This story reminds me of UCLA chemistry professor Patrick Harran. There seems to be a culture of arrogance and carelessness in elite institutions.
C.D.C. Closes Anthrax and Flu Labs After Accidents
By DONALD G. McNEIL Jr.
New York Times
JULY 11, 2014
Showing posts with label neglect. Show all posts
Showing posts with label neglect. Show all posts
Monday, July 14, 2014
Arrogance and carelessness in elite institutions: C.D.C. Closes Anthrax and Flu Labs After Accidents
After
potentially serious back-to-back laboratory accidents, federal health
officials announced Friday that they had temporarily closed the flu and
anthrax laboratories at the Centers for Disease Control and Prevention
in Atlanta and halted shipments of all infectious agents from the
agency’s highest-security labs.
The
accidents, and the C.D.C.’s emphatic response to them, could have
important consequences for the many laboratories that store high-risk
agents and the few that, even more controversially, specialize in making
them more dangerous for research purposes.
If
the C.D.C. — which the agency’s director, Dr. Thomas Frieden, called
“the reference laboratory to the world” — had multiple accidents that
could, in theory, have killed both staff members and people outside,
there will undoubtedly be calls for stricter controls on other
university, military and private laboratories.
In one episode last month, at least 62 C.D.C. employees may have been exposed to
live anthrax bacteria after potentially infectious samples were sent to
laboratories unequipped to handle them. Employees not wearing
protective gear worked with bacteria that were supposed to have been
killed but may not have been. All were offered a vaccine and
antibiotics, and the agency said it believed no one was in danger.
In
a second accident, disclosed Friday, a C.D.C. lab accidentally
contaminated a relatively benign flu sample with a dangerous H5N1 bird
flu strain that has killed 386 people since 2003. Fortunately, a United
States Agriculture Department laboratory realized that the strain was
more dangerous than expected and alerted the C.D.C.
In addition to those mistakes, Dr. Frieden also announced Friday that two of six vials of smallpox recently found stored in a National Institutes of Health laboratory since 1954 contained live virus capable of infecting people.
All
the samples will be destroyed as soon as the genomes of the virus in
them can be sequenced. The N.I.H. will scour its freezers and storerooms
for other dangerous material, he said.
“These
events revealed totally unacceptable behavior,” Dr. Frieden said. “They
should never have happened. I’m upset, I’m angry, I’ve lost sleep over
this, and I’m working on it until the issue is resolved.”
The
anthrax and flu labs will remain closed until new procedures are
imposed, Dr. Frieden said. For the flu lab, that will be finished in
time for vaccine preparation for next winter’s flu season, he said.
Dr.
William Schaffner, the head of preventive medicine at Vanderbilt
University’s medical school, said he thought all American labs should
stop shipping all hazardous agents until they have reviewed their safety
procedures. Although there is no obvious way to force them to do that,
he said, the federal grants that most labs depend on “could be the
stick.”
Dr.
Frieden himself suggested that the accidents had implications for labs
beyond his agency, arguing that the world needs to reduce to absolute
minimums the number of labs handling dangerous agents, the number of
staff members involved and the number of agents circulating.
Scientists
doing the most controversial work — efforts to make pathogens more
lethal or more transmissible — say the research helps predict mutations
that might arise in nature so that vaccines can be created. But other
scientists feel that creating superstrains is unacceptably dangerous
because lab accidents are more common than is often acknowledged, as Dr.
Frieden’s announcement indicated.
The revelations at the C.D.C. renewed calls for a moratorium by opponents of such “gain of function” research.
“This
has been a nonstop series of bombshells, and this news about
contamination with H5N1 is just incredible,” said Peter Hale, founder of
the Foundation for Vaccine Research, which lobbies for more funding for
vaccines but opposes “gain of function” research. “You can have all the
safety procedures in the world, but you can’t provide for human error.”
At
the C.D.C. itself, Dr. Frieden said, staff members who knowingly failed
to follow procedures or who failed to report dangerous incidents will
be disciplined. A committee of experts will be convened to revise
procedures.
In
the flu-related incident, a C.D.C. lab accidentally contaminated a
sample of less-dangerous H9N2 bird flu, which it was preparing for
shipment to an Agriculture Department laboratory, with the H5N1 bird flu
strain.
Though
the contamination was discovered on May 23, Dr. Frieden said that he
was dismayed to discover that senior C.D.C. officials were not informed
until July 7, and that he was told only 48 hours ago.
Nonetheless,
he said, “we have a high degree of confidence that no one was exposed.”
The flu material was handled in high-biosafety-level labs in both
agencies, and the workers wore breathing apparatuses.
In theory, the flu-related accident could have been much worse than the anthrax one.
Anthrax
can kill those who inhale it, but is not normally transmitted between
humans, so an infected laboratory worker presumably could not have gone
home and passed it on. H5N1 bird flu has killed about 60 percent of
those known to have caught it, almost always after contact with poultry.
Although it does not easily jump from person to person, it is thought
to have done so several times.
The
anthrax episode took place on June 5 in the agency’s bioterrorism rapid
response lab as part of testing a new mass spectrometry method.
The
new C.D.C. report found several errors: A scientist used a dangerous
anthrax strain when a safer one would have sufficed, had not read
relevant studies and used an unapproved chemical killing method.
The
error was discovered by accident. The door to an autoclave that would
have sterilized samples taken for safety tests was stuck, so they were
left in an incubator for days longer than normal. Only then did a lab
technician notice that bacteria believed to be dead were growing.
Later
tests done at the C.D.C. and at a Michigan State Health Department lab
as part of the investigation confirmed that the chemical method would
have killed any live, growing anthrax in the samples that were sent out,
but might not have killed all spores, which are surrounded by a hard
shell and can also be lethal.
Although
anthrax terrifies laymen, “when you work with it day in and day out,
you can get a little careless,” Dr. Frieden said. “The culture of safety
needs to improve at some C.D.C. laboratories.”
Monday, December 26, 2011
Reasons unclear for fatal CPS decision to return a child to her parents
Reasons unclear for fatal CPS decision to return a child to her parents
By Brad Branan
The Sacramento Bee
Dec. 26, 2011
Giovanni Melchor was just a year old when he drowned in the stagnant water of his family's backyard swimming pool in late 2006. The family's single-story, purple-trimmed home in south Sacramento seemed well maintained on the outside. But inside, a neighbor said, the house was infested with roaches and city inspectors later cited Giovanni's father for an unsecured pool fence, the lack of a door closing off the garage from the pool, and a host of other health and safety code violations.Not even three years later, Giovanni's sister, Yeinira, who had been removed from the home and then returned, was also dead, a victim of medical neglect by her parents. Case files from Sacramento County Child Protective Services, recently obtained by The Bee, show how the 2-year-old girl died. Court records show that her parents, Jose Jaime Melchor, 35, and Elizabeth Melchor, 29, pleaded no contest to child endangerment charges in July and were deported this year.What the records don't explain is how the agency made the decision to return the child to care that led to her death.County officials say they cannot discuss the case or the records because of confidentiality laws.But without documentation, evaluating the agency's actions is difficult, said Ed Howard, senior counsel at the Children's Advocacy Institute in San Diego, who reviewed Yeinira's file at the request of The Bee."If we take them at face value – that there is no documentation for reuniting this child with a very troubled family – then this is a fiasco," Howard said. "You can't do this job without documenting your reasons for making such a decision."Specifically, CPS records for Yeinira do not show whether the agency conducted an assessment about the risk of returning her to the home – using what's called the Structured Decision Making tool – in violation of its own policies."In all of its reports, the (CPS) Oversight Committee has recommended comprehensive and consistent use of the tool," said Gina Roberson, co-chair of the committee. "It means social workers are using the best practices in trying to prevent child abuse."The CPS Oversight Committee, echoing the complaints of experts and child welfare advocates, has repeatedly found the agency's social workers have made questionable decisions and serious errors in high-risk cases such as the Melchor's. That assessment was repeated in other reports this year, including one by the California State Auditor.CPS released two sets of files on the Yeinira case. The first contained 12 pages and no information about the family's extensive record with CPS. The second, released after The Bee requested it under the California Public Records Act, had 124 pages.County Health and Human Services Director Ann Edwards said the release of the incomplete file was unintentional. But neither set answers the questions about the fatal decision to return her to her parents. A troubled historyThe year Giovanni died, the Melchors were living in a working-class neighborhood on Center Parkway. They had five children.Neighbors, attorneys and a social worker who had contact over the years with the Melchors, an immigrant family from Mexico, said the family needed help. They said Elizabeth Melchor seemed incapable of caring for her children and, according to court records, Jose Jaime Melchor physically abused his wife.Five reports of alleged abuse or neglect involving the family were made to CPS prior to Yeinira's birth in July 2006, court records show.Some of the reports involved the father, who allegedly had a drinking problem and abused his wife, according to court and CPS files. Other reports involved the mother, accused of hitting the children. Two of the reports were upheld by CPS.Yeinira had a heart defect and a cleft palate that made feeding her difficult. Less than a month after she was born, CPS received another complaint, noting the mother wasn't learning how to take care of her fragile daughter. The