Protecting building environments from airborne chemical, biologic, or radiologic attacks

In November 2001, following the discovery that letters containing Bacillus anthracis had been mailed to targeted locations in the United States, the Secretary of the U.S. Department of Health and Human Services requested site assessments of an array of public- and private-sector buildings by a team of engineers and scientists from CDC's National Institute for Occupational Safety and Health (NIOSH). In November 2001, this team assessed six buildings, including a large hospital and medical research facility, a museum, a transportation building, two large office buildings, and an office/laboratory building. In January 2002, additional building assessments were conducted at CDC campuses in Atlanta and, in April 2002, at a large, urban transportation facility. A total of 59 buildings were evaluated during this 5-month period.

Chemical-biological-radiological (CBR) response: a template for hospital emergency departments

Chemical, biological and radiological (CBR) incidents have the potential to shut down emergency departments that do not have an adequate CBR response. Secondary contamination also poses a threat to the safety and wellbeing of staff and other patients. On activation of a CBR response, "clean" and "contaminated" areas should be clearly marked, and all patients decontaminated before being allowed into the emergency department or outpatients department. Personal protective equipment (PPE) is needed for all staff. Staff using PPE must be monitored for signs of heat illness. Stocks of coveralls, bags for contaminated clothes, plastic sheeting for radiological incidents, barriers for crowd control, and selected drugs should be obtained. Staff required include medical, nursing, security, clerical, orderlies, patient care assistants and other staff, depending on the type of threat. An on-call roster that allows regular rotation of staff is needed. All hospital personnel should understand the response plan, and recognise that the emergency department and hospital is a community asset that requires protection.

Chemical and biological weapons. Implications for anaesthesia and intensive care

In the wake of recent atrocities there has been renewed apprehension regarding the possibility of chemical and biological weapon (CBW) deployment by terrorists. Despite various international agreements that proscribe their use, certain states continue to develop chemical and biological weapons of mass destruction. Of greater concern, recent historical examples support the prospect that state-independent organizations have the capability to produce such weapons. Indeed, the deliberate deployment of anthrax has claimed several lives in the USA since September 11, 2001. In the event of a significant CBW attack, medical services would be stretched. However, victim survival may be improved by the prompt, coordinated response of military and civil authorities, in conjunction with appropriate medical care. In comparison with most other specialties, anaesthetists have the professional academic background in physiology and pharmacology to be able to understand the nature of the injuries caused by CBWs. Anaesthetists, therefore, play a vital role both in the initial resuscitation of casualties and in their continued treatment in an intensive care setting. This article assesses the current risk of CBW deployment by terrorists, considers factors which would affect the severity of an attack, and discusses the pathophysiology of those CBWs most likely to be used. The specific roles of the anaesthetist and intensivist in treatment are highlighted.

Simulation-based training of medical teams to manage chemical warfare casualties

With chemical warfare becoming an imminent threat, medical systems need to be prepared to treat the resultant mass casualties. Medical preparedness should not be limited to the triage and logistics of mass casualties and first-line treatment, but should include knowledge and training covering the whole medical spectrum. In view of the unique characteristics of chemical warfare casualties the use of simulation-assisted medical training is highly appropriate. Our objective was to explore the potential of simulator-based teaching to train medical teams in the treatment of chemical warfare casualties. The training concept integrates several types of skill-training simulators, including high tech and low tech simulators as well as standardized simulated patients in a specialized simulated setting. The combined use of multistimulation modalities makes this maverick program an excellent solution for the challenge of multidisciplinary training in the face of the looming chemical warfare threat.

