Don’t let the superbugs bite

But don't despair - we might be struggling but we are not beaten yet.

Evolution continues to be a bitch. Recently scientists gathered in Kensington, London, to have a good moan and to plan what can be done about it. “Superbugs and Superdrugs” is a great title for a meeting. Unfortunately the bugs seem to be more super than the drugs.

While that meeting went on, the US Centres for Disease Control and Prevention (CDC) issued a warning that we are entering a “nightmare” era. The CDC’s problem is a killer bacterium known as CRE, which is spreading in the US. Some strains of CRE are not only resistant to all antibiotics; they are also passing on that resistance to other bacteria, creating drug-resistant strains of E coli, for instance. On 11 March, Sally Davies, the UK government’s chief medical officer, asked the government to add the superbug problem to its “strategic risk register”, which highlights potentially catastrophic threats to the UK.

For a while, it all looked so good. When scientists discovered penicillin, then ever more weapons for our antibiotic arsenal, it seemed that bacteria had been defeated. The problem is, they fought back.

For all the worry over CRE, perhaps nowhere is this antibiotic resistance more evident than with tuberculosis. In the west, we won the war on TB so convincingly that receiving the BCG vaccine against it – once a waymark in British childhood – is no longer routine. Only in certain inner-city communities where migrant populations increase the likelihood of encountering the TB bacterium are children routinely immunised. However, in 2011, the World Health Organisation marked London out as the city with the highest TB infection rate in western Europe.

Many resistant bacteria originate in hospitals, where pharmaceutical regimes kill off the normal strains, making space in which bacteria that are naturally resistant can proliferate. Yet you can’t always blame the drugs. Research published at the end of February shows that drug resistance can arise even when the bacteria have never encountered a chemical meant to kill them.

In the study, E coli bacteria were made to suffer by exposing them to heat and restricting the nutrients in their environment. According to conventional wisdom, this should have kept proliferation in check – but it caused a spontaneous mutation that made the E coli resistant to rifampicin, one of the weapons in our antibiotic arsenal. What is worse is the observation that there was good reason for this mutation to arise: it made the stressful conditions more survivable. Bacteria with the mutation grew much faster.

Bacteria are survivors – if they can’t magic up a spontaneous mutation, they’ll pick one up in the street. A sampling of puddles in New Delhi showed that almost a third contain the genetic material that allows bacteria to produce an enzyme that destroys a swath of antibiotics. The NDM-1 gene is particularly evil. Its tricks include forcing itself into gut bacteria such as E coli that are incorporated into faeces; as a result, the resistant strains travel between hosts with ease.

Many infections involving a bacterium carrying NDM-1 are untreatable. GlaxoSmithKline is reportedly developing a drug to deal with it but it is years behind the curve. In the autumn, an EU project to mine the seabed for so far undiscovered antibiotics will start up, but it will take years for that, too, to bear fruit.

Let’s end on a positive note. Superbugs might be evolving in fiendish ways but they’re doing it blind and they’re up against evolution’s greatest invention – the human brain. We might be struggling but we are not beaten yet.

The EHEC bacteria. Image: Getty Images

Michael Brooks holds a PhD in quantum physics. He writes a weekly science column for the New Statesman, and his most recent book is At the Edge of Uncertainty: 11 Discoveries Taking Science by Surprise.

This article first appeared in the 25 March 2013 issue of the New Statesman, After God

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How hackers held the NHS to ransom

NHS staff found their computer screens repleaced by a padlock and a demand for money. Eerily, a junior doctor warned about such an attack days earlier. 

On Friday, doctors at Whipps Cross Hospital, east London, logged into their computers, but a strange red screen popped up. Next to a giant padlock, a message said the files on the computer had been encrypted, and would be lost forever unless $300 was sent to a Bitcoin account – a virtual currency that cannot be traced. The price doubled if the money wasn’t sent within six days. Digital clocks were counting down the time.

It was soon revealed Barts Health Trust, which runs the hospital, had been hit by ransomware, a type of malicious software that hijacks computer systems until money is paid. It was one of 48 trusts in England and 13 in Scotland affected, as well as a handful of GP practices. News reports soon broke of companies in other countries hit. It affected 200,000 victims in 150 countries, according to Europol. This included the Russian Interior Ministry, Fedex, Nissan, Vodafone and Telefonica. It is thought to be the biggest outbreak of ransomware in history.

Trusts worked all through the weekend and are now back to business as usual. But the attack revealed how easy it is to bring a hospital to its knees. Patients are rightly questioning if their medical records are safe. Others fear hackers may strike again and attack other vital systems. Defence minister Michael Fallon was forced to confirm that the Trident nuclear submarines could not be hacked.

