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(CNN) -- Four days after the Centers for Disease Control and
Prevention concluded its investigation into June's accidental anthrax
exposure, more details are being released about the government
health agency's mishandling of potentially dangerous pathogens.
The CDC concluded its investigation into the anthrax incident last
week, saying that no lab workers had been infected with the
disease. But the public health agency's report also detailed other
instances in which lab workers had not followed protocol.
The U.S. Department of Agriculture has also been investigating the
anthrax incident. In a memo prepared for a congressional hearing
this week, the USDA says it had to track down missing anthrax
containers and found the infectious bacteria "stored in unlocked
refrigerators in an unregistered hallway" where workers were freely
passing through.
USDA inspectors also found that "select agent materials" were
transferred using Ziploc bags, which do not meet CDC requirements
for carrying these materials.
The problems date to 2011, according to the USDA memo. A report
from the U.S. Department of Health and Human Services "found
weaknesses in inventory records and expressed concerns about the
lack of biosafety and security training for workers with access to
these labs."
In March 2014, a USDA inspector again expressed concerns about
the CDC's bioterrorism lab, including incomplete inventory records
for select agents, such as botulinum and anthrax.
The anthrax incident was discovered June 13.
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Anthrax investigation: USDA finds more
CDC lab problems
By Jen Christensen, CNN
July 15, 2014 -- Updated 1546 GMT (2346 HKT)
EDITION: INTERNATIONAL U.S. MXICO ARABIC
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STORY HIGHLIGHTS
USDA investigation into anthrax
exposure at CDC f inds other lab
saf ety problems
CDC investigation concluded no
lab workers were inf ected with
anthrax
The CDC director is "upset" and
"angry" that it happened
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The CDC report says the potential exposure happened
between June 6 and June 13. A lab that had been
preparing the anthrax samples for use in two other labs
on the CDC's Atlanta campus "may not have adequately
inactivated the samples."
That means the other labs were working with samples
thought to be harmless; therefore, workers didn't wear
protective equipment they would otherwise have been
using when handling such infectious material.
Procedures in two of the three labs may have exposed
workers to the anthrax, the CDC said. Hallway and lab
areas have since been decontaminated.
The leader of one of the labs was reassigned shortly after
the incident was revealed. CDC spokesman Tom Skinner
would not confirm the name of the person who was reassigned.
There are three types of anthrax infection: cutaneous (through the
skin), inhalation (through the lungs) and gastrointestinal (through
digestion).
According to the report, the exposure happened because the lab
that was handling the dangerous material initially didn't use an
approved sterilization technique. It didn't have a written plan
reviewed by senior staff to make sure all safety protocols were
followed, and there was a limited knowledge of peer-reviewed
literature about the process that would make it less dangerous. The
lab also did not have a standard operating procedure that would
make sure the transfer of the material would be safe.
Bottom line, "the scientists failed to follow a scientifically derived and
reviewed protocol that would have assured the anthrax was
deactivated," CDC Director Tom Frieden said Friday. It "should have
happened, and it didn't."
The lab involved in the anthrax incident will remain closed for such
dangerous microbes until Frieden personally approves its reopening
under conditions that prevent any such mishap from happening
again, Frieden said.
The CDC has also stopped moving any biological material out of its
two highest-level labs while their procedures are being reevaluated.
As a result of these problems, the CDC has created a high-level
group of leaders who will work on lab safety issues. It has also
started putting together an external advisory group to take a closer
look at lab safety. And the CDC is carefully reviewing all the other
procedures for labs working with dangerous pathogens, and it has
put together a rapid-response command structure to hopefully help
the labs avoid future incidents.
"I will say that I'm just astonished that this could have happened
here," Frieden said.
He stands by his labs, which are considered some of the best in the
world, and he stands by his scientists. But he added that he is
"upset" and "angry" and has lost sleep over the incidents, and he is
"working around the clock" to make sure it never happens again.
CDC lab leader reassigned during anthrax investigation
CNN's Jacque Wilson and Miriam Falco contributed to this report.
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