Sulfur mustard intoxication, oxidative stress, and antioxidants

Sulfur Mustard (SM) is a potent alkylating agent with electrophilic property which has been used as a chemical warfare agent in at least 12 conflicts. It has reemerged as a major threat in recent years. Medical attention is primarily concerned with its action on the skin, eyes, and respiratory tract which may be complicated by damage to ophthalmic, pulmonary, and gasterointestinal systems, followed by bone marrow depression. The cytotoxicity of SM and production of reactive oxygen substances (ROS) has been proposed to result from electrophilic or oxidative stress with depletion of cellular detoxifying thiol levels including glutathione. Also, ROS are transformed by iron-requiring reactions into highly toxic oxidants that cause a chain reaction with membrane phospholipids to form lipid peroxides, leading to loss of membrane function, membrane fluidity, and finally membrane integrity. Provision and availability of scavengers of ROS and electrophilic compounds such as glutathione, sulfhydryls compounds, antioxidants, and substances that will increase production of endogenous scavengers may be considered protective and useful. Thereby, the role of substances such as selenium, copper, zinc, and antioxidants including vitamin E, vitamin C, and compounds like beta-carotene against SM cytotoxicity and lipid peroxidation might be interesting to be investigated in experimental animal models.

Training Israeli medical personnel to treat casualties of nuclear, biologic and chemical warfare

Recent events have significantly increased concern about the use of biologic and chemical weapons by terrorists and other countries. Since weapons of mass destruction could result in a huge number of casualties, optimizing our diagnostic and therapeutic skills may help to minimize the morbidity and mortality. The national demands for training in medical aspects of nuclear, biologic and chemical warfare have increased dramatically. While Israeli medical preparedness for non-conventional warfare has improved substantially in recent years especially due to extensive training programs, a standardized course and course materials were not available until recently. We have developed a core curriculum and teaching materials for a 1 or 2 day modular course, including printed materials.

Heat strain reduction by ice-based and vapor compression liquid cooling systems with a toxic agent protective uniform

BACKGROUND

The purpose of this study was to compare a vapor compression microclimate cooling system (MCC) and a personal ice cooling system (PIC) for their effectiveness in reducing physiological strain when used with cooling garments worn under the impermeable self-contained toxic environment protective outfit (STEPO). A second comparison was done between the use of total body (TOTAL) and hooded shirt-only (SHIRT) cooling garments with both the MCC and PIC systems. It was hypothesized that the cooling systems would be equally effective, and total body cooling would allow 4 h of physical work in the heat while wearing STEPO.

METHODS

Eight subjects (six men, two women) attempted four experiments at 38 degrees C (100 degrees F), 30% rh, 0.9 m x sec(-1) wind, while wearing the STEPO. Subjects attempted 4 h of treadmill walking (rest/exercise cycles of 10/20 min) at a time-weighted metabolic rate of 303 +/- 50 W.

RESULTS

Exposure time was not different between MCC and PIC, but exposure time was greater with TOTAL (131 +/- 66 min) than with SHIRT (83 +/- 27 min) for both cooling systems (p < 0.05). Cooling rate was not different between MCC and PIC, but cooling rate while wearing TOTAL (362 +/- 52 W) was greater than with SHIRT (281 +/- 48 W) (p < 0.05). Average heat storage was lower with MCC (39 +/- 20 W x m(-2)) than with PIC (50 +/- 17 W x m(-2)) in both TOTAL and SHIRT (p < 0.05). Also, average heat storage while wearing TOTAL (34 +/- 19 W x m(-2)) was less than with SHIRT (55 +/- 13 W x m(-2)) for both cooling systems (p < 0.05). The Physiological Strain Index (PSI) was lower in MCC-TOTAL (2.4) than MCC-SHIRT (3.7), PIC-SHIRT (3.8), and PIC-TOTAL (3.3) after 45 min of heat exposure (p < 0.05).

CONCLUSIONS

Total body circulating liquid cooling was more effective than shirt-only cooling under the impermeable STEPO uniform, providing a greater cooling rate, allowing longer exposure time, and reducing the rate of heat storage. The MCC and PIC systems were equally effective during heat exposure, but neither system could extend exposure for the 4 h targeted time.

