The US Centers for Disease Control and Prevention says it has
uncovered a new safety breach at one of its high-security
research laboratories involving dangerous avian flu, just as
it ia 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
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 U.S. 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 the avian flu or anthrax incidents.
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 told
"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 is 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
that scientists working with the deadly bacteria failed to
follow an approved, written study plan that met all
laboratory 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
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 future 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.