After Lapses, U.S. Disease Control Agency Admits to Lax Culture of Safety

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International New York Times

July 15, 2014

Dr. Thomas R. Frieden, the head of the Centers for Disease Control and Prevention (CDC), spent much of last Wednesday completing a report that would let the public see, in embarrassing detail, how the sloppy handling of anthrax by scientists at its headquarters here had potentially exposed dozens of employees to the deadly bacteria.

But just as he was sitting down for a late-afternoon lunch at his Washington office, an urgent call came in. There had been another accident, this one just as disturbing, if not more so—and no one in the agency's top leadership had been informed about it until that Monday, though the CDC's lab had been told about it more than a month earlier.

CDC workers had somehow shipped a dangerous strain of avian influenza to a poultry research lab run by the Department of Agriculture. Known as H5N1, the virus had killed more than half of the 650 people who had been infected with it since 2003.

''I was, just frankly, stunned and appalled,'' Dr. Frieden said in an interview Saturday.

The recent revelations have created a crisis of faith in the federal agency, prompting calls for an independent body to investigate such episodes in the future, as well as for sweeping changes at the agency and to a sprawling web of research labs that has grown after the 2001 terrorist attacks led to an intensified focus on microbes that could be used as biological weapons.

Dr. Michael Bell, a 19-year CDC veteran who has been appointed by Dr. Frieden to a new position overseeing lab safety, said in an interview Saturday that he was most concerned about the ''potential for hubris'' among researchers who grow so inured to the daily grind of working with deadly microbes that they cease to follow safety protocols. The agency both conducts that research and is charged with ensuring that other labs adhere to federal safety standards.

The agency's internal investigation of the troubling events, made public Friday, found that senior staff members had failed to write up a plan for researchers to follow in the anthrax study. It also faulted scientists who neglected to review the existing literature before working with the deadly pathogen and found that the agency was ill-prepared to respond to a potential exposure episode.

''It is ironic that the institution that sets U.S. standards for safety and security of work with human pathogens fails to meet its own standards,'' Richard H. Ebright, a professor of chemistry and chemical biology at Rutgers University, wrote in an email Saturday. ''It is clear that the CDC cannot be relied upon to police its own select-agent labs.''

Dr. Frieden has closed the agency's flu and bioterror laboratories and has banned all shipments from the agency's highest-security labs while safety protocols are reviewed—a move that could freeze work at many public-health labs that rely on such shipments.

Later this month, the CDC will invite outside experts to form an advisory group on lab safety. But some experts say that the agency should not police itself.

Najmedin Meshkati, an engineering professor at the University of Southern California who teaches a course in investigating accidents, commended Dr. Frieden for his candor. But he said that the CDC should turn to an independent institution like the United States National Academies, which includes the National Academy of Sciences, to address safety problems. Others suggested an agency with subpoena powers comparable to the National Transportation Safety Board, which investigates airline crashes and can ground whole fleets it deems unsafe.

Dr. Frieden said the idea of an independent investigative agency was ''certainly worth exploring.''

The anthrax accident occurred on June 5 in the agency's bioterrorism rapid response lab. CDC researchers in Atlanta had been preparing to test a faster way to identify dangerous substances. The lab used a virulent anthrax strain in the test when a weaker one would have worked.

The work was conducted in an area classified as a three on the biosafety scale, with four being the highest security level. Such labs work with microorganisms that may lead to serious illness or death if inhaled, and they follow strict safety rules: Workers wear safety hoods that filter air and typically work with infectious materials in special ventilated boxes called biosafety cabinets.

On June 2, according to the report, a lab supervisor called a scientist at another lab who had done similar work on a different bacterium, brucella, which can cause fevers and swelling in humans.

The written protocol for preparing brucella for the test was sent to the bioterrorism lab, and the supervisor told a scientist to follow it while preparing eight dangerous pathogens, including anthrax. But anthrax forms hardy spores, while brucella does not.

In addition, the brucella protocol required that bacteria be killed in a bath of formic acid for 10 minutes and that small samples of it be incubated for 48 hours to be sure it was dead.

But a mix-up occurred when the instructions were conveyed over the phone. The scientist incubated the test samples for only 24 hours before sending the bulk of the bacteria to less-secure labs. Some of the bacteria were not filtered to remove spores.

After 24 hours, one scientist tried to sterilize the test plates in a high-power steam autoclave. But its door was stuck, so the plates were returned to the incubator. It was an inconvenience that would prove extremely lucky.

Over the next few days, scientists in two other labs where breathing equipment was not used agitated the bacteria and sprayed them with compressed gas, which could have sent spores into the air.

On June 13, one scientist checked the incubated plates and saw that anthrax was growing. If the door to the autoclave had opened properly and, as the report noted, the plates had been sterilized, ''the event would not have been discovered.''

CDC officials learned of the avian flu blunder from the Agriculture Department's poultry lab in Athens, GA. It had received a CDC shipment of what was supposed to be a relatively benign H9N2 bird flu virus. But it was contaminated with H5N1 bird flu and rapidly killed test chickens. H5N1 is deadly to humans but not easily transmitted between them. In birds, it can wipe out flocks overnight.

Fortunately, both labs had used high-security precautions. Had it slipped out of either laboratory, it might have killed some people and would possibly have devastated the American poultry industry, several experts said.

The close call should have been reported immediately to top leadership, but it was not. The flu lab heard from the Agriculture Department on May 23, but it was not reported to senior CDC leadership until July 7.

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