An investigation into the mistaken shipment of deadly bird-flu virus from a government laboratory earlier this year found that a scientist took shortcuts to speed up the work and accidentally contaminated the samples, the Centers for Disease Control and Prevention in Atlanta reported Friday.
As a result, the CDC shipped a virulent avian flu virus rather than a relatively benign animal strain to a poultry research laboratory of the U.S. Department of Agriculture.
No one became infected or fell ill, and the pathogen was destroyed. But after CDC lab members learned of the safety lapse, they didn’t notify supervisors up the chain of command until more than six weeks later.
CDC Director Tom Frieden has called that reporting delay the “most distressing” aspect of several recent incidents involving the mishandling of dangerous pathogens at the nation’s labs, including potentially exposing dozens of employees to live anthrax. Last month, several vials of long-forgotten smallpox virus were discovered in a building on the Bethesda, Md., campus of the National Institutes of Health.
The internal CDC investigation into the flu lab case found that the scientist failed to follow “best practices” in the Jan. 17 episode, and no approved laboratory-specific operating procedures existed for the work being done, the report said.
The errors most likely happened because the scientist was growing cell cultures from both virus strains at the same time at the same work station, the report found. There were no written records to document the procedures performed.
“We’re pretty sure the person took shortcuts, ” said Anne Schuchat, director of CDC’s National Center for Immunization and Respiratory Diseases. “In laboratory work, it’s so important to follow every step, and when you’re working with unusual pathogens, it’s even more important that every single step is followed.”
She added: “This wasn’t a question of someone who was poorly trained. There was substantial experience and knowledge.”
It should have taken the scientist a minimum of 90 minutes to process the specimens, including 30 minutes for decontamination. But the scientist spent only 51 minutes in the lab — based on card key readers showing lab entry and exit times — including time spent to shower and change into street clothes, the report said.
The scientist “acknowledged being rushed to attend a laboratory meeting” due to begin 15 minutes after leaving the lab, the report said. At the time, the influenza division had a heavy work load preparing for a coming vaccine meeting of the World Health Organization.
The scientist and the team leader are experienced researchers in the CDC’s influenza division, said the report, which did not identify any individuals by name.
Frieden said it’s possible that when working with deadly organisms “day in and day out for weeks, months and years, you can get a little careless. And that’s something that may have happened.”
Schuchat and other top CDC officials have called the lapses unacceptable. The flu incident involves a lab that works with exotic flu viruses. It has been closed since July 9, when senior CDC leaders were told about the contamination. The CDC’s work on seasonal flu surveillance and vaccines has not been affected and is ongoing, officials said.
The deficiencies described in the report come at a time when the CDC is in the spotlight for its role battling the worsening Ebola outbreak in West Africa. The agency has about 30 specialists in the countries hardest hit — Sierra Leone, Liberia, Guinea and Nigeria. Another 50 specialists are expected to arrive by the end of August. In the United States, the CDC has the only lab capable of performing diagnostic tests for suspected cases of Ebola.
“We understand how high the stakes are,” Schuchat said.
Agency officials have put in place a series of measures in response to the safety lapses, including a moratorium on any biological material leaving CDC’s numerous labs. The moratorium will be lifted after procedures meet new safety protocols, officials said.
The agency is testing all preparations done by the flu lab scientist dating from a year ago; it is also testing preparations sent by the influenza division to other labs over the past year. All influenza labs must now have daily record-keeping.
Staff members also must undergo training to understand when events must be reported. Researchers did not report the bird-flu contamination initially because they didn’t think the incident qualified as a release of a “select agent,” a designation reserved for the most dangerous pathogens.
Paul Keim, a well-known pathogen expert at Northern Arizona University, said the CDC’s findings suggest that either the lab workers tried covering up the original mistake by not reporting it sooner or that they simply lacked proper training to realize that the incident required immediate reporting.
“Neither of these two things is good,” he said.