CDC Director Confirms Dangerous Pattern and “Insufficient Culture of Safety” Surrounding Recent Incidents Involving Anthrax

July 16, 2014

WASHINGTON, DC – The House Energy and Commerce Subcommittee on Oversight and Investigations, chaired by Rep. Tim Murphy (R-PA), today held a hearing to review recent incidents at the Centers for Disease Control involving anthrax and other dangerous pathogens. The CDC announced in June that more than 80 workers at a CDC lab in Atlanta may have been exposed to live anthrax, prompting an investigation from this committee. Over the past month, additional reports have emerged, adding urgency to this investigation.

Full committee Chairman Fred Upton (R-MI) explained that these incidents taken together raise serious red flags about a lack of oversight and necessary caution. “Add to the possible anthrax exposure the delayed notice provided to CDC leadership about avian flu shipments and the discovery of smallpox vials in a cardboard box in an FDA storage room on the NIH campus, and these incidents no longer appear isolated; a dangerous pattern is emerging, and there are a lot of unknowns out there. When dealing with pathogens such as the ones being discussed today, unknowns are unacceptable.”

CDC Director Tom Frieden acknowledged, “The pattern is an insufficient culture of safety.”

Murphy noted, “The Centers for Disease Control is supposed to be the gold standard in the U.S. public health system and it has been tarnished. We rely on CDC to protect us and uphold the highest standards of safety. But the recent anthrax event and newly disclosed incidents have raised very serious questions about the CDC’s ability to safeguard properly select agents in its own labs.”

Read the complete statement from Subcommittee Chairman Tim Murphy (R-PA) online here.

Dr. Nancy Kingsbury, the Managing Director for Applied Research and Methods at the Government Accountability Office testified on findings from GAO investigations of these incidents. “Our work on this issue has found a continued lack of national standards for designing, constructing, commissioning, and operating high-containment laboratories.” Kingsbury testified, “We believe it’s also important that those procedures be validated, and by that we mean independently tested so that we can be assured that if these procedures be followed, there will be no further episodes.”

The United States Department of Agriculture has also investigated this incident. Dr. Jere Dick, Associate Deputy Administrator at the U.S. Department of Agriculture, testified that the USDA found “a number of the disinfectants used in the response were expired and impacted laboratories used inconsistent methods of disinfection. We found that employees did not have appropriate training in the application of the inactivation protocol, appropriate disinfection of exposed laboratory areas or actions to take in the event of exposure.”

Dick added, “we found no clear management oversight of the incident within the various laboratories that were impacted. There also was no clear, single manager overseeing the overall CDC incident response, which resulted in employee confusion about how to manage the response to the incident.”

Dr. Richard Ebright, Board of Governors Professor of Chemistry and Chemical Biology at Rutgers University, reviewed steps outlined in a 2005 report prepared by the CDC following anthrax incidents at the Southern Research Institute and Children’s Hospital Oakland Research Institute in 2004. Ebright noted, “Had the CDC implemented the recommendations in its 2005 report on the 2005 SRI-CHORI anthrax incident, the 2014 CDC anthrax incidents would not have occurred.”

In addition to the use of expired bleach, the committee learned that in this most recent anthrax incident, “materials were transferred within two plastic Ziploc bags between labs… Anthrax was stored in unlocked refrigerators in an unrestricted hallway, and workers freely passed through the area at the time of inspection.”

Upton added, “There is zero tolerance for unlocked refrigerators and Ziploc bags – those days are over.”

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