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One scientist may have been exposed to the Ebola virus and as many as a dozen others are being assessed for potential exposure at a lab of the Centers for Disease Control and Prevention in Atlanta, agency officials said Wednesday.
The potential exposure took place Monday when scientists conducting research on the virus at a high-security lab mistakenly transferred a sample containing the potentially infectious virus to another CDC lab in same building.
The technician has no symptoms of illness and is being monitored for 21 days. Agency officials said others who entered the lab have been contacted, and based on assessments, it’s likely no one else was exposed. They said the number of people who entered the lab could be as many as a dozen, but more likely far fewer.
Agency officials said there was no possible exposure outside the secure laboratory at CDC and no exposure or risk to the public. The mistake took place Monday afternoon and was discovered by laboratory scientists Tuesday; it was reported to leadership within an hour of the discovery.
The event is under internal investigation by the CDC, and it was reported to Secretary of Health and Human Services Sylvia Burwell and to the program that has oversight over “select agents” such as Ebola and anthrax.
This is the largest outbreak of the Ebola virus in history.
The accident comes after a series of incidents earlier this summer involving the mishandling of dangerous pathogens at the nation’s labs, including one in June at a CDC lab that potentially exposed dozens of employees to live anthrax because employees failed to properly inactivate the anthrax when transferring samples.
“I am troubled by this incident in our Ebola research laboratory in Atlanta,” said CDC Director Tom Frieden in a statement. “We are monitoring the health of one technician who could possibly have been exposed and I have directed that there be a full review of every aspect of the incident and that CDC take all necessary measures. Thousands of laboratory scientists in more than 150 labs throughout CDC have taken extraordinary steps in recent months to improve safety. No risk to staff is acceptable, and our efforts to improve lab safety are essential — the safety of our employees is our highest priority.”
The lab where Monday’s potential exposure occurred was decontaminated and the material destroyed as a routine procedure before the error was identified. The laboratory was decontaminated for a second time and is now closed, and transfers from the high-security lab have stopped while the review is taking place.
The CDC officials said two experienced technicians made mistakes at the high-security lab, known as a BSL-4 lab. One technician mistakenly put samples of material that could have contained live Ebola virus into the equivalent of the lab’s out basket, for transfer to the second lab, a BSL-2 lab. That material should have remained and been stored in a freezer.
The second mistake came on the receiving end: The technician in the BSL-2 lab should have recognized, via the color coding on the test tubes, that this was material that should have stayed at Level 4. That second technician is the person who could have exposed, and is now in the 21-day monitoring period, agency spokeswoman Barbara Reynolds said.
The CDC has technologically advanced biosafety laboratories in which dangerous pathogens such as Ebola can be handled by investigators who wear elaborate biohazard suits that keep them from being exposed. But what happened this week illustrates the impossibility of eliminating human error from even a state-of-the-art facility.
The mistake was discovered when workers looked in the freezer and saw material that was supposed to be sent down the hall for a genetic analysis. They realized the samples had been switched.
The CDC officials said two experienced technicians made mistakes at the high-security lab, known as a BSL-4 lab. One technician mistakenly put samples of material that could have contained live Ebola virus into the equivalent of the lab’s out basket, for transfer to the second lab, a BSL-2 lab. That material should have remained and been stored in a freezer.
“I am troubled by this incident in our Ebola research laboratory in Atlanta,” said CDC Director Tom Frieden in a statement.
Asked about the CDC's report in September that in certain scenarios, Ebola cases could reach 550,000 by January, Frieden said: "The projections we released a few months ago showed what could happen if nothing more were done -- in fact an enormous amount has been done."
He said what had changed was the world's reaction response to not letting that happen.
The killer virus Ebola may not be front and center in the news, but it’s still in the forefront of efforts by health officials nationwide. As of today, more than 1,400 people in 44 states in the U.S. are being actively monitored by state and local health departments after returning from West Africa. The good news is that no new cases have been reported in the U.S. since Oct. 23.