child was still in the hospital and at risk of dehydration if not properly nourished.Melchor "admits she is depressed and overwhelmed," according to an unidentified reporter quoted in the CPS case file. The mother and the father were refusing the training needed to feed Yeinira, according to the report. The source recommended placing Yeinira in a special foster home for her medical needs.The complaint was upheld. CPS started monitoring the child, but allowed her to go home with her mother. Yvette Washington, a home visitation worker with the county's Birth and Beyond program, was assigned to counsel the family."She seemed withdrawn," Washington said of Elizabeth Melchor in an interview with The Bee.Washington said she brought a public health nurse to the family's home to explain the risks of having a pool with stagnant water and a small and unsecured fence.The mother didn't seem to take the matter seriously, Washington said, adding that she stopped providing service to the family in 2006 because Melchor was unreceptive.Giovanni drowned in October that year. Melchor told police she was taking care of Yeinira, and left her other children unattended in the garage for about an hour, records show. Giovanni apparently wandered from the garage and into the pool.Police found the missing garage door and the unsecured pool fence. Neither parent was charged. CPS also initially declined to take protective action, determining that an allegation of neglect was unfounded, court records show.That reluctance befuddled some of the Melchors' neighbors.Andrea Garcia, who lived next door to the family, said the Melchors were troubled. Her interactions with the family usually came when something went wrong, she said, such as when the children were left outside in diapers in cold weather.The Garcias watched the other Melchor children while the parents dealt with the emergency of finding Giovanni in the pool.Andrea Garcia said the children were filthy. She said she entered the Melchor home for clean clothes and saw cockroaches everywhere.Her father, Jesus Garcia, said he had worried about the safety of the Melchor children under their mother's care."We never understood why CPS let her keep the kids," he said.Taken away, brought backTen months after the drowning, the four Melchor children became dependents of the county as a result of abuse and neglect, court records show.In Yeinira's case, her parents repeatedly failed to bring her to doctor's appointments, CPS records show. She missed eight appointments in seven months. Doctor's notes indicated a growing concern about her well-being.In foster care, she had surgery for her ailments and had recovered well. But in May 2008, less than two months after her surgery, Yeinira returned to her parents' home, joining her siblings who had been reunited with them several months earlier.To place a foster child back in a parent's home, CPS must convince a dependency court judge that the conditions that originally made the home unsafe had been fixed. For Yeinira, CPS needed to ensure the issues at home had been addressed, said Bill Grimm, senior counsel at the National Center for Youth Law in Oakland, who reviewed the child's file at The Bee's request."Given all that was going on before, there was a pretty high threshold for them to resume care," Grimm said.The lack of documentation calls the agency's decisions into question, said Grimm, adding that returning Yeinira home without doing a risk assessment would have been a serious error, if that's what happened.Without careAfter Yeinira returned, she did not see a doctor for about a year because the family didn't have insurance, her father told Sacramento police investigators in 2009.During that time, Yeinira had a seizure, her mother told police. She said she put rubbing alcohol on a cotton ball and placed it under Yeinira's nose to revive her.A couple of months later, Yeinira had another seizure. Yeinira "fell back, arched her back, and her feet twisted" as she fell onto concrete, her mother said, according to the investigative report. She again used rubbing alcohol and an onion to revive Yeinira.The problem returned the next day, as Yeinira "fell forward, and her head hit the wall and her eyes went up," her mother said.Again, Melchor turned to an onion and rubbing alcohol to revive her daughter. Her father was holding Yeinira in his lap when the mother noticed Yeinira wasn't breathing, she told investigators.The father brought her to Kaiser Permanente Medical Center, south Sacramento, minutes away from their home. Two days later, April 20, 2009, Yeinira died at Kaiser's Roseville hospital because of a lack of oxygen in the brain, an autopsy found.The Coroner's Office said physical abuse also may have contributed to her death, noting that she'd had a broken arm and other recent injuries.In court documents, Dr. Michael Myette of Kaiser said he could say with "95 percent to 99 percent certainty that if the parents had accessed care when she began seizing, she would still be alive."One of the Melchors' attorneys, Lori Calvert, said the couple grew up without doctors and that Elizabeth Melchor had been taught to revive her mother, who also suffered from seizures, as she had revived Yeinira.The Melchors faced a number of obstacles, their attorneys said. They were illiterate in their native Spanish, couldn't speak English and were poor.The prosecutor handling their neglect case agreed and cited those factors when explaining to a judge why she sought approval for a plea agreement resulting in a two-year jail sentence for the Melchors, the lowest under sentencing guidelines.The judge agreed to the sentencing recommendation. The Melchors had served about a year in jail awaiting trial and, with various credits, were released in July after pleading no contest to the charges. They were deported to Mexico shortly afterward, without any of their children. Their attorneys said the children were put up for adoption by the county.
