CDC director admits to pattern of unsafe practices

The New York TimesJuly 16, 2014 

Under sharp questioning from members of Congress on Wednesday, Dr. Thomas Frieden, head of the Centers for Disease Control and Prevention, admitted that recent laboratory accidents involving flu viruses and anthrax were not isolated mistakes, but rather part of a broader problem of unsafe practices at the agency.

Similar blunders had occurred before, but in addressing them, Frieden said, “We missed the broader pattern.”

Frieden, other officials and biosafety experts testified at a hearing held by a House Energy and Commerce subcommittee to review an accident last month in which dozens of CDC employees were potentially exposed to live anthrax bacteria.

The bacteria were sent from one laboratory without being properly killed off, and could have infected dozens of people along the way. So far, no one has fallen ill, but Frieden called the episode a “tipping point” that has forced the agency to realize that safety procedures must be improved.

Lawmakers were also harshly critical of the disease centers’ response. A memo by the subcommittee detailed a series of lapses, including that one of the anthrax labs was not properly secured on the day the release became known, so people tracked in and out. Workers had not been trained in how to decontaminate the lab, and no one knew who was in charge of decontamination. The clinic to care for potentially exposed employees was overwhelmed, physical exams were delayed and yet clinic officials did not request more staff members. Once the accident was recognized, the amount of anthrax bacteria involved and its location were not recorded.

Frieden testified that one of his agency’s mistakes was its failure to activate the emergency operations center that it normally uses when it responds to disasters like hurricanes, flu epidemics and severe outbreaks of food-borne disease. Using the center would have led to a better and more organized response, he said.

An outside expert who testified, Richard Ebright, a molecular biologist and laboratory director from Rutgers University, said the disease centers funds and conducts research, and also regulates it and oversees its safety - a serious conflict of interest, he said. He recommended that an independent agency be established to regulate research with dangerous organisms.

Asked by a subcommittee member how he would deal with a lab worker who made a serious safety mistake, Ebright said there would be consequences, possibly even termination.

Sean Kaufman, a former CDC employee who is now president of a company that teaches lab safety, warned against penalizing researchers who made errors. Punishing individuals would lead others to try to cover up the truth and hide their mistakes, which could ultimately cause greater harm. A better response, Kaufman said, would be to improve training and procedures, to minimize human error.

“Are you kidding me?” said the subcommittee chairman, Rep. Tim Murphy, R-Penn., suggesting that Kaufman was making excuses for the CDC.

Also on Wednesday, officials released new details about the government’s mishandling of another deadly pathogen, smallpox.

Six vials of freeze-dried smallpox virus were found on July 1 in a laboratory belonging to the Food and Drug Administration, on the campus of the National Institutes of Health. The vials had apparently been stored and forgotten at least 50 years ago.

So far, viable smallpox virus has been found in two vials. The drug agency revealed Wednesday that the vials were part of a larger cache of infectious agents and other biological materials - 12 boxes containing 327 vials, many labeled with the names of various diseases, including dengue, influenza and Q fever. Officials said they did not know if any of the other materials posed a risk.

Some vials were destroyed, and 279 others were sent to the Department of Homeland Security’s National Bioforensic Analysis Center.

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