CDC finds lapses in latest lab mishap with Ebola virus

Scientists at the Centers for Disease Control and Prevention were lucky in their latest laboratory accident that had the potential to expose its workers to the deadly Ebola virus, according to results of a CDC investigation released Wednesday.

On Dec. 22, a worker at CDC's biosafety level 4 lab in Atlanta — where scientists wear spacesuit-like, full-body protective gear that filters the air they breathe — accidentally confused some specimens and sent an un-killed sample from an Ebola experiment to a lower-level lab with minimal protections.

The agency's investigation of the incident has now found that the sample sent to the biosafety level 2 lab at CDC likely never contained any live Ebola virus because it is now believed that animals used in the experiment no longer had detectable live virus in their bodies at the time of the mistake.

But on Dec. 23, when the mistake was discovered, CDC scientists thought there may be live virus in the specimen, and an unprotected lab technician who received the un-killed specimen had to undergo 21 days of monitoring over the holidays for possible Ebola infection. No illness resulted.

"CDC has made real progress over the past year to improve laboratory safety, but we have more to do," CDC Director Tom Frieden said in a statement. "Our scientists will continue to work to make the agency a model not only of laboratory excellence but also of laboratory safety."

The Ebola incident involved samples collected for both live-virus studies and studies involving killed samples. The samples taken from lab animals were initially put in tubes that were identical in brand and size and but had different-colored caps. The wrong samples were sent to the lower level lab and the investigation said the incident occurred because of "inadequate safeguards," including lack of a supervisor-approved, written study plan and a research workflow that was "not designed to sufficiently minimize the possibility that human error could result in potential exposure," the agency said Wednesday.

The mistake was made by staff in CDC's elite Viral Special Pathogens Branch, which works with deadly diseases and has been involved in the agency's response to the ongoing Ebola outbreak in West Africa. Despite recent high-profile lab accidents by other scientific teams at CDC and what were touted as agency-wide reforms, this elite branch had failed to fully enact recent lab safety enhancements that "may have had the potential to reduce the likelihood of this incident," according to the CDC's investigation of the Ebola mistake.

The branch lacked a designated individual responsible for monitoring lab safety and compliance with laws governing research with pathogens that are potential bioterror agents, the report said. And its staff didn't follow a new CDC requirement to fill out a form detailing inactivation steps, which must be signed by all involved, before specimens were transferred from the maximum-containment lab to the lower-level lab.

To improve lab safety practices in facilities that work with many of the world's deadliest pathogens, the CDC said it is installing more than 60 camera systems across agency labs in the U.S. and abroad to better monitor safety protocols. The agency also is hiring an associate director for laboratory science and safety and is expanding biosafety training for its staff that includes a biological risk assessment course that launches this month.

On Jan. 5, USA TODAY filed a request under the federal Freedom of Information Act seeking a copy of the initial incident report or reports about the Ebola lab mistake. Although CDC granted the request expedited processing, it has not released the records and the agency won't give an estimate of when it will, as it is required to by law.

December's Ebola incident was the latest in a series of serious biosafety accidents in the past year by CDC scientists in Atlanta that have drawn bipartisan concern from Congress and the White House. Since last summer, Frieden has made sweeping promises of laboratory safety reforms, including imposing a moratorium in July on all transfers of biological materials from the agency's biosafety level 3 and biosafety level 4 labs — the two highest levels of containment where research is conducted on the most dangerous pathogens — until each lab documented its safety practices to the satisfaction of agency officials.

In July, the head of CDC's bioterrorism response lab resigned in the wake of his staff's mishandling of live anthrax spores and the potential exposure of dozens of agency employees to a particularly lethal strain of the bacteria. None was infected.

Like the Ebola mistake in December, the anthrax mistake in June involved concerns that specimens were not properly inactivated before being transferred from a higher-containment lab to a lower-level lab that isn't supposed to work with such a dangerous pathogen in its live form.

In early 2014, other CDC lab staff unwittingly cross-contaminated a relatively mild strain of avian influenza with a dangerous strain that can kill people, then shipped it to a U.S. Department of Agriculture laboratory. That mistake was discovered in May when birds unexpectedly died in the USDA lab's experiments. A CDC investigation concluded that sloppy lab practices by an experienced but overworked scientist rushing to get to a meeting was the likely cause of error.

USA TODAY has reported for years about several other serious safety lapses at CDC's labs in Atlanta, including repeated problems with air-flow systems designed to prevent the release of infectious agents and failures to maintain proper security in areas working with dangerous pathogens.

Private government audits obtained in 2013 by USA TODAY cited the CDC for failing to ensure that those working with and around potential bioterror agents had received required training. A 2010 report said auditors couldn't verify that 10 of 30 employees sampled had required training. A 2009 report said the CDC labs "did not provide biosafety and security training to 88 of 168 approved individuals" before they were given access to work areas for bioterror agents.

The recent high-profile incidents at CDC — considered one of the world's premier public health laboratories — plus the discovery of forgotten samples of deadly smallpox virus at a lab at the National Institutes of Health, prompted a congressional hearing last summer.

In August, top White House advisers on homeland security and science issued a memorandum to all federal agencies that work with infectious agents urging them to engage in a "Safety Stand-Down" to review protocols and inventories and "to take immediate and long-term steps to enhance safety and security of research to minimize the potential for future incidents."

During inventory sweeps conducted as part of the "Stand-Down," federal agencies identified 27 instances of improperly possessed pathogens that are regulated as "select agents" — because of their potential threat as bioterrorism agents or the serious threat they pose to public health or agriculture.

Many of the discovered specimens — which included ricin, botulinum neurotoxin, avian influenza virus and Yersinia pestis, the bacterium that causes plague — appeared to have been left behind by scientists that no longer worked for the agencies. All of the specimens were located in secure laboratory space and there were no indications of any human exposures, according to a report in December by the CDC, which, with the USDA, jointly runs the Federal Select Agent Program that regulates labs working with select agents.

To read USA TODAY's coverage of laboratory accidents, go to: biolabs.usatoday.com

Follow investigative reporter Alison Young on Twitter: @alisonannyoung