The US Centres for Disease Control and Prevention said yesterday it had uncovered a new safety breach at its bioterror research laboratories involving dangerous bird flu, just as it was investigating the failures behind the potential exposure of researchers to live anthrax bacteria.
In its first findings from an internal probe into the anthrax incident last month, the CDC said multiple failures by individual scientists and a lack of agency-wide safety policies had led to the potential exposure of more than 80 lab workers to the dangerous bacteria at its campus in Atlanta.
During the probe, investigators also discovered a previously unreported incident: Workers at a high-security CDC lab sent samples containing a dangerous strain of bird flu to counterparts at the US Department of Agriculture in March. Mishandling of avian flu could have far graver consequences for the public than with anthrax.
So far, no one has been found to have been infected due to either incident.
The CDC's director, Dr. Thomas Frieden, called the bird flu incident "the most distressing" because it occurred six weeks ago, but was not reported to senior agency leadership.
"I learned about it less than 48 hours ago," Frieden said.
"These events should never have happened," he said, adding that the events likely "have people questioning government".
Although the report identifies failures to adhere to biosafety protocols at multiple levels - including scientists working with anthrax who were not familiar with relevant studies on the kind of research they were conducting - it does not name any of the responsible individuals and CDC has not said how any will be disciplined, if at all.
The agency said it was suspending any transfers inside or outside the agency of biological materials, including infectious agents and even inactivated specimens, from high-biosecurity labs. The moratorium will remain in place pending review by an advisory committee.
The CDC influenza laboratory is also now closed and will not reopen until adequate procedures are put in place, CDC said.
In reconstructing the anthrax incident, investigators found scientists working with the deadly bacteria failed to follow an approved, written study plan that met all safety requirements.
The scientists lacked standard operating procedures to document when microbes are properly inactivated. In the anthrax case, scientists working in a high-biosecurity lab sent samples they believed had been inactivated to a lower-biosecurity lab; it turned out that the samples had not been properly inactivated and thus could have infected people.
CDC laboratories also lacked proper oversight of scientists performing work with dangerous pathogens, the report found.
Once CDC officials were alerted that live anthrax may have been transferred from the high-security lab, their response also fell short. For instance, CDC scientists in other labs first learned of the event not through official communication but "by witnessing CDC closing and/or decontaminating laboratories," the report said.
To prevent mishaps with dangerous organisms, CDC is creating a "lead laboratory science" position to be accountable for safety and setting up an external advisory committee on biosafety.