CDC releases report on anthrax incident, highlights steps to improve laboratory quality and safety

July 14, 2014

The Centers for Disease Control and Prevention (CDC) released a report last week that reviews the early June incident that involved the unintentional exposure of personnel to potentially viable anthrax at the CDC’s Roybal Campus. The report identifies factors found to have contributed to the incident, and highlights actions taken by the agency to address these factors and prevent future incidents. Based on a review of all aspects of the incident, CDC concludes that while it is not impossible that staff members were exposed to viable B. Anthracis, it is extremely unlikely that this occurred. None of the staff who was potentially exposed has become ill with anthrax.

While finalizing this report, CDC leadership was made aware that earlier this year a culture of non-pathogenic avian influenza was unintentionally cross-contaminated at the CDC influenza laboratory with the highly pathogenic H5N1 strain of influenza and shipped to a BSL-3 select-agent laboratory operated by the U.S. Department of Agriculture. There were no exposures as a result of that incident. The CDC influenza laboratory is now closed and will not reopen until adequate procedures are put in place. Further investigation, review, and action are underway.

As a result of these two incidents, CDC is issuing, effective immediately, a moratorium on the movement transfer inside or outside the agency of biological materials (infectious agents, active or inactivated specimens) from BSL-3 or BSL-4 facilities. The moratorium will remain in place pending review by an advisory committee.

Based on an internal review called for by the CDC director, the report concludes that the scientists’ failure to follow an approved, written study plan that met all laboratory safety requirements led to dozens of employees being potentially exposed. It also finds that there was a lack of standard operating procedures to document when biological agents are properly inactivated in laboratories and a lack of adequate laboratory oversight of scientists performing work in these labs. Read the report.

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