Power, airflow, safety issues plague high-tech CDC labs
Multimillion-dollar, high-tech laboratory buildings at the Centers for Disease Control and Prevention that house deadly bacteria and viruses continue to suffer power outages and failures of important airflow systems that help prevent pathogens from being released, records obtained by USA TODAY show.
The incidents have resulted in staff being evacuated and have exposed flaws in safety communication systems that are critical in emergencies, according to a 14-page summary of selected CDC lab incidents the agency provided in response to a federal Freedom of Information Act request.
The document obtained by USA TODAY for the first time provides new information about dozens of mishaps that have occurred in CDC research labs – beyond the three high-profile mistakes the agency made public in 2014 and that prompted a congressional hearing last summer.
The CDC came under scrutiny last year after three serious incidents that potentially exposed dozens of lab workers to anthrax and one worker to Ebola, and mistakenly sent a specimen containing a deadly strain of bird flu to another lab. Since January, the CDC has refused to release copies of reports of all incidents that occurred in the agency’s numerous labs in Atlanta and Fort Collins, Colo., during 2013 and 2014. The CDC has told USA TODAY it will take until sometime in 2018 to collect and release all of the incident reports.
The newly released lab incident summary document, which is likely not comprehensive, indicates that power outages and airflow system failures have occurred about a dozen times from January 2013 through July 2014 –
continuing despite congressional scrutiny in 2012 in response to previous reporting by USA
Though in most cases the document provides little or no detail about what happened, it says a lightning strike and electrical surge in July 2013 caused airflow changes that “made it nearly impossible to open the lab hallway doors over approximately 1 hour” in a $365 million, 16-story CDC lab tower in Atlanta known as Building 23 that also lost phone service and had no backup communication plan.
“It is unacceptable that the CDC, our nation’s premier institution committed to preventing the spread of infectious disease, has not resolved these problems after years of oversight and attention,” said U.S. Rep. Diana DeGette of Colorado, the ranking Democrat on a House oversight and investigations subcommittee that has held hearings on CDC’s lab safety issues.
“It is more vital than ever that the CDC, from leadership on down, commit to a strategy that will prevent future lapses in safety,” DeGette said.
CDC spokesman Tom Skinner said that addressing airflow issues is critical. He noted that the negative air-pressure systems used in the agency’s high-containment labs are only one of several layers of safety protections that keep pathogens from being released. “Airflow is not our primary means of containment,” he said.
The newly disclosed incidents, listed among about 170 line items in a spreadsheet, include workers potentially exposed to pathogens through needle sticks and cuts, building maintenance workers propping open doors to restricted lab areas and malfunctions of full-body, spacesuit-like protective gear used to protect scientists from exposures to the most deadly types of viruses, such as Ebola.
But the summary document — which the CDC says was created last year for the agency’s director and includes mishaps and selected clinic visits that occurred from 2013 through early August 2014 — provides few details. The CDC also notes that its total number of incidents cannot be tallied by reviewing the spreadsheet. Some incident summaries appear to be duplicates; other line items indicate the description is one of many similar incidents.
Further clouding the agency’s lab-safety picture: The CDC has redacted the names of the viruses or bacteria involved in several of the incidents, citing a law that involves oversight of bioterror pathogens. Lab incidents include workers potentially being exposed to prairie dogs and fleas infected with undisclosed bioterror agents, and a fluid leak that possibly contained an undisclosed “Tier 1” bioterror agent, considered among the most dangerous of all. USA TODAY has filed an appeal contending the redactions are not justified under the law.
Sean Kaufman, a biosafety consultant who previously worked for the CDC and has conducted training at the agency, said the limited number of incidents contained in the summary document — given the vast number of labs operated by the agent — raises questions.
“This is not a comprehensive list,” said Kaufman, who testified before Congress last summer in the wake of the CDC’s anthrax lab incident. “I look at these documents, and it’s very clear to me that leadership has not defined for the workforce what is a reportable incident or accident.”
In order to identify emerging risks and trends to prevent future accidents, Kaufman said it’s important for lab staff to report all incidents and unintentional events, even if they may not seem important at the time.
Marian Downing, president of the American Biological Safety Association and a biosafety consultant, said she couldn’t comment on CDC’s incident-reporting practices. But when she worked for a major pharmaceutical company, Downing said incidents where a biological exposure occurred — as well as “near-misses” — were entered into a central safety database, and there was a structure in place to determine the root causes of events.
In responses to USA TODAY’s questions this week, the CDC gave a series of evolving answers about whether any single office at the agency collects and reviews information about lab incidents of all types to spot emerging safety trends.
The CDC initially said that only lab incidents that result in visits to the agency’s health care clinic are reviewed regularly in a centralized fashion and that all other incidents are reported to numerous individual safety directors who oversee separate research programs. Later the agency said that the agency’s newly created office of the associate director for laboratory science and safety has been receiving and reviewing all lab incident reports since it was established in late 2014.
The agency said it has a policy that requires reporting of all lab incidents to this new safety office, but it refused to provide a copy of the policy or say when it was enacted. The CDC later conceded the policy only requires reporting of a subset of incidents that meet certain criteria. Reporting is only required for an “exposure” occurring in biosafety level 3 and 4 labs — the two highest levels of containment, or incidents that involve “significant” injury or exposure with a “high likelihood” of infection, treatment for a laboratory acquired infection, or exposure to a potential bioterror agent or genetically manipulated organism, as well as any incident involving a lab visitor.
The criteria do not generally require reporting of near-miss incidents where a worker isn’t determined to be exposed or injured and largely leaves it up to individual workers to determine if something must be reported.
“Near-misses are important for obvious reasons because you don’t want them to happen again and involve a person next time,” Downing said. She also noted that about 60% of laboratory-associated infections are not due to any known exposure.
Kaufman says the CDC’s definition of reportable incidents “is too vague and incomplete,” offering scientists little concept of what is expected of them. “There is an absence of leadership,” he said of CDC’s approach to incident reporting.