professor raina macintyre - university of nsw - emerging bioterrorism threats
TRANSCRIPT
School of Public Health and Community Medicine
Emerging threats in
Bioterrorism
Professor C Raina MacIntyre
Police Technology Conference 2016
I acknowledge the Ngunnawal people as the traditional owners of the land
Days after the Paris Terror
attacks, protective suits and
PPE were stolen from
Paris's Necker hospital,
sparking fears of a
bioterrorism attack. "Theft of
A Dozen Protective Suits
Invokes French Prime
Minister Warnings of the
Threat of a Biological Attack
in Paris
History
•Common – all through history
• Biowarfare dates back at least to 300 B.C, when the Greeks,
Romans and Persians used cadavers to contaminate water
supplies
•Biological agents, like any other weapon, will be used if
available to those with intent to harm.
•May be unrecognised by health authorities and invisible to law
enforcement
•http://www.cs.amedd.army.mil/borden/Portlet.aspx?ID=66cffe45-c1b8-4453-
91e0-9275007fd157
The game changer - genetic engineering
• If a method for hacking bank accounts is published on the
Internet, will it used by criminals?
• If a method creating a 3D printer gun is published on the
Internet, will criminals use it?
• If a method for engineering deadly super-viruses is
available on the Internet, will terrorists use it?
• Methods ARE publicly available
• So if an engineered outbreak occurs, how do we know it’s
unnatural?
CC. Wikimedia. https://commons.wikimedia.org/wiki/File:Hacker_-_Hacking_-_Symbol.jpg
Natural or unnatural?
Source: Wikipedia. CC https://en.wikipedia.org/wiki/Oklahoma_City_bombing Source: CC YANG WEIHUA/CHINAFOTOPRESS/GETTY IMAGES
Salmonella outbreak in 1984
Natural or unnatural?
• Key difference of bioterrorism from other terrorism is the difficulty of recognising it.
• Most category A bioterrorism agents occur in nature – Ebola, plague, anthrax.
• The only BT that can be recognised instantly is that involving an eradicated organism – smallpox.
• Default assumption by public health officials of natural epidemics
• New pathogens which are not on the list – eg SARS, MERS Cov, avian influenza – how do you determine if emerged naturally or unnaturally?
Bioterrorism cannot be identified unless… 1. The possibility is considered
2. If you assume that all epidemics are natural, you will never
detect unnatural ones
3. Public health authorities need to ask whether patterns are
natural or unnatural, and refer suspicious epidemics to law
enforcement professionals
4. Substantial capability needed in law enforcement
5. Coordinated and collaborative approaches are needed to
investigate.
6. Proof of BT can only be obtained by law enforcement – public
health authorities do not have the tools to prove BT, only to
raise a suspicion.
Terrorism
• No universally agreed definition
• First used in France to describe the systematic use of terror
by the French government in 1793
• The term has changed in meaning throughout history, and
now often used to describe actions of non-state actors against
states.
• Most definitions include the use or threat of serious violence
to elicit “terror”
• Distinction between private (eg domestic violence/terror) and
public violence/terror.
Bioterrorism
“A bioterrorism attack is the deliberate release of viruses,
bacteria, or other germs (agents) used to cause illness or death in
people, animals, or plants.”*
• The scope of this definition is unclear
• How many people? One or many?
• Motives (private vs public violence)?
• Creation of terror depends on awareness of the threat – what
about deliberate epidemics which are not recognised as such?
*US CDC - http://www.bt.cdc.gov/bioterrorism/overview.asp
An artificial divide • Biological agents as weapons (bioweapons) – used against an
individual as a gun may be used; or against populations as a bomb
may be used.
• Artificial to separation of response capability and define
“bioterrorism” based on motive (public terror)
• A bioweapon used against one person could spark an epidemic
because of contagion
• Who is responsible for everything else, when the end result is the
same for the population?
• .
