The head of the federal government’s public health laboratories in Atlanta told Congress Wednesday that researchers mishandled live anthrax and other deadly pathogens in the past because agency officials failed to see a broad pattern of safety lapses.
In the past, officials at the Centers for Disease Control and Prevention focused too narrowly on responding to specific incidents at individual laboratories without addressing more systemic issues.
“We missed a critical pattern,” said CDC Director Thomas Frieden. “And the pattern is an insufficient culture of safety.”
Frieden testified before an oversight subcommittee of the House Energy and Commerce Committee that focused on laboratory safety after more than 80 CDC employees may have been exposed to live anthrax last month, when samples were transferred from one lab to other CDC labs.
As a result of the CDC’s internal investigation, the agency disclosed last week that there had been four other incidents in the past decade when deadly pathogens were mishandled. None had been previously disclosed by the CDC.
Subcommittee Chairman Tim Murphy (R-Pa.) said government watchdogs have documented numerous and systemic safety lapses over the years. He called the most recent incident at the agency “sloppy” and “inexcusable.” He said the agency’s labs are supposed to be “the gold standard” for the world.
Noting that Frieden had made similar promises to improve safety, training and accountability when other incidents have taken place, Rep. Fred Upton (R-Mich.) said, “Why should we believe you this time that things are going to be different?”
Although Frieden said no one had been hurt and all pathogens were killed in the incidents, he said that was no excuse. He said the agency was taking several measures, including stronger internal and external oversight and accountability. Workers must be encouraged to report incidents, all staff need to take responsibility for safety, and CDC needs to “apply the same rigor” to safety as it does to disease prevention and research, he said. He pledged to oversee “sweeping measures” to improve the culture of safety and noted that if the agency uncovers more problems in the near future, it may be the result of better reporting and not an indication of deeper problems.
At several points during the hearing, Murphy held up a Ziploc bag containing petri dishes with photos of anthrax bacteria glued to them and asked why scientists would be using the plastic bags to transport dangerous pathogens. Murphy was referring to an investigation by the Agriculture Department’s animal and plant health inspection service into the anthrax incident. The probe found that samples of the bacteria were stored in unlocked refrigerators in unrestricted hallways and that dangerous materials were transferred using Ziploc bags, among a host of other safety lapses.
Frieden said researchers who were working with those samples believed them to have been inactivated. But scientists at the CDC bioterror lab had not killed the anthrax bacteria before transferring samples to other labs, so the “core error” was the initial failure to kill the bacteria, he said.
Much of the testimony centered on the laboratories inside and outside the federal government that conduct research on microbes that could be used as bioterror agents. Nancy Kingsbury, a managing director of the Government Accountability Office, told the committee that since the 2001 anthrax attacks in Washington and New York, her agency has noted the rapid increase in the number of biosafety labs. There are nearly 1,500 registered laboratories in the United States that conduct this kind of research, according to the GAO.
But there is no single agency setting national standards or providing oversight, she said. She said no one has been able to address some fundamental questions: “How many do we really need? For what purpose? Against what threat?”
Richard Ebright, a chemical biology professor from Rutgers University who conducts biosafety research, said multiple safety lapses at CDC labs over the years have been documented by government watchdogs, including the inspector general’s office at the Department of Health and Human Services and the GAO.
Last month’s event was “not an isolated event,” he said. It was a pattern that could have and should have been recognized a half decade ago.”
Moreover, he said, neither the CDC nor the USDA should be involved in overseeing the labs because both organizations fund this kind of research, posing a clear conflict of interest that may be partly responsible for continuing safety problems.