Microbiological, biological, and chemical weapons of warfare and terrorism

Microbiological, biological, and chemical toxins have been employed in warfare and in terrorist attacks. In this era, it is imperative that health care providers are familiar with illnesses caused by these agents. Botulinum toxin produces a descending flaccid paralysis. Staphylococcal enterotoxin B produces a syndrome of fever, nausea, and diarrhea and may produce a pulmonary syndrome if aerosolized. Clostridium perfringens epsilon-toxin could possibly be aerosolized to produce acute pulmonary edema. Ricin intoxication can manifest as gastrointestinal hemorrhage after ingestion, severe muscle necrosis after intramuscular injection, and acute pulmonary disease after inhalation. Nerve agents inhibit acetylcholinesterase and thus produce symptoms of increased cholinergic activity. Ammonia, chlorine, vinyl chloride, phosgene, sulfur dioxide, and nitrogen dioxide, tear gas, and zinc chloride primarily injure the upper respiratory tract and the lungs. Sulfur mustard (and nitrogen mustard) are vesicant and alkylating agents. Cyanide poisoning ranges from sudden-onset headache and drowsiness to severe hypoxemia, cardiovascular collapse, and death. Health care providers should be familiar with the medical consequences of toxin exposure, and understand the pathophysiology and management of resulting illness.

Pyridostigmine bromide and the long-term subjective health status of a sample of over 700 male Reserve Component Gulf War era veterans

Data from a 1996-1997 survey of approximately 700 Reserve Component male veterans indicate that the consumption of pyridostigmine bromide pills, used as a pretreatment for potential exposure to the nerve agent Soman, was a significant predictor of declines in reported subjective health status after the war, even after controlling for a number of other possible factors. Reported reactions to vaccines and other medications also predicted declines in subjective health. While higher military rank generally predicted better health during and after the war, educational attainment, minority status, number of days in theater, and age generally did not predict changes in subjective health. Although servicemembers were directed to take three pills a day, veterans reported a range of compliance--less than a fourth (24%) followed the medical instructions compared to 61% who took fewer than three pills daily and 6% who took six or more pills a day. Implications for use of pyridostigmine bromide are discussed.

Occupational response to terrorism

Occupational health nurses are facing new challenges that seriously imperil health and safety in the workplace. The risks faced in the current world pose threats for which the occupational health nurse may not be prepared. These threats go beyond any unexpected workplace emergency. It is critical for all occupational health professionals to understand the implications of these modern threats and the proper response procedures, including the limits of a safe and prudent response. This knowledge will prevent further fatalities. Occupational health nurses need to translate this knowledge into corporate policies and procedures written so safety is the paramount consideration.

Chemical and biological agent incident response and decision process for civilian and public sector facilities

In the event of a terrorist attack or catastrophic release involving potential chemical and/or biological warfare agents, decisionmakers will need to make timely and informed choices about whether, or how, to respond. The objective of this article is to provide a decision framework to specify initial and follow-up actions, including possible decontamination, and to address long-term health and environmental issues. This decision framework consists of four phases, beginning with the identification of an incident and ending with verification that cleanup and remediation criteria have been met. The flowchart takes into account both differences and similarities among potential agents or toxins at key points in the decision-making process. Risk evaluation and communication of information to the public must be done throughout the process to ensure a successful effort.

Airway management by physicians wearing anti-chemical warfare gear: comparison between laryngeal mask airway and endotracheal intubation

BACKGROUND AND OBJECTIVE

To evaluate the ease with which successful insertion of a laryngeal mask airway can be performed in comparison with endotracheal intubation by medical personnel wearing chemical protective equipment.

METHODS

Anaesthetists and non-anaesthetists (each n = 20) participated in the prospective comparative trial in an animal laboratory. The time and success rates of laryngeal mask airway vs. endotracheal tube insertions were measured as performed on anaesthetized monkeys.

RESULTS

The results showed that the laryngeal mask airway was inserted more rapidly than the endotracheal tube by both groups (3.6 s and 28.6 s, P < 0.0001). Failed intubation occurred in 35% (anaesthetists) vs. 55% (non-anaesthetists) (P = 0.17).

CONCLUSIONS

In view of the 100% success rate of insertion even in unfavourable conditions, the possible role of the laryngeal mask airway in the scenario of a toxic mass casualty event should be considered.

