| NEW YORK
NEW YORK Aug 15 A U.S. government scientist
working with bird flu rushed through a procedure designed to
ensure safety, allotting only about half the time necessary, in
order to get to a staff meeting, health officials said on
The lab worker's haste likely contributed to a potentially
fatal mishap, in which samples of mild avian flu were tainted
with a highly deadly strain and sent from the U.S. Centers for
Disease Control and Prevention (CDC) to researchers at the U.S.
Department of Agriculture.
The CDC disclosed on Friday details from its investigation
of the avian flu incident. The agency is under congressional
scrutiny over repeated safety lapses, including the potential
exposure of its workers to live anthrax bacteria in June.
A CDC spokesman said disciplinary action against those
involved in the avian flu incident is under consideration.
As serious as the sample mix-up, which occurred in January,
was the failure to report it as required by federal law when the
contamination became clear in May, according to biosafety
"The matter needs to be referred for civil and/or criminal
investigation," said biologist Richard Ebright of Rutgers
University, an expert in biosafety who testified before Congress
last month on the CDC lapses.
According to the report, CDC shipped the avian flu sample
from its Atlanta campus to a USDA poultry lab in March, and
scientists there began using it in research in May.
When the supposedly non-lethal viruses killed an entire
flock of chickens, a USDA scientist sequenced the genome of the
virus. That revealed it was not low-pathogenicity H9N2, as CDC
said, but highly pathogenic H5N1, which has killed hundreds of
people since 2013.
USDA scientists, out of an abundance of caution, handled the
sample under stringent biosafety conditions, including with
gloves, suits, and respirators, and no one was infected.
On May 23, USDA scientists told the CDC flu lab about the
mix-up. CDC scientists did not report it to managers, or file a
form required when dangerous pathogens are mishandled, until
July 9, just as CDC officials were completing a report on the
anthrax breach that occurred in June.
LACK OF JUDGMENT
Failure to report reflected "a lack of sound professional
judgment by those aware of the contamination," the CDC
investigators wrote. Among those aware of the release were the
head of the flu lab and the Virology Surveillance and
Diagnostics Branch Chief, the report said.
To outside experts, CDC scientists' failure to report the
breach "strains credulity," Rutgers' Ebright said in an
How the original mix-up of flu strains occurred is unclear,
the report said, because the CDC scientists said they could not
recall everything they did and did not keep a lab notebook or
other written documentation.
As best the investigators could tell, however, a flu lab
scientist transferred H9N2 virus received from Hong Kong, and
H5N1 from Vietnam, into cell cultures on the same morning.
Based on card-key readers that record entries and exits, the
investigators concluded that the scientist rushed through a
procedure that required 90 minutes to ensure safety - basically,
putting enough time between working with H9N2 and then with H5N1
- in just 51 minutes in order to make a noon meeting. That
included time to shower and change.
In addition, the report found, there was no approved
procedure for what the scientist was doing, colleagues who might
have noticed a breach were frantically rushing to finish
experiments ahead of a February scientific meeting, and the lab
director had a "heavy work load".
The flu lab scientists told CDC investigators they did not
realize they were required to file a 'Form 3' about the
accidental release of a dangerous pathogen. A USDA spokeswoman
did not respond to a question about whether the poultry lab
scientists were required to file the form.
CDC said it is reviewing existing laboratory protocols,
taking steps to improve record-keeping and compliance, testing
for cross-contamination before samples are transferred within or
outside CDC, and "providing additional extensive training" of
lab staff, including reporting requirements.
(Reporting by Sharon Begley; Editing by Michele Gershberg and