Trouble at the CDC

Petri dishes

Image courtesy Microsoft

Trouble at the CDC
| published July 13, 2014 |

By Earl Perkins
Thursday Review features editor

I've seen lemonade stands that were managed better than some of our governmental agencies, and they're beginning to make Peyton Place look like a walk in the park. The 1960's soap opera at least had the decency to write a script and attempt to stick with a program, but the Center for Disease Control and Prevention in Atlanta has discovered how to infect almost 100 of its own employees with no outside help.

Where is Barney Fife when you need him? We don't need terrorists with bitter attitudes and an ax to grind against the United States—not while we have political appointees and social climbers running our agencies, where they use patronage, threats and favors to control underlings. Hot on the heels of the Department of Veterans Affairs fiasco where the nationwide plan was apparently to avoid patients and stuff appointment logs in desk drawers until people died, we now evidently have CDC-Gate.

The United States Department of Agriculture (USDA) has been forced to investigate a breach of security, which exposed at least 84 government workers to anthrax, according to the website Tech Times. In mid-June the CDC announced 75 workers had been exposed to the potentially-hazardous bacteria Bacillus anthracis, with the official number being raised by nine soon thereafter.

This type of investigation would normally be handled by the agency's Division of Select Agents and Toxins (DSAT), which has experience involving similar pathogens. However, in order to avoid a conflict of interest, the safety breach is being investigated by the Animal and Plant Health Inspection Service (APHIS), which is operated by the USDA.

Workers were exposed to the potentially deadly virus at three Atlanta area locations, and at least 32 workers are being treated with the antibiotic Cipro, also known as ciprofloxacin. According to a CDC press release, at least 20 workers were prescribed doxycycline, which is a different antibiotic, and up to 27 others are receiving an anthrax vaccine to prevent infection. No illnesses or symptoms have been reported among those exposed.

"Based on the review to date, CDC believes that other CDC staff, family members, and the general public are not at risk of exposure and do not need to take any protective action," agency officials said. The incident occurred at the Bioterror Rapid Response and Advanced Technology laboratory, where scientists were sending live anthrax from their high-security facility to a low-security station, but the bacteria was not successfully neutralized.

Nutrients and pathogen samples were placed in a petri dish, and the cultures were assumed to be dead after no bacterial growth was seen 24 hours later. The dishes were accidentally left in a warming incubator, and additional anthrax was later shown to be growing on the plate, thus proving samples sent to the second facility were alive.

Researchers at the second facility are developing chemical techniques designed to kill bacteria, hopefully replacing current techniques which use radiation. Anthrax released in the accident is the same highly-dangerous Ames strain used in terror attacks following 9-11.

The CDC has now concluded its investigation on the incident, but discovered another "more distressing" problem which revealed lab workers not following protocol, according to CNN on July 12. The CDC said although it is "not impossible" the staff was exposed to viable B. anthracis (anthrax), it is "extremely unlikely" this happened. The lab workers' health is being monitored, and they received antibiotics as a precaution. There have been no reports that those exposed have become sick. The CDC report says the potential exposure happened between June 6 and June 13, and the incident was discovered June 13.

A lab that prepared anthrax samples for use in two other labs on CDC's Atlanta campus "may not have adequately inactivated the samples." The other labs worked with supposedly harmless samples, so they weren't wearing protective equipment they otherwise would have used.

The CDC concluded that procedures in two of the three labs may have exposed workers to anthrax, so they decontaminated hallway and lab areas. The director of the bio-terror lab was supposedly reassigned shortly after the incident was reported. That means one person took the fall for the accident, thus limiting fallout for upper management. CDC spokesman Tom Skinner chose not to reveal the identity of the reassigned worker.

The report acknowledged the exposure happened because the lab didn't use an approved sterilization technique, and did not have a standard operating procedure to ensure safe material transfers. There also was no written plan reviewed by senior staff to ensure safety protocols were followed, and there was limited knowledge of peer-reviewed literature concerning safety procedures.

"The scientists failed to follow a scientifically derived and reviewed protocol that would have assured the anthrax was deactivated," said CDC Director Tom Frieden. It "should have happened, and it didn't." During the investigation "multiple other problems were found," according to Frieden.

Another troubling case involving a dangerous material transfer was revealed that occurred six weeks earlier. But what's "most distressing," Frieden said, is that he found out about it "less than 48 hours ago."

A culture of nonpathogenic avian influenza was unintentionally cross-contaminated with a potentially deadly flu strain--the highly pathogenic H5N1. This strain has killed millions of birds and infected more than 600 people in the last decade. No lab workers were exposed during this occurrence, but it was shipped to a USDA lab.

The CDC closed the facilities involved in the incidents, and the lab where the contamination occurred won't reopen until better safety procedures are in place, Frieden said.

CDC scientists were investigating methods to quickly identify anthrax in samples of unknown materials, thus minimizing effects during similar future attacks. Congress has begun an investigation of CDC safety procedures, noting the agency has received criticism for several safety breaches dating to 2007. That means we could still see two sets of people acting pompous and shocked in front of a national television audience, and then arguing over a lack of funding.

Although the CDC has attempted to blunt criticism before the investigation grinds into a protracted battle, we are discussing topics that could have potential worldwide implications. The world constantly monitors how this nation handles crises, and our system of democracy demands transparency.

The APHIS investigation and an internal CDC inquiry sought to know why one of the world's premier public health labs sent live samples of the deadly Ames strain of anthrax to other agency labs, where workers thought the bacteria was deactivated, according to USA Today.

Regardless of whether those infected receive antibiotic treatment, anthrax still has a fatality rate between 28 and 45 percent, depending on the type of exposure, according to the CDC. It also could take weeks or months for symptoms to develop, so you can understand my reticence to believe the CDC public relations people.

"There are a lot of people going through a lot of unnecessary anxious moments," said CDC spokesman Tom Skinner. "Things like this shouldn't happen. These are 'never' events. They should never happen. Period."

Scientists, lab technicians, administrative and maintenance staff who passed through common areas where the samples were handled are at risk of exposure. About seven scientists are at heightened risk because of more direct exposure, but they almost certainly had already been vaccinated against anthrax because of their jobs. They have since received antibiotics and were offered a booster vaccine, he said.

The researchers agitated or shook test tubes of what they considered deactivated anthrax spores, before lifting the tops off the tubes. This could have aerosolized the spores, thus creating the risk they inhaled some anthrax. Scientists work in Biosafety Level 3 with special safety equipment while working with live anthrax. The pathogen should be handled under negative air pressure in a specialized safety cabinet, where scientists wear personal breathing equipment.

The researchers associated with the recent incident opened test tubes in two Biosafety Level 2 labs with minimal protections, Skinner said. They may have worn gloves, gowns and goggles, but they wouldn't have used a safety cabinet or personal air supply.

More than 50 employees are on a 60-day course of antibiotics, and active diseases will be diagnosed through symptoms and chest x-rays. Blood tests will not identify antibodies that might show bacterial exposure, he said. Skinner also said the labs where the possible exposures occurred were recently decontaminated.

"We've done some environmental testing in the labs and so far the samples are negative," he said.

The anthrax incident is the latest among a series of safety and security failures at CDC labs that constantly handle dangerous pathogens. Reports show inadequate training for those working with bioterror agents, and failures associated with airflow systems designed to prevent release of infectious agents.

Other recent Thursday Review articles:

Earth's Declining Air Quality; Earl Perkins; Thursday Review; March 26, 2014.