So how did this happen? The virus, called WannaCry or WannaDecrypt0r, was an old piece of ransomware that had gained a superpower. It had been combined with a tool called EternalBlue which was developed by US National Security Agency spies and dumped on the dark web by a criminal group called Shadow Brokers. Computers become infected with ransomware when somebody clicks on a dodgy link or downloads a booby-trapped PDF, but normally another person has to be fooled for it to harm a different computer. EternalBlue meant the virus could cascade between machines within a network. It could copy itself over and over, moving from one vulnerable computer to the next, spreading like the plague. Experts cannot trace who caused it, whether a criminal gang or just one person in their bedroom hitting "send".

Like a real virus, it had to be quarantined. Trusts had to shut down computers and scan them to make sure they were bug-free. Doctors – not used to writing anything but their signature – had to go back to pen and paper. But no computers meant they couldn’t access appointments, referral letters, blood tests results or X-rays. In some hospitals computer systems controlled the phones and doors. Many declared a major incident, flagging up that they needed help. In Barts Health NHS Trust, ambulances were directed away from three A&E departments and non-urgent operations were cancelled.

The tragedy is that trusts had been warned of such an attack. Dr Krishna Chinthapalli, a junior doctor in London, wrote an eerily premonitory piece in the British Medical Journal just two days earlier telling hospitals they were vulnerable to ransomware hits. Such attacks had increased fourfold between 2015 and 2016, he said, with the money being paid to the criminals increased to $1bn, according to the FBI. NHS trusts had been hit before. A third reported a ransomware attack last year, with Imperial College London NHS Trust hit 19 times. None admitted to paying the ransom.

Hospitals had even been warned of this exact virus. It exploited a vulnerability in Microsoft Windows operating systems – but Microsoft had been tipped off about it and raised the red flag in March. It issued a patch – an update which would fix it and stop systems being breached this way. But this patch only worked for its latest operating systems. Around 5 per cent of NHS devices are still running the ancient Windows XP, the equivalent of a three-wheeled car. Microsoft said it would no longer create updates for it two years ago, rendering it obsolete.

There are many reasons why systems weren’t updated. Labour and the Lib Dems were quick to blame the attack on lack of Tory funding for the NHS. It is clear cost was an issue. Speaking on BBC Radio 4’s PM programme on Saturday, ex-chief of NHS Digital Kingsley Manning estimated it would take £100m a year to update systems and protect trusts against cyber attacks. Even if that money was granted, there is no guarantee cash-strapped trusts would ringfence it for IT; they may use it to plug holes elsewhere.

Yet even with the money to do so updating systems and applying patches in hospitals is genuinely tricky. There is no NHS-wide computer system – each trust has its own mix of software, evolved due to historical quirk. New software or machines may be coded with specific instructions to help them run. Changing the operating system could stop them working – affecting patient care. While other organisations might have time to do updates, hospital systems have to be up and running 24 hours a day, seven days a week. In small hospitals, it’s a man in a van manually updating each computer.

Some experts believe these are just excuses; that good digital hygiene kept most trusts in the UK safe. "You fix vulnerabilities in computers like you wash your hands after going to the toilet," said Professor Ross Anderson, a security engineering expert at Cambridge University. "If you don't, and patients die, excuses don't work and blame shifting must not be tolerated."

It is not known yet if any patients have died as a result of the attack, but it certainly raised fears about the safety of sensitive medical records. This particular virus got into computer files and encrypted them – turning them into gooble-de-gook and locking doctors out. Systems were breached but there have been no reports of records being extracted. Yet the scale of this attack raises fears in future the NHS could be targeted for the confidential data it holds. "If it’s vulnerable to ransomware in this way, it could be vulnerable to other attacks," said Professor Alan Woodward security expert at the University of Surrey's department of computing.

In the US, there have been examples where ransomware attacks have led to patient data being sucked out, he said. The motivation is not to embarrass people with piles or "out" women who have had an abortion, but because medical information is lucrative. It can be sold to criminals for at least $10, a price 10 times higher than can be earned by selling credit card details. Dossiers with personal identification information – known as "fullz" on the dark web – help crooks commit fraud and carry out scams. The more personal details a conman knows about you the more likely you are to fall for their hustle.

Hospital data is backed up at least hourly and three copies are kept, one offsite, so it is unlikely any medical records or significant amounts of data will have been lost – although the hack will cost the NHS millions in disruption. A British analyst, who tweets under the name Malware Tech, became an unlikely hero after accidentally finding a killswitch to stop the virus replicating. He registered a website, whose presence signalled to the virus it should stop. Yet he admits that a simple tweak of the code would create a new worm able to infect computers.

Experts warn this event could trigger a spate of copycat attacks. Hacker may turn their eyes to other public services. Dr Brian Gladman, a retired Ministry of Defence director, and ex-director of security at Nato, points out that our entire infrastructure, from the national grid, food distribution channels to the railways rely on computer systems. We now face an arms race – and criminals only have to get lucky once.

"We’re going to get more attacks and more attacks and it’s going to go on," he said. "We’ve got to pay more attention to this."

Madlen Davies is a health and science reporter at The Bureau of Investigative Journalism. She tweets @madlendavies.

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