Lab Safety Report on Ebola Virus Transfer

The Centers for Disease Control and Prevention is reporting today that a small amount of material from an Ebola virus experiment that was securely transported from a Select‐Agent‐approved BSL‐4 lab to a Select‐Agent‐approved BSL‐2 lab may have contained live virus. The material was on a sealed plate but should not have been moved into the BSL‐2 laboratory. We cannot rule out possible exposure of the one laboratory technician who worked with the material in the BSL‐2 laboratory.

There was no possible exposure outside the secure laboratory at CDC and no exposure or risk to the public. The event was discovered by the laboratory scientists yesterday, December 23, and reported to leadership within an hour of the discovery.

The event is under internal investigation by CDC, was reported to Secretary of Health and Human Services Sylvia Burwell, and reporting to the internal and national Select Agent Programs has been initiated. CDC will provide a report on the event when the investigation concludes. The BSL‐2 laboratory area had already been 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 BSL‐4 lab have been stopped while the review is taking place.

"I am troubled by this incident in our Ebola research laboratory in Atlanta," said CDC Director Tom Frieden, M.D., M.P.H. "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."

CDC will continue to provide support during the Ebola epidemic through its research and diagnostic lab work. Skilled lab scientists in the Ebola response are valued contributors to ending this epidemic.

Based on what was learned during the lab science and safety reviews earlier this year, CDC has taken several immediate actions in this incident including closure of the laboratory, notification of staff, initiation of a complete internal review, and notifications of regulatory oversight agencies. This review will give us a clear understanding of what happened in this case and what can be done to further improve laboratory safety.

CDC has established a CDC‐wide single point of accountability for laboratory science and safety and this will aid in ensuring accountability in this situation.

CDC will also report this event to its external advisory committee which provides ongoing advice and direction for laboratory science and safety.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES