Incident report finds errors | Safety lapse that sent bird flu sample to ag researchers wasn’t initially reported
NEW YORK, N.Y. (Reuters) — A U.S. government scientist working with bird flu rushed through lab procedures to get to a staff meeting, setting off what could have been a fatal mishap, health officials said last week.
They said the U.S. Centers for Disease Control and Prevention (CDC) lab worker, who was not identified, allotted only about half the time necessary to carry out the procedures safely.
As a result, samples of mild avian flu were tainted with a highly deadly strain and sent from CDC to researchers at the U.S. Department of Agriculture.
CDC released the report of its investigation of the avian flu incident and said disciplinary action is under consideration.
The agency is under congressional scrutiny over repeated safety lapses, including the potential exposure of scores of its workers to live anthrax bacteria in June.
As serious as the sample mix-up, which occurred in January, was the failure to report it as required by federal law when the contamination became clear in May, according to biosafety experts. CDC did not report the incident until July.
“The matter needs to be referred for civil and/or criminal investigation,” said biologist Richard Ebright of Rutgers University, an expert in biosafety who testified before Congress last month on the CDC lapses.
According to the report, CDC shipped the avian flu sample from its Atlanta campus to a USDA poultry lab in Athens, Georgia, in March, and scientists there began using it in research in May.
When the supposedly non-lethal viruses killed an entire flock of chickens, a USDA scientist sequenced the genome of the virus. That revealed it was not low-pathogenicity H9N2, as CDC said, but highly pathogenic H5N1, which has killed hundreds of people since 2013.
USDA scientists, out of an abundance of caution, handled the sample under stringent biosafety conditions, including with gloves, suits, and respirators, and no one was infected.
On May 23, USDA scientists told the CDC flu lab about the mix-up. CDC scientists did not report it to managers, or file a form required when dangerous pathogens are mishandled, until July 9, just as CDC officials were completing a report on the anthrax breach that occurred in June.
Failure to report reflected “a lack of sound professional judgment by those aware of the contamination,” the CDC investigators wrote. Among those aware of the release were the head of the flu lab and the Virology Surveillance and Diagnostics Branch chief, the report said.
The CDC investigators concluded that the failure to report the breach was not deliberate, which Rutgers’ Ebright said in an interview “strains credulity.”
How the original mix-up of flu strains occurred is unclear, the report said, because the CDC scientists said they could not recall everything they did and did not keep a lab notebook or other written documentation.
As best the investigators could tell, however, a flu lab scientist transferred H9N2 virus received from Hong Kong and H5N1 from Vietnam into cell cultures on the same morning.
Based on card-key readers that record entries and exits, the investigators concluded that the scientist rushed through a procedure that required 90 minutes to ensure safety — basically, putting enough time between working with H9N2 and then with H5N1 — in just 51 minutes in order to make a noon meeting. That included time to shower and change.
In addition, the report found, there was no approved procedure for what the scientist was doing, colleagues who might have noticed a breach were frantically rushing to finish experiments ahead of a February scientific meeting and the lab director had a “heavy work load.”
The flu lab scientists told CDC investigators they did not realize they were required to file a “Form 3” about the accidental release of a dangerous pathogen.
A USDA spokeswoman did not respond to a question about whether the poultry lab scientists were required to file the form.
CDC said it is reviewing existing laboratory protocols, taking steps to improve record keeping and compliance testing for cross-contamination before samples are transferred within or outside CDC and “providing additional extensive training” of lab staff, including reporting requirements.