By Brad Branan
The Sacramento Bee
Dec. 26, 2011
Giovanni Melchor was just a year old when he drowned in the stagnant water of his family's backyard swimming pool in late 2006. The family's single-story, purple-trimmed home in south Sacramento seemed well maintained on the outside. But inside, a neighbor said, the house was infested with roaches and city inspectors later cited Giovanni's father for an unsecured pool fence, the lack of a door closing off the garage from the pool, and a host of other health and safety code violations.Not even three years later, Giovanni's sister, Yeinira, who had been removed from the home and then returned, was also dead, a victim of medical neglect by her parents. Case files from Sacramento County Child Protective Services, recently obtained by The Bee, show how the 2-year-old girl died. Court records show that her parents, Jose Jaime Melchor, 35, and Elizabeth Melchor, 29, pleaded no contest to child endangerment charges in July and were deported this year.What the records don't explain is how the agency made the decision to return the child to care that led to her death.County officials say they cannot discuss the case or the records because of confidentiality laws.But without documentation, evaluating the agency's actions is difficult, said Ed Howard, senior counsel at the Children's Advocacy Institute in San Diego, who reviewed Yeinira's file at the request of The Bee."If we take them at face value – that there is no documentation for reuniting this child with a very troubled family – then this is a fiasco," Howard said. "You can't do this job without documenting your reasons for making such a decision."Specifically, CPS records for Yeinira do not show whether the agency conducted an assessment about the risk of returning her to the home – using what's called the Structured Decision Making tool – in violation of its own policies."In all of its reports, the (CPS) Oversight Committee has recommended comprehensive and consistent use of the tool," said Gina Roberson, co-chair of the committee. "It means social workers are using the best practices in trying to prevent child abuse."The CPS Oversight Committee, echoing the complaints of experts and child welfare advocates, has repeatedly found the agency's social workers have made questionable decisions and serious errors in high-risk cases such as the Melchor's. That assessment was repeated in other reports this year, including one by the California State Auditor.CPS released two sets of files on the Yeinira case. The first contained 12 pages and no information about the family's extensive record with CPS. The second, released after The Bee requested it under the California Public Records Act, had 124 pages.County Health and Human Services Director Ann Edwards said the release of the incomplete file was unintentional. But neither set answers the questions about the fatal decision to return her to her parents. A troubled historyThe year Giovanni died, the Melchors were living in a working-class neighborhood on Center Parkway. They had five children.Neighbors, attorneys and a social worker who had contact over the years with the Melchors, an immigrant family from Mexico, said the family needed help. They said Elizabeth Melchor seemed incapable of caring for her children and, according to court records, Jose Jaime Melchor physically abused his wife.Five reports of alleged abuse or neglect involving the family were made to CPS prior to Yeinira's birth in July 2006, court records show.Some of the reports involved the father, who allegedly had a drinking problem and abused his wife, according to court and CPS files. Other reports involved the mother, accused of hitting the children. Two of the reports were upheld by CPS.Yeinira had a heart defect and a cleft palate that made feeding her difficult. Less than a month after she was born, CPS received another complaint, noting the mother wasn't learning how to take care of her fragile daughter. The child was still in the hospital and at risk of dehydration if not properly nourished.Melchor "admits she is depressed and overwhelmed," according to an unidentified reporter quoted in the CPS case file. The mother and the father were refusing the training needed to feed Yeinira, according to the report. The source recommended placing Yeinira in a special foster home for her medical needs.The complaint was upheld. CPS started monitoring the child, but allowed her to go home with her mother. Yvette Washington, a home visitation worker with the county's Birth and Beyond program, was assigned to counsel the family."She seemed withdrawn," Washington said of Elizabeth Melchor in an interview with The Bee.Washington said she brought a public health nurse to the family's home to explain the risks of having a pool with stagnant water and a small and unsecured fence.The mother didn't seem to take the matter seriously, Washington said, adding that she stopped providing service to the family in 2006 because Melchor was