Nuclear, biological, and chemical combined injuries and countermeasures on the battlefield

The Armed Forces Radiobiological Research Institute (AFRRI) has developed a research program to determine the major health risks from exposure to ionizing radiation in combination with biological and chemical warfare agents and to assess the extent to which exposure to ionizing radiation compromises the effectiveness of protective drugs, vaccines, and other biological and chemical warfare prophylactic and treatment strategies. AFRRI's Defense Technology Objective MD22 supports the development of treatment modalities and studies to assess the mortality rates for combined injuries from exposure to ionizing radiation and Bacillus anthracis, and research to provide data for casualty prediction models that assess the health consequences of combined exposures. In conjunction with the Defense Threat Reduction Agency, our research data are contributing to the development of casualty prediction models that estimate mortality and incapacitation in an environment of radiation exposure plus other weapons of mass destruction. Specifically, the AFFRI research program assesses the effects of ionizing radiation exposure in combination with B. anthracis, Venezuelan equine encephalomyelitis virus, Shigella sonnei, nerve agents, and mustard as well as their associated treatments and vaccines. In addition, the long-term psychological effects of radiation combined with nuclear, biological, and chemical (NBC) injuries are being evaluated. We are also assessing the effectiveness of gamma photons and high-speed neutrons and electrons for neutralizing biological and chemical warfare agents. New protocols based on our NBC bioeffects experiments will enable U.S. armed forces to accomplish military operations in NBC environments while optimizing both survival and military performance. Preserving combatants' health in an NBC environment will improve warfighting operations and mission capabilities.

Medical planning considerations in consequence management

The job of military medical planners is to prepare for the unthinkable and then establish a response that allows the civilian system of healthcare to continue to function. This article provides information and perspective that civilian healthcare providers can gain from their counterparts in the military. Two issues need to be considered simultaneously: preparedness, in the form of force health protection, and response, applying consequence management. The critical need for ongoing planning is clear. However, three things remain true despite our best planning efforts: individual behavior drives the response to mass casualty events, flexibility is the key to the success of any plan, and interagency coordination and trust is vital for an effective response.

An educational imperative: The role of ethical codes and normative prohibitions in CBW-Applicable research

This paper examines the role of ethics in research with potential applicability to chemical and biological warfare. If focuses upon biological warfare research, and examines the ethical dilemmas faced by those working with dual-use potential technologies. It discusses the normative, legal and ethical prohibitions against participation in chemical and biological warfare programmes from a Western perspective. It examines the motivations of individuals participating in CBW research and concludes with recommendations for increasing awareness about ethical and normative prohibitions. An appendix lists the results of a survey of ethical codes in relevant scientific disciplines conducted via the Internet.

Mass casualty chemical incidents--towards guidance for public health management

The aim of this paper is two-fold. A review of mass casualty chemical incidents occurring naturally or as a result of industrial activities or deliberate release provided an opportunity to consider the problems experienced in medical and public health response. In addition, a literature review of procedures to assist in the management of chemical incidents by medical and public health professionals was conducted, targeted at summarising what tools exist to minimise the impact on public health from such events. We found that most of the large chemical incidents worldwide were unprecedented and unexpected, and as a consequence emergency services, hospitals and public health had access to very little relevant information in the first few hours. Several lessons were highlighted that would aid future response. The review of procedures showed that there are currently no written procedures that are both sufficiently generic and sufficiently detailed to effectively support the public health management of the emergency response to chemical incidents. There is therefore a need to fill this obvious gap and to develop a procedural guide for the emergency management of chemical incidents by public health professionals. This work is now under way.

[Nerve paralytic agents--the greatest threat for mass poisoning during chemical warfare or terrorist attacks]

Since thirties of the previous the highly toxic organophosphorus compound called nerve agents have been considered the most dangerous chemical warfare agents that could be misused in local and world wars or during terrorist attacks. Beside the historical introduction, the article summarizes contemporary knowledge on the mechanism of toxicity of these agents, on the possibilities of diagnosis, prophylaxis and treatment. The possibility of using similar methods of diagnosis, prophylaxis and treatment for acute poisoning with organophosphorus insecticides is also mentioned.

Biological and chemical terrorism: recognition and management

Primary care physicians will be on the front line in detecting and managing any future terrorist attacks that use chemical or biological agents. This article reviews how to recognize and treat disease caused by exposure to nerve agents, blistering agents, hydrogen cyanide, ricin, anthrax, smallpox, plague, and botulinum toxin.

