Via CDC: CDC Director Releases After-Action Report on Recent Anthrax Incident; Highlights Steps to Improve Laboratory Quality and Safety. Excerpt and then a comment:
Based on an internal review called for by the CDC Director, the report released today concludes that the scientists’ failure to follow an approved, written study plan that met all laboratory safety requirements led to dozens of employees being potentially exposed.
The report also found that there was a lack of standard operating procedures to document when biological agents are properly inactivated in laboratories as well as a lack of adequate laboratory oversight of scientists performing work in these labs.
The report concludes that the critical nature of CDC investigations to detect and respond to naturally occurring and man-made events with select agents while ensuring the safety of staff are paramount and should be guided by the highest standards.
In response to these incidents, CDC has initiated following steps, in addition to the moratorium:
• Established a high-level working group, reporting to the CDC Director, to, among other duties, accelerate improvements in laboratory safety, review and approve, on a laboratory-by-laboratory basis, resumed transfer of biological materials outside of BSL3 and BSL4 laboratories, and serve as the transition group for the single point of accountability on laboratory safety called for in the review of the potential exposure to anthrax incident.
• Begun the process of establishing an external advisory group for laboratory safety. Invitations to participate in this group will be issued by July 18, 2014.
• Initiated an investigation to determine root causes that led to contamination of another avian influenza virus by the H5N1 virus.
• Reported the incident through the proper channels to the select agent oversight body, APHIS.
• Established a review group, under the direction of CDC’s Associate Director for Science, to look at the systems, procedures, and personnel issues leading to this event and means of preventing similar events in the future. This review will be done in conjunction with the internal investigation and in coordination with the working group.
• Undertaking appropriate personnel action expeditiously.
CDC has also implemented or is in the process of implementing the following key recommendations highlighted in the report to address the root causes of the anthrax incident:
• CDC will establish a CDC-wide single point of accountability for laboratory safety.
• The Bioterrorism Rapid Response and Technology (BRRAT) Laboratory will not be conducting work with any select agent until a series of reviews and approvals are completed. BRRAT laboratory scientists do not have access to select agents, which have been placed in storage-only mode. These restrictions will remain in place until changes have been put in place to prevent similar future incidents.
• Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident.
• All inactivation procedures for laboratories working with select agents and other dangerous pathogens throughout CDC are being carefully reviewed and will be updated as needed.
• CDC will improve its response to future internal incidents by the rapid establishment of an incident command structure, as CDC uses for external events.
• The implications for the use of select agents, including for CDC’s regulatory functions through CDC’s Division of Select Agents and Toxins will be carefully reviewed to incorporate any lessons learned.
The incident amounts to an "own goal" miraculously prevented by the goalie's heroic lunge. If you watch soccer (such as the almost-over World Cup), you've seen furious goalies reaming out their defenders for the lapses that permitted such disasters.