The Centers for Disease Control and Prevention has released a report on its investigation into an incident that occurred in December 2014 at the agency's Ebola virus laboratory in Atlanta.
An error resulted in a high-security lab sending live Ebola samples — instead of samples of a killed virus — to another CDC lab that is not equipped to handle live Ebola, nearly exposing a lab technician to the virus. The lab technician was cleared after showing no signs of the disease but the CDC still conducted an investigation into the incident.
According to the CDC report, two inadequate safeguards led to the laboratory incident. First, there was no written, supervisor-approved plan that outlined the steps that were to be followed in the experiment. Second, a study plan workflow was not designed to sufficiently minimize the possibility that human error could lead to exposure.
Under the study plan workflow, identical tubes were used for swabs, with only a blue cap differentiating between the swabs marked for inactivation and the swabs marked for isolation. Removing the tube caps to place the swabs in the tubes allowed lab technicians to mix up the tubes.
Additional factors that contributed to the incident included the incomplete installation of a camera system that would allow the lab to verify procedures were performed according to protocol, and the incomplete implementation of a protocol that required the completion of a Material Transfer Certificate to transfer any material from high containment laboratories to lower biosafety level laboratories.
The CDC included numerous recommendations in its report for the continued implementation of ongoing CDC laboratory safety improvement efforts as well as additional safety enhancements for the CDC's Viral Special Pathogens Branch and high containment labs.
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