The technician will be monitored for signs of infection for 21 days, the incubation period of the disease. A small number of other employees, fewer than a dozen, who entered a lab where the mistake occurred will also be assessed for exposure.
The error occurred Monday when a high-security lab at the CDC in Atlanta, working with Ebola virus from the epidemic in West Africa, sent samples that should have been inactivated to another CDC laboratory, which was down the hall. But the lab sent out the wrong samples — ones that had not been inactivated, and that may have contained the live virus. The second lab was not equipped to handle the live virus.
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The technician who worked with the samples wore gloves and a gown, but no mask, and may have been exposed. The error was discovered Tuesday.
The accident is especially troubling because dangerous samples of anthrax and flu were mishandled at the CDC in June, eroding confidence in an agency that has long been one of the most respected scientific research centers in the world. The CDC promised last summer to improve its safety procedures.
“I’m working on it until the issue is resolved,” the agency’s director, Thomas R. Frieden, said in an interview in July. Under harsh questioning from members of Congress that month, Dr. Frieden admitted that the errors at CDC labs had not been not isolated mishaps, but rather part of a broad pattern of unsafe practices. He called one of the episodes a “tipping point” that had forced agency officials to realize that they needed to take action.
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In the June incident, CDC scientists sent anthrax samples, supposedly killed, to laboratories unequipped to handle dangerous pathogens. But the bacteria turned out to be live because a deactivating technique too weak to wipe out anthrax spores had been used. Dozens of employees were offered antibiotics and anthrax vaccine; none became infected.
The head of the laboratory that shipped the bacteria resigned a few weeks after the mistakes came to light. Although CDC officials gave no reason for his resignation and said it was voluntary, they had previously indicated that they feared that laboratory workers had grown careless because of lax supervision.
In another blunder, a CDC lab accidentally contaminated a relatively benign flu sample with a dangerous H5N1 bird flu strain that can be fatal in humans, then shipped it to a Department of Agriculture lab. Scientists there detected the error, and no one was harmed.
Although the flu accident occurred in May, senior CDC officials were not told about it until July 7, and Dr. Frieden did not hear about it until two days after that. He said in an interview in July that he was “stunned and appalled” by the incident.
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The mistakes led the CDC to appoint a panel of outside safety experts in July to advise Dr. Frieden on how to correct sloppy procedures at government laboratories. The CDC temporarily closed its flu and bioterrorism laboratories and halted shipments of all infectious agents from its high-security labs until the labs could pass muster with a newly formed safety panel within the agency.
The special pathogens branch, where the Ebola accident occurred Monday, soon received permission to start sending out infectious agents again.
This latest accident is being investigated, said agency spokeswoman Barbara Reynolds. “We’ll learn from this mistake, as we’ve learned from the others,” she said.
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