror research lab sent vials of anthrax DNA that CDC workers "believed [were] inactivated," but were found to be viable to two outside facilities;
- Another 2006 incident in which a different CDC lab shipped live botulism bacteria to an outside facility; and
- A discovery in 2009 that a CDC lab had shipped a live strain of Brucella, a toxic bacteria, to outside facilities as early as 2001 because researchers inaccurately thought it was a vaccine.
Comments, Next Steps
During a conference call with reporters on Friday, Frieden said, "These events should never have happened," adding that U.S. residents "may be wondering whether [CDC is] doing what we need to do to keep them safe and to keep our workers safe." However, he noted that no one has been infected because of the incidents.
Frieden said he has developed a high-level working group -- for which he appointed a top official to be the single point of accountability -- to review the agency's safety on a lab-by-lab basis (Washington Post, 7/11).
In addition, CDC said it would:
- Establish two separate internal working groups that will review the agency's procedures for handling infectious materials and make recommendations for improvements;
- Form an external advisory group on lab safety;
- Work to determine the "root causes" of the influenza incident; and
- Take unspecified "personnel actions" related to the anthrax and flu incidents (MedPage Today, 7/11).
Further, Frieden halted all shipments from CDC's highest-security facilities while the safety protocols are reviewed.
Meanwhile, experts have suggested that CDC should no longer police itself. Rutgers University chemistry and chemical biology professor Richard Ebright wrote Saturday in an email, "It is clear that the CDC cannot be relied upon to police its own select-agent labs" since its employees failed "to meet its own standards" of working "with human pathogens."
Frieden said that the idea of using an independent investigative agency was "certainly worth exploring."
In addition, the CDC report suggested that fewer laboratories be permitted to work with dangerous microbes (New York Times, 7/13).
House Subcommittee Announces Hearing on Incidents
According to the announcement, the committee will hear testimony from:
- CDC Office of Security and Emergency Preparedness Deputy Director Joseph Henderson;
- USDA Animal and Plant Health Inspection Services Associate Deputy Administrator Jere Dick;
- U.S. Government Accountability Office Managing Director Nancy Kingsbury; and
- Behavioral-based Improvement Solutions President Sean Kaufman.
The subcommittee aims to discover what led to the lapses, according to Reuters (Morgan, Reuters, 7/13).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.