Key differences between terrorism and
bioterrorism
Terrorism Bioterrorism
Weapon Visible (macroscopic) Invisible (microscopic)
Attack Recognisable as
unnatural
May appear natural (stealth)
Terror Present May be absent (if not recognised
as an attack)
Target Often many people Many people or one person, but
one infected person can infect
others and result in an epidemic
Is “bioterrorism” a misnomer?
What are infectious diseases?
A range of different clinical syndromes caused by different pathogens which can infect humans in different ways and are spread by different routes. Infections are caused by:
• Bacteria (eg anthrax, plague)
• Viruses (eg influenza, Ebola, smallpox)
• Fungi (eg Candida)
• Parasites (eg malaria)
• Prions (eg CJD – “mad cow disease”)
What’s unique about infections?
• Infectious diseases are unique because they
have the capacity to be transmitted (from human
to human or animal to human)
• Potential for epidemics
Routes of transmission
• Person to person (smallpox, influenza)
• – infection of one person can spark an epidemic
• Soil/water/food/vehicle to person
• (salmonella, anthrax) – point source outbreaks
• Vector (animal or insect) to person (plague, tularemia) – continuing vector borne outbreaks (eg tularemia in Kosovo)
Person-to-person transmission • Respiratory (measles, influenza)
• Faecal-oral (hepatitis A, rotavirus)
• Fomite/contact (Norovirus, Ebola)
• Sexual (HIV, Syphillis)
• Blood-borne (Hepatitis B, C, HIV)
• Vertical (HIV, hepatitis B)
Many pathogens have multiple modes of transmission, with one dominant mode.
Source: CDC Public Health Image Library
http://phil.cdc.gov/phil/details.asp?pid=11162
Vectors for bioweapons?
Biological Weapons Convention
• First multilateral disarmament treaty banning an entire
category of weapons .
• Supplement to the 1925 Geneva Protocol.
• Opened for signature in 1972 and implemented in 1975 –
ratified by 22 countries including the US and USSR.
• Not enforceable or auditable.
•7th review in 2011
•Assumes major threat and activity in biological weapons
development is from states •Outdated concepts
http://www.un.org/disarmament/WMD/Bio/
Classification of bioterrorism agents
Category A agents
• Anthrax
• Smallpox
• Plague
• Botulism
• Tularemia
• Viral Haemorrhagic fevers Ebola, Marburg, Lassa fever, New World arenaviruses,
Rift Valley fever, yellow fever, Kyasanur Forest disease
and Omsk hemorrhagic fever viruses
Viral Haemorrhagic fevers • Many different VHFs endemic worldwide
•Currently: yellow fever in Angola; Lassa fever in Nigeria
•Of human to human transmissible VHFs, Ebola has caused an
unprecedented epidemic in 2014
•First time documented in West Africa
•First time Ebola has occurred in more than 1 country
simultaneously
•First time in capital cities
•2 genetically different Ebola outbreaks (DR Congo and West
Africa), and Marburg outbreak in Uganda simultaneously in 2014
•High genetic mutation rate
•Outpaced control efforts throughout most of 2014
•Resurgence in Guinea 2016
•How would an unnatural Ebola epidemic look compared to a
natural one?
What is DURC?
• Dual Use Research of Concern
• More commonly known as “Gain of Function”
research (GOF) or GOF of concern (GOFoc)
• Research intended to benefit humankind, but
which can also result in harm.
• Harm can occur generally by two mechanisms:
a laboratory accident, or deliberate release.
• DURC has been controversial since 2011, when
scientists sought to publish methods for
engineering of an avian influenza virus to make
it contagious in humans.
