A laboratory mistake at the Centers for Disease Control and Prevention in Atlanta may have exposed a technician to the deadly Ebola virus, federal officials said on Wednesday. The technician will be monitored for signs of infection for 21 days, the incubation period of the disease.
Word of the accident provoked concern and disbelief from some safety experts. Dangerous samples of anthrax and flu were similarly mishandled at the C.D.C. just months ago, eroding confidence in an agency that has long been one of the most respected research centers in the world.
Other employees who entered the lab where the mistake occurred were being examined for possible exposure. There are fewer than a dozen, and so far it appears that none were infected, said Thomas Skinner, a C.D.C. spokesman.
The samples were properly contained and never left the C.D.C. campus, so there is no risk to the public, officials said.
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The error occurred on Monday, when a high-security lab, working with Ebola virus from the epidemic in West Africa, sent samples that should have contained killed virus to another C.D.C. laboratory, down the hall.
But the first lab sent the wrong samples — ones that may have contained the live virus. The second lab was not equipped to handle live Ebola. The technician there who worked with the samples wore gloves and a gown, but no face shield, and may have been exposed.
The mixup was discovered on Tuesday, Dr. Stuart Nichol, chief of the C.D.C.’s Viral Special Pathogens Branch, said in an interview. He ascribed it to human error.
In a statement, Dr. Thomas R. Frieden, director of the C.D.C., said he was “troubled by this incident” and promised “a full review of every aspect.” Thousands of agency scientists, he said, “have taken extraordinary steps in recent months to improve safety.” The C.D.C. promised last summer to improve its safety procedures and chose a panel of outside experts to advise it on how to do so.
Under harsh questioning from members of Congress in July, Dr. Frieden admitted that the errors at C.D.C. labs were not isolated mishaps, but rather part of a broad pattern of unsafe practices. He called one of the episodes a “tipping point” that had forced agency officials to realize they needed to take action.
Upon hearing of the latest incident, Richard H. Ebright, a molecular biologist at Rutgers University and an expert on biological weapons, said: “They did not learn. They do not learn. They seem incapable of learning.”
He said the errors were inexcusable. Labs that produce samples of killed virus should test to make sure they are dead, Dr. Ebright said, and labs receiving those samples should test them before working with them.
“C.D.C. labs that receive putatively inactivated samples still are working with them with no safety and security precautions beyond those at a dentist’s office,” Dr. Ebright said.
Najmedin Meshkati, a professor of industrial and systems engineering at the University of Southern California and an expert on human error, said: “I am speechless. This is yet another indication that this organization needs to do a serious soul searching to improve its safety culture.”
The previous incidents occurred in the spring and summer. In June, C.D.C. scientists sent anthrax samples, supposedly killed, to laboratories that were not equipped to handle dangerous pathogens. But the bacteria turned out to be live, because a deactivating technique too weak to wipe out anthrax spores had been used. Dozens of employees were offered antibiotics and anthrax vaccine; none became infected.
The head of the laboratory that shipped the bacteria resigned a few weeks after the mistakes came to light. Although C.D.C. officials gave no reason for his resignation and said it was voluntary, they had previously indicated that they feared workers in that laboratory had grown careless because of lax supervision.
In another blunder, a C.D.C. lab accidentally contaminated a relatively benign flu sample with a dangerous H5N1 bird flu strain that can be fatal in humans, then shipped it to a laboratory at the Department of Agriculture. Scientists at the receiving lab detected the error, and no one was harmed.
Although that incident occurred in May, senior C.D.C. officials were not told about it until July 7, and Dr. Frieden did not hear about it until two days after that. He said in an interview in July that he was “stunned and appalled” by the incident.
The mistakes led the C.D.C. to appoint a panel of outside safety experts in July to advise Dr. Frieden on how to correct sloppy procedures at government laboratories. The C.D.C. temporarily closed its flu and bioterrorism laboratories, and halted shipments of all infectious agents from its high-security labs until those labs could pass muster with a newly formed safety panel within the agency.
In August, the special pathogens branch — where the Ebola accident occurred on Monday — received permission to start sending out infectious agents again.
Dr. Nichol said that the high-security lab where the mistake occurred had prepared two sets of fluid samples from guinea pigs infected with Ebola. The fluid was handled as if it contained live virus, though it is not certain that the virus was present.
One set of samples was to remain in the high-security lab so that researchers could try to isolate the virus from it. The other was to be treated with a solution that would kill the virus and then sent to a lower-level laboratory where a technician would try to extract genetic material from it.
Somehow, the samples were switched: The ones with killed virus stayed in the high-security lab, and the ones that may have contained live virus were sent to the lower-level lab and processed there.
The accident is being investigated, said Barbara Reynolds, a C.D.C. spokeswoman.
“We’ll learn from this mistake as we’ve learned from the others,” she said.
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