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Ebola Exposure Mishap the Latest in Chain of CDC Laboratory Safety Lapses

The ability of the Centers for Disease Control and Prevention (CDC) to safely handle the world’s deadliest pathogens was recently called into question after a biosafety accident that could have resulted in a CDC laboratory worker’s exposure to the Ebola virus. But CDC says it’s made significant process in addressing the problems that could have exposed workers.

"CDC has made real progress over the past year to improve laboratory safety, but we have more to do," CDC Director Tom Frieden said in a statement. "Our scientists will continue to work to make the agency a model not only of laboratory excellence but also of laboratory safety."

On December 22, 2014, staff from CDC’s Viral Special Pathogens Branch were conducting an animal-model study of the Ebola virus in a biosafety level 4 lab in Atlanta. The study involved taking two oral swabs daily from each of the study animals and then placing the swabs in two sets of tubes—one for live-virus studies and one for inactivated samples.

The tube for the live-virus studies was inadvertently sent to a lower level lab instead of the tube with the inactivated samples. The following day CDC scientists discovered the mishap and reported the incident to leadership.

A team of CDC laboratory scientists conducted an internal investigation of the incident. Although no illness resulted from accident, the report indicated the incident “highlights the need for continued improvements in laboratory safety practices across the agency.”

CDC pointed to a number of underlying causes behind the incident including lack of a centralized point of contact for laboratory safety, lack of project oversight and day-to-day leadership continuity and failure to implement recent laboratory safety enhancement requirements, such as filling out a Material Transfer Certificate prior to transferring any material from high containment laboratories to lower biosafety level laboratories.

However, the overriding cause behind the incident was lack of a written study plan that had been approved by a supervisor—a problem that has been behind other dangerous CDC safety mishaps in the past.

To improve lab safety practices, CDC said it’s crucial that appropriate lab safety procedures are followed and that laboratory safety practices are continually improved.

CDC also plans to establish a new office of the Associate Director for Laboratory Science and Safety. The new position will report to the CDC director and haveresponsibility to provide agency-wide leadership and accountability for laboratory science, safety and quality.

CDC indicates that, “Moving forward, this individual will engage leadership from high containment laboratories both within and outside of CDC to gather lessons learned and establish practices and standardization across CDC that can directly and effectively enhance laboratory safety.”

Not the first time: CDC’s pattern of high-profile laboratory safety mishaps

This is not the first time the CDC’s laboratory safety practices have been called into question. USA Today reported last year government reports uncovered more than 1,100 laboratory incidents involving bacteria, viruses and toxins that pose significant or bioterror risks to people and agriculture were reported to federal regulators during 2008 through 2012.

Moreover, in early 2014, CDC cross-contaminated a benign strain of bird flu, H9N2, with a deadly one, H5N1. The contaminated specimens were sent to a US Department of Agriculture lab, which discovered the contamination issue after chickens in their research became seriously ill and died.

Similarly, in June, Homeland Security Today reported that approximately 75 Atlanta-based CDC staff were unintentionally exposed to live Bacillus anthracis—a bacteria that can cause severe infectious disease— “after established safety practices were not followed.”

The incident occurred in a biosafety level 3 laboratory at CDC where the laboratory used a procedure that may not have adequately inactivated the B. anthracis samples. The samples were sent to lower biosafety level laboratories for experimentation where the proper protective equipment for handling infectious samples was not used, since the researchers were unaware that the samples may not have been inactivated.

Like in the Ebola exposure lab mishap, CDC determined the scientists’ failure to follow an approved, written study plan that met all laboratory safety requirements led to dozens of employees being potentially exposed to anthrax.

In addition, the report also found that there was a lack of standard operating procedures to document when biological agents are properly inactivated in laboratories.

In the after-action review, CDC commented that “This is not the first time an event of this nature has occurred at CDC … At the time of this writing, CDC is aware of four other such incidents in the past decade.”

Although the review of the incident determined it was unlikely any workers were exposed to B. anthracis, CDC concluded that, “response to the incident should have been better organized from the outset” and “this was a serious and unacceptable incident which should never have happened.”

During a congressional hearing last year, Frieden said, “With the recent incidents, we recognize a pattern at CDC where we need to greatly improve the culture of safety. What we’re seeing is a pattern that we missed, and the pattern is an insufficient culture of safety."

But with the recent Ebola exposure incident, CDC’s pattern of laboratory safety mishaps continues.

Homeland Security Todayhttp://www.hstoday.us
The Government Technology & Services Coalition's Homeland Security Today (HSToday) is the premier news and information resource for the homeland security community, dedicated to elevating the discussions and insights that can support a safe and secure nation. A non-profit magazine and media platform, HSToday provides readers with the whole story, placing facts and comments in context to inform debate and drive realistic solutions to some of the nation’s most vexing security challenges.

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