CC. Source: https://en.wikipedia.org/wiki/Influenza
Types of dual-use research
1. Synthetic genomics – first synthetic virus created in 2002;
no industry-wide regulation
>50 private companies in the US, China and Europe
Guidance on voluntary screening of orders for suspicious
sequences
2. Genetic modification of pathogens
Documented since the Soviet bioweapons program
H5N1 avian influenza controversy
CC. Source: https://en.wikipedia.org/wiki/Influenza
H5N1 – bird flu, not human flu
• H5N1 – highly pathogenic avian influenza virus which
emerged in 1997, and spread globally in birds.
• 844 human cases worldwide*, mostly in Indonesia and
more recently, Egypt
• Not transmissible from human to human
• Majority of human cases had close contact with sick or
dead poultry/birds
• Sparked pandemic fears and global pandemic planning
since 2005
*January 2014, WHO. Image Source: http://www.who.int/influenza/human_animal_interface/EN_GIP_20140124CumulativeNumberH5N1cases.pdf
Rationale for creation of transmissible H5N1
• A pandemic may arise from random natural
mutation of H5N1, which is not infectious
between people
• More research needed to anticipate and prepare
for this possibility. This MAY help with drugs and
vaccines.
• Genetic engineering to create mutant H5N1
which can be spread between people.
To publish or not to publish?
• Dec 2011 to May 2012, voluntary moratorium on
engineered H5N1 research
• Scientific community divided – censorship of science vs
risk of bioterrorism
• 2012, publication allowed
• The gates are open, the horse has bolted
Insider threat: “trust me, I’m a scientist/doctor/professor”
• Numerous cases of misconduct in science, some
involving infectious diseases.
• Insider threat – a real issue
• US Commission on the Prevention of Weapons of Mass
Destruction Proliferation and Terrorism: ‘Given the high level of knowhow needed ..(we) should be less concerned that terrorists will become biologists and far
more concerned that biologists will become terrorists.’
• 2001 anthrax attacks in the US and subsequent
investigation of a US Army scientist as the main suspect
led to “The Fink Report” 2004.
Insider threat
• Seen an stealing of secrets in other crime, but in biological
sciences may include illegal, risky research.
• The same factors apply as for other crimes: greed,
revenge, divided loyalty, blackmail, ego, work or family
problems or ideology.
• Additional factors: patents on drugs and vaccines, fame,
high impact publications, grant funding, funding of
laboratories. Who profits?
• Lone wolf or colluding with outside groups.
• Terrorist groups may seek to infiltrate labs from grass roots
(junior scientist “sleepers”, PhD students), or may co-opt
scientists within.
• Universities, defence and research institutions at high risk
Where does DURC occur?
• Universities
• Scientific institutions
• DIY labs
• Homes
• Anywhere
DIY Biology
– anyone, anywhere
Even in Sydney
New toys, freely available
Regulation
• Universities and research
institutes regulated
• DIY biology poorly
regulated, guided by
“codes of conduct”. No
ethical oversight.
• Research that would not be
approved in universities
can be conducted in DIY
labs.
• Difficult to monitor in the
community
Keeping up with rapid developments in science
• Systems and policies lagging behind
momentous changes in science
• Regulation of science vs freedom for
researchers
• Rights of scientists vs the public interest
• Explosion in DIY Biology
• Conflict of interest poorly addressed in
biosecurity
• The threat is here and accessible
• How prepared is law enforcement?
• Is it core business?
How would biological agents be used as weapons?
The target:
• Mass harm/killing
• Targeted assassination
• Disabling the enemy – en masse or key individuals.
The mode:
• By stealth (to appear natural) – can still create terror due
to fear of epidemics
• Overt (attacks will create “terror” as intended in
“terrorism”, but only eradicated organisms will
immediately be recognised as an attack)
• Historical attacks very rarely overt – biowarfare realised
later, after the event, rarely recognised at the time.
Mass harm
• One hit or ongoing epidemic?
• One hit – example anthrax, or point source food outbreak, no
further spread after initial attack.
• If agent is highly infectious, a single or few releases will
result in an epidemic or pandemic.