unreceptive.Giovanni drowned in October that year. Melchor told police she was taking care of Yeinira, and left her other children unattended in the garage for about an hour, records show. Giovanni apparently wandered from the garage and into the pool.Police found the missing garage door and the unsecured pool fence. Neither parent was charged. CPS also initially declined to take protective action, determining that an allegation of neglect was unfounded, court records show.That reluctance befuddled some of the Melchors' neighbors.Andrea Garcia, who lived next door to the family, said the Melchors were troubled. Her interactions with the family usually came when something went wrong, she said, such as when the children were left outside in diapers in cold weather.The Garcias watched the other Melchor children while the parents dealt with the emergency of finding Giovanni in the pool.Andrea Garcia said the children were filthy. She said she entered the Melchor home for clean clothes and saw cockroaches everywhere.Her father, Jesus Garcia, said he had worried about the safety of the Melchor children under their mother's care."We never understood why CPS let her keep the kids," he said.Taken away, brought backTen months after the drowning, the four Melchor children became dependents of the county as a result of abuse and neglect, court records show.In Yeinira's case, her parents repeatedly failed to bring her to doctor's appointments, CPS records show. She missed eight appointments in seven months. Doctor's notes indicated a growing concern about her well-being.In foster care, she had surgery for her ailments and had recovered well. But in May 2008, less than two months after her surgery, Yeinira returned to her parents' home, joining her siblings who had been reunited with them several months earlier.To place a foster child back in a parent's home, CPS must convince a dependency court judge that the conditions that originally made the home unsafe had been fixed. For Yeinira, CPS needed to ensure the issues at home had been addressed, said Bill Grimm, senior counsel at the National Center for Youth Law in Oakland, who reviewed the child's file at The Bee's request."Given all that was going on before, there was a pretty high threshold for them to resume care," Grimm said.The lack of documentation calls the agency's decisions into question, said Grimm, adding that returning Yeinira home without doing a risk assessment would have been a serious error, if that's what happened.Without careAfter Yeinira returned, she did not see a doctor for about a year because the family didn't have insurance, her father told Sacramento police investigators in 2009.During that time, Yeinira had a seizure, her mother told police. She said she put rubbing alcohol on a cotton ball and placed it under Yeinira's nose to revive her.A couple of months later, Yeinira had another seizure. Yeinira "fell back, arched her back, and her feet twisted" as she fell onto concrete, her mother said, according to the investigative report. She again used rubbing alcohol and an onion to revive Yeinira.The problem returned the next day, as Yeinira "fell forward, and her head hit the wall and her eyes went up," her mother said.Again, Melchor turned to an onion and rubbing alcohol to revive her daughter. Her father was holding Yeinira in his lap when the mother noticed Yeinira wasn't breathing, she told investigators.The father brought her to Kaiser Permanente Medical Center, south Sacramento, minutes away from their home. Two days later, April 20, 2009, Yeinira died at Kaiser's Roseville hospital because of a lack of oxygen in the brain, an autopsy found.The Coroner's Office said physical abuse also may have contributed to her death, noting that she'd had a broken arm and other recent injuries.In court documents, Dr. Michael Myette of Kaiser said he could say with "95 percent to 99 percent certainty that if the parents had accessed care when she began seizing, she would still be alive."One of the Melchors' attorneys, Lori Calvert, said the couple grew up without doctors and that Elizabeth Melchor had been taught to revive her mother, who also suffered from seizures, as she had revived Yeinira.The Melchors faced a number of obstacles, their attorneys said. They were illiterate in their native Spanish, couldn't speak English and were poor.The prosecutor handling their neglect case agreed and cited those factors when explaining to a judge why she sought approval for a plea agreement resulting in a two-year jail sentence for the Melchors, the lowest under sentencing guidelines.The judge agreed to the sentencing recommendation. The Melchors had served about a year in jail awaiting trial and, with various credits, were released in July after pleading no contest to the charges. They were deported to Mexico shortly afterward, without any of their children. Their attorneys said the children were put up for adoption by the county.
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