Airflow problems plague CDC bioterror lab

by jeeg 13. June 2012 22:12

A $214 million bioterror germ lab at the Centers for Disease Control and Prevention in Atlanta has had repeated problems with airflow systems designed to help prevent the release of infectious agents, government documents and internal e-mails show.


While the agency says no one has been infected, a biosafety expert says the problems appear to be major violations of laboratory operating standards.

The area of the building with problems involves Biosafety Level 3 labs that can be used for experiments involving anthrax, dangerous strains of influenza, the SARS coronavirus, monkeypox and other microbes that have the potential to be used as bioweapons.


In February, air from inside a potentially contaminated lab briefly blew outward into a "clean" corridor where a group of visitors weren't wearing any protective gear which raised concern about exposure risks, according to e-mails reporting and discussing what happened. Research animals in the lab had not yet been infected at the time of the incident, the records say.


CDC engineers have raised written concerns about the air containment systems since at least 2010. At that time, scientists working with poxviruses, such as monkeypox, expressed concerns about airflow and said they "don't want to go into that facility because they don't feel comfortable with the way it is currently designed," according to minutes from a February 2010 meeting to discuss reversing the way air flowed through the labs and animal-holding areas.


According to the minutes, CDC safety manager William Howard said: "Bottom line is we can't continue to operate the building the way it is ? if (a bioterror lab inspector) finds out air is moving this direction they will shut this place down."


The CDC refused to grant interviews or answer any questions submitted in writing about the problems inside the high-containment labs and animal-holding area of the agency's 11-story Emerging Infectious Diseases Laboratory, also known as CDC Building 18.


In a statement, the CDC said there have been no releases of germs and no one has been injured. Experiments in the building's high-containment labs are "done in an environment with highly skilled staff, technical equipment, and safety systems that unfortunately, at times, experience challenges. Fortunately, this unique facility has multiple systems in place that provide appropriate redundancy, so when there is an incident, the public's safety, as well as worker safety, is not compromised." The agency said it always takes "appropriate steps" to address incidents when they occur, but provided no details.


BSL-3 labs are required under federal safety guidelines to have "sustained directional airflow by drawing air into the laboratory from 'clean' areas toward 'potentially contaminated' areas."


The airflow system is designed to protect against the release of microbes, especially those that have the potential to become airborne and infect workers who could spread disease in the community.


The CDC is responsible for inspecting its own labs, as part of a federal program where it also oversees labs nationwide that work with germs or toxins that could potentially be used as bioweapons.


Rutgers University biosafety expert Richard Ebright said excerpts of CDC documents provided to him by USA TODAY "raise serious concerns. There appear to be significant irregularities." The problems seem to be the type that CDC's inspectors "would flag as major violations in inspections of non-CDC facilities," Ebright said.


The same lab building, which opened in 2005 and was touted by the agency as the world's most advanced laboratory, made news in 2007 when backup generators didn't work to keep airflow systems working during a power outage, then again in 2008 for a high-containment lab door that was being sealed with duct tape. The duct tape was applied after a 2007 incident where a ventilation system malfunctioned and pulled potentially contaminated air out of the lab and into a "clean" hallway; nine CDC workers were tested for potential exposure to Q fever bacteria. None were infected.


Most CDC staff quoted in the documents obtained by USA TODAY referred questions to the agency's press office or did not respond to requests for interviews.


Anthony Sanchez, the building's high-containment lab manager, in a brief interview said that although no building is perfect, "the scientists are happy with the facility ? It is safe, and we have highly professional persons working in there, and they don't have anything to worry about."

Sanchez added: "I think the American public has gotten its money worth, and more."


The records show that other CDC staff have expressed safety concerns.


The CDC "will do anything ? to hide the fact that we have serious problems with the airflow and containment in this whole building," wrote CDC animal resources biologist Kismet Scarborough in an April 9 e-mail to several agency officials, including CDC Director Thomas Frieden. Scarborough's CDC voice-mail greeting describes her position as a high-containment lab manager for the agency's Animal Resources Branch.


Scarborough, e-mails indicate, was a witness to the Feb. 16 incident.

where air blew out of a potentially contaminated BSL-3 lab into a "clean"



Another witness was Eddie Jackson, a biologist and inspector with CDC's Division of Select Agents and Toxins - the arm of CDC that is responsible for inspecting U.S. labs that work with bioterror germs. Jackson e-mailed a top CDC safety official the day the incident happened. Jackson described how he was part of an escorted group standing outside the door of a lab when an animal technician inside opened an interior door to an animal room. "As the door closed a very noticeable puff of air could be felt coming through the slit in the window out into the 'clean' corridor."


Jackson noted in his e-mail that Scarborough told him the room didn't house infected animals at the moment, but there is a room with infected animals on the same corridor. He asked whether there is any risk of exposure for people walking down the hallway without respiratory protection. "Don't know whether this was a fluke or the norm, and the reason I'm commenting is one of the visitors seemed concerned and has been talking about it since we've come back," Jackson wrote.


It is unknown what answer Jackson received to his question. According to Scarborough's April 9 e-mail, CDC safety officials dismissed concerns about the incident saying "it doesn't matter if the dirty BSL 3 lab blows positive into the clean corridor as long as it is not sustained."

Scarborough called this a "totally ridiculous response" and wrote that she is "horrified and dismayed at the events surrounding safety and the fact that even though this has been taken clear up the chain of command all the way to Dr. Frieden, no one is willing to admit the mistake or more importantly fix it."


The mistake Scarborough appears to reference is a decision CDC implemented around late 2010 to re-engineer the air movement within these labs and nearby animal-holding areas. CDC engineers warned in early 2010 that reversing the airflow in this area could have "unintended consequences,"

including back-washing dirty air into clean areas when doors are opened and closed.


According to presentation slides for a February 2010 meeting about reversing the airflow in the lab and animal areas, CDC engineers Karen Moss and Tom Blanchard wrote that with the proposed changes "the potential exists to create large airflow disturbances, vortices and flow mixing between corridor and rooms will result, rooms may become same pressure as dirty corridor." If the airflow is going to be reversed, they wrote, anterooms - with negative air pressure - would need to be built to preserve airflow integrity.


The records indicate that CDC never built the anterooms, in part because of concerns about cost and time delays, and because some safety officials questioned whether they were necessary.


In a February 2010 e-mail, Blanchard proposed sending a bluntly worded memo to the agency's safety office warning that reversing the airflows in the lab area "represents an extreme departure from the existing design and operation" and that the change will result in "no safeguards against flow disturbances." It noted that there was not universal acceptance of "such a radical change" by those involved in the building, including animal staff and researchers working with tuberculosis.


After the air was reversed, air pressure problems developed in some areas resulting in fire code violations. Under certain circumstances, the pressure needed to open doors that scientists and other workers would need to escape through in an emergency is more than three times what the fire code allows, according to a contractor's report from December 2010 and an e-mail from Moss in January 2011.


The report noted: "Also, on some doors the excessive negative pressure prevented the release of the electronic security latch as commanded by the card reader; it was necessary to push/pull the door inward/outward before turning the handle and opening the door." CDC assumed responsibility for reopening the lab area with the "known code violation" and was going to begin work to address it, the contractor's report said. The CDC wouldn't say whether the problem has been fixed.


Allison Young, USA Today



7/4/2012 8:35:29 AM #


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