• Therefore distinguishing natural from unnatural pandemic
very difficult for a highly infectious agent, once the epidemic
has been initiated.
• If low infectious potential, multiple, ongoing releases
required to simulate a “natural” epidemic. Pattern might be
aberrant.
• Distinguishing natural from unnatural epidemics is absent
from public health training, practice and discourse.
Red flags for planned attack
• For surveillance/epidemic intelligence – precursor attacks of
smaller scale may precede main attack.
• May see “testing” of naturally occurring agents on Cat A list
• If genetic engineering is involved, may see multiple
outbreaks of related but different pathogens (“field testing”)
• May see multiple genetic variants detected at same or
similar time, even in the same outbreak
• May see multiple outbreaks of a desired syndrome (eg
pneumonia, encephalitis) caused by different pathogens,
clustered in time.
• May see discrepant epidemiologic pattern
• Dead animals or birds
Targeted attacks
• To disable or remove critical targets
• Likely done to appear “natural” (so homicide not suspected)
• If designed to appear “natural”, such an attack would not
involve agents such as anthrax of smallpox.
• May involve an agent which causes rapid onset severe
illness (eg salmonella, influenza)
• May involve an agent with a longer onset but universally
fatal outcome – eg vCJD
• One target may experience multiple (serial) attacks
(abnormal frequency of infections, more severe infections)
Mode of transmission determines mode of attack
• Agents spread by contact easier to use as a
weapon
• Airborne pathogens require aerosolisation.
• Aerosolisation through air-conditioners,
ventilation systems, cooling towers easier than
through a customised weapon.
• Viability of organism in environment determines
timing of attack.
Image source: Pixabay
Aerosol
• If direct aerosolisation into surrounding air, efficacy
depends on how long the pathogen persists in the air
• Influenza can persist 3 hours + in the air
• Aircraft known for transmission of airborne pathogens
(eg TB).
• Overhead spraying by crop duster planes traditionally
thought of, but would be obvious and visible
• Ventilation systems, cooling towers, air conditioning
systems more likely to be used than direct spraying.
Image sourced from: commons.wikimedia.
Direct contact
Images sourced from: Pixabay and commons.wikimedia.
Blood borne
Dose response relationship
• The higher the dose of exposure, the shorter the
incubation period, and the more severe the symptoms
and illness.
• Deliberate attack would likely involve much higher doses
than natural exposure, and therefore more severe illness
and quicker onset.
• For any infection, there is an expected distribution of
severity (from asymptomatic to death).
• Clusters of infection that show a higher than expected
rate of severe infection, shorter mean incubation than
expected, (or recurrent severe infections in a single
individual with normal immune function) could flag
potential bioweapon.
Potential locations for targeted attacks
Images sourced from: Flickr (CC), Pixabay, pexels.com and commons.wikimedia.
Potential locations for mass attacks
The multi-dimensional nature of crime and
terrorism
• In this day and age, a raid on a premise suspected of
containing weapons, may also contain drugs and
biologicals.
• Law enforcement must assume the potential for
biological substances
• Know what to look for
• Be protected - PPE
Image source: AFR http://www.afr.com/opinion/columnists/terror-laws-we-must-strike-balance-between-safety-and-liberty-20150709-gi8k9t
PPE
First responders to BT incident or lab raid
• Precautionary principle
• Assume worst case scenario
and protect responders maximally
• Police, paramedics at greatest risk because of frontline
role and less awareness
• Organisational culture
Image source: Wikimedia https://upload.wikimedia.org/wikipedia/commons/8/8d/Disp-med-ppe.jpg
PPE for unknown hazard – assume the worst
• All skin, hair and mucous
membranes should be covered.
