Behind CDC's Anthrax Lapse, an 'Insufficient Culture of Safety'

Anthrax cells Photograph by Anthrax Vaccine Immunization Program/Getty Images

The most troubling thing about the Centers for Disease Control’s recent disclosure that 81 agency employees may have been exposed to live anthrax last month is that it wasn’t the first lapse of its kind.

Government watchdogs have warned for years about weaknesses in federal labs dealing with dangerous bugs. The CDC’s own report on the June incident details four other times that pathogens inappropriately left high-security labs since 2006, including an earlier case involving anthrax. While investigating the latest mishap, CDC Director Tom Frieden also discovered that a contagious strain of avian flu was unintentionally shipped to a lower security Department of Agriculture lab in March.

“What we’re seeing is a pattern that we missed, and the pattern is an insufficient culture of safety,” Frieden told a congressional panel on Wednesday. There may be more disclosures to come as the agency reviews its practices, he said. ”If we do uncover problems in the coming weeks and months, this may well be a result of strengthening our culture of safety.”

The pattern shouldn’t have come as a surprise. Nancy Kingsbury, a managing director with the Government Accountability Office, told Congress in 2009 that the U.S. needed more oversight in light of lab safety lapses. ”Taken as a whole, these incidents demonstrate failures of systems and procedures meant to maintain biosafety in high-containment laboratories,” she said. That testimony came just months after Frieden left the New York City Health Department to take over the CDC.

The problem goes beyond the CDC. Vials of live smallpox virus dating from 1954 were recently discovered in a storage room at the National Institutes of Health. A half-dozen U.S. agencies operate labs that deal with dangerous microbes. No one official or entity in Washington is in charge of their safety, Kingsbury told the House panel Wednesday, repeating points she made five years ago. The pattern at CDC also predates Frieden. His predecessor, Julie Gerberding, now runs the vaccine business for Merck, which declined to make her available for comment.

No one was sickened by the potential anthrax exposure. And it’s possible the samples were sterilized, as CDC scientists believed they were when they shipped them to a lower security lab. Frieden called the risk to CDC employees “very small” and the risk to the public “nonexistent.” The lab involved has been closed, and the agency has barred its scientists from transferring any biological materials until procedures are reviewed.

The CDC also needs to keep workers from getting complacent, Frieden says. “Sometimes if you work year in an year out with pathogens that are scary, you can get inured to that danger.”

The number of labs dealing with infectious microbes mushroomed after the anthrax attacks of 2001, to respond to a perceived threat of biological terrorism. The FBI concluded in 2010 that those incidents, which killed five people, were the result of a rogue Army scientist who used anthrax from a military lab.

In the years since, the country has never comprehensively assessed its network of labs that handle potentially dangerous pathogens, the GAO’s Kingsbury told the House panel Wednesday. ”How many of these laboratories do we really need, for what purpose, against what threat?” she asked. The U.S. government doesn’t know the answer, but the more there are, the greater the risk that someone will be inadvertently exposed.

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