Pharmacy preparedness for incidents involving weapons of mass destruction

Recent worldwide terrorist acts and hoaxes have heightened awareness that incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radionucleotides, anthrax, botulism, and other possible WMD.

Conjunctival dysplasia in soldiers exposed to mustard gas during the Iraq-Iran war: scrape cytology

OBJECTIVE

To describe the conjunctival scrape cytology findings in Iraq-Iran war veterans exposed to mustard gas and to detect malignant transformation at an early stage.

STUDY DESIGN

Twenty-two male war veterans (29-54 years old) who were exposed to chemical bombing about 14 years earlier, formed the base of this study. All of them had chronic eye problems, such as dryness, conjunctival scarring and decreased visual acuity. Conjunctival scrape cytology was performed for cytologic study.

RESULTS

Among 22 cases of conjunctival scarring, 9 were diagnosed as dysplasia. Mild inflammation and squamous metaplasia were also noted. Squamous cell carcinoma was not identified.

CONCLUSION

Conjunctival scraping cytology is useful for the diagnosis of dysplasia in soldiers exposed to mustard gas during of the Iraq-Iran war. This method is also effective for follow-up study.

Toxins as weapons of mass destruction. A comparison and contrast with biological-warfare and chemical-warfare agents

Toxins are toxic chemical compounds synthesized in nature by living organisms. Classifiable by molecular weight, source, preferred targets in the body, and mechanism of action, they include the most potent poisons on the planet, although considerations of production, weaponization, delivery, environmental stability, and host factors place practical limits on their use as WMD. The two most important toxin threats on the battlefield or in bioterrorism are probably botulinum toxin (a series of seven serotypes, of which botulinum toxin A is the most toxic for humans) and SEB, an incapacitating toxin. Ricin and the trichothecene mycotoxins, including T-2 mycotoxin, are of lesser concern but are still potential threats. Botulinum toxin is a neurotoxin, ricin and trichothecene mycotoxins are membrane-damaging proteins, and SEB is a superantigen capable of massive nonspecific activation of the immune system. The clinical intoxications resulting from exposure to and absorption (usually by inhalation) of these agents reflect their underlying pathophysiology. Because of the hybrid nature of toxins, they have sometimes been considered CW agents and sometimes BW agents. The current trend seems to be to emphasize their similarities to living organisms and their differences from CW agents, but examination of all three groups relative to a number of factors reveals both similarities and differences between toxins and each of the other two categories of non-nuclear unconventional WMD. The perspective that groups toxins with BW agents is logical and very useful for research and development and for administrative and treaty applications, but for medical education and casualty assessment, there are real advantages in clinician use of assessment techniques that emphasize the physicochemical behavior of these nonliving, nonreplicating, intransmissible chemical poisons.

Mortality among US veterans of the Persian Gulf War: 7-year follow-up

To assess the long-term health consequences of the 1991 Persian Gulf War, the authors compared cause-specific mortality rates of 621,902 Gulf War veterans with those of 746,248 non-Gulf veterans, by gender, with adjustment for age, race, marital status, branch of service, and type of unit. Vital status follow-up began with the date of exit from the Persian Gulf theater (Gulf veterans) or May 1, 1991 (control veterans). Follow-up for both groups ended on the date of death or December 31, 1997, whichever came first. Cox proportional hazards models were used for the multivariate analysis. For Gulf veterans, mortality risk was also assessed relative to the likelihood of exposure to nerve gas at Khamisiyah, Iraq. Among Gulf veterans, the significant excess of deaths due to motor vehicle accidents that was observed during the earlier postwar years had decreased steadily to levels found in non-Gulf veterans. The risk of death from natural causes remained lower among Gulf veterans compared with non-Gulf veterans. This was mainly accounted for by the relatively higher number of deaths related to human immunodeficiency virus infection among non-Gulf veterans. There was no statistically significant difference in cause-specific mortality among Gulf veterans relative to potential nerve gas exposure. The risk of death for both Gulf veterans and non-Gulf veterans stayed less than half of that expected in their civilian counterparts. The authors conclude that the excess risk of mortality from motor vehicle accidents that was associated with Gulf War service has dissipated after 7 years of follow-up.