H5N1 Photo Credit – CDC PHIL
For those who missed yesterday’s bombshell press conference on recent government lab biosafety incidents involving anthrax, smallpox and avian H5N1, the CDC has posted the audio file, transcript, and some timeline graphics.
While there has been a great deal of excellent media coverage over the past 18 hours (including Helen Branswell’s What happened at the CDC’s flu lab? & Lisa Schnirring’s More problems shutter CDC labs, prompt review for CIDRAP News), many will still want to hear this press conference in its entirety.
CDC Press Conference on laboratory quality and safety after recent lab incidents
Friday, July 11, 2014 11:30 a.m. ET
These incidents are still under investigation, and so there are still large gaps in our understanding of how they occurred. The H5N1 cross-contamination incident in particular has two large and critical holes in the timeline (see below) that will require filling in.
The first is what transpired between March 12, when the (presumed H9N2) samples are shipped from the CDC to the USDA lab in Athens, Ga and May 23rd, when the USDA determined they were working not with H9N2, but with the highly pathogenic H5N1 virus.
How the virus sample became cross contaminated, and how that went undetected for 40 days, remain open questions.
Even more troubling is how the discovery of this mistake could have been made on May 23rd - and shared between two major government agencies (USDA & CDC) - and yet senior management at the CDC were not informed until July 7th, a gap of more than six weeks.
- CDC Influenza Division (ID) shipped low pathogenic avian influenza H9N2 to USDA SEPRL in Athens, Ga
Genetic analysis confirmed identity of H9N2
- Shipment delivered on March 13 to USDA Southeast Poultry Research Laboratories (SEPRL) (Athens GA)
SEPRL observed pathogenicity in chickens inconsistent with H9N2 virus
SEPRL performed molecular analyses on SEPRL virus stock and material sent by CDC
SEPRL confirmed highly pathogenic H5N1 contamination and destroyed all SEPRL virus stocks in biosafety level 3
- SEPRL notified CDC ID that SEPRL virus stock was contaminated and destroyed
- CDC ID confirmed H9N2 virus was contaminated by H5N1 virus
- CDC Responsible Official was notified; investigation is ongoing
The H5N1 flu incident, while apparently contained, could have been an economic disaster had the virus escaped the USDA lab and entered the poultry and/or wild bird population of the United States.
Regarding the Anthrax investigation, you’ll also find a graphic timeline available at this link.
Although none of these incidents resulted in the infection of lab personnel, or the release of a pathogen outside of the lab, they all had the potential to do so – and in the words of the CDC’s Director, `These events should never have happened.’
An obviously anguished Dr. Frieden went on to say:
`Together, these events I’m sure have many people asking and questioning government labs. They may be wondering whether we're doing what we need to do to keep our workers and our communities safe. And I think it's fair to raise those questions. I’m disappointed by what happened, and frankly, I’m angry about it.'
The post mortem on all of this is likely to be long and messy, and the fallout is likely to extend well beyond the CDC and USDA labs. These incidents show that no matter how sophisticated the laboratory, no matter how detailed the safety protocols, there is always the risk of human error.
Something which is sure to re-ignite the debate over the wisdom and safety of GOF (`Gain of Function’) and DURC (`Dual Use of Concern’) research has been simmering for several years. While I’ll have more on that in future blogs, for now you may wish to revisit: