Error at CDC puts lab tech at risk for Ebola – The Seattle Times

Posted: Thursday, December 25, 2014

A laboratory mistake at the Centers for Disease Control and Prevention (CDC) in Atlanta may have exposed a technician to the deadly Ebola virus, federal officials said Wednesday. The technician will be monitored for signs of infection for 21 days, the incubation period of the disease.

Other employees who entered the lab — fewer than a dozen — where the mistake occurred are being examined for possible exposure. It appears that none of them was exposed, said Thomas Skinner, a CDC spokesman.

The samples were properly contained and never left the disease centers, so there is no risk to the public, officials said.

The error occurred Monday, when a high-security lab at the CDC, working with Ebola virus from the epidemic in West Africa, sent samples that should have been killed to another CDC laboratory, down the hall.

But the first lab sent the wrong samples, ones that may have contained the live virus. The second lab was not equipped to handle live Ebola. The technician who worked with the samples wore gloves and a gown, but no face shield, and may have been exposed. The worker was not identified.

While the Ebola virus is generally not transmitted via the air, as are flu viruses, it is highly virulent through exchanges of body fluids. It wasn’t immediately made clear how the lab technician might be at risk.

The mix-up of the samples was discovered Tuesday, Dr. Stuart Nichol, chief of the CDC’s Viral Special Pathogens Branch, said in an interview. He ascribed it to human error.

CDC spokeswoman Barbara Reynolds said the lab has been decontaminated twice.

The possible exposure is under internal investigation and was reported to Secretary of Health and Human Services Sylvia Burwell, Reynolds said.

The accident is especially troubling because dangerous samples of anthrax and flu were similarly mishandled at the CDC just months ago, eroding confidence in an agency that has long been one of the most respected scientific-research centers in the world.

The CDC promised last summer to improve safety procedures and chose a panel of outside experts to advise how to do so.

“I’m working on it until the issue is resolved,” the agency’s director, Dr. Thomas Frieden, said in an interview in July.

Under harsh questioning from members of Congress that month, Frieden acknowledged the errors at CDC labs were not isolated mishaps but part of a broad pattern of unsafe practices. He called one of the episodes a “tipping point” that had forced agency officials to realize they needed to act.

Reacting to the latest accident, safety experts expressed outrage. Richard Ebright, a molecular biologist at Rutgers University and an expert on biological weapons, said: “They did not learn. They do not learn. They seem incapable of learning.”

He said the errors were inexcusable. Labs that produce samples of killed virus should test to make sure they are dead, he said, and labs receiving those samples should test them before working with them. “CDC labs that receive putatively inactivated samples still are working with them with no safety and security precautions beyond those at a dentist’s office,” Ebright said.

Najmedin Meshkati, a professor of industrial and systems engineering at the University of Southern California and an expert on human error, said: “I am speechless. This is yet another indication that this organization needs to do a serious soul searching to improve its safety culture.”

In June, CDC scientists sent anthrax samples, supposedly killed, to laboratories that were not equipped to handle dangerous pathogens. But the bacteria turned out to be live because a deactivating technique too weak to wipe out anthrax spores had been used. Dozens of employees were offered antibiotics and anthrax vaccine; none became infected.

The head of the laboratory that shipped the bacteria resigned a few weeks after the mistakes came to light.

In another blunder, a CDC lab accidentally contaminated a relatively benign flu sample with a dangerous H5N1 bird-flu strain that can be fatal in humans and then shipped it to a laboratory at the Department of Agriculture. Scientists at the receiving lab detected the error, and no one was harmed.

Although that occurred in May, senior CDC officials were not told until July 7, and Frieden did not hear about it until two days after that. He said in an interview in July that he was “stunned and appalled” by the incident.

The mistakes led the CDC to appoint a panel of outside safety experts in July to advise Frieden on how to correct sloppy procedures at government laboratories. The CDC temporarily closed its flu and bioterrorism laboratories and halted shipments of all infectious agents from its high-security labs until those labs could pass muster with a newly formed safety panel within the agency.

In August, the special pathogens branch — where the Ebola accident occurred Monday — received permission to start sending out infectious agents again.

Material from The Associated Press and McClatchy Washington Bureau is included in this report.

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