One Lesson From the CDC Debacles–Always Check Your Materials Before You Start Working

And for that matter, before you send stuff to other people. By now, you might have heard about the CDC’s bad week. Most of the attention has focused on the discovery of smallpox vials, two of which contained virus that could replicate (‘live virus’), at the NIH campus in a building originally used by the NIH, but now used by FDA. But, for me, what’s scarier is that the CDC accidentally sent an FDA laboratory a influenza sample that contained ‘two for the price of one!’: a relatively harmless influenza strain along with the H5:N1 bird flu, which has a very high mortality rate.

But this is the puzzling part of the story (boldface mine):

When laboratories work with H5N1, the research is done in BSL 3 or BSL 3-enhanced facilities. Those are the highest-but-one level of biosafety and biosecurity containment, designed to ensure that pathogens what’s worked on within their walls do not infect the researchers and do not escape to infect people on the outside.

CDC was supposed to be sending an H9N2 virus to a laboratory owned by the U.S. Department of Agriculture. H9N2 is also a bird flu virus, but it doesn’t kill chickens; fewer people have been infected with it and those who have been infected have been less sick.

But the USDA lab noticed that the virus that was supposed to be H9N2 wasn’t behaving the way they would have expected it to – which likely means chickens started to die. So they tested it to see what they actually had on their hands. And they discovered the CDC had sent by error a sample that also contained H5N1. In the lab world, this is a bad mistake to make.

Frieden said that discovery was made around May 23, at which point the USDA lab notified the CDC flu division. Just who in the flu division knew about the mix up isn’t clear. What is known is that the agency leadership was only notified of the biosecurity breach this week. Frieden said on Friday he had known about the incident for less than 48 hours.

I’ll turn it over to Bill Hanage to deal with the last part:

But here’s what I don’t get: why didn’t anyone at USDA test the sample when it came in? Even if you didn’t suspect that it would contain something dangerous–though any BL3 microorganism is dangerous–wouldn’t you want to assure its purity? Likewise, at the CDC end, wouldn’t you want to not send out bad samples (again, ignore the issue of whether or not they’re highly virulent pathogens)? You wouldn’t have to sequence the whole thing either: PCR or other methods (pdf*) would do.

I ran into something like this back when I was a wee Mad Biologist–though no pathogens were involved–when a prestigious lab group shipped me an entire misidentified (and published) collection. It’s difficult to believe that other microbiologists at these agencies haven’t have similar experiences–this shouldn’t, in 2014, be a new problem. Testing your materials before you begin your experiments (and, keep in mind, animals were needlessly** used due to the mixup) should be standard for any microbiologist, not just pathogen researchers.

Seems like a new viral shipping and receiving protocol needs to be instituted.

*Yes, the article is authored by an FDA group.

**We need to use animals in research, but we shouldn’t use them–that is, make them ill or dead, because someone screwed up. It happens–scientists are human–but it’s a serious thing, not to be taken lightly.

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5 Responses to One Lesson From the CDC Debacles–Always Check Your Materials Before You Start Working

  1. Ned Mantei says:

    It also seems rather common for labs to send out the wrong plasmid construct (the kind requested for expression in cell culture, for in situ hybridization, or whatever).

  2. fionamcgier says:

    All of which enhances the believability of the premise of the latest Planet of the Apes movie, which hypothesizes that a “simian flu” accidentally gets released into the general population and wipes out a large section of humanity. For all of our hubris, we’re still animals, vulnerable to the smallest of creatures, viruses and bacteria.

    And you’re right: mistakes like this are unacceptable in any level of research, but particularly when dealing with the deadliest of strains.

  3. maryn says:

    Important point and thanks for making it. Just two small agency mix-ups:
    – the lab where the smallpox was discovered was FDA’s (but in the 1950s was NIH’s Div of Biological Standards)
    – the lab where the flu went was USDA (SEPRL, I think: Southeast Poultry Research Laboratory, near UGa).

  4. When I was a post-doc, I sent repeated requests to a big lab for several published plasmids. And each time, the motherfuckers kept sending me empty pBluescript, over and over again. Turns out these motherfuckers are known in the field for intentionally sending out bogus shit to slow down their perceived competitors.

  5. coloncancercommunity says:

    When I was a graduate student, it seemed like plasmids got shuffled around like a deck of cards. I got caught once early on and wasted a ton of time and materials before realizing I was working with the wrong construct. It never happened again. Rule #1 – make sure you know what you are working with….and I was never working with anything remotely pathogenic. You multiply that imperative by about 100 if you are.

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