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PITTSBURGH (KDKA) — As the coronavirus pandemic spreads from big cities to rural areas, will hospitals in these communities be ready for a surge?

“We’re the only game in town, really,” says Dr. Surabhi Gaur, the chief medical officer at Uniontown Hospital. “So if we didn’t step up and do this, nobody was going to do it.

We might not live on top of each other as they do in New York City or central Philly or even downtown Pittsburgh. But there is still a risk.”

Clarion Hospital hospitalist Dr. Catherine Cunningham says the pandemic is palpable even in her remote county. The 145-bed Uniontown Hospital has an intensive care capacity for 15. In March, hospital leaders prepared for a rush.

“We took PPE very seriously. We made sure we had equipment, how to roll that out to our employees,” says Dr. Gaur. “We converted part of our perioperative unit. We made those into critical care beds.”

With this expansion, the hospital could accommodate 28 critically ill patients. But even at the worst in the spring, it had only 10 hospitalized COVID patients, five in the ICU. And the summer pattern is different, with a higher percent positive there at 10 percent.

“In the spring, everything was locked down. And this time around, people have been milling around a lot more,” says Dr. Gaur.

Also, the average age of those needing to be admitted is younger — 75 years old in the spring compared to 60 years old now. And the people coming in do not need a ventilator.

The 80-bed Clarion Hospital has a similar observation. It has seven ICU beds and very few COVID patients.

“A total of seven or eight since the whole thing started,” says Dr. Cunningham. “We had a couple of patients in the ICU, but I see now that a lot of our patients, even when they’re positive for COVID, do not seem to be as sick as they were in March or April, and I’m grateful for that.”

Clarion Hospital has not had to transfer any patients and having a partnership and telemedicine availability with Butler Hospital helps. Both hospitals can get remdesivir or convalescent plasma with a call.

“We do have enough (remdesivir) for at least half a dozen (patients),” says Dr. Gaur. “We are part of the consortium through the Mayo Clinic to get convalescent plasma.”

While she wishes she could have a few more staff, even in the middle of nowhere, Dr. Cunningham feels ready.

“We have what we need right now. I’ve never said to anybody, ‘I just don’t have what I need,'” Dr. Cunningham said.

Part of Uniontown Hospital’s strategy is to take on the public health messaging to the community via newspaper and radio.

“We’re very pro masking, we’re very much about making good decisions, you don’t need to be in large gatherings,” says Dr. Gaur. “We want to take on some of that public health burden because we know down the road, it makes our job as hospital leaders easier.”

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FBI warns of "imminent" ransomware attacks on hospital systems

Federal agencies warned that cybercriminals are unleashing a wave of data-scrambling extortion attempts against the U.S. healthcare system designed to lock up hospital information systems, which could hurt patient care just as nationwide cases of COVID-19 are spiking.

In a joint alert Wednesday, the FBI and two federal agencies warned that they had "credible information of an increased and imminent cybercrime threat to U.S. hospitals and healthcare providers." The alert said malicious groups are targeting the sector with attacks that produce "data theft and disruption of healthcare services."

The cyberattacks involve ransomware, which scrambles data into gibberish that can only be unlocked with software keys provided once targets pay up. Independent security experts say it has already hobbled at least five U.S. hospitals this week and could impact hundreds more.

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The offensive by a Russian-speaking criminal gang coincides with the U.S. presidential election, although there is no immediate indication they were motivated by anything but profit.

"We are experiencing the most significant cyber security threat we've ever seen in the United States," Charles Carmakal, chief technical officer of the cybersecurity firm Mandiant, said in a statement.

Alex Holden, CEO of Hold Security, which has been closely tracking the ransomware in question for more than a year, agreed that the unfolding offensive is unprecedented in magnitude for the U.S. given its timing in the heat of a contentions presidential election and the worst global pandemic in a century.

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The federal alert was co-authored by the Department of Homeland Security and the Department of Health and Human Services.

Agence France-Presse notes that the agencies urged U.S. healthcare providers to take "timely and reasonable precautions" such as patching their operating systems, software and firmware as soon as possible and running antivirus and anti-malware scans regularly.

The cybercriminals launching the attacks use a strain of ransomware known as Ryuk, which is seeded through a network of zombie computers called Trickbot that Microsoft began trying to counter earlier this month.U.S. Cyber Command has also reportedly taken action against Trickbot.

While Microsoft has had considerable success knocking its command-and-control servers offline through legal action, analysts say criminals have still been finding ways to spread Ryuk.

Recent attacks

The U.S. has seen a plague of ransomware over the past 18 months or so, with major cities from Baltimore to Atlanta hit and local governments and schools hit especially hard.

In September, a ransomware attack hobbled all 250 U.S. facilities of the hospital chain Universal Health Services, forcing doctors and nurses to rely on paper and pencil for record-keeping and slowing lab work. Employees described chaotic conditions impeding patient care, including mounting emergency room waits and the failure of wireless vital-signs monitoring equipment.

Also in September, the first known fatality related to ransomware occurred in Duesseldorf, Germany, when an IT system failure forced a critically ill patient to be routed to a hospital in another city.

Holden said he alerted federal law enforcement Friday after monitoring infection attempts at a number of hospitals, some of which may have beaten back infections. The FBI didn' immediately respond to a request for comment.

He said the group was demanding ransoms well above $10 million per target and that criminals involved on the dark web were discussing plans to try to infect more than 400 hospitals, clinics and other medical facilities.

"One of the comments from the bad guys is that they are expecting to cause panic and, no, they are not hitting election systems," Holden said. "They are hitting where it hurts even more and they know it."

U.S. officials have repeatedly expressed concern about major ransomware attacks affecting the presidential election, even if the criminals are motivated chiefly by profit.

Mandiant's Carmakal identified the criminal gang as UNC1878, saying "it is deliberately targeting and disrupting U.S. hospitals, forcing them to divert patients to other healthcare providers" and producing prolonged delays in critical care.

"As hospital capacity becomes more strained by COVID-19, the danger posed by this actor will only increase," he added.

Carmakal called the eastern European group "one of most brazen, heartless, and disruptive threat actors I've observed over my career."

Kremlin links?

While no one has proven suspected ties between the Russian government and gangs that use the Trickbot platform, Holden said he has "no doubt that the Russian government is aware of this operation - of terrorism, really." He said dozens of different criminal groups use Ryuk, paying its architects a cut.

Dmitri Alperovitch, co-founder and former chief technical officer of the cybersecurity firm Crowdstrike, said there are "certainly lot of connections between Russian cyber criminals and the state," with Kremlin-employed hackers sometimes moonlighting as cyber criminals.

Neither Holden nor Carmakal would identify the affected hospitals. Four healthcare institutions have been reported hit by ransomware so far this week, three belonging to the St. Lawrence County Health System in upstate New York and the Sky Lakes Medical Center in Klamath Falls, Oregon.

Sky Lakes acknowledged the ransomware attack in an online statement, saying it had no evidence that patient information was compromised. It said emergency and urgent care "remain available" The St. Lawrence system did not immediately return phone calls seeking comment.

Increasingly, ransomware criminals are stealing data from their targets before encrypting networks, using it for extortion. They often sow the malware weeks before activating it, waiting for moments when they believe they can extract the highest payments, said Brett Callow, an analyst at the cybersecurity firm Emsisoft.

A total of 59 U.S. healthcare providers/systems have been impacted by ransomware this year, disrupting patient care at up to 510 facilities, Callow said.

Carmakal said Mandiant had provided Microsoft on Wednesday with as much detail as it could about the threat so it could distribute details to its customers. A Microsoft spokesman had no immediate comment.

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