• Water-resistant materials
• Double gloves
• Gown or suit
• Apron
• Boots or rubber shoes with
shoe/boot covers to knee
• Head and neck cover
• Goggles or face shield
• Disposable suit underneath
• Order of donning and doffing
matters
Donning and doffing
• Removal of PPE must be done safely, and observed
(risk of self-contamination)
• Contained area for removal of PPE
• Removal (doffing) poses the highest risk of self-
contamination
• Order of donning (dressing) determines risk of doffing
• In the case of serious infection hazard (eg Ebola)
clothing used at the scene must not be taken home
• Video protocols available
Image source: Herald Sun. Picture by Jake Nowakowski http://www.heraldsun.com.au/news/victoria/spy-agencies-to-receive-450m-in-federal-
budget-to-take-the-fight-to-homegrown-terrorists/news-story/3b65936da3f9da8cda8d2c259d0af4a0
An epidemic emergency
Systems, accountability and integration
health police military
Emergency
services
Law,
ethics,
other ? ? ? ?
Global response?
Traditional preparedness planning
• Uses cat A, B, C framework
• Legal framework of biological weapons convention focuses on
state actors
• Planning often assumes recognition of biothreat
• Public health response draws heavily on pandemic planning (not
always appropriate)
• Health systems capacity a key limiting factor
• Surge capacity planning
• Front line role of law enforcement not integrated in planning
• Critical infrastructure (often assumed to be functioning)
• High level inter-sectoral committees, reactive, often lacking
content expertise
• Lack of global governance and coordination
Escalation of threat, evasion from detection
• Criminals and terrorists who previously worked in silos now
connected in extensive global communities on the dark web.
• New ways of colluding
• Coalescence and collaboration between organised crime,
terrorists, insiders and other groups
• How do you identify an insider networking on the dark web?
• Under the radar, detection difficult (eg Silk Road)
• Easy access to technologies and weapons, including
bioweapons
• Payment by Bitcoins
• Law enforcement – working with outdated laws, in outdated
frameworks which do not account for complexities of current
landscape
Laws need to be appropriate for the speed of
epidemics
• US anthrax attacks/Ivins case – investigation took 7 years
before charges could be laid.
• Rajneesh salmonella case – 12 months before FBI raided
the Rajneesh lab.
• An epidemic can spread around the world in days to
weeks
• The rights of the public must override the rights of
suspects working with dangerous pathogens
A perfect storm for biosecurity
Increased risk of pandemics of natural or unnatural origin
Poor mechanisms for regulation, response and mitigation
Lack of global
governance
Genetic engineering
of pathogens
Insider threat
Emerging
infectious
diseases
Lab accidents
Bioterrorism
DIY science
Finally….. medicine as a weapon
Time for quantum change in approaches to
biosecurity
• New developments in science need new tools, new
approaches, new systems and frameworks, new ways of
thinking about bioterrorism and biosecurity.
• Substantial capability in biosecurity needed
• If not law enforcement, then who?
• https://www.youtube.com/watch?v=KYyOyLg-aHU
• https://www.youtube.com/playlist?list=PLHSIfioizVW29tfr
qDW6s1Aw9XgfpJU8W
ISER: new Centre in Epidemic Response
• NHMRC funded Centre, 5 years funding from 2016.
• Conceived during the 2014 Ebola epidemic and observations of
systems failures and global nature of the problems, on the
background of long-term thinking about gaps in epidemic response.
• Team of experts in epidemic response, military experts, international
law and risk science experts, and government and non-government
agencies involved in epidemic response.
• Partners in Australia, New Zealand, USA, China, Malaysia and
Indonesia.
• Research, collaboration and capacity building for epidemic control.
• Biosecurity and epidemic intelligence focus.
• https://sphcm.med.unsw.edu.au/centres-units/centre-research-
excellence-epidemic-response
ISER Academy
• A think-tank and convenor of
important dialogue, capacity building
and generation of ideas, between all
stakeholders and sectors involved in
epidemic response.
• Inclusive
• Building of linkages between
• sectors at the grass roots level
• 1st stakeholder workshop
May 23rd, Canberra
• All stakeholders welcome
Thank you