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