The CDC’s labs handle the deadliest pathogens on earth, but some workers there told a special team of biosafety experts that they’re afraid to report accidents or other safety problems.
“The concern was that they could get in trouble, or the whole lab could get in trouble,” said Dr. Kenneth Berns, who co-chaired an advisory committee that assessed lab safety at the U.S. Centers for Disease Control and Prevention.
In addition, Berns said, many employees believe the CDC is more focused on security threats from outside the agency than on maintaining high safety standards within the agency.
The committee’s report, which came to light last week, arrived on the heels of three high-profile breaches in safety at CDC over the past year. The committee determined that the agency lacked a “consistent safety mission, vision or direction” and is “on the way to losing credibility.”
After the report was posted on the CDC’s website, The Atlanta Journal-Constitution decided this week to dig deeper into the advisory panel’s work by contacting key members, as well as CDC workers and experts in lab safety, to talk about the issues the panel uncovered.
Committee members found “aha moments” in what CDC workers said — and what they didn’t say. Dr. Joseph Kanabrocki, the committee’s other chairman, said that’s how he found gaps in the risk assessments done on pathogens.
“Are the hard questions being asked? Does this experiment need to be done this way? These (questions) were not being asked,” said Kanabrocki, associate vice president for research safety at the University of Chicago. “How can you mitigate risk, if you haven’t identified it?”
‘We’ve made great strides’
CDC Director Dr. Thomas Frieden said he agreed in principle with most of committee’s recommendations. His staff noted that the experts did their research last August and September, and that numerous changes are already underway.
“CDC began last year to take 360 degree look at its laboratory safety program. We’ve made great strides but still have more work to do,” said agency spokesman Tom Skinner. “We’re committed to doing everything humanly possible to make our labs safe.”
For example, the agency is hiring for a new position, associate director for laboratory science and safety, which will oversee lab safety across the agency and report directly to Frieden. The move reflects the committee’s finding that leadership in the sprawling agency has fragmented into silos, some which properly emphasize safety and others that don’t.
Beyond that, CDC is establishing additional safeguards for lab protocols, enhancing training and standardizing its approach for assessing the risks of working with these hazardous materials, officials said.
That hardly satisfies workers who say they’ve seen the emphasis on safety diminish over the years.
“Workers are a little bit jaded and skeptical when there’s an incident and CDC says its taking steps to address it. That’s the same thing we’ve been hearing for years,” said Pam Gilbertz, an employee and head of the union that represents 2,000 agency workers, including some who work in labs. “How are we supposed to protect the public, if we can’t even protect ourselves?”
She said workers who speak up about safety concerns are branded as troublemakers and “once you’re identified as a troublemaker your career is shot at CDC.”
Gilbertz criticized the way the agency made the report available to the public. The committee submitted the report in January. It was discussed during a public meeting shortly after that. It drew public attention after the agency posted it on its website last week. Gilbertz, whose union, Local 2883 of the American Federation of Government Employees, believes the agency should have announced the results through a press release.
‘Frustratingly slow response’
CDC spokesman Skinner said the committee findings were sent for review to officials at the U.S. Department of Health and Human Services, and “that took through February.” He said the agency followed a federal process in handling the release of the information.
Members of Congress also expressed concerns about the response by the agency.
“Frankly, I am perplexed about the frustratingly slow response from the CDC when a clear commitment to fix these problems was made by Dr. Frieden at my oversight hearing last July,” said U.S. Rep. Tim Murphy, R-Pa., chairman of the oversight and investigations subcommittee of the House Energy and Commerce Committee.
Frieden understands the importance of safety in handling these materials, Berns said. But responses from workers made it clear that “the message was not getting down to the rank and file.”
A review of one lab mishap that occurred last year revealed several troubling trends, committee members said. Berns said the incident —in which a CDC lab accidentally shipped a deadly flu virus to a lab in Athens — revealed how workers felt pressured to produce results. “The danger is people are tempted to take shortcuts,” he said.
In that instance, a staffer failed to clean his or her work station between working with two types of flu, thereby contaminating a more benign flu sample with H5N1, the potentially lethal strain of avian flu that has killed about 400 people since 2003.
Making matters worse, workers didn’t notify top CDC officials, including Frieden, of the cross-contamination until six weeks after the fact. That spoke to the reticence of workers to speak up when problems occur, Berns said.
‘Safety concerns are secondary’
Scientists involved in that incident told the committee they were concerned that they had violated the federal select agent rules, put in place to ensure the security of elements that could be dangerous in the hands of terrorists. But they made no mention of concerns about biosafety, the committee report said.
Kanabrocki believes that in the post 9/11 age, the emphasis on protecting these agents against theft has come at the expense of safety. “Safety concerns are secondary,” he said.
He added that, by and large, CDC does a good job and continues to be held in high regard. The safety concerns were not so much directed at the labs with the highest level of containment, called BSL-4 labs. Rather the concerns largely focused on the BSL-2 and -3 labs, which handle materials such as salmonella, anthrax, HIV and flu viruses.
Still, the critical report, carried in media across the country, had a significant impact on CDC, a federal agency generally considered the country’s top authority on the handling of pathogens. Kanabrocki himself keeps on his desk a copy of the book on biosafety co-authored by CDC, which he said is considered the bible in the field. The agency works with hospitals, universities and labs across the nation, often called in as a consultant on program safety.
“If things continue, some places may not want to work with CDC,” said Patrick Stockton, director of biosafety at the University of Georgia, who worked 18 years at CDC. “I can’t think for other people, but the possibility could be there.”
Murphy, whose subcommittee brought in Frieden to testify last summer, said the safety lapses reflect a “culture of complacency.”
There is always a general concern that the labs ensure the safety of these materials in Atlanta, where the agency occupies a campus on Clifton Road, not far from Emory University, said Gilbertz, the union leader.
“There’s quite a bit of